Dear Dr. Bob,
I just read a newspaper story that said more than 50 percent of doctors surveyed said they would endorse fudging data to get significant procedures approved by HMOs. Is this true in your experience?
Doctors lie all the time. Lying is intrinsic to the practice of medicine.
A family story can serve as an example. My father had a quadruple coronary bypass for intractable angina. Post-op, he continued to have some chest pain. The surgery had been successful, except for one small marginal coronary artery that was technically inaccessible and could not be bypassed. The surgeons told me that they doubted that the tiny vessel would make a symptomatic difference. They told my father nothing. My father continued having chest pain. Maybe it was post-surgical, maybe it was residual angina, and maybe it was partly apprehension. Further diagnostic tests were inconclusive.
He consulted his internist, a bright, capable, dear man with sparkling blue eyes and an impeccable sense of honesty. The internist told my father that one of the diseased vessels hadn't been bypassed. My father went home, plopped down in his chair and gave up. He never left the house again.
After he died, my mother asked me whether I thought his internist was wrong in telling him that one bad artery was left behind. No further treatment was available, so what was the point?
I asked his doctor. He answered, "Your father wanted to know. He was my friend. I felt I had to level with him." (I did not mention that a third of patients undergoing a sham bypass procedure will actually experience symptomatic improvement via the placebo effect, so strong is the power of suggestion in such serious matters.)
A variety of remedies for pain work exclusively via placebo effect. The irony is that the more convinced the physician is that his unproven treatment is of value, the more likely it is to have this non-specific benefit. A conscientious physician who is honest ("I don't know if this will work or not; there's no firm evidence") is less effective than the cavalier doc who ignores statistics ("I know this will work. All my patients get better. You will be fine.").
Both good medicine and quackery rely in part on this peculiar, paradoxical relationship between lying and patients' health. Honesty is not always in a patient's best interest, yet dishonesty always puts the doctor in an ethically difficult position. There are no guidelines. Even the best of intentions can have an unexpected outcome.
When I first read the recent Archives of Internal Medicine survey that the newspaper story you refer to was based on, I wasn't surprised. Everyone in the medical trenches realizes that the war is on, that the HMO doctor now occupies an intermediate territory -- he is simultaneously the employee of the insurance company and the patient's advocate. Pitting the patient against the insurance company is white hats against black -- it's no contest. I dismissed the article as obvious.
Then I reconsidered.
Twenty years ago I had dinner with a close friend's father, the chief justice of a state supreme court, a man of the highest intellectual and ethical standards. We were discussing his adamant anti-death-penalty stance. "Robert," he said, "I could not stand the thought of allowing one innocent man to be executed, even if it meant a thousand guilty ones are one day released back into society. Each and every man is more important than any presently prevailing majority opinion. Remember, always err on the side of the individual."
He paused, stroked his chin, looked out into his garden. A long silence ensued. Then he turned back to me, his eyes brimming with tears. "Do you think I'm wrong? Sometimes I feel so old, as though maybe I'm out of touch. But," he added, his voice firm, "that's what I believe in. The individual. So shoot me if I'm wrong."
Consider this story, told to me by a prominent local neurologist. He was consulted by a middle-aged woman with a 10-year history of headaches that were slowly increasing in frequency. By description, the headaches were fairly typical of migraine, and were unassociated with any neurological findings. The consulting neurologist sensed something out of the ordinary, though he couldn't articulate his feeling. He requested a brain MRI, but was declined by the patient's HMO. He called, reached a claims adjuster (with no medical experience) who again declined the scan because the patient did not meet the minimum approval criteria. The neurologist persisted. After 90 minutes and five put-on-holds, his staff reached the medical director. The neurologist fibbed, said that the woman had a recent onset of severe headaches. Reluctantly the director approved the scan.
The woman had a large, benign brain tumor. Subsequent surgery was successful; the tumor was removed in its entirety.
Later, the neurosurgeon asked the neurologist why he'd ordered the scan. "Call it a hunch or gut feeling," the neurologist answered. The neurosurgeon said that he probably wouldn't have bothered to get the scan as it was so much trouble to go through bureaucratic channels for such a low yield possibility. (The claims adjuster may have been correct from a cost-effectiveness standpoint. The chance of an uncomplicated headache of 10 years duration being secondary to brain tumor is quite small).
The neurologist confided to me that he alters approximately 10 percent of submitted claims in order to get scans approved. I asked if this bothered him. He laughed. "Absolutely not. This is the new medicine. You either lie or the patients die." This is from a doctor that I highly respect, to whom I have referred my own family members.
In earlier times, when the concerned doctor was solely the patient's advocate and wasn't wearing opposing hats, we could tolerate, even appreciate his lying as primarily well-intended. Now, when we realize that the physician's very job might be at stake, we are less certain. If he will lie to help me, will he also lie to save his ass, or to save the insurance company, or even to get a bigger year-end bonus? Doesn't the very knowledge that your physician is willing to lie undermine the doctor-patient relationship?
On a lighter note, an endocrinologist called to tell me that "white lies don't count." He gave the example of osteoporosis, for which bone-density scans are HMO-approved mainly for post-menopausal women. But men, primarily the elderly, can also get osteoporosis. If the endocrinologist wants to get a scan on a man, he makes sure that the indication on the request form reads: 40 years of amenorrhea (lack of periods). The endocrinologist leaves out any of mention of gender. He says that gender isn't on the claims examiners' list of indications for disapproval, as long as the person is post-menopausal!
Certainly there is some philosophical or theological way out of the woods on this. Some higher authority must have considered the distinctions between good and bad lies. I consulted St. Augustine and his 40-page tract on mendacity, and found nothing but split hairs. I checked out several recent books on lying; all indicated the problem was epidemic, but were surprisingly weak in the area of moral distinctions.
I ran across a book on patient falsification. Here's an amazing statistic: Three percent of "kidney stones" passed in emergency rooms are fictitious (bits of gravel, pieces of concrete, even flecks of paint), the purpose being for the patient to get immediate narcotics.
Lying is everywhere; it is as intrinsic to daily life as any search for truth. The ethical problem of the lie now is subjective, self-referential, in the eye of the beholder.
I am interrupted from my writing. A close friend with mild multiple sclerosis is on the line. Over the past three years I've been very frank with her, explained all the intricacies of the disease, including the pros and cons of treatment. She isn't really a candidate for medication as she has no disability and only intermittent mild fleeting symptoms of extremity numbness. But now she's very excited. This morning she saw an acupuncturist who told her that he'd been to three years of medical school in Japan and that, in his opinion, she did not have M.S. "What do you think?" she asks.
I have seen her MRI scan. There are multiple lesions, though this doesn't necessarily dictate the severity of symptoms or absolute prognosis. She worries constantly about what might happen, yet is playing tennis regularly. "I'm glad that you are feeling better," I say, wondering if avoidance is a lie. She doesn't ask again, thanks me and hangs up.
I go back to the article on lying. What would the state supreme court justice have done if he were an HMO physician? What would he have said to my friend with M.S.?
I conclude: Trust one's heart. As Mark Twain once said, "An awkward, unscientific lie is often as ineffectual as the truth."