Map of life expectancy at birth from Global Education Project.

Thursday, February 09, 2012

Dr. Pinocchio?

Some of what's in this survey in the new Health Affairs (you only get to read the abstract but that's probably good enough) isn't quite straightforward to interpret, but on the whole it gives one pause. It seems that about 1/3 of physicians who responded do not entirely agree that they are obliged to disclose significant errors that they make to their patients. More than 11% think they don't have to fully inform patients of the benefits and risks of treatments, and 17% think it's okay to tell patients "something that is not true." More than 1/3 also think they don't have to disclose financial relationships with drug and device companies.

As for fessing up to actually doing stuff like this, yep, 11% say they have in fact told a patient or child's guardian something that is not true in the past year. Now, that could be ethically justified, if, for example, a pediatrician concealed something a child said in confidence. (In fact, under the laws of most states, children of varying ages less than 18 can seek reproductive care or substance abuse treatment without parental knowledge or consent.) The authors don't go into this possibility. But it isn't just pediatricians who reported doing this.

More strikingly, more than half said they had described a patient's prognosis in inaccurately positive terms. Some said they did this often. Now this does constitute telling them something that is not true, but I guess they don't necessarily see it that way. And 20% fessed up to not disclosing a medical error because they didn't want to be sued. And watch out for this one -- 28.4% said they had violated a patient's confidentiality.

This is just what they admit to, and even though it's confidential, we social scientists know that "social desirability response bias" is to be expected. That is why, for example, hardly anyone will tell an interviewer that they don't like black people or stuff like that. You have to figure it out by trickeration.

I'm not sure what to make of this. Res ipsa loquitur, I suppose, but I will make a couple of comments. It's human nature not to want to give people bad news, and it used to be the norm to conceal dire prognoses from patients. But it's no longer considered ethical, nor in the patient's interest emotionally or otherwise. As for concealing conflicts of interest, that's just one more evidence of the corruption that is deeply embedded in the professional culture. It's sad, really. As for not confessing to mistakes, what evidence there is suggests that makes you more, not less, likely to be sued. And I suppose many of those violations of confidentiality were inadvertent or thoughtless and immediately regretted (elevator talk). But still . . .

At the medical school where I used to teach, we had a first year course called Patient, Doctor and Society, where we tried to instill some professional values right up front. Then they canceled it because students were complaining it took up time they needed to cram for the anatomy final. I don't particularly care if my doctor remembers the names of all the bones in the ankle. I do care if he lies to me.


kathy a. said...

i wonder if some of those violations of confidentiality might have been because it was in the patient's interest? HIPPA sets very strict limits on disclosure.

when my mom had her stroke (and before we found the medical power of attorney), for example, my sister and i collared a variety of doctors to find out what was going on, give medical history, and make decisions about her care. we were next of kin and this was a very serious situation, but i don't know that what we were doing was hippa-compliant. it was simply what had to be done, paperwork or no.

the tendency to not give the whole story, not be straightforward about bad news, give orders and not explain the reasoning -- sure, that happens a lot. my favorite doc from the whole ordeal with my mom was the orthopedic surgeon -- we couldn't get much from the neurosurgeon, the neurologist, or the attending, but the ortho had happened to be in the ER when my mom came in, and he described how very serious her condition was. (they thought she wouldn't make it; he wasn't brought into the case until the next day, when they discovered she had broken her hip in the fall.)

Cervantes said...

Yes, I suspect it's a mixture of motives and reasons, some more defensible than others. But clearly, an open and inclusive discussion of the ethical issues involved is needed.