Telling Patients They are Terminal (2): Doctor’s Fear of Failure

My posting of August 12, 2005 received this comment from a medical student today:

Dr. B.
As a current medical student and future physician reading your posting, “Telling patients they are terminal” I felt a surprising emotion: fear. My feeling of fear came from your comment that physicians often cause much of the confusion that surrounds end of life care. Specifically you stated that certain physicians will order more aggressive therapies and more diagnostic test when they know in their hearts that there is nothing more to do but ease the pain. In this situation, as you stated, the families will often get an unclear message as to the condition of the patient and how much time is left with their loved one. This confusing message that doctors often give patients can translate into disastrous effects. In this example the family might not understand that the last few days are near and the opportunity to say goodbye may pass them by.

It is easy to say that such physicians that give unclear messages are "bad doctors." However, although I promise to be the best physician possible I fear that I could someday make the same mistake. As a student among so-called "overachievers" in medical school the idea of failure is so frightening that we all work as hard as we can. In fact this fear of failure is what was selected for when we were accepted to medical school among thousands of applicants. Certainly this culture of fear will increase competition and cause us to study harder and ultimately work harder. So, as a medical student it is easy to see how a physician, who is deathly afraid of failure, would try to guard himself/herself as a human by squeezing any feeling of personal success out of every sick patient. However, as evident here, the patient's best interests may not always be aligned with those of the physician.

It is clear then that a truly great physician is one that is not afraid of being exposed to the feelings of failure (and this rationale should be taught in school) and is able to identify the patient's needs as much more important than any feeling of personal success. I guess a good way to look at this situation is that a physician can gain a small victory of personal success by giving a clear message to the patient and his/her family so that the concluding days are filled with love and goodbyes. By acknowledging small victories like this a physician can maintain his/her sense of purpose and provide the best care for patients all the while.

Dear Medical Student, doctors are human. Doctors have feelings and can make mistakes. Sometimes the mistake is not a technical error but one related to feelings. Think about perhaps knowing and caring for a patient for years and then having to provide care when the patient becomes terminally ill. Perhaps the physician also has known the family for a long time. The physician may find it difficult emotionally to discard understandably subjective concern for the patient and proceed in a purely objective manner. So sympathy is the culprit that enters into the physician’s decisions. Then, there is the doctor’s concern of what others expect of him or her. Unfortunately, the public sees modern medicine and physicians as possible miracle makers. Can the physician have enough self-confidence to be able to tell the patient and family that there are no miracles that he or she can provide but there is always hope that the body and the illness will change course? Everybody eventually dies, even those under the best medical care, so failure to cure is not necessarily a stigma of a “bad physician”. Failure to acknowledge this truism and instead provide unrealistic hope to the patient and family is the doctor’s real problem.

I agree, medical school education should include a curriculum beyond what diagnosis to make and when and how to treat. The curriculum should also include the issue of “when to give up”. There are signs in the complexity of organ failure, the response of the patient to treatment, the available statistics of recovery and the patients known desires of a wanted quality of life if some degree of recovery occurs which are markers of the current illness. They all will lead to a fairly reliable conclusion of when energetic attempts at treatment of the illness becomes futile and when to concentrate on comfort care alone.

You are correct that it is the multiple “small victories” that enhance the physician’s love for his or her profession. Remembering also that the “big defeats” are often beyond the physician’s skills. ..Maurice.