Doctors Not Always Honest With Patients - Study

[Lunasly]

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[YOUTUBE]http://www.youtube.com/watch?v=uY5iayOgMeI&feature=mfu_in_order&list=UL[/YOUTUBE]

Besides possibly getting sued, why else would a doctor be less honest with their patients?

 

[nuance]

For people who prefer articles over videos:

The original study: http://content.healthaffairs.org/content/31/2/383.abstract

A nice summary by the Associated Press: http://news.yahoo.com/study-finds-mds-not-always-honest-patients-210241111.html

 

[nuance]

Personally, I think a large reason many doctors are not completely honest is that they want to maintain hope in their patients. The balance between being honest and cultivating hope has always been an ethical gray-area, and I think there could be some real benefits from more training in this area.

A lot of literature has been published about balancing honesty & hope, especially in fields like oncology. Here's an article I found that has been cited 77 times: http://jco.ascopubs.org/content/13/7/1817.citation (google cache here ) by researchers at Case Western for the Journal of Clinical Oncology.

Edit: Hopefully others can view it through the google cache. It was a little tl;dr so I focused on the conclusion

 

[NickNaylor]

Personally, I think a large reason many doctors are not completely honest is that they want to maintain hope in their patients. The balance between being honest and cultivating hope has always been an ethical gray-area, and I think there could be some real benefits from more training in this area.

A lot of literature has been published about balancing honesty & hope, especially in fields like oncology. Here's an article I found that has been cited 77 times: http://jco.ascopubs.org/content/13/7/1817.citation (google cache here ) by researchers at Case Western for the Journal of Clinical Oncology.

Edit: Hopefully others can view it through the google cache. It was a little tl;dr so I focused on the conclusion

There is no ethical gray area. Lying to patients is wrong under all circumstances. Leaving out information that a patient might use to decide between treatment options is also a no-go under nearly all circumstances.

 

[nuance]

There is no ethical gray area. Lying to patients is wrong under all circumstances. Leaving out information that a patient might use to decide between treatment options is also a no-go under nearly all circumstances.

Yeah, I agree. I am not condoning doing that--I was mainly referring to what the article said about the style of the disclosure, not whether or not a diagnosis and/or prognosis should be disclosed.

Edit: I think it's important to include that I don't think the balance of 'honesty and hope' is the same as the balance of 'honesty and dishonesty' or 'honesty and nondisclosure'. I do, however, think that many doctors may confound hope with nondisclosure, and that sort of thing is what leads to the issues in the OP's study.

 

[pkwraith]

I don't think it's terribly surprising. About the same line as physicians subscribing placebos, which is fairly common (45% at last survey I saw) and have been done for a while.

 

[NickNaylor]

I don't think it's terribly surprising. About the same line as physicians subscribing placebos, which is fairly common (45% at last survey I saw) and have been done for a while.

Even placebos (unless in the context of clinical trials) are generally considered to be unethical when used as they historically were (i.e., telling the patient they were receiving a "medication" when in reality they were receiving placebo).

 

[deleted307836]

I don't think it's terribly surprising. About the same line as physicians subscribing placebos, which is fairly common (45% at last survey I saw) and have been done for a while.

How does this even work in the modern healthcare system? Does the placebo have a name identical to an actual drug? Are they filled through a pharmacy? I completely don't understand how this can work in our current system and agree that in the vast majority of cases it is probably an unethical practice. The only exception I can possibly see is psychosomatic medicine but even that still seems unethical to me.

 

[NickNaylor]

How does this even work in the modern healthcare system? Does the placebo have a name identical to an actual drug? Are they filled through a pharmacy? I completely don't understand how this can work in our current system and agree that in the vast majority of cases it is probably an unethical practice. The only exception I can possibly see is psychosomatic medicine but even that still seems unethical to me.

My understanding is that the only ethical way to prescribe a placebo (or at least the only way I've heard of) is to tell the patient, "I have two drugs here. One is a placebo, and one is a prescription. Choose one." In other words, the patient has to be aware that one of the drugs is a placebo but is still unsure about which drug he/she receives (thus preserving the placebo effect).

I don't know how that would go with respect to writing and filling a prescription. I imagine some kind of prescription is written (otherwise that'd be too obvious), but I don't know how that would work.

 

[pkwraith]

How does this even work in the modern healthcare system? Does the placebo have a name identical to an actual drug? Are they filled through a pharmacy? I completely don't understand how this can work in our current system and agree that in the vast majority of cases it is probably an unethical practice. The only exception I can possibly see is psychosomatic medicine but even that still seems unethical to me.

The stats (well, IM survey) that I saw had it break down to about 50% of physicians having written placebos. The biggest one was antibiotics (30%) for virals/nonbacterial (which I think might not be great). Others are vitamins (20%), subtherapeutic doses, herbal supplements. And there's also actual placebo and sugar pills that can be filled out pharmacies, but that's the smallest subset.

And as how they told patients, I think the breakdown is

30% told patients it was "a substance that may help and will not hurt,"

20% described the placebo as medication
10% said it was "medicine with no specific effect."

5% explicitly used the word "placebo"

 

[ppfizenm]

I agree that lying to patients is not a good practice. However, certain times I do think a placebo would suffice as "treatment" without disclosing to that patient they may possibly be receiving a placebo. I, not even being a medical student, only have anecdotal evidence to support this.

A 20-something female patient came into the ED of the hospital I was interning at. She was complaining about fatigue, weight loss, pain, ect. She had a whole host of reported symptoms. Sometime during the history she pulled out test results from some "clinic" in Florida (keep in mind we are in the northeast now) showing that she had high thallium levels (no baselines were established on the results for what constitutes acceptable levels) and that the clinic had instructed her to undergo chelation therapy for which many other hospitals had turned her away.

As an intern I was instructed to keep a journal of my patient interactions and long before the thallium bit had come up I wrote hypochondriac on my sheet. The attending I was shadowing agreed with me. He ended up ordering a few lab tests and sending her on her way. I couldn't help but thinking maybe just give her placebo and tell her it removes the thallium from her body so she wouldn't continue to waste money on pointless healthcare.

 

[NickNaylor]

I agree that lying to patients is not a good practice. However, certain times I do think a placebo would suffice as "treatment" without disclosing to that patient they may possibly be receiving a placebo. I, not even being a medical student, only have anecdotal evidence to support this.

A 20-something female patient came into the ED of the hospital I was interning at. She was complaining about fatigue, weight loss, pain, ect. She had a whole host of reported symptoms. Sometime during the history she pulled out test results from some "clinic" in Florida (keep in mind we are in the northeast now) showing that she had high thallium levels (no baselines were established on the results for what constitutes acceptable levels) and that the clinic had instructed her to undergo chelation therapy for which many other hospitals had turned her away.

As an intern I was instructed to keep a journal of my patient interactions and long before the thallium bit had come up I wrote hypochondriac on my sheet. The attending I was shadowing agreed with me. He ended up ordering a few lab tests and sending her on her way. I couldn't help but thinking maybe just give her placebo and tell her it removes the thallium from her body so she wouldn't continue to waste money on pointless healthcare.

If you're ok with lying to your patients about what treatments they're getting, then go for it. Very few, if any, physicians will support you. Unfortunately just because something is "easier" doesn't necessarily make it right.

 

[MelMelisqueen]

I agree that lying to patients is not a good practice. However, certain times I do think a placebo would suffice as "treatment" without disclosing to that patient they may possibly be receiving a placebo. I, not even being a medical student, only have anecdotal evidence to support this.

A 20-something female patient came into the ED of the hospital I was interning at. She was complaining about fatigue, weight loss, pain, ect. She had a whole host of reported symptoms. Sometime during the history she pulled out test results from some "clinic" in Florida (keep in mind we are in the northeast now) showing that she had high thallium levels (no baselines were established on the results for what constitutes acceptable levels) and that the clinic had instructed her to undergo chelation therapy for which many other hospitals had turned her away.

As an intern I was instructed to keep a journal of my patient interactions and long before the thallium bit had come up I wrote hypochondriac on my sheet. The attending I was shadowing agreed with me. He ended up ordering a few lab tests and sending her on her way. I couldn't help but thinking maybe just give her placebo and tell her it removes the thallium from her body so she wouldn't continue to waste money on pointless healthcare.

That's just straightforward lying though. I could maybe justify Vitamin D supplements or something, and tell her it could help with the fatigue?

 

[ppfizenm]

If you're ok with lying to your patients about what treatments they're getting, then go for it. Very few, if any, physicians will support you. Unfortunately just because something is "easier" doesn't necessarily make it right.

I didn't say it was easier. I actually think it would be in this patient's best interest to "treat" her. She openly refused to talk to a psychiatrist. She can keep hitting up emergency departments bankrupting herself or she could take a placebo and hopefully get over it.

The easier thing was done. She was sent away with no treatment.

 

[kami333]

I didn't say it was easier. I actually think it would be in this patient's best interest to "treat" her. She openly refused to talk to a psychiatrist. She can keep hitting up emergency departments bankrupting herself or she could take a placebo and hopefully get over it.

The easier thing was done. She was sent away with no treatment.

Thereby throwing more fuel to the alt med claims that practitioners of traditional medicine lie to their patients, are corruptly supporting big pharma by writing unneeded prescriptions, etc.

 

[ppfizenm]

Thereby throwing more fuel to the alt med claims that practitioners of traditional medicine lie to their patients, are corruptly supporting big pharma by writing unneeded prescriptions, etc.

so your philosophy is "not my problem, let it fall to someone else"?

 

[NickNaylor]

I didn't say it was easier. I actually think it would be in this patient's best interest to "treat" her. She openly refused to talk to a psychiatrist. She can keep hitting up emergency departments bankrupting herself or she could take a placebo and hopefully get over it.

The easier thing was done. She was sent away with no treatment.

The more difficult thing would be to continue trying to educate the patient and get her to realize how nonsensical the whole thing is rather than saying, "ok, here's your treatment!" *wink*

 

[ppfizenm]

The more difficult thing would be to continue trying to educate the patient and get her to realize how nonsensical the whole thing is rather than saying, "ok, here's your treatment!" *wink*

It was explained to her, and this wasn't the first doctor she was hearing it from. You've obviously had patient contact and know that some people cannot be reasoned with. She had it in her mind that something was wrong, someone provided her a "cause" (for a considerable amount of money), and now she was seeing treatment. To her the problems were not nonsensical. Trying to rationalize with her failed.

I'm not pretending to know every course of action in cases like this but I don't think sending someone away with a phantom treatment for a phantom disease should be thrown off the table. She refused to speak to mental health professionals and the doctor was making no progress. The bed was needed for actual sick people. What are the alternatives?

 

[FIREitUP]

I can see giving a patient a placebo if they were seeking antibiotics for a cold or something, since antibiotics can cause harm to the patient, especially if that patient were gung ho enough to go doctor shopping to get some antibiotics.