A new study of doctors’ ethical attitudes is disturbing. In a survey of 24,000 physicians, Medscape reports that, amongst other findings, 34 percent would prescribe a fake treatment to a patient who insisted on unnecessary treatment; 16 percent would cover up an error they made; and 10 percent said they would lie to a dying patient if it would lift the patient’s spirits. (heraldonline.com)
These figures are pretty depressing.
But what if the same information were presented differently? Some 48 percent report that they would not prescribe a fake treatment to a patient who insisted on unnecessary treatment; 63 percent would not cover up an error they made; and 72 percent said they would not lie to a dying patient even if it would lift the patient’s spirits. (The remainder said that what they would do depends on the particular circumstances.)
Now the results seem pretty encouraging.
The point is that how we understand information often turns on the order in which it is presented.
I thought about this recently when a hospital ethics committee of which I am a member considered the situation of a 46-year-old with a developmental disability. He had no next of kin or health care guardian.
While in a residential facility, he injured himself and required hospitalization. In the course of examining his fractured leg, the x-ray revealed a possible bone cancer.
The patient needed to sign a consent form before surgery could proceed, both to fix the fracture and to take a biopsy. Upon hearing about the possible negative consequences of such a procedure, as there are in any surgery, he refused to give his approval.
The physicians explained that without the intervention, he faced months of traction for the fracture and life-threatening delays for treatment of a possible carcinoma. Still refusing treatment, he was deemed incompetent by the doctors to make his own decisions. (An emergency board was convened to consider the situation and a health care guardian was appointed.)
But what if the patient had received the information in a different order? What if instead of initially hearing about the possible side effects of the surgery he was presented first with the consequences of not having the surgery?
The doctors involved in this man’s case thought his refusal to go ahead with the procedure proved his mental incapacity. They saw his decision as irrational; in their view any reasonable person would opt for the procedures. Yet when I heard the case my reaction wasn’t so different from the patient’s. I prefer nature taking its course, so when I hear about side effects first, it reinforces my choice to forgo invasive procedures. Only later do I weigh the risks against benefits. Unlike many patients—and this man for certain—I also know the power of framing, so I can take a cooler second look.
The physicians, in a way, are as irrational as the patients in so far as they think that “facts are facts.” While they believe they are acting in the patient’s best interest, they aren’t when they communicate poorly or think that only those who reach the same conclusions about health care matters as they do are rational.
There is more to good medicine than being a good technician. Great diagnostic skills and state-of-the-art computers can’t take the place of someone who knows how to talk to you and understands how the human mind works.
Risk aversion—preferring avoiding losses to acquiring gains—is a powerful tendency. (wikipedia.org/Loss_aversion.) Knowing how information is presented biases decisions helps both physicians and patients make more rational decisions.
We can’t expect doctors to also be psychologists. But we can expect that continuing medical education can provide the communication skills and psychological insights needed in order for doctors to become the kind of physicians they would like to be.