By Dr. Kate Scannell, Syndicated columnist; First published in print 02/18/2012
Last week, the journal Health Affairs published a study exploring physicians' attitudes about truth-telling that generated abundant media attention. Many public commentators deemed the results "shocking" -- although few seem to have read the fine print. You almost needed a tranquilizer to withstand headlines that "asked" whether YOUR DOCTOR IS LYING TO YOU!
In comparison, the study's actual title reads less sensationally: "Survey shows that at least some physicians are not always open or honest with patients." Although not much of an attention grabber, it concisely summarizes the researchers' main conclusion based upon a survey of 1,891 practicing physicians in the United States.
The actual media reports about the content of the new survey also tended to be off-key and misleading.
For example, when 89 percent of physicians "completely agreed" that they should fully inform patients about the risks and benefits of interventions or treatments, the media tended to convey that as "1 in 10 doctors not agreeing" they should always inform patients.
But the media spin on this and several other questions was distorted, because the researchers had allowed only two possible categories of physician responses. Oddly, physicians could either "completely agree" about the rightfulness of an action -- or they could "somewhat agree or disagree." Obviously, however, you really shouldn't equate "somewhat agreeing" with "disagreeing" -- it's like equating being somewhat tall with being short.
Nonetheless, some troubling findings from the study firmly stand. Although painted with blunt instruments, the overall picture reflects serious concern that some patients are not receiving complete, meaningful and truthful information about their health, prognosis and exposure to medical mistakes.
The medical profession has struggled with notions of truth-telling since antiquity. Hippocrates counseled doctors to conceal "most things from the patient while you are attending him."
The Hippocratic oath -- ceremoniously taken by generations of newly minted doctors -- does not even mention an obligation to truth-telling.
Within many of our lifetimes, it was not uncommon for physicians to "doctor the truth" when they genuinely believed that would benefit a patient and prevent harm. During my medical training, I remember a senior physician withholding a grim diagnosis from a suicidal patient, and another painting a rosier picture of the future for a dying woman who had just given birth.
Serious cancer diagnoses were frequently concealed from patients -- generally with encouragement from family members. For example, in 1961 a landmark publication in the Journal of the American Medical Association revealed that fully 90 percent of 219 surveyed physicians in the U.S. would not disclose the diagnosis of a fatal cancer to a patient.
Obviously, things are quite different now. The old paternalistic approach -- of doctors asserting they always knew what was best for patients -- is much less common. Instead, greater emphasis is placed upon supporting patient choice regarding what information can and should be accessible -- regardless of speculative harm or their potential emotional reactions.
Patients are generally encouraged to know about all possible options for their care, to make a fully informed choice among those options, and to take responsibility for the consequences of their choices.
This modern approach supports medical decision-making that prioritizes patients' preferences and values -- not the doctors'. It also resonates with findings from many current surveys indicating that most patients want their doctors to tell them the truth about their medical conditions.
For example, by 2003 a survey revealed that about 90 percent of 200 elderly adults wanted to be told if they had Alzheimer's disease or terminal cancer.
Nowadays, doctors are generally advised to provide sufficient information that a "reasonable person" would want to know in order to understand a given diagnosis and options for care. Providing patients with truthful information allows them to become reality-based decision-makers about their own health care.
Still, "if truth be told," in actual medical practice it is often problematic to tell the truth, the whole truth, and nothing but the truth to patients. We doctors often don't know which clinical truth or practice guideline to believe. We sometimes wonder whether claims for a new miracle drug or medical device are backed by honest research stripped of corporate self-interest. "In truth," multiple doctors can provide multiple divergent opinions about a patient's diagnosis or best treatment option.
When I was diagnosed with cancer, my doctor provided me with therapeutic options and a strong recommendation based upon his staging of my disease. With his encouragement, I sought a second opinion -- only to receive an alternate recommendation and a more serious staging of my cancer. Hoping that a third opinion would reconcile the difference proved to be completely wrong. As did a fourth. In the confused and desperate end, I had to make a critical decision about my treatment, fully informed by four contrasting views -- all truthfully and competently offered, shaped from the same objective evidence.
The point is, as Oscar Wilde so astutely noted, "the truth is rarely pure and never simple." This is certainly true in medicine, and we could all benefit from greater acceptance of the genuine uncertainty that pervades clinical practice.
Last week, the journal Health Affairs published a study exploring physicians' attitudes about truth-telling that generated abundant media attention. Many public commentators deemed the results "shocking" -- although few seem to have read the fine print. You almost needed a tranquilizer to withstand headlines that "asked" whether YOUR DOCTOR IS LYING TO YOU!
In comparison, the study's actual title reads less sensationally: "Survey shows that at least some physicians are not always open or honest with patients." Although not much of an attention grabber, it concisely summarizes the researchers' main conclusion based upon a survey of 1,891 practicing physicians in the United States.
The actual media reports about the content of the new survey also tended to be off-key and misleading.
For example, when 89 percent of physicians "completely agreed" that they should fully inform patients about the risks and benefits of interventions or treatments, the media tended to convey that as "1 in 10 doctors not agreeing" they should always inform patients.
But the media spin on this and several other questions was distorted, because the researchers had allowed only two possible categories of physician responses. Oddly, physicians could either "completely agree" about the rightfulness of an action -- or they could "somewhat agree or disagree." Obviously, however, you really shouldn't equate "somewhat agreeing" with "disagreeing" -- it's like equating being somewhat tall with being short.
Nonetheless, some troubling findings from the study firmly stand. Although painted with blunt instruments, the overall picture reflects serious concern that some patients are not receiving complete, meaningful and truthful information about their health, prognosis and exposure to medical mistakes.
The medical profession has struggled with notions of truth-telling since antiquity. Hippocrates counseled doctors to conceal "most things from the patient while you are attending him."
The Hippocratic oath -- ceremoniously taken by generations of newly minted doctors -- does not even mention an obligation to truth-telling.
Within many of our lifetimes, it was not uncommon for physicians to "doctor the truth" when they genuinely believed that would benefit a patient and prevent harm. During my medical training, I remember a senior physician withholding a grim diagnosis from a suicidal patient, and another painting a rosier picture of the future for a dying woman who had just given birth.
Serious cancer diagnoses were frequently concealed from patients -- generally with encouragement from family members. For example, in 1961 a landmark publication in the Journal of the American Medical Association revealed that fully 90 percent of 219 surveyed physicians in the U.S. would not disclose the diagnosis of a fatal cancer to a patient.
Obviously, things are quite different now. The old paternalistic approach -- of doctors asserting they always knew what was best for patients -- is much less common. Instead, greater emphasis is placed upon supporting patient choice regarding what information can and should be accessible -- regardless of speculative harm or their potential emotional reactions.
Patients are generally encouraged to know about all possible options for their care, to make a fully informed choice among those options, and to take responsibility for the consequences of their choices.
This modern approach supports medical decision-making that prioritizes patients' preferences and values -- not the doctors'. It also resonates with findings from many current surveys indicating that most patients want their doctors to tell them the truth about their medical conditions.
For example, by 2003 a survey revealed that about 90 percent of 200 elderly adults wanted to be told if they had Alzheimer's disease or terminal cancer.
Nowadays, doctors are generally advised to provide sufficient information that a "reasonable person" would want to know in order to understand a given diagnosis and options for care. Providing patients with truthful information allows them to become reality-based decision-makers about their own health care.
Still, "if truth be told," in actual medical practice it is often problematic to tell the truth, the whole truth, and nothing but the truth to patients. We doctors often don't know which clinical truth or practice guideline to believe. We sometimes wonder whether claims for a new miracle drug or medical device are backed by honest research stripped of corporate self-interest. "In truth," multiple doctors can provide multiple divergent opinions about a patient's diagnosis or best treatment option.
When I was diagnosed with cancer, my doctor provided me with therapeutic options and a strong recommendation based upon his staging of my disease. With his encouragement, I sought a second opinion -- only to receive an alternate recommendation and a more serious staging of my cancer. Hoping that a third opinion would reconcile the difference proved to be completely wrong. As did a fourth. In the confused and desperate end, I had to make a critical decision about my treatment, fully informed by four contrasting views -- all truthfully and competently offered, shaped from the same objective evidence.
The point is, as Oscar Wilde so astutely noted, "the truth is rarely pure and never simple." This is certainly true in medicine, and we could all benefit from greater acceptance of the genuine uncertainty that pervades clinical practice.