Sunday, 23 February 2014

The Hope Peddlers

When treatment choices are limited or when true effectiveness is not clear, patients want hope: they want to have a chance to get better. Doctors hold this valuable commodity, and dispense it on demand, for a fee, after which they claim any perceived improvement as being due to their efforts. Even when a treatment is not proven to be effective, or when it is proven to be no better than placebo, doctors too easily fall into the role of hope-peddler, without considering the hidden costs or unintended consequences.

An anonymous article in this month’s Surgical News (our local college’s bulletin) highlights the problem. The article was about doctors' fees, but included this anecdote. A patient presents with recurrence of a (presumably brain) tumour. The initial surgeon and the author both advise against any further surgery as the condition is terminal. The family consult a “top” surgeon who offers them hope: a re-exploration. They grasp at this chance, increase their mortgage (due to the high fees deemed appropriate for such ‘heroic’ surgery), and proceed.

Complications ensue and the patient is transferred to the public system, and the patient dies a few months later, presumably from the tumour. At the funeral, they thank the “top” surgeon for taking on the case so that they could provide “everything possible”.

The problem
1. When there is no effective treatment, offering no treatment is unpalatable, to the patient and the doctor; it is interpreted as a failure. This is covered in a previous post: Don’t just do something, stand there.

2. Offering ineffective, expensive and risky treatment adds cost and harm, and diverts the patient from acceptance of (and therefore efforts to cope with) the underlying condition.

3. It is well known that patients overestimate the likely benefits and underestimate the harms from medical interventions (here). Even in trials of treatments where the likely effect is not known, patients often think that they are the one for which it will work (see Therapeutic Misconception and Therapeutic Misestimation here). Our job should be to correct the patient’s distorted interpretation of the risks and benefits, not to play on it or profit from it.

The solution
Doctors should be fact peddlers, not hope peddlers. Hope implies chance, and all our decisions are based on probability (chance), so why not give the real numbers? Don’t stop talking after you have told the family that there is (say) a 10% chance of improving the underlying condition. Tell them about the 10% chance of not waking up from the anaesthetic and needing permanent intubation, the 10% chance of worsening the underlying condition, and the 10% chance of other complications directly related to the treatment.

A real life example
Many patients ask about stem cell injections for knee arthritis when the other non-operative treatments have failed. Instead of telling them that most patients improve afterwards (true statement), tell them what proportion will improve, by how much they will improve, and for how long. Then tell them that the best available evidence is that it is no more effective than placebo and that it may lead to complications. Then see how quickly they grab the straw of hope, especially when it comes with a $10,000 price tag.

I understand that some patients are desperate and will try anything, but that eagerness doesn’t make an ineffective treatment suddenly become effective. Many of these desperate treatments either have no effect, or they result in a net harm; proponents are simply cashing in on the lottery mentality, often without a realistic chance of a prize.

The bottom line

Hope is easy for doctors to produce and easy to sell. Patient information should not be restricted to the good chances (probabilities); patients should be provided with realistic probabilities of all likely outcomes, untainted by persuasive language and the fear of interpreting a failure to intervene as a failure to treat or to care. Doctors should be ‘whole-truth’ fact peddlers, not ‘part-truth’ hope peddlers.

3 comments:

  1. Great post! I'm curious: have there been any sham surgery trials of stem cell injection for osteoarthritis? Seems like a fairly benign form of sham surgery could be done.

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    1. The only study of which I am aware is a pilot study of 40 patients with knee OA (blinded, placebo trial) conducted in Australia and reported at a Scientific Meeting (currently being submitted for publication). There were several MRI / chemical findings that favoured the stem cell group, and good clinical improvement at 12 months in the stem cell group. Problem was that the clinical improvement was identical to that seen in the placebo group. (Study title is OSCARS, senior author is March, L. Look out for it)

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  2. Thanks for another great post, Dr Skeptic.

    Peddling hope is a very human trait, but one which can potentially cause substantial harm. The more the peddler has to gain financially, the more worried we should be about their motives.

    Peddling placebo-based hope is de rigueur for alternative practices, but is more ethically problematic for the scientific-based professions.

    At least if someone with cancer chooses a coffee enema cleansing treatment, some family or friends have probably warned them that they should be wary of spending their money on it.

    But if a highly recommended surgeon, oncologist or nutritional doctor has just returned from a US study tour and suggests a cutting-edge treatment which ‘the government currently refuses to fund’, the unsceptical patient is very vulnerable.

    Beware the ‘best doctor in town’!

    Dr Justin Coleman http://drjustincoleman.wordpress.com/

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