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Will You 'Like' the Doctor Who Tells You You're Dying?

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April 10, 2014

This article originally appeared on CNN.com on April 10, 2014.

By Mary Mulcahy

Honesty may be the best policy, but when delivering bad news to patients, physicians must prepare to pay a price for that honesty.

You simply do not like the doctor who tells you what you are afraid to hear. In this age of greater accountability in health care, the satisfaction of patients and the subtle nuance of likeability is connected directly to doctor payment. And patients who don't like what their doctor tells them won't "like" that doctor on the growing number of physician rating services springing up on the Internet.

The complex task of adding unwelcome and difficult content to a conversation may impede physicians from having dialogues about the most sensitive issues. Often these hard conversations arrive as a patient nears the end of life.

Martha, 65, came to see me for a second opinion regarding her incurable pancreatic cancer. She could accurately describe the extent of her disease, its implications and her goals of "buying more time" with therapy.

Aware of the dismal survival statistics, Martha remained hopeful about recent therapeutic advances reported in the media. We were able to discuss a treatment plan that set reasonable goals, and she told me she was very grateful.

However, she then described the "cruel" physician she had seen prior to our visit who told her "there was nothing more to do" and to "go home and die." Martha was surprised that there was no disciplinary action to be taken against this doctor.

What was the doctor's crime? She had the unfortunate duty of being the first person to tell Martha the truth.

Knowing this doctor -- a compassionate, thoughtful and experienced oncologist with superb communication skills -- I knew those words weren't the ones she actually said.

By the time Martha arrived in my exam room, she had stirred the information around in her head, digested the statistics and had found a hopeful morsel. A little of the bitterness was blanched out.

While there are some doctors who knowingly give false hope, most believe in the principle of veracity -- a term used in medicine to denote the ethic of truth-telling.

However, veracity applies to both happy news and sad. When addressing those with terminal or life-limiting illnesses, I may be a good cop today -- yet tomorrow -- maybe a bad one.

How patients perceive a difficult, yet honest, conversation can impact the confidence and satisfaction they feel with their doctor.

A recent study reported in The New England Journal of Medicine evaluated patients' understanding of their cancer treatment goals. More than 70% of advanced cancer patients enrolled did not understand that they had an incurable disease.

Using a five-item questionnaire, patients rated physician communication. Those patients rating high scores for physician communication were more likely to respond inaccurately to the inquiry into the goal of their chemotherapy regimen. Responses suggest that many patients perceive physicians as better communicators when conveying more optimistic views.

The implications of these findings are enormous. In the comedic parody "Anchorman 2," the bumbling Ron Burgundy changes the tactics of television news by giving people what they want, not what they need.

The result is a sensationalized newscast of car chases and puppy stories, devoid of any public value. This mentality of enablement is seen regularly in medicine -- the skyrocketing number of Cesarean sections and the overuse of antibiotics are telling examples.

By doling out what patients want instead of what they need, many physicians become known as "good" doctors.

An underlying and ambitious aim of the Affordable Care Act is the improvement of health care quality. Attempting to disprove Robert Pirsig's take in the book "Zen and the Art of Motorcycle Maintenance": "Even though quality cannot be defined, you know what quality is," numerous programs have been implemented to measure the quality of hospitals, physicians and medical systems. At best, these metrics are inexact and complex.

Concrete measures, such as morbidity (the prevalence of disease) and mortality, have long been used with associated and well-established limitations. Clearly, hospitals treating the most medically complex patients will also suffer higher rates of mortality than others. Likewise, those institutions in underserved areas will be hampered by limitations in social services and patient compliance.

In an effort to obtain more accurate quality measures, numerous private and government-funded organizations have emerged using various tools to gauge outcomes -- both system and patient-reported.

Patient-reported outcomes reflect the status of a patient's condition in his or her own words, without the interpretation of a clinician or anyone else. Resources allowing patients to rate their health care experiences are increasingly littering the Internet; healthgrades.com , ratemds.com and vitals.com are just a few of myriad examples.

These consumer-oriented, online medical report cards intend to stimulate quality improvement efforts among practitioners. However, an unforeseen consequence is that they may act as a sounding board for unhappy patients with no distinction between ineffective systems and unfortunate circumstances.

Barriers to honest, difficult conversations about terminal illness, the end of life and the limitations of modern medicine are numerous.

In these days of instant "likes" that can impact physician payment without the tools to distinguish a conversation's quality from its content, physicians may feel pressured to provide patients with the answers they want -- instead of the critical answers they need.

- Mary Mulcahy is an associate professor of medicine at Northwestern University