The trick of hope — and the medical decision

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.

JMM

6 comments

  1. You said: “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.”

    Whew! Now I feel better. I was a little concerned that “successful” ablations didn’t safely cure afib based on the high rate of failure, recurrence, and complications I read on afib support groups every day. Have a great week!

  2. How can you think this way and still be an EP?
    Of course, you’d address lifestyle changes first – correcting what lead to arrhythmia in the first place.
    But then, in what circumstances do you still perform possibly “deadly” ablations; still prescribe possibly “deadly” antiarrhythmics?
    AF itself is deadly, is it not — without modern anticoagulants?
    Your practice involves choice: the least of several evils, failing lifestyle changes?

  3. Jeff, it was a singular thought on a singular conversation from an interview. I wouldn’t question someone’s career based on that. It is thought provoking, and anything that can get future patients to think about their situation a bit more objectively before they are in the weeds deciding based only on what one dr. in front of them suggests is a good thing.

  4. I’m uncomfortable with SM’s word choice. Hope is rarely toxic or lethal.

    It is rare that in a clinical trial both results are equivalent; it happens, but not too often. So, we know that one outcome will be more beneficial–we just don’t know which one. In the example, the life of a child is riding on a computer-generated coin toss. Imagine a patient/parent knowing that for the duration of the “experiment” that an outcome in out of their control. It is understandably disquieting.

    I think that bias may be inherent in all of us and may cloud reason. I just hate to see the word “hope” construed in this way.

    1. Hope isn’t lethal in itself, but an unproven “aggressive” treatment seized upon by people who are desperate to avoid their own or a loved one’s death might be. Think bone marrow transplant for metastatic breast cancer. Most of the women who were outright killed by that treatment would have soon died of cancer anyway, but if they had not been fed the poison of false hope they might have had more time, feeling well enough, to wrap up their lives doing things they valued.

      Of course “real” cancer (as opposed to overdiagnosed cancer) is on some time scale relentlessly progressive, which AF is not, yet too many electros push insanely aggressive treatments as fanatically as any oncologist. Those did not work out well for my husband. He experienced recurrence of what will soon be defined as permanent flutter or AF and preferred to deal with it conservatively by rate control rather than submitting to more cut-burn-and poison from the last guy to commit outright malpractice on him. He got fired from the man’s practice for it. He feels lucky.

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