Skip to main content

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

By Mary Mulcahy
updated 9:45 AM EDT, Thu April 10, 2014
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
updated 1:33 AM EST, Thu December 25, 2014
Danny Cevallos says the legislature didn't have to get involved in regulating how people greet each other
updated 6:12 PM EST, Tue December 23, 2014
Marc Harrold suggests a way to move forward after the deaths of NYPD officers Wenjian Liu and Rafael Ramos.
updated 8:36 AM EST, Wed December 24, 2014
Simon Moya-Smith says Mah-hi-vist Goodblanket, who was killed by law enforcement officers, deserves justice.
updated 2:14 PM EST, Wed December 24, 2014
Val Lauder says that for 1,700 years, people have been debating when, and how, to celebrate Christmas
updated 3:27 PM EST, Tue December 23, 2014
Raphael Sperry says architects should change their ethics code to ban involvement in designing torture chambers
updated 10:35 PM EST, Tue December 23, 2014
Paul Callan says Sony is right to call for blocking the tweeting of private emails stolen by hackers
updated 7:57 AM EST, Tue December 23, 2014
As Christmas arrives, eyes turn naturally toward Bethlehem. But have we got our history of Christmas right? Jay Parini explores.
updated 11:29 PM EST, Mon December 22, 2014
The late Joe Cocker somehow found himself among the rock 'n' roll aristocracy who showed up in Woodstock to help administer a collective blessing upon a generation.
updated 4:15 PM EST, Tue December 23, 2014
History may not judge Obama kindly on Syria or even Iraq. But for a lame duck president, he seems to have quacking left to do, says Aaron Miller.
updated 1:11 PM EST, Tue December 23, 2014
Terrorism and WMD -- it's easy to understand why these consistently make the headlines. But small arms can be devastating too, says Rachel Stohl.
updated 1:08 PM EST, Mon December 22, 2014
Ever since "Bridge-gate" threatened to derail Chris Christie's chances for 2016, Jeb Bush has been hinting he might run. Julian Zelizer looks at why he could win.
updated 1:53 PM EST, Sat December 20, 2014
New York's decision to ban hydraulic fracturing was more about politics than good environmental policy, argues Jeremy Carl.
updated 3:19 PM EST, Sat December 20, 2014
On perhaps this year's most compelling drama, the credits have yet to roll. But we still need to learn some cyber lessons to protect America, suggest John McCain.
updated 5:39 PM EST, Mon December 22, 2014
Conservatives know easing the trade embargo with Cuba is good for America. They should just admit it, says Fareed Zakaria.
updated 8:12 PM EST, Fri December 19, 2014
We're a world away from Pakistan in geography, but not in sentiment, writes Donna Brazile.
updated 12:09 PM EST, Fri December 19, 2014
How about a world where we have murderers but no murders? The police still chase down criminals who commit murder, we have trials and justice is handed out...but no one dies.
updated 6:45 PM EST, Thu December 18, 2014
The U.S. must respond to North Korea's alleged hacking of Sony, says Christian Whiton. Failing to do so will only embolden it.
updated 4:34 PM EST, Fri December 19, 2014
President Obama has been flexing his executive muscles lately despite Democrat's losses, writes Gloria Borger
updated 2:51 PM EST, Thu December 18, 2014
Jeff Yang says the film industry's surrender will have lasting implications.
updated 4:13 PM EST, Thu December 18, 2014
Newt Gingrich: No one should underestimate the historic importance of the collapse of American defenses in the Sony Pictures attack.
updated 7:55 AM EST, Wed December 10, 2014
Dean Obeidallah asks how the genuine Stephen Colbert will do, compared to "Stephen Colbert"
updated 12:34 PM EST, Thu December 18, 2014
Some GOP politicians want drug tests for welfare recipients; Eric Liu says bailed-out execs should get equal treatment
updated 8:42 AM EST, Thu December 18, 2014
Louis Perez: Obama introduced a long-absent element of lucidity into U.S. policy on Cuba.
updated 12:40 PM EST, Tue December 16, 2014
The slaughter of more than 130 children by the Pakistani Taliban may prove as pivotal to Pakistan's security policy as the 9/11 attacks were for the U.S., says Peter Bergen.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT