Medical Decision Making and Conflicts of Interest

Dr. Peter Ubel is a professor at Duke University and gave a guest lecture for Dan Ariely’s (also a professor at Duke) Coursera class on Irrational Behavior economics. Ubel’s lecture talks about a colleague who told a leukemia patient that the patient’s chance of recovery if he undergoes chemotherapy was 20%, which was an overstatement of the 5% benefit of chemotherapy for leukemia, especially considering the side effects:

“In Mr. Andrews case, a 5% chance that his leukemia would respond to chemotherapy and yet the oncologist told him that it was 20% odds. Is that a lie? Well here I want just tell you. It’s not just patients who are prone to strange decisions in medical contexts. We physicians are prone to those too. And I don’t think that that oncologist lied. I think that oncologist when asked straight up front what are my odds of getting benefit from the chemo had that 5% number in her head. And immediately started recalculating because it’s so hard to give someone such dismal news.” [Source: Coursera week 3 on Dishonesty

One of the students in the course was outraged that Dr. Ubel did not come right out and confront his colleague as well as tell the patient that his colleague “had lied.” I was troubled that Dr. Ubel did not have a conversation with his colleague about his concerns, because this must happen not just with this one oncologist, but many others who pull numbers out of their own “clinical judgment” hats. However, Dr. Ubel did go back to challenge the patient’s decision, but in a way that also elicited the patient to reveal why he had chosen to go with the most aggressive treatment (the patient revealed that his partner had passed away of AIDS and was a fighter and that his partner would have wanted the patient to fight as well).

I believe that if Dr. Ubel had learned that the patient was swayed primarily by the oncologist’s judgment and nothing else, then he would make sure that the patient understands the “true statistics” and what aggressive chemotherapy or radiation therapy entails. This is the reason why Dr. Ubel did have that follow-up conversation with the patient, and based on the patient’s own explanation, knew that the patient was truly making an informed decision that respects the patient’s own wishes, not just relying on what the oncologist claims.

It is indeed true that the medical profession upholds a certain “code of brotherhood” where physicians don’t call out each other’s biases, and that this poses a major problem in deciding in the “best” interest of patients. However, I personally didn’t perceive this to have happened in Dr. Ubel’s example. I perceived that he felt as troubled by the oncologist’s claim as we all did when we knew the conflict of interest in the oncologist’s claim.

Part of the office hour video, which I wasn’t able to watch completely, included Dr. Ubel talk about how “hope” is important to patients and therefore physicians must also take into consideration the effect of hope and not necessarily give patients false hope, but also not to dash hope by quoting death statistics. Yet this oncologist who had overstated the chemotherapy’s benefit of 20% instead of the truthful 5%, had done so by calculating her own biases of hope (these may not necessarily be false hope, it may very well reflect her own hope for the patient).

We don’t like physicians to give us cold, clinically calculated statistics that may or may not be true for us as individual patients. But we also don’t like physicians to overstate and give us false hope. This is the kind of balance that makes medicine more an “art” than science even when we have all this scientific data at our fingertips.

More from Dr. Ubel

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