Skip to main content

Will you 'like' the doctor who tells you you're dying?

By Mary Mulcahy
April 10, 2014 -- Updated 1345 GMT (2145 HKT)
Mary Mulcahy says doctors should be encouraged to be honest with patients.
Mary Mulcahy says doctors should be encouraged to be honest with patients.
STORY HIGHLIGHTS
  • Will doctors be penalized for being honest to patients?
  • Mary Mulcahy says patients will give lower marks to doctors who tell them the truth
  • Study found 70% of advanced cancer patients didn't understand their disease was incurable
  • Mulcahy: Doctors may tell patients what they want to hear, not what they need to hear

Editor's note: Dr. Mary F Mulcahy is an associate professor in the hematology oncology department at Northwestern University Feinberg School of Medicine, and a co-founder of Life Matters Media, which provides information and support for those involved in end of life decision-making. The opinions expressed in this commentary are solely those of the author.

(CNN) -- 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.

Mary Mulcahy
Mary Mulcahy

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.

Polio-like illness stumps doctors
Brain dead: What it is, what it isn't
Debating the definition of "Dead"
Is pot addictive? Two doctors debate

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.
Mary Mulcahy

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.

Follow @CNNOpinion on Twitter

Join us at Facebook/CNNOpinion

ADVERTISEMENT
Part of complete coverage on
October 31, 2014 -- Updated 1819 GMT (0219 HKT)
As a woman whose parents had cancer, I have quite a few things to say about dying with dignity.
October 31, 2014 -- Updated 1304 GMT (2104 HKT)
David Gergen says he'll have a special eye on a few particular races in Tuesday's midterms that may tell us about our long-term future.
October 31, 2014 -- Updated 1452 GMT (2252 HKT)
What's behind the uptick in clown sightings? And why the fascination with them? It could be about the economy.
October 31, 2014 -- Updated 1301 GMT (2101 HKT)
Midterm elections don't usually have the same excitement as presidential elections. That should change, writes Sally Kohn.
October 30, 2014 -- Updated 1539 GMT (2339 HKT)
Mike Downey says the Giants and the Royals both lived through long title droughts. What teams are waiting for a win?
October 30, 2014 -- Updated 1832 GMT (0232 HKT)
Mel Robbins says if a man wants to talk to a woman on the street, he should follow 3 basic rules.
October 29, 2014 -- Updated 2103 GMT (0503 HKT)
Peter Bergen and David Sterman say more terrorism plots are disrupted by families than by NSA surveillance.
October 29, 2014 -- Updated 2125 GMT (0525 HKT)
Time magazine has clearly kicked up a hornet's nest with its downright insulting cover headlined "Rotten Apples," says Donna Brazile.
October 29, 2014 -- Updated 2055 GMT (0455 HKT)
Leroy Chiao says the failure of the launch is painful but won't stop the trend toward commercializing space.
October 29, 2014 -- Updated 1145 GMT (1945 HKT)
Timothy Stanley: Though Jeb Bush has something to offer, another Bush-Clinton race would be a step backward.
October 28, 2014 -- Updated 1237 GMT (2037 HKT)
Errol Louis says forced to choose between narrow political advantage and the public good, the governors showed they are willing to take the easy way out over Ebola.
October 27, 2014 -- Updated 1803 GMT (0203 HKT)
Eric Liu says with our family and friends and neighbors, each one of us must decide what kind of civilization we expect in the United States. It's our responsibility to set tone and standards, with our laws and norms
October 27, 2014 -- Updated 1145 GMT (1945 HKT)
Sally Kohn says the UNC report highlights how some colleges exploit student athletes while offering little in return
October 26, 2014 -- Updated 1904 GMT (0304 HKT)
Terrorists don't represent Islam, but Muslims must step up efforts to counter some of the bigotry within the world of Islam, says Fareed Zakaria
October 24, 2014 -- Updated 1302 GMT (2102 HKT)
Scott Yates says extending Daylight Saving Time could save energy, reduce heart attacks and get you more sleep
October 27, 2014 -- Updated 0032 GMT (0832 HKT)
Reza Aslan says the interplay between beliefs and actions is a lot more complicated than critics of Islam portray
ADVERTISEMENT