Several years ago, I wrote a column titled, Five Great Lies of Medicine (Oncology Times, 1/25/08 issue). It was well-received with responses mainly from laypeople. Recently, a reader of Oncology Times asked me if I planned to write an expanded version. I liked the idea and the result follows. Since the original is almost 10 years old, readers at that time are unlikely to remember it. So I started this column with the old one, I made some edits in it and then added a few more “great lies.” The last several are lies of omission, usually the failure to provide necessary information or a service that can be of profound importance to the patient and should be addressed.
I was in my late thirties or early forties before I was willing to call them “lies.” I think I had to reach a certain threshold of maturity, experience, and open-mindedness to accept the lies as such. These are not “white lies,” largely innocent with no damage done to another person (damage to the liar is another matter). Some of these are frank lies, others are half-truths, and still others are statements meant to mislead or convince the patient that only he/she is responsible for a decision. The statements listed are not always lies, but too often they are. When there is a major unspoken reservation after one of these statements, it is my belief that it becomes a lie. Here are some relatively common lies in medicine.
We got it all.
This is the king of all lies in cancer. It is not uncommon today for a cancer surgeon to tell a patient or family member triumphantly, “We got it all.” Although it is justified in some instances, for most carcinomas this is blatantly wrong and biologically impossible since many are systemic in nature and micro metastases remain in the patient even with “clear surgical margins.” It misleads the patient and family into thinking the patient is cured. Surgeons who tell this lie defend themselves by saying, “What I meant was that we got all of the tumor we could see at surgery,” or “Of course, the patient will need chemotherapy for the remaining microscopic cancer.” So why didn't he say that? I hear various explanations: “No need to burden the family and patient at this time,” or, “You never know; I might have gotten it all. I had a patient once that...” This introduces the second great lie.
You never know.
When I made rounds with fellows and junior faculty and we were faced with a difficult diagnostic or therapeutic decision, I would ask each to give his or her opinion and to explain the choice. One junior faculty member back in the 1970s often chose what seemed to be an excess of additional diagnostic tests or images, and he often chose therapeutic options that had a next to zero chance of success. When his choice was challenged he would say, “You never know,” meaning this might be the one in a million in which there is a useful or positive result.
It drove me nuts. I wanted to grab his lapels and shake him saying, “Of course we can't be 100 percent positive about any action we take; this is biology and medicine about which we are woefully ignorant, but we must apply what we know to make the best reasoned choice we can. You are using sloppy logic and, even worse, you are lying to yourself and possibly to the patient as well.” Fortunately, I never did show any emotion or grab his lapels. Unfortunately, this lie is still used today, if not in so many words, or even with no words at all. The cancer patient with the third or fourth recurrence is offered an ineffective therapy because, “You never know,” and the lie is compounded when there is a substantial financial incentive to give the therapy. A related “big lie” follows.
I did it because the family insisted on more therapy.
This is a common excuse for giving or doing something that is almost certainly not in the patient's short- or long-term best interests. It is often excused by confusing “patient choice” and sound medical advice. Patients and/or families should be participants in decisions so they may express the boundaries of action they are most comfortable with. But the doctor is duty bound to do the same. To blame the family for highly questionable interventions is an abrogation of responsibility by the doctor. It is very hard to say “no” to a desperate patient or family. Nobody said this would be easy.
It's your decision.
This is a variant of the preceding lie. There is no question doctors influence patients' decisions. Doctors have biases that may be based on scientific data or a common standard of practice, and it may therefore be reasonable to make a strong recommendation. But in some cases the bias is personal, such as wanting to get more patients on a clinical trial, to do more surgery, to increase revenues, or to avoid having to deal with a difficult patient. In these cases, how the choice is presented along with the enthusiasm and salesmanship of the doctor can make it far more unlikely the patient will choose an alternative option, even when at the end of the explanation the doctor says, “It's your decision.”
In a technical sense, it is indeed the patient's decision to go forward, but the strong conviction of the doctor has severely reduced the patient's degrees of freedom. As noted above, a strong recommendation is sometimes indicated, but when those instances are based on a personal preference, one must be extra careful to balance any bias by providing clearly understood information and transparency.
He's a “good doctor.”
Patients require referrals to specialists and most often depend on their current physician to recommend one. Physicians usually refer to specialists they know personally or know to be competent by experience or word of mouth. But they may refer a patient because the specialist is a golfing buddy, works in the same building, or is a business partner. The specialist may be quite competent, but one must ask oneself the simple question: If the patients were members of my family, would I send them to this specialist? Or when one tells the patient, “She is a good doctor,” does he really mean, “She is a good enough doctor,” or “She can probably handle this case because it isn't so complicated?” Referral relationships are fragile and may be influenced by non-medical issues. One must be diligent to avoid exposing patients to unnecessary risks in order to satisfy a social or business obligation.
Failure to explain the relative costs of diagnostics and therapy.
I don't know many physicians who enjoy discussing the costs that must be borne by the patient and his family. Most avoid the topic unless asked. But in today's world, it is not uncommon for the patient and family to carry a huge burden of debt they cannot possibly manage with their income. I am not suggesting one offer a cheaper regimen that is inferior therapeutically. It is the physician's responsibility to describe the choices along with their relative costs. If the best therapeutic regimen is clearly superior for curing or has the likelihood of a prolonged period of a high quality of life, the choice is clear, but the costs should be explained to the patient and family so they can begin asking about payment options and dealing with insurance agents.
Failure to describe the usual post-therapy quality of life of similar patients.
The short- and long-term handicaps that may occur in the ensuing months or years of therapy is a lie of omission. Edema in the arm after a mastectomy is common enough that helping the patient prepare for such an event would be prudent. Failure to prepare the post-prostatectomy patient for a leaky bladder or impairment of erection is another lie of omission. In the early days of bone marrow transplantation, the long inpatient stays and the ravages of graft-versus-host disease were new and puzzling problems, with the dangers of immunosuppression thrown in. As time passed, transplant doctors did a much better job of explaining these problems to families and patients, including their therapeutic options.
The unavailability problem.
As a retired physician, I am often asked at civic groups or by acquaintances, family members, and other casual friends about not being able to contact their doctor, or the nurse or knowledgeable clerk. The doctor is too busy or traveling or in the OR. This often leaves the patient with no way to ask a question or get even minimal information. I am sympathetic with the doctor's busy day with a waiting room full of more patients. And, at times, patients can expect too much attention. But at least there should be a window of time when the doctor or staff person would be accessible to triage the seriousness of the issue.
Thus, while each of the above statements or actions can be used honestly and justly, they are too often used for more negative and sometimes shameful reasons and biases. The test is the motivation found when being honest with oneself and, at the very least, facing the fact when one is not.
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