Optimism

A survey about doctors’ behavior grabbed the momentary attention of the Twittersphere earlier today, and the reaction focused mostly on the topline result—about 11% of doctors admit to having lied to a patient or patient’s guardian. Shocking!—or perhaps not. I do wonder what comparable results would be for other professions; I suspect that instances of admitted mendacity among lawyers, bankers, etc. are pretty high too.

Aaron Carroll went deeper and found it troubling that roughly a third of doctors in the sample think it’s OK not to admit whatever financial conflicts of interest might be entangled with your care.

That’s certainly troubling, but I found another result worth highlighting: about 55% of doctors admitted to having described the prognosis to a patient in a more favorable manner than warranted. While I would guess there are several consequences to this behavior, the one consequence I fixated on was end-of-life care.

Atul Gawande had an excellent New Yorker article on this subject, of which this small excerpt gets at what I mean:

Sara underwent blood tests and body scans. Dr. Paul Marcoux, an oncologist, met with her and her family to discuss the findings. He explained that she had a non-small cell lung cancer that had started in her left lung. Nothing she had done had brought this on. More than fifteen per cent of lung cancers—more than people realize—occur in non-smokers. Hers was advanced, having metastasized to multiple lymph nodes in her chest and its lining. The cancer was inoperable. But there were chemotherapy options, notably a relatively new drug called Tarceva, which targets a gene mutation commonly found in lung cancers of female non-smokers. Eighty-five per cent respond to this drug, and, Marcoux said, “some of these responses can be long-term.”

Words like “respond” and “long-term” provide a reassuring gloss on a dire reality. There is no cure for lung cancer at this stage. Even with chemotherapy, the median survival is about a year. But it seemed harsh and pointless to confront Sara and Rich with this now. Vivian was in a bassinet by the bed. They were working hard to be optimistic. As Sara and Rich later told the social worker who was sent to see them, they did not want to focus on survival statistics. They wanted to focus on “aggressively managing” this diagnosis.

The doctors exhibit the same behavior the survey does—Gawande quotes a doctor saying, “I’m running a warehouse for the dying.” Has this doctor informed her patients of this opinion? Probably not.

A lot of health care is consumed with optimism and the idea that something can and must be done and has a decent shot of working if it does. That’s an attitude that’s helpful for producing outliers—your Lance Armstrongs—but may not be terribly helpful on the average.