For most people I know, being open-minded is considered a virtue, but many in practice are not open-minded. I have been interested in this dichotomy for a long time, particularly in the medical arena, and have done some reading recently to dig deeper. In order to explore this value further, we need to define and describe it.
There are four general definitions of being open-minded:
- Being receptive to new and different ideas or opinions of others;
- Being accepting of new suggestions, ideas, influences, or opinions;
- Having a mind receptive to new ideas, opinions, or values, and being unprejudiced; and
- Being receptive to investing seriousconsideration of new ideas, opinions, or values.
I actually prefer “serious consideration” to “acceptance” or “receptive,” since those latter terms imply a degree of acceptance that I believe is a step too far.
The writer Danielle DiPirro has described the environment faced by the open-minded thus: “Being open-minded can be really tough sometimes. Most of us are brought up with a set of beliefs and values and, throughout our lives, tend to surround ourselves with people who share the same values and beliefs. Therefore, it can be difficult when we're faced with ideas that challenge our own and, though we may wish to be open-minded, we may struggle with the act of it from time to time.”
In my own experience, arrogance, laziness, political constraints, a lack of self-confidence, protection of a monetary advantage or social status, hidden biases, and plain stupidity or ignorance keep many minds closed. And the most difficult close-mindedness often surfaces when the issue is politics or religion, which are largely the basis for the seemingly perpetual state of wars around the earth.
And we also have a shortage of open-mindedness in medicine. Some of it is subtle, but much of it is clearly evident. Before we go any further, I want it understood that there are many medical situations for which there is no clear or superior option so the physician must use her experience and judgment to recommend a direction for the patient. However, experience and judgment can also be used as an excuse for choosing an option that is more comfortable, easier, more lucrative, or less complex, so other options are not seriously considered.
Here are a few examples.
A medical oncologist and a urologist share the same patient who has a cancer of the bladder that has spread to multiple sites in the bladder. The surgeon wants to do an extensive operation to remove all or most of the cancer in the bladder. The medical oncologist points out that there is strong evidence that the injection of chemotherapeutic agents (including BCG, the tuberculosis vaccine) in the bladder will over time control the disease without a radical change in the urinary passageway.
The surgeon's rationale is that with surgery you cut it out and you needn't deal with it thereafter. That is not a reliable guarantee, of course, and he refuses to even consider the chemotherapy option, which may be better for the patient's quality of life; but the surgeon is not open-minded on this issue.
Another reason for overtreatment is the feeling by physicians of wanting to do something and avoid the sense of being “powerless” to help; doctors are often reluctant to accept the reality that some suffering in life cannot be cured.
Why is the surgeon so reluctant to seriously consider the chemotherapy option? It could be any one of the options mentioned above: skill and familiarity with the surgical technique (“I've done 499 of these operations”), a deeply imbedded belief that surgery is always superior to chemotherapy because you “remove” the cancer, and, sadly, sometimes for monetary reasons or professional pride.
The Case of Proton Beam Radiation Therapy for Prostate Cancer
Another example is the public kerfuffle over the use of proton beam radiation for prostate cancer instead of more traditional radiation or surgery. There is no convincing evidence, such as large, independent, controlled study, that proton beam therapy is more curative or less toxic than modern traditional therapy using the latest advanced focusing technology on the tumor. The argument that proton beam has greater precision might be more convincing if one could know precisely where every single cancer cell was located. It should come as no surprise that proton beam therapy costs two to four times more than traditional therapy.
The public has been told it is better, more precise, and has fewer side effects. But the major attraction to the public, which is not qualified to examine evidence for superiority, is that proton beam is a more recent technology and therefore it “must” be better. We Americans are addicted to the latest of everything, including cars, TVs, medical care, kitchen renovations, iPhones, and the rest, even when the last generation of these things is in perfect working order and the main effects of the latest product is more shine and less money in one's wallet.
Proton beam facilities make a lot of money charging for the use of a $330,000 Ferrari that gets 13 miles per gallon in the city instead of a luxurious Mercedes or Porsche at one-third the price and twice the mileage that does everything for the average driver that the Ferrari can do. In this case, pride, in the sinful sense, and a balanced view of life with common sense are at odds.
However, in medicine one of the saddest examples of a close-minded view are physicians who manage end-of-life care badly.
For the most part, oncologists today know when a cancer is incurable and, further, when there is no likely treatment that will extend the patient's life with reasonable quality. Still, there are those who continue offering yet another chemotherapy regimen that will not work because “you never know”—a stupid, bogus way to escape responsibility.
And there are those who continue useless therapy because the family insists; if that is how it works, what do they need a doctor for? They might as well go to Mexico for coffee enemas (no kidding!).
These physicians have failed to take seriously and be open-minded to convincing data showing that when the cancer is no longer curable or even responsive to any anti-cancer therapy, a strong effort in supportive care by experts can make whatever time the patient has more tolerable, comfortable, and rewarding by providing time under good conditions to visit with family and friends, and get all affairs in order without rushing, often in their own homes. Studies have shown that these patients usually live longer than those given ineffective chemotherapy and, without question, have a much better quality of life.
It is very hard to tell a family that there is no effective therapy remaining for their mother or father (or their child—I had to do this many times). Some parents of children with cancer understand that extending life a few weeks with suffering is harder to bear than supportive therapy at home with all the comforts that can be applied. It is the doctor's responsibility to help families understand that extending useless therapy, often in a hospital or even an ICU, can be, as one patient told me, “torture worse than death.”
Supportive-care programs for end-of-life cancer patients are multiplying in this country and provide pain control, and a variety of social and medical services to ease the patient's final journey. Prof. Matthew Loscalzo at City of Hope, Dr. Jimmie Holland at Memorial Sloan Kettering, and other pioneers in the field have helped build these programs and train others to practice this “new” specialty.
Just a bit more open-mindedness would be a great asset for physicians who manage patients with cancer. If, God forbid, I had an incurable cancer, I would prefer to go home and have the needs of my last days managed by these experts.