Last night, during the intro show for the PBS documentary, Cancer: The Emperor of All Maladies, a Ken Burns film based on the book by Siddhartha Mukherjee, Katie Couric interviews both Ken Burns and Dr. Mukherjee.
The moment occurred about 10 minutes into the video.
There is a poignant scene in which two young parents struggle with the decision to enroll Olivia, their 17-month-old baby who has leukemia, into a randomized clinical trial to test one treatment over another. When the doctor tells the parents a computer randomization will determine Olivia’s treatment, you see anguish in their faces. They don’t want that. The parents want the treatment–the one that works. Presumably the active arm.
Immediately after that scene the producers cut to the interview. Focus on Dr. Mukherjee’s answer.
Katie Couric: We see Olivia’s parents agonizing over whether to participate in this clinic trial. It seems a sort of Russian Roulette with this person most precious to you.
Siddhartha Mukherjee: Medicine is the most human of all the sciences that is stuck with the least human of all the experiments. And that is the randomized trial. Randomization doesn’t exist because doctors are maligned or because medicine is nasty. It exists for precisely the opposite reason. Because we hope too much. We are so hopeful, we want things to work so badly, that we will trick ourselves to believing that things are working. And there is nothing as toxic or lethal as that trick, the trick of hope.
I loved that statement. I live these tricks every day. We doctors trick ourselves. Patients, too, allow themselves to be tricked. Why? Because of our innate bias towards the hope of action.
In a recent Medicine peer review meeting at my hospital, we had a diabetes specialist speak about the importance of monitoring blood sugar. Why? Because hospital medicine writ large was tricked into believing aggressive blood sugar control was best. Now, we struggle with outbreaks of low blood sugar–a life-threatening problem.
In the care of patients with atrial fibrillation, I fight the trick of hope and the bias of treatment nearly every day. Doctors and patients want AF fixed. The problem with AF care–similar to cancer care–is that treatment can be more deadly than the disease. Both parties get tricked into believing things are working.
Dr. Mukherjee helps us understand the take-home message of the medical decision:
See the trick. Face the bias. Always start from a place of uncertainty. Uncertainty is normal and good. Move slowly from that place. Be afraid, very afraid, when a medical person says he is certain, or uses that bad word…need. As in you need this treatment.
If we were less sure of ourselves, perhaps we would be less susceptible to being tricked.