Great (if Unrealistic) Expectations

Good ethics begins with good facts. Right decisions and truly informed consent require correct information — or, at the least, the best information we have — and accurate expectations. A review recently published in JAMA Internal Medicine online suggests that this most basic condition for making good decisions is, in many instances of medical decision-making, lacking.

The article reviews studies that evaluated patients’ expectations about the potential harms and potential benefits of various medical procedures, including screening tests, diagnostic tests, medications, and procedures. The results are perhaps not surprising: the majority of patients overestimated the benefits and underestimated the harms of a host of interventions, from mammograms to cholesterol-lowering medications to prenatal ultrasounds to coronary bypass surgery.

There are no doubt many reasons for this. One is that many health care providers themselves don’t understand the potential harms and benefits of the things they order. Another is our society’s technical orientation: the imperative to just do something about it, and the belief that doing something is always better than not doing anything. Advertising — from sources like direct-to-consumer drug advertising, pharmaceutical reps, specialty “centers” (such as cancer centers), companies that go around performing ultrasound screening for a myriad of ailments — is more often designed to obfuscate and create unreasonable desires and expectations than to clearly inform. Our current medical system often pays doctors based on “production” — cranking through as many patients as possible as quickly as possible — which does not lend itself well to taking the time to sit down and discuss whether the potential benefits of a test or procedure really outweigh the potential harms. And our current medical system rewards doctors for doing stuff to people more handsomely than for taking time with them.

The results of these mistaken expectations? Patients with false expectations are in essence giving uninformed consent to tests and procedures. And the more good we think tests and medicines and procedures will do, the more we will perform and prescribe them, the more unwieldy the cost of healthcare will become, and the more healthcare dollars we will waste on less-than-beneficial interventions.

The solution? None I can think of that are easy, unless incentives in medicine are changed. Until the time doctors spend with patients is valued as much as the things they do to them, until subtly misleading and manipulative advertising is reined in, until we understand and accept concepts like “All screening tests do harm; some screening tests do good,” until we understand and accept the limitations of medicine, we will not be able to curb the bloated “appetite that people have for medical interventions.”

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Jon HolmlundJoe GibesSusan HaackCarol J. Eblen Recent comment authors
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Carol J. Eblen
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Carol J. Eblen

I agree with your conclusions! Obviously, the “MESS” we have in health care today is because the physicians and clinics were NOT put under the provisions of the 1991 Patient Self Determination Act by The Congress of the USA and, therefore, they felt they had no legal obligation to inform patients about the two distinct and exclusive standards of care available under Medicare Insurance. Physicians, since 1991, were put under no obligation to educate their elderly/disabled Medicare patients with terminal diseases as to the pros and cons of both standards of care with any neutral “prognostics” statistics that were available… Read more »

Susan Haack
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Susan Haack

Excellent analysis and conclusion, Joe

Jon Holmlund
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Jon Holmlund

Three brief comments: 1) the post is consonant with the sentiment of Atul Gawande’s book, Being Mortal–and the challenge is to set treatment goals realistically, without erring on the side of neglecting to treat, or, heaven forbid, allowing reimbursement to be some sort of default decision-maker; 2) Both the physician’s enthusiasm–if that is the right word–and a patient’s desire, in the moment, to take a “hopeful gamble” can lead to a miscalculation of risks and benefits; 3) in the content of clinical research, true informed consent is further challenged by the absolute blizzard of information thrown into consent forms, typically… Read more »