nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Saturday, November 27, 2010

The Conundrum Of How You Communicate Uncertainty To Patients

What do you imagine is going on in your doctor's head when she/he sees you?  How absolute is the duty to inform fully?

More often than not, when you have a medical problem, your doctor will evaluate you and give you a semi-definite diagnosis and treatment recommendation.

However, if they were extremely honest, here's what they would say:
"I've seen many, many cases just like yours, and it's usually very hard to say exactly what's wrong. Different treatments work to varying degrees for different people with this sort of problem, it's very hard to predict which will work for any person, and most of the time none of the treatments is all that successful. I really can't predict what, if anything, is likely to work for you. I suggest we try treatment A, which usually doesn't work but which at least tends to work slightly more often on patients like you then do any of the other treatments. Come back in a month, and if it's working we'll continue it, and if it isn't we'll try something else." (From Wrong: Why experts keep failing us..., by David H. Freeman)
The referenced book is highly recommended.  From the author's experience, few people would be happy with such an approach.  They want, "Here's the diagnosis, this is the treatment, it'll fix you up." (my paraphrase).  In all probability, this second doctor is significantly inferior in diagnostic acumen than the first, and is more likely to cause frustration and a poor result.

But, rather than discuss doctor honesty, I'm more interested in what this tells us about patient's expectations.  The first, better diagnostician is failing to recognize that in addition to a solution and a cure, most people are looking for certainty and reassurance, and in almost equal measure.

But there are patients who do want the first approach.  There are actually people out there who are rational, believe it or not, and internalize rationality in their decision-making.  The trick is to correctly identify who they are before adopting one or the other (or a mix) of the approaches above.  I've done both.

You don't tell someone who may be unstable that they are going to die of cancer, lest they harm themselves.  However, you owe a reasonable person an honest assessment of a poor prognosis.  In fact, to conceal pertinent consequences is not only unethical, but legally actionable.

People can fool you.   Decades ago, I shared in a decision with other consultants--and the whole treatment team--where this occurred.  The patient, who had a lethal form of cancer, appeared the ideal candidate for honesty.  He made a strong case that he intended to pursue all the treatment even if the chances were not good, but needed accurate information in order to prepare, both for himself and his family.  He discussed insurance, wills, bequests, healing rifts with loved ones, experiencing his remaining life to the fullest.  He had no history of mental illness, no depressive symptoms, and was forthright and outgoing.  So we told him that the diagnosis was not good, treatment options were weak, most people succumbed, but there was always hope.

He jumped out the eighth floor window of his hospital room later that day.

Doc D

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