A recent article in Health Affairs caught my eye. It is entitled “Survey Shows That At Least Some Physicians Are Not Always Open Or Honest With Patients.” At first I thought, “they needed a study for that?” But I read the article anyway (2012;31:383-391).
Dr. Lisa Iezzoni and her colleagues surveyed nearly 2,000 physicians from across the country in a broad spectrum of specialties, posing a series of questions regarding openness and truthfulness with patients. They used as their basis for “openness and honesty” a document entitled, “The Charter on Medical Professionalism,” which has been endorsed by over 100 professional groups worldwide and the U.S. Accreditation Council of Graduate Medical Education. Some believe it is the new Hippocratic Oath attuned to modern issues.
I must admit that I didn't remember seeing or even hearing of the Charter, so I looked it up. It was developed through a collaboration of the American Board of Internal Medicine Foundation, the American College of Physicians-American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine. It was first published in the Annals of Internal Medicine in 2002 (136; 243-246; http://www.annals.org/content/136/3/243.full ).
3 Fundamental Principles
The Charter lists three fundamental principles:
- Principle of primacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.
- Principle of patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
- Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.
Based on these principles, a set of professional responsibilities were developed;
I list only the title for all but the one concerning honesty, which is quoted in full (the full text for all can be found at the website shown above):
- Commitment to honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy.
Physicians should also acknowledge that in health care, medical errors that injure patients do sometimes occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.
- Commitment to professional competence.
- Commitment to patient confidentiality.
- Commitment to maintaining appropriate relations with patients.
- Commitment to improving quality of care.
- Commitment to improving access to care.
- Commitment to a just distribution of finite resources.
- Commitment to scientific knowledge.
- Commitment to maintaining trust by managing conflicts of interest.
- Commitment to professional responsibilities.
This is a laudable list of physicians' responsibilities and I have little or no quibble with them, but I wondered how honesty and truthfulness were assessed in the Health Affairs article since its application of this responsibility can at times be very dicey and subject to differences in physicians' honest judgment.
Here is a summary of the findings of the survey in Health Affairs (descriptors used in the survey are in quotes): The vast majority of physicians “completely agreed” that physicians should fully inform patients about the risks and benefits of interventions (11.3% “somewhat agreed or disagreed”) and should never disclose confidential information to unauthorized persons (8.6% “somewhat agreed or disagreed”).
A majority of physicians “completely agreed” with disclosing serious medical errors to patients, but about one-third “somewhat agreed or disagreed.” Most also “completely agreed” that physicians should never tell a patient something untrue, but 17% “somewhat agreed or disagreed.”
About two-thirds of physicians “strongly agreed” that they should disclose their financial relationships with drug and device companies to patients; 35% “somewhat agreed or disagreed.”
In the prior year 11% said they had told patients something untrue. And also in the prior year, 55% of physicians had described the patient's prognosis in a more positive manner than was warranted “rarely, sometimes or often.”
The authors conclude that despite the endorsement of many professional medical societies of these precepts, a substantial number of U.S. physicians did not “completely” endorse them, and many deviate from the norms.
Despite the limitations of this type of study, it provides some interesting information, but it has a number of weaknesses. For example, it is difficult to make sense of “somewhat agree” lumped with “disagree.” I could see myself answering some of the questions “somewhat agree,” depending on the patients' conditions, cultural connectivity, and other factors. Physicians asked whether the have told a patient something that wasn't true could choose “never” or “rarely, sometimes or often,” the only two choices; the latter was chosen by 11%. That number is small, but might be even smaller if we knew more, like how many chose “often,” which is clearly more worrisome than rarely.
Although doctors as a whole did the right thing in this survey, I was particularly disappointed in a few outcomes. Only 65% of doctors thought they should disclose financial relationships with drug and device companies; 35% chose “disagree” or “somewhat agree.” Also, only 66% of doctors “completely agreed” with disclosure of all significant medical errors to the patient, while 34% “somewhat agreed” or “disagreed.”
Also, the temptation to describe the prognosis in more positive terms than warranted seems to be difficult to resist (55%). I wonder if it is “how” or “if” the prognosis is conveyed that is the problem. I suspect both factors play a role. We all know of the surgeon who approaches the family after surgery and says, “we got it all,” instead of “we got all that we could see.” Or the medical oncologist who says this new agent is very promising, though he has no convincing data, dangling a vain hope in front of a desperate soul.
The study has attempted to draw a sharp line between black and white. For example, although lying to a patient is reprehensible, I have seen rare circumstances where withholding part of the truth (as long as it did not influence decisions or outcomes) was the most humane action one could have taken in that particular circumstance.
Thankfully, the authors recognize that there is a gray zone in some cases, hopefully only a few. So I give them the last word: “Despite the relative clarity and unambiguous language of the Charter precepts, many factors can affect how and what physicians communicate to patients. Some might argue that knowing when to breach these rules—when individual patients require a different approach—constitutes clinical wisdom and true patient-centeredness. For instance, providing a patient with every detail about his or her case is rarely feasible, nor is it necessarily desirable. Physicians must sort through often contradictory and confusing information as their clinical assessments evolve and finally crystallize.”
Overall I see this article as a useful cautionary tale about physician honesty and openness. The best test, I believe, is what we would want if we were the patients.