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Tuesday, October 22nd 2013

Bias & Poor Communication Skills

Patient advocate Steve Wilkins has an interesting personal story up at his blog Mind The Gap. It is really worth a read.

In short he reports poor communication and planning with several physicians who appeared to hold a relatively poor opinion for his wife’s future with recurrent NSCLC.

It sounds like really terrible communication between multiple physicians and his family.

He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.” The doctor never called us back.

He reports his wife is improving back on a tyrosine kinase inhibitor, despite some of the physicians they saw seemingly having reluctance about further treatment.

But I’m not sure their anecdote speaks to a failure based on bias. I would argue what comes across as a bias in this story is really physicians doing their job. Here is what he says about the ordeal,

Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door. These attitudes and beliefs color the decisions clinicians make.

[...]

Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about…the person’s odds of survival – slim to none.

You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.

But physicians are supposed to prognosticate and that’s supposed to help drive the discussion. Advanced, recurrent adeno does have a poor prognosis. It seems to me a thoracic surgeon should seriously question the utility of a risky, painful, invasive procedure and have a discussion on the merits of such. Similarly for an oncologist discussing chemotherapy; even chemotherapy as comparatively well tolerated as erlotinib. These discussions don’t appear to have happened appropriately and that seems to be the failure of the story. Prognostication is imperfect but I don’t think though that represents a bias or something inappropriate in these settings.

Beyond “people’s lives…cut short” by “wrong conclusions” plenty of cancer patients in this country get aggressive treatments that offer extremely poor chances of contributing to their survival or quality of life. These treatments often have side effects and consequences including hastening death if by no other means than by lowering functional status (which is something strongly associated with survival). I would argue in my neurooncology experience probably far more people get unnecessary, overtreatment than don’t get the care they should based on biases.

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