Lying to patients

This is a transcript of a video presentation on Medscape. Medscape is a site that requires registration and logging in, so I reproduce the transcript here to permit wider observation and discussion.

 Lying to Patients: No Huge Ethical Failure, Says Bioethicist Arthur L. Caplan, PhD

 I am Art Caplan, and I am at the University of Pennsylvania in the Department of Medical Ethics and Health Policy. Today I would like to talk to you about a pretty thorny subject and one that is fascinating because it is so ethically rich: Should doctors ever lie to their patients?

The trigger for this discussion is a study that just came out that found that doctors do lie. In fact, the study found that 20% of more than 2000 doctors surveyed admitted that they had not told patients the truth when an error had taken place. They found out that more than 10% hadn't discussed financial conflicts of interest, and 15% said they gave a rosier picture about prognosis and risk and benefit with respect to a disease.

There has been a good deal of interest in this survey, and the public and some media reports are saying that this is shocking. We expect our physicians to always be truthful; this survey apparently shows that there is a considerable amount of lying going on, withholding of the truth, and not being forthright. What's wrong? Is there a huge ethical failure going on out there among doctors and medical practitioners?

The answer is no. It is inexcusable and not advisable to lie about an error. You may dodge a bullet on that one by having the patient not find out, but if it really affects their care, if they wind up harmed, if they wind up having to pay more and it comes out later that you didn't tell the truth or that there was an omission of the fact that an error occurred, you are going to get clobbered. I have seen it again and again in courtrooms. It may seem the easiest way out, to avoid telling the truth when an error takes place, but getting it out there and getting it over with early is the best protection in terms of malpractice associated with error. It isn't lying.

With respect to financial conflict of interest, patients have a right to know about it, and it should be brought up. But a lot of patients don't care, so you can get around that very quickly. You don't have to lie or withhold information. You can simply offer the patient the opportunity to know that you see a lot of drug representatives or that you went out to dinner and learned about this drug, and they probably will say, "Doctor, I don't care. What do you think is the right thing for me to do?" Making the offer is a better way to deal with something that a lot of patients don't think is all that important.

What about that circumstance in which a better prognosis is offered than is really the case for the patient? That circumstance, and a couple of other topics, are real ethical gray zones. It is not as clear that lying is always bad. Think about the use of a placebo. If you think that you can save a patient money and save them a lot of risk and side effects by giving them a placebo to see if it will calm their anxiety or help restore their sexual function, I am not sure that it is always wrong to prescribe a placebo. It is controversial, but I am not sure one is always wrong in trying to deal with a difficult or noncompliant patient, or one who has a bad, unhealthy lifestyle.

Is it wrong to "up the ante" a little bit and scare the patient more than you might otherwise about the consequences that might follow from their bad behavior? I am not sure that that is wrong either. The goal is good, and by being a little bit on the far end of the truth about what could happen to them, I am not sure that it isn't worth it. With respect to the "rosy prognosis," if someone has cancer or Parkinson disease or Alzheimer disease, I'm not sure that they want to hear in the first visit exactly what is going to happen to them or the grim nature of the statistics.

You might say that telling the truth is a noble thing to do, an important thing to do, and it is the way that we are going to keep patients trusting the doctor. At the same time, however, truth is not an event; it is a process. The survey may have failed to capture that insight. Telling the truth is important, but letting it come across in a humane way, letting it come across sometimes in "dribs and drabs" so that the patient can absorb it and not be psychologically devastated or emotionally harmed, is the right thing to do.

So, don't lie about mistakes, don't lie about conflict of interest, and be forthright when things go wrong. When there is a reason not to be trusted, let the patient decide how they want to manage that. Truth is a better policy. In some other areas, the truth, although it ought to come out eventually, is probably something that is more of a tool to be worked with in trying to help patients than it is an absolute necessity all of the time.

I am Art Caplan at the University of Pennsylvania. Thanks for watching.

Visit the outback's mechanical victims

Visit the outback's mechanical victims - ABC Southern Queensland - Australian Broadcasting Corporation

Just a little light diversion from medical, but a look at the outback that many of us "out here" are familiar with.

Another useful post for Locum doctors

.. Here ..

Three weeks break and back to it

After a three week break and a settlement on a new property in Port Douglas (we are now officially mortgage stressed according to the stats) I return to work with three weeks of 24/7 at Julia Creek and nearly four weeks (also 24/7) at Normanton. Both places are in far north Queensland but are vastly different.

 Well ... I guess a comment on the property purchase first. Having worked in FNQ for over 5 years and especially loving the area around Cairns, and having watched the real-estate market for over three years around the Mossman Port Douglas area, I decided to make a significant life decision. Instead the option of working locums part time and relatively casually, I have effectively committed myself to working close to full time for at least another 5 years. I guess it was to create an additional purpose to the reason why one works for an income by buying a second "home away from home". Melbourne is still our home, and for quite important family reasons will remain so for at least the medium term future (if one can plan for such anyway) but a house/villa in Port Douglas gives my family a second locale to enjoy the fruits of my labours.

 Julia Creek ... in central north Queensland on the main road between Mt Isa and Townsville. A relative small town, with a 16 bed hospital built in 1972, in the middle of cattle country. A wide, open and expansive place. Two pubs in town, two small "supermarket" type stores, railway along the edge of town. Friendly people. Had Christmas and New Year in Julia Creek. I have a few photos of the area in my Project 366 album. The work was relatively quiet, apparently those who would have left town for the holiday break had already left, and others were preparing for a long, isolated stay on station when the wet hits.

 Normanton ... further to the north and much closer to the Gulf of Carpentaria, about 75km circuitous drive to the coast. I am there currently. It has a high proportion of indigenous people in town, three pubs, a couple of small "supermarket" style stores. It is on the edge of "wet country". The bird life is abundant, including the more exotic brolgas that are a delight to see both on the ground and in the air. 

The work is quite different to what I was doing in Julia Creek, including more after hours work, more hospital admissions and a twice a week trip to Karumba on the coast to run a clinic. It is now wet season and despite (at this instant in time) it not raining every day, when it does rain it is quite heavy, and add to that the water from "upstream" and the wet country being tidal, many roads into and around Normanton are now closed.

 Had an interesting experience yesterday when the road to Karumba was officially open but the 07:30 report said there was 450mm (others in the know were saying 350mm+) of water (flowing) over the bridge on the road to Karumba. 4WD only and "use extreme caution" ... well no way I was going to attempt the trip in a yuppy 4WD (a lot of these around but the high clearance work vehicles usually not supplied by Queensland Health) so my "extreme caution" measure was to not go. Council refused to authorise a helicopter shuttle (about 9 minutes flying time I am told) because the road was still officially open, so the clinic had to be cancelled.

 Interesting "tropical medicine" in the area ... learned about a few bugs I had never heard of and some I had forgotten about.

  Stenotrophomonas maltophilia causing a wound infection is not nice. I am also reminded that alcohol consumption is the bane of some remote communities and a significant reason for after hours presentation for medical treatment.

 Yarrabah from the end of February is not a happening thing, other arrangements are in place to cover the medical services from Cairns doctors on rotation. I expect this will eventually be good for the community at Yarrabah to have the "indigenous medicine naive" medicos become aware of the different needs of our indigenous brothers and sisters and hopefully temper the racism in the medical care in the larger centres.  Interestingly a recent study confirms that racism (unconscious or otherwise) is present in our medical system in Australia.

 I am currently having my locum agents (hi Sarah and Charlie !!) working on getting me a placement in Gladstone (its been a long time since I have been there) and possibly followed by work in Mt Isa (twelve months since being there). Nothing definite booked after that except just over 2 months in Uluru October - December this year.

Will chat again another time.

Cross promotion

Another rural locum blog .. a little more generic and probably designed to be more politically correct with the intention to promote life as a rural doctor, not that I need convincing but many city doctors haven't a clue what they are missing out on.

http://ruralchampions.govspace.gov.au/author/rhwa/

It has been remiss of me ...

.. and I once again find my blog languishing, but given the close knit nature of the communities I have worked in over the last 6 months it is difficult to share my experiences without risking breach of patient privacy. Not that it can't be done, it will just require more thought that just random placing of thoughts on virtual paper.

I promise, an entry with particular references to my experiences up here in Julia Creek and Normanton/Karumba will be forthcoming.