Mock 21: Should a doctor disclose all his/her suspicions?

[Guest sassy101]

I have an issue to present that for awhile had me torn but now I think I have taken a stance.

 

Do you think that a physician should always inform a patient about suspected illness? In other words, if a physician suspects an illness ( lets suppose a severe one ) should they tell the patient they MAY have the illness or keep the patient in the dark until tests are performed that actually confirm the physician's suspicions?

 

I intend to be a physician that is very open and honest to my patients. They have a right to know about their bodies and I want all decisions to be made with their input ( provided they are willing to partcipate ).

 

Therefore, I feel a patient should know why a particular test is being done, however I would not want to cause unnecessary worry when the diagnosis is only a suspected one.

 

For example, the results of a female patient's PAP test come back saying that she has some abnormal cells that need to be further examined via colposcopy. My question is: is it just to tell the patient that " I recommend that you have a colposcopy exam performed because I am unsure as to the cause of these abnormal cells " When in reality, I am aware that the abnormal cells MAY be a sign of an underlying serious condition

 

OR

 

Should the physicians response be indepth to include the ' truth ' that her abnormal cells MAY be the start of cervical cancer?

 

Is with-holding information ' lying ' and unethical? ( in this case not completely informing the patient as to possible outcomes of the test )

 

I have come to decide that a patient should be informed of all outcomes of significance, but however they should be told in a careful manner. In this case I may say to the patient that " the reason I recommend a colpo exam is to ensure that the presence of the abnormal cells is not due to an underlying condition including cervical cancer ". However I would emphasize that the patient should not be overly concerned with the possibilty that the cells are cancerous due to the fact that .....( insert medical facts here ) I would also be sure to include " do you have any questions for me? "

 

I just think that a patient should be aware of the possibilty in case the serious condition is present. I would not want my patients to feel that an huge bomb had been dropped on them out of the blue. I certainly wouldn't want my patient to come to me later and say " why didn't you warn me "?

 

what do you guys think.....

 

 

 

 

 

Edited to provide a more descriptive subject heading. -Ian

[Guest UWOMED2005]

I actually just got somewhat in trouble today in a Clinical Methods session with standardized patients this morning over EXACTLY this issue. The standardized patient came in with a History suggesting physical, and Folstein mini mental score of 22, suggesting cognitive deficits which I suspected to be Alzheimer's (it causes 60% of dementia in the elderly) but couldn't be sure. My decide plan of management was a referral to a specialist, but also I suggested the standardized patient might have Alzheimer's. That didn't go over so well - the patient freaked, refused to see the specialist, and even refused to see me again in follow up. Lesson learned.

 

This wasn't a real case, but I think the purpose was to show us as med students that sometimes leaping too quickly to a conclusion, or delivering that conclusion before you've really established rapport, can be harmful. So while I dislike the idea of being "dishonest," if you're not 100% sure of a diagnosis I think there are times you shouldn't share your suspicions.

[Guest Ian Wong]

Interesting question, and one that really wasn't ever formally taught in med school for me.

 

This is the kind of thing that my classmates and I just picked up from watching and working with innumerable other people (staff physicians, residents, and other health care workers).

 

Unfortunately, time constraints prevent you in many ways from doing this with each of your patients. Beyond that however, is that speculating on what a patient might actually have (while still waiting for your confirmatory test), won't change the patient's final management.

 

If it turns out that the Pap test, or the cytopathologist who read it was incorrect, then you've alarmed your patient unnecessarily. If the Pap test turns out to be correct on the culpo, and there's a true lesion there, then you complete your workup and send the patient on to a gynecologist to manage the problem.

 

Thinking back to the way I've handled these issues on my clerkships, generally I end up telling the patient that we are ordering ZYX to check this, and we will let you know what the results are either way, and discuss them with you at that time. ie. "We'll order an ultrasound to look at your gall bladder and liver because you are having pain in that area, and I'll tell you what I've found, and what your options are after I've got a better idea of what the problem is."

 

Something like that.

 

I think UWOMEDS2005 hit the nail on the head when he mentioned that this interaction is going to vary greatly depending on the pre-existing doctor/patient relationship.

 

Ian

UBC, Med 4

[Guest UWOMED2005]

Something similar to what Ian suggests is what was recommended to me after my clinical methods interview. Instead of bringing up the "A" word (Alzheimer's) with the patient there and then, it was suggested that I should have recommended a consult with a neurologist to "look into the memory problems" or something along that lines.

[Guest Ceds]

Good thread! Thanks for the interesting caes that you experienced UWOMED2005. I think that having an open and honest relationship with patients is very important. I like the deontological way of looking at the way a patient should be treated: "As an end, not as a means". In UWOMED2005's case, I do think that the suggested approach to recommend consultation with a specialist is totally appropriate. You did suspect cognitive deficits, and telling the patient that you want to have a specialist do some more tests to explore that posibility would be appropriate even though you wouldn't have mentioned the specific condition. Often I'm sure that given certain symptoms there may be more than one disease/condition that is suspected and it would be impractical and irresponsible to make the patient more anxious than he/she already is by giving a list of possible causes especially when you're not sure and further tests are required.