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 11:38 AM EDT, Wed July 23, 2014
The idea is difficult to stomach, but John Sutter writes that eating dog is morally equivalent to eating pig, another intelligent animal. If Americans oppose it, they should question their own eating habits as well.
updated 12:30 PM EDT, Wed July 23, 2014
Bill van Esveld says under the laws of war, civilians who do not join in the fight are always to be protected. An International Criminal Court could rule on whether Israeli airstrikes and Hamas rocketing are war crimes.
updated 8:05 AM EDT, Wed July 23, 2014
LZ Granderson says Ronald Reagan went horseback riding and took a vacation after the Korean Air Crash of 1983. So why does the GOP keep airbrushing history to bash Obama?
updated 9:38 AM EDT, Wed July 23, 2014
Aaron Miller says Kerry needs the cooperation of Hamas, Israel, Egypt and others if he is to succeed in his peacemaking efforts
updated 8:51 AM EDT, Wed July 23, 2014
Errol Louis says the tragic death of Eric Garner at the hands of the NYPD has its roots in the "broken windows" police strategy from the crime-ridden '80s.
updated 10:08 AM EDT, Wed July 23, 2014
Gordon Brown says the kidnapped Nigerian girls have been in captivity for 100 days, but the world has not forgotten them.
updated 7:27 AM EDT, Wed July 23, 2014
Ruben Navarrette says Texas Gov. Rick Perry is right to immediately send 1,000 National Guard troops to the U.S.-Mexico border in response to the border children crisis.
updated 9:56 AM EDT, Tue July 22, 2014
Ukraine's president says the downing of MH17 was a terrorist act, but Richard Barrett says it would be considered terrorism only if it was intentional
updated 4:15 PM EDT, Tue July 22, 2014
Robert McIntyre says the loophole that lets firms avoid taxes should be closed
updated 11:35 AM EDT, Tue July 22, 2014
Jeronimo Saldana and Malik Burnett say Gov. Perry's plan to send National Guard to the border won't solve the escalating immigration problem.
updated 1:42 PM EDT, Tue July 22, 2014
Sally Kohn: The world's fish and waters are polluted and under threat. Be very careful what fish you eat
updated 8:42 AM EDT, Tue July 22, 2014
Les Abend says threat information that pilots respond to is only as good as the intelligence from air traffic controllers. And none of it is a match for a radar-guided missile
updated 8:35 AM EDT, Mon July 21, 2014
Frida Ghitis: Anger over MH17 is growing against pro-Russia separatists. It's time for the Dutch government to lead, she writes
updated 8:27 AM EDT, Mon July 21, 2014
Julian Zelizer says President Obama called inequality the "defining challenge" of our time but hasn't followed through.
updated 7:57 AM EDT, Mon July 21, 2014
Gene Seymour says the 'Rockford Files' actor worked the persona of the principled coward, charming audiences on big and small screen for generations
updated 10:17 AM EDT, Mon July 21, 2014
Daniel Treisman says that when the Russian leader tied his fate to the Ukraine separatists, he set the stage for his current risky predicament
updated 12:42 PM EDT, Fri July 18, 2014
Andrew Kuchins says urgent diplomacy -- not sanctions -- is needed to de-escalate the conflict in Ukraine that helped lead to the downing of an airliner there.
updated 9:50 PM EDT, Fri July 18, 2014
Jim Hall and Peter Goelz say there should be an immediate and thorough investigation into what happened to MH17.
updated 11:07 AM EDT, Fri July 18, 2014
Pilot Bill Palmer says main defense commercial jets have against missiles is to avoid flying over conflict areas.
updated 1:55 PM EDT, Sun July 20, 2014
Valerie Jarrett says that working women should not be discriminated against because they are pregnant.
updated 3:53 PM EDT, Mon July 21, 2014
David Wheeler says the next time you get a difficult customer representative, think about recording the call.
updated 3:33 PM EDT, Fri July 18, 2014
Newt Gingrich says the more dangerous the world becomes the more Obama hides in a fantasy world.
updated 6:11 AM EDT, Fri July 18, 2014
Michael Desch: It's hard to see why anyone, including Russia and its local allies, would have intentionally targeted the Malaysian Airlines flight
updated 3:14 PM EDT, Thu July 17, 2014
LZ Granderson says we must remember our visceral horror at the news of children killed in an airstrike on a Gaza beach next time our politicians talk of war
updated 8:06 AM EDT, Thu July 17, 2014
Sally Kohn says now the House GOP wants to sue Obama for not implementing a law fast enough, a law they voted down 50 times, all reason has left the room.
updated 8:14 AM EDT, Thu July 17, 2014
A street sign for Wall Street
Sens. Elizabeth Warren, John McCain and others want to scale back the "too big to fail" banks that put us at risk of another financial collapse.
updated 4:16 PM EDT, Thu July 17, 2014
Newt Gingrich writes an open letter to Robert McDonald, the nominee to head the Veterans Administration.
updated 12:01 PM EDT, Fri July 18, 2014
Paul Begala says Dick Cheney has caused an inordinate amount of damage yet continues in a relentless effort to revise the history of his failures.
updated 10:04 AM EDT, Fri July 18, 2014
Kids who takes cell phones to bed are not sleeping, says Mel Robbins. Make them park their phones with the parents at night.
updated 1:29 PM EDT, Thu July 17, 2014
Buzz Aldrin looked at planet Earth as he stood on talcum-like lunar dust 45 years ago. He thinks the next frontier should be Mars.
updated 2:04 PM EDT, Wed July 16, 2014
Mark Zeller never thought my Afghan translator would save his life by killing two Taliban fighters who were about to kill him. The Taliban retaliated by placing him on the top of its kill list.
updated 11:18 AM EDT, Thu July 17, 2014
Jeff Yang says an all-white cast of Asian characters in cartoonish costumes is racially offensive.
updated 9:24 PM EDT, Wed July 16, 2014
Gary Ginsberg says the late John F. Kennedy Jr.'s reaction to an event in 1995 summed up his character
updated 12:41 PM EDT, Wed July 16, 2014
Meg Urry says most falling space debris lands on the planet harmlessly and with no witnesses.
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT