not telling your patient new information about his health (a new lung mass!) doesn’t protect him from stress. it only protects you from the responsibility of upholding patient autonomy and to at least attempt to dispel any stress he has. if you want to be paternalistic, stop hiding things from him, and actually be there for him. it doesn’t matter that his cancer will be handled by another doctor.
This article reminds me of a situation when a patient’s primary care physician (PCP) and myself colluded to not tell a patient about a suspicious x-ray finding — for a little while.
Behind the Medic: The TSK of when Cranquis Paternalized a Patient.
I’d seen 50-something “Bob” in the urgent care, and he was in bad shape. As far as I could tell, his stomach pains and nausea were due to gastritis, secondary to a mixture of excess NSAID use for his chronic pain + his recent resumption of a heavy alcohol habit (He was back to drinking a fifth of vodka every night, after being sober for 3 months — “There’s so much stress in my life right now, doc. My mom and I have been fighting, and I couldn’t stay sober and deal with the stress.”). The only reason I did a chest xray as part of his workup was because his lung-sounds were suspicious for fluid around the lung bases (a possible secondary effect of “abdominal ascites,” fluid collecting in the abdomen after liver failure).
The labs and xrays looked ok for him to go home instead of being admitted to the hospital, and he was happy about this because he didn’t have health insurance and was already stressing about the cost of that day’s Urgent Care visit. But I arranged for him to see his PCP early next week, and admonished him to start cutting back on his alcohol in preparation for getting off the sauce again. He said all the right things: “I’ll go to AA tomorrow morning, my brother will drive me home and stay with me for a couple days,” but it was hard for me to take him seriously. After all, I’d felt the metal flask in his cargo-pants pocket while I was examining his stomach.
The radiologist’s report came in the next morning: “Chest film shows a small irregularly-shaped density in right lower lobe, concerning for soft-tissue malignancy vs overlying chest-wall abnormality, cannot rule out old rib fractures in this area.”
Oh great. What am I supposed to do now? Follow my usual routine — call the patient, inform them of an irregular finding on the chest xray, and arrange for ASAP follow-up with their PCP? This would just give Bob even MORE stress, which would shoot down any attempts he might be currently making to cut back on the alcohol use.
When I spoke with his PCP about the situation, he agreed with my hesitancy: “Bob’s anxiety and alcoholism can’t handle this extra piece of stressful news right now. I’ll call and remind him to keep the appointment on Monday, and break the news to him then and order a chest CT.” I felt relieved that Bob’s PCP was going to take over and handle it, but I felt a little dishonest at not notifying the patient of his results myself immediately, as I usually do with any tests that I order. But there was more at stake here than just “being transparent and honest” and “upholding the patient’s autonomy.”
Were his PCP and I being paternalistic? Yeah, a bit — but I hope that it was in the best sense of “behaving as a father”: making a hard decision on his behalf, a decision which would protect him from carrying increased (and out-of-his-control) stress during a difficult moment in his life. Bob was hurting, and he was striving to hide the hurt in a way which was killing him. He couldn’t even turn to his mother for peace, since she was one of the major causes of his stress. What he really needed was a Father, but the best I could offer him was my own fatherly instinct.
(Note: The chest CT came out clean, but as of Bob’s most-recent visit with his PCP, he’s still drinking.)