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Harpham, Wendy S. MD

doi: 10.1097/01.COT.0000387272.54437.06


Do you want your patients to choose the right treatment? Or the best treatment?

The right treatment, of course. Unless the right treatment is the best treatment.

I suppose this sounds like a Who's-on-first joke. But I'm talking about a serious problem in the world of cancer care: the tension between “right” and “best.”

When I was in practice I made every effort to provide the best care to each of my patients. And, naturally, I trusted my physicians to do the same after I developed cancer.

Confident of my care, I was surprised to see my mailbox fill up with unsolicited advice about the “right” steps to renewed health, from cancer-curing diets to off-label cancer therapies. The disciplined physician in me recognized “right” as a red flag. This made it easier to dismiss unfounded advice and to focus on taking the “best” steps.

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Right. Best. What's the difference?

To make the “right” choice” or take the “right” path is to pursue a course of action that leads to the desired outcome. Just think about when you try to pick the right checkout line at the grocery store. Are you making the right choice if you avoid long lines of people pushing carts that are bursting at the seams with cereals and sodas and, instead, commit to a shorter line of people carrying baskets that contain only a carton of milk or a frozen pizza?

Maybe not, if the customer in front of you needs a price check, pays in pennies or, heaven forbid, pulls out a checkbook. Certainly not, if the cashier goes on lunch break and you have to go to the end of one of the longer lines you passed earlier.

When faced with grocery lines, cancer treatments, or any other decision where the outcome might be affected by factors beyond your ability to predict or control, you cannot possibly know which choice is right until after the outcome is affirmed. In these situations, you have to settle for best.

When I got sick, my early struggles to make the best choices in all spheres of my life gave rise to my notion of a Healthy Survivor, namely, a survivor who gets good care and lives as fully as possible.

I didn't pluck the Healthy Survivor label out of the air. “Healthy” means conducive to a healthy outcome with no guarantees. Now, two decades later, the Healthy Survivor label has been tested from every angle and proven itself. Healthy Survivor has been providing a compact way for me to encourage myself and others to strive to make life the best it can be, and to accept what life brings.

What about patients who want more, even when their physicians and nurses are clearly doing their best to help them make the best treatment decisions? How can intelligent, rational patients possibly hope for certainty in their cancer care?

For one thing, uncertainty stirs patients' emotions—fears, anxieties, wishes, and hopes. A sense of pursuing the right path can calm unpleasant emotions, especially when reinforced by a culture that glorifies being right. That's fine if things go well.

But if they don't, patients can too easily conclude they made the wrong decision or are doing something wrong. Feelings of disappointment, embarrassment, loss of confidence and even shame can make it difficult to move on.

For another thing, in medicine, progress connotes decreased uncertainty. Patients may develop unrealistic expectations of certainty as a response to reports from the front lines of medical research.

In 1990, progress in diagnostics enabled pathologists to delineate the pathognomonic pattern of surface antigens on my cancer cells and thus confirm exactly what type of lymphoma I had. In general, hoping to eliminate all uncertainty—to make the right diagnoses—is adaptive for patients and clinicians when evaluating patients.

But it is a different story when treating patients. No amount of progress in therapeutics can eliminate the uncertainty about patients' future health. The most that clinicians and patients can hope for is to stack the odds favorably and then to find the serenity, courage, and strength to deal with whatever happens. In general when choosing treatment, the right choice is the best choice.

As clinicians, we help the healing process by guiding patients to strive for certainty about their diagnoses and certainty about their current condition, while at the same time helping patients let go of hope for certainty about their future health.

We can remind patients that cancer doesn't make life uncertain; cancer simply exposes the uncertainty of life. We can reassure patients that they don't have to live with the burden of untamed fear, because we can teach them techniques and prescribe therapies for managing this fear so it no longer interferes with their life in significant ways.

We can offer Healthy Survivorship as an antidote to the lure of pseudoscience that promises patients control if only they make the “right” choices. Doing so leads patients to the confidence that comes with making informed choices and the comfort that comes with knowing they are doing the best they can do.

Healthy Survivorship holds the key to the holy grail of 21st Century medicine: personalized cancer care. Because in order for physicians, nurses, and all the other members of the health care team to guide and support patients' efforts toward making the best choices, these clinicians must know each of their patients as unique individuals before they can determine what is, indeed, best.

Imagine a world where clinicians empower each and every one of their patients to embark with them on a shared mission of forging and following the best path at each point in time. These healing efforts can begin right now. This is the promise of Healthy Survivorship.

© 2010 Lippincott Williams & Wilkins, Inc.
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