When right is wrong

When a patient leaves you for another physician, they simply cancel their appointments.  You might get a message that says they are moving on and, two months later, you get a follow up letter from the new doc.  However, Sam was unusual; he came in to tell me that because of my mistakes, his wife was transferring her care. What made our confrontation remarkable is that Sam is wrong.

I had recommended that his wife undergo complex surgery, which I believe would not only extend her life, but greatly improve its quality.  After several long conferences, they sought a second opinion.  That doctor prescribed a radically different therapy, based instead on chemotherapy and radiation.  Apparently, that consultation was convincing because by the time Sam walked into the office, his wife was a week into radiation and had received the first cycle of intravenous treatment.

Sam wanted me to know how disappointed they were, that they “had expected more” from me.  He conveyed the anger of the time they had “wasted.”  Even though I had spent several hours in family meetings and had focused particularly hard on her medical issues, Sam and his wife believe that I never gave her case the attention it deserved.

The dilemma confronting me in that brief meeting with Sam was two-fold.  First, I firmly believe the care she is receiving is a mistake.  However, they are now fully committed to this course, and cannot change even if they wish.

On the other hand, in private practice my reputation is important.  Sam had taken the time to confront me in the office; how many people will he, his family and friends tell that I failed them?  Their complaints may go viral.  This could mean many patients whom I might never have the opportunity to assist. Having committed my life to fighting the dread disease in my community, this potential loss hurts.

So, what did I say?  The obvious.  I said nothing at all.  I listened to Sam’s words.  Thanked him, very much, for coming to speak with me and indicated that I understood the basis for their decision to change doctors and therapy.  I expressed my hopes that his wife would have a speedy recovery.  I offered that if any questions came up in the future, if I could help in any way, they should not hesitate to call.

Why not say more? Why not climb the bully pulpit and defend my honor?   What good would it do to convince Sam of the error?  If I succeeded in sowing confusion, would it bring comfort?  Coping with cancer, for a patient and family, is one of the most difficult things anyone must do, and adding more doubt could not possibly assist healing.  If things do not go well, what will be gained by giving Sam further guilt?

I failed Sam and his wife.  I presented them with “the truth,” but did not connect in a way that would have allowed her to follow that path.  I get an “A” in science, but an “F” in art.  Therefore, my reputation probably should take a bruise or two.  After all, while I was right, in the end, for Sam’s wife, what happened was wrong.


  • Paula Kaplan-Reiss
    This was so honest, but painful. You did the right thing. We, unfortunately, cannot always connect with everyone. Even we, as patients, when we brag about our doctors, inevitably we hear from someone who did not have a good experience and we also feel the need to defend and take the criticism personally. Rest in the knowledge that the majority may trust your good care and judgment and your reputation is safe.
    • James Salwitz, MD
      Thank you very much, jcs
  • Liz
    Considering the idiotic things some cancer patients do involving snake oil, quacks, "miracle cures" it is not surprising that some patients will change doctors over treatment options/decisions. When people talk about second opinions one thing that does not get discussed is what to do if the second opinion differs from the original opinion. If it confirms it - great. Everyone is set. If it contradicts it, the underlying assumption is often that the first doctor was wrong (this is based on how getting second opinions are often presented as well - at least in my experience - looking at this would make a good research study). When first talking about second opinions one needs to address issues with second conflicting opinions, and/or how there may not be one clear "gold standard" of treatment and so based on X factors of this patient's case Y treatment makes the most sense in your professional judgement and L, M and N treatments (anticipating alternative suggestions) was rejected by you for Z reasons... I'd also suggest telling a patient that if someone gives a second opinion that conflicts with what you are suggesting that you'd welcome them to come discuss it with you and you will waive the doctor office copay charge (frankly these add up at, in my case $40 a pop when I have to pay it even after I have met my out of pocket and deductible and need to do so each time I breathe doctor office air even if I don't see the doctor - chemo week I was paying $120 a total in copays for 2 days of chemo and 1 day with only a neulasta shot); and tell them that a third opinion might be useful if they get two that disagree... Patients and families often have preferences for types of treatment for both rational and irrational reasons (combine that with ignorance, information overload, misreading of good information, belief in wrong information, drawing incorrect conclusions from information, stress, etc.) and if one doctor presents options more in line with preferences they are more likely to go with that treatment plan (confirmatory bias at play here I am sure - again another good study on patient treatment choices needed here). Finding out the patient's biases for treatments, their hesitations with what you had suggested... in advance of a second opinion might help you set up conditions where treatments are accepted or rejected for more "rational" reasons. As for actually coming back to tell you they were firing you... I can see several reasons for doing that: (1) the patient has a relationship with the doctor and would feel guilty just walking away (and has the energy to actually then follow though with the apt and the money to pay the co-pay), 2) they are mad and want to vent, (3) they have a relationship with you and feel betrayed that the second opinion doesn't agree and follow the "second opinion must be right and first opinion must be wrong" theory (which reminds me - I think some of this comes from second opinions are more likely to be at big cancer centers further from home and so doctors at that center are somehow perceived as more competent than a local community oncologist - if the opinions match then their estimation of the local doctor goes up a notch, if they disagree the local doctor is the one who is wrong)... (4) things I haven't thought of at the moment...
    • James Salwitz, MD
      Thanks for your comprehensive response. I really appreciate the list of "why" a patient might need to confront the primary doc, even as they are leaving... it will help me empathize in similar situations. Still, sometimes, you just want to grab the patient by the collar .... jcs
      • Liz
        and sometimes we patients want to grab the doctor by the collar too and shake them until their teeth rattle LOL... relationships involve two way frustrations at times. Rational patient though and cancer don't always go hand in hand and as a doctor you may be beating your head against the wall at times over this. Then if they didn't fire you this may mean that the doctor is left left picking up the pieces from the train wreck you saw coming. Hanging out on cancer patient yahoo groups I get totally frustrated with the large number of cancer patients who apparently don't believe in science, or if they do, they believe it only holds when they want it to hold. Sigh. They really need to do a reality check, for example using the laws of science and gravity and conditions under which it holds, even when they don't want it too (for example when you trip on the stairs, when a heavy can falls out of your hand and you are in bare feet...)... Anyway back to the point - I think being a doctor must be a lot like parenting a teenager - you know more than they do much of the time (but not always), they can hold some pretty strong opinions and overlook that gravity always holds (on occasion) and sometimes teens say things that cause the parent to grit their teeth and know that the school of hard knocks is going to get them. As a parent you often have the ability to intervene if the lesson the kid is about to learn the hard way is too risky. As a doctor you can't do that, nor can you say "I told you so" when the sky falls like you know it likely will. Unfortunately all jobs have a down side. Knowing a patient has chosen a path likely to end in a train wreck, unable to persuade them another choice is better and being powerless to intervene is likely one frustration of your job. I used to work with adjudicated youth where the default decision processes were usually train wreck ones. I had to learn how to emotionally distance myself (this isn't quite an accurate way to state this, but I am at a loss for how to accurately describe what I mean - it is sort of like how you can feel grief sometimes and you are a goner basket case and other times you can mange the grief you are feeling so you aren't drowning) from the kids and at the same time care about them and about what happens to them. To do otherwise would have resulted in major burn out (actually I had to learn this lesson several times before it stuck). I found when I did that I could handle anything (and I do mean anything) those kids could dish out and not get upset with them, I could respond appropriately, I still cared about them and what happened to them, but there wasn't the deep personal toll when I had to suddenly jump out of the way of the train crash. I was upset for them but I somehow didn't have the desire anymore to shake them until their teeth rattled and they listened to me. I would guess that that high wire act is also true in the medical field and that some doctors have figured out the self preservation part of emotionally distancing themselves but haven't yet (perhaps not ever) figured out the other part of still caring after emotionally distancing. Then there are the ones who have the caring part down and struggle with the personal emotional distancing and can burn out if they are not careful. Caring it is tricky thing when we care about people whom we can't control - especially when we see the impending train wreck if they stay on the current track and we know that the consequences of wreck are likely not able to be undone.
      • Anne
        If we believe in patient autonomy, do we not also believe in the patient's right to make a bad decision? I have trouble with this, because bad decisions can come with a lot of fallout for more than just the patient. But on some level, I think patients do have a right (sometimes) to fail.
  • If I were the patient, it might have helped to hear that the surgery was preferable instead of the alternative because . . . Also, when lumbar fusion was indicated, I was bombarded regularly with lay people's insistence that I NOT have the surgery. I wonder if that was your patient's experience?
    • James Salwitz, MD
      Interesting point. When you are first meeting a patient and family you really do not know the "back story."...i.e. what other people are telling them and their past experience. These things certainly color decisions in ways the physician cannot always appreciate. jcs
  • Mary
    So sorry this affected you so much - your burden is great enough. I have sometimes stayed with the second opinion and sometimes stayed with the original opinion. Your post causes me to reflect on WHY.
    • James Salwitz, MD
      These are very hard decisions for every person. jcs
  • Elaine Newcomb
    I was diagnosed with stage IV metastatic colon cancer in May, 2009. Out of the blue, one day I'm fine and two days later l am going to die! The oncologist was a highly respected physician with a prominent cancer center, but he offered me no treatment options. When l pressed him, he recommended waiting 6 weeks and scanning to see, "how fast the liver tumors were growing". Of course, l sought a second opinion! I have been NED since, thanks to a fantastic team at UPMC Liver Cancer Center in Pittsburgh. I have never confronted this physician and only a few close friends know the whole story including his name. I see him socially now and again and he still holds to his opinion that this cancer will eventually kill me. He did not offer any alternatives. He did not want to help me in any way. Unlike you, Dr. Salwitz, he simply dismissed me and asked his nurse to send in the next patient.
    • James Salwitz, MD
      1. What a fantastic, hopeful, encouraging story. 2. One thing we now know about colon cancer is that if you keep fighting, really incredible things can happen. 3. UPMC is a remarkable place. 4. I personally have a number of "Stage IV" colon cancer patients who somehow failed to read the book. They look fabulous, feel fabulous and are leading "normal" (in New Jersey?) lives. 5. I am impressed you are able to see this physician socially and not hit him. jcs
  • IBS
    Dr. S, with the internet, people go on medical blogs and read what the patients write and the after affects. Every patient has a different dx and with that, different ways to deal with it. Sam should have come to you after hearing what the 2nd opinion was and discuss it with you first. I don't feel you made a mistake so please don't take it personally. The problem was that Sam never discussed going someplace else for a second opinion and then talking to you about it. I was in a situation like that. I also went to another oncologist that only researched with what I had and other problems. I told my local Onc I was going and discussed what medication the Dr in NY wanted to try. At first, he didn't think it was a good idea, but I promised if my IgG went higher, I would definitely stop. I was also seeing a highly recommended rheumatologist. I told him too, and he said NO and went nuts. I think it was the time my BMB was 25%. I felt I had nothing to lose. This Rheum really lost his mind; yelling at me, taunting me in the lobby with people listening. From the stress I was feeling, my entire body broke out in a SLE rash. I wrote him a letter telling him how I felt. I didn't understand his feelings to try one or two pills and then stop if it was hurting me. He kept writing me; all mis-spelled words, and didn't make sense. It turned out, I stopped going because my IgG was going higher. It ended up my NYC Onc. wrote many articles in the medical journals because I have horrible genetics due to my family. And the Rheum? He had a nervous breakdown and never practiced again. No one has ever said NO to him and I did. As far as Sam, he took the route of not putting his wife through more pain with complex surgery even though he might have agreed with you but not what his wife wanted. I thought what you said was wonderful to Sam. Patients must talk to their MD's as to what they want and don't want. Sam should have discussed the two options with Dr. S, as I did with my local onc. Please don't let one patient make you feel your reputation will be in trouble. Think of all your patients you have helped. A Palliative patient
    • James Salwitz, MD
      Your comment and support are greatly appreciated. Your words point out to me a slightly different view of this issue; the responsibility of doctors not to put the patient in the middle and to communicate with each other. Otherwise, patients are stuck "playing doctor," which is not only unfair, it increases the likelyhood of mistakes and guilt. When patients need to make decisions the physicians should at least come together to present the recommendations and possibilities in a way that does not require a graduate degree to decifer. Thanks, jcs
      • Liz
        I was lucky two oncologists did that with me - the one at the NIH comprehensive cancer center was against one treatment (pretty much would never use it - and he was not an out of the box thinker - if there hadn't been a head to head clinical trial, forget it. I, on the other hand am willing to draw conclusions based on logical what if's using the if A>B and B>C then A has to be >C logic), the local oncologist that the medical school was for it. They hashed out their differences and decided they'd jointly OK it under certain labwork conditions that were a bit more rigorous than usually used - good reasons for that as explained to me (if they had jointly said no I would have grilled them and probably not doc shopped since if two of them had said no then it was likely I had missed something important - google MD degree not withstanding LOL) I had been pushing for it because I had yet to learn (well I knew it intellectually but had not yet accepted that - having had breast cancer on each side where you do talk about a cure colored my approach as well) that no matter what I did I was going to die from this indolent non-hodgkin's lymphoma and was hanging on to hope that somehow, if I was aggressive in what we did, I might be in that very lucky, very tiny minority who somehow were cured. The entire thing became a moot point because I then had a late rituxan crash, a white count of 0.5 and no neutrophils so couldn't do it. HOWEVER because they had come together with a decisions and done that without catching me in the middle I was not stuck trying to figure out how to deal with one person who opposed what I wanted to do and one who was in favor. Could I still keep both as a doctor? What would the doctor on the "losing side" of the decision think? Think of me? Would he still want me as a patient?...Very awkward at best. And how I would rebuild a relationship after effectively defying him and "shopping docs" until I found one who would do what I wanted to do (well in this case didn't have to shop the docs as my local oncologist was on board with the decision, but you know what I mean). Because unfortunately it is often left to the patient's to be the one to rebuild the relationship. The outcome then can be a patient who fires the doc by never coming back rather or doesn't come back because he/she fears/assumes how the doctor will react than a patient who decides to make an apt to discuss the entire thing (yes slightly different than your original example of the apt to be told you were being fired)..
  • meyati
    This hit me--in 7 months I had radiation treatment (6 weeks) while I was out of range with hypothyroid. My oncologist refused 2 care 4 me, and wouldn't release me to another one in the clinic. My PCP had to order the base lab work , while the quack talked about radical surgery. After more than a month of me not being lady like -I had to scream lawyer. Then I was assigned a new one. I did good, walked the dogs, got bit by a dog, ER bungled. Hospital bungled I was left with a constant fever, got weaker, sometimes chills, felt better, then got sicker. My PCP refused to run a THS screen, and told me that I'm old get used to it. I finally found an 80 year-old Urgent Care Dr. that ran a strep test. I had acute step. he also listened to me the pain was in front of my throat- not the back. Then in the post-op cat, the reading radiologist decided that a tonsil stub was a cancer. I knew it was a stub and my ENT yanked it out and it was negative of anything, but being a tonsil stub. When you're 71 and have both of those things going-you can feel like you're having heart problems, and either one can cause serious heart damage. After the stress test this week, I was told by the cardiologist to get a new doctor-quickly-as my life depended on it. In late July I confronted him on the patient portal that my body couldn't take anymore of the thyroid symptoms-so he ran a screen and inc my thyroid. He originally told me in Jan. for me to wait until Oct. to run a scan. i cheated and had my follow-up screen done last week. I knew that I quit having dry skin. I wish that I had my current oncologist to begin with-my health plan trapped me. Then the other cancer clinic is much worse. My plan has a year long waiting list to change PCPs. I found a loop hole, and I'm going to meet my new PCP next week. I used to date a French medic sans frontieres, and I gave him my password. I asked him to go over my thyroid labs, correspondence, urgent care and ER. He Emailed me that a decent doctor would have said that he couldn't care for me anymore, and would've done the paperwork to release me. he said- "Run, run as fast as you can.before he damages you anymore." The post-rad CAT with radiation showed the cancer tumors to be dead. If you had been my oncologist, you wouldn't have been happy about my decision. I have atypical BCC by my nose. I had 2 surgeons tell me that radiation would work for only a few years-then I'd be back begging them. Notions of a notional cancer patient, as one above suggested. #1 the oncologist I hate said I'd look exotic in an eye patch.-You have to agree that only Johnny Depp looks exotic in an eye patch. #2- I ran into a BCC patient that followed the ACS plan, and it came back in 4 years, he'd already been through chemo and radiation. #3- It went down hill from there. My family met the oncologist that I called names, wrote letters, Emailed everybody that he was a son of a bitch and I need a different doctor, and they said -We won't let him care for he- he's a prick. Doctor, with all due respect, different people have different values and different goals. I watched my father die from intestinal cancer when I was 13. I watched him go from surgery to surgery. My goal and plan is to be as pleasant as I can with my family and others, get my strength back from the strep, thyroid problems. To eat Thanksgiving dinners with my family. Today I can smile, go to the credit union, and be happy. I'm thankful that I'm not in some home in Houston, 2,000 miles away. Unable to talk, wasting away, being strapped down while I'm gagging from a lubricated tube being shoved up and down my throat several times, listening to the news about the fate of medicare. One of the things they didn't factor in is that my daughter is a speech pathologist. At the VA she had 3 patients die because the gag reflex stopped working and they swallowed their own tongues and strangled. After my daughter's VA contract was up, she changed to violent disturbed children that needed a speech pathologist. . This strep and thyroid-lack of antibiotics has enforced my determination not trust anybody very much. Do you know what I like about my new oncologist, ENT,dermatologist, and oncology radiologist? They asked me what my goal was, and they said they'd help me as much as possible. Several asked me if I was suicidal, I told them that if I was, I'd already had done it or tried that, as thyroid problems didn't get me thinking that way.
    • James Salwitz, MD
      Thank you for your remarkable comment and for sharing your story. It would be fabulous if every doctor started the conversation, "what are your goals?" jcs
  • Anne
    You didn't fail. Judging from what you describe here, you did everything you could for this patient and her husband. Sometimes you just cannot make the connection with someone else, perhaps because they aren't ready to hear it or their own values and beliefs get in the way. This is somewhat of an aside, but I think the lay public often doesn't know how to sort through conflicting opinions and make a meaningful medical decision. They go with whatever sounds best to them, or whatever they heard most recently. Critical thinking skills are difficult to master, and obviously it's much harder when you're confronted with a decision as important as which cancer treatment to seek. I remember being thrown for a loop when I was dx'd with NHL. Pathologists at two different facilities disagreed about the tumor histology. It was discussed at length and we ultimately got a third opinion from the Mayo which agreed with the 2nd pathologist. It's easier when the answers are cut and dried, but we're talking about real life here, and I was grateful the team was being so careful to make the best decisions we could. (I was in my 30s at the time and have survived for almost 20 years, so clearly the process was vindicated.) But you did not fail.
    • James Salwitz, MD
      Thanks for the support ... you raise the challenge of the very difficult problem of making complicated decisions when one is emotionally (and physically) connected to the result, especially when your advisors do not aggree. It can be so very very tough. jcs
  • D Someya Reed
    Actually, both Sam AND you are wrong. Sam for the way he handled the transfer and you for thinking you failed him and his wife. Although few would agree with Sam’s overall actions, I can understand, potentially, why he might have taken them. It may have to do with bias but somewhat different than what others have mentioned. You’re an oncologist. Sam and his wife simply may have expected or wanted an oncological treatment not a surgical one. They know you’re not a surgeon. Perhaps, they don’t understand the depth of knowledge you possess or that which is required to be a good oncologist. How many times do we hear (and substitute whatever profession you want): “If I wanted a surgical solution, I’d go ask a surgeon.” Maybe his wife is surgery-averse and they never told you. The bias comes into play with the expectations of doctors by patients based on their specialty. Some feel because you know about “this” you couldn’t possibly know about “that” (specialty bias). This could explain his comments that they “expected more” and didn't feel that you gave them enough attention. Somewhat confirmed when they found another oncologist who recommended a treatment that you had not (and, in your opinion had you even known about it, would not have recommended anyway). They, on the other hand, may feel you should have known or offered it. They also didn’t know (and still don’t) that you would oppose it and why. Should you have explained? No, you’re right on that…it wouldn’t have made a difference. But I also said you are wrong in thinking you failed Sam and his wife. There are two reasons why you did not. First, based on what you knew of her condition, you did what you honestly thought best and in the best interests of your patient. None of us can ask more of any doctor. Second, you don’t know the outcome yet. It just might, as you and we all hope, turn out to be a positive one. Who knows, perhaps this course may end up in your own treatment arsenal some day. You also left the door open for Sam and his wife to return. Had you gotten the least defensive, I don’t think they ever would. Will you take a hit for this…maybe...but do you really believe even should this go viral, which I doubt but understand your concern, that an appreciable number of patients that have you as a choice would be swayed? My first questions would be why would the doctor recommend a bad surgery (for you) when it wouldn’t benefit the doctor’s practice at all and what chance of success did he say it would have? In our “immediate gratification” society, there are many patients who would prefer the prospect of a relatively quick, though complex, surgery when compared to weeks of the onslaught of chemotherapy and radiation. You can lead a horse to water…
  • For years in lectures to physicians and patients, I made sure that they understood I was presenting the Truth as I perceived it. In the next suite over, the radiotherapist's concept of acceptable toxicity, if not statistical outcome, is guaranteed to be different. Unhappily, we are not only bound by our perceptions, but by the healthcare dollar.

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