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Full Disclosure vs. TMI

Columnist: James DeVore, M.D.
June, 2015 Issue
Columnist

James DeVore, M.D.
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I hated that moment. I’d told the patient I’d let him know what the X-ray showed; he was expecting a call.

 
I’ll ask a simple question: As you seek medical care, how much information do you really want your doctor to give you about your condition? This is a fair question—and something that’s worth a moment of consideration.
 
In today’s world, it seems there’s a strong push for complete transparency and full disclosure. Doctors are trained to be totally open and direct, and many patients are now directly involved in their care and have access to all their records and reports through their electronic medical records access portal. Cancer patients are routinely given exact survival statistics based on the specific details of their disease state and some complex number crunching. Even for patients going in for the most routine elective surgery, doctors are required to inform them of their chances of dying or being paralyzed for life or of losing their limb. And yes, of course, there are legal implications. Add it all up and full disclosure is the rule of the day.
 
But is this always good? As a way of considering this further, I’ll relate a recent case history.
 
It started when I pulled up a chest X-ray on my computer late one afternoon after I’d finished seeing patients for the day. I just sat there numbly staring at the image trying to understand what I was seeing. The patient had been in earlier that day with some vague respiratory symptoms and a cough. It didn’t seem like a big deal for this healthy 68-year-old man, but I did hear a few crackles in his left lung and ordered the X-ray.
 
And now this: There was what appeared to be a large mass in his left lung! I pulled up the radiologist report and read it over and over while trying to fight off that sickening feeling that this was something very bad. As described in the report, “There is a 4-centimeter round density in the left lower lobe. While it could be inflammatory, a bronchogenic neoplasm is suspected.” That’s radiology speak for: This might just be pneumonia, but it’s more likely to be a nasty form of lung cancer. I immediately called the radiologist and discussed this in detail. Of course, he couldn’t be sure which it was. After much deliberation, he finally concluded it was “probably about 50-50.”
 
I hated that moment. I’d told the patient I’d let him know what the X-ray showed; he was expecting a call, but I was still in a daze. Pneumonia or cancer. No big deal or very big deal. Better in a few weeks or a very long, tough ordeal ahead. What should I tell him? How much should I say? The call I was about to make would define my role as a doctor, my integrity and the very heart of the doctor-patient relationship—honesty. Does this call demand full disclosure? I wasn’t going to be dishonest of course but, should I be completely truthful?
 
On one hand, I still believed it was most likely pneumonia, given the symptoms. I could protect him from the details and the anxiety and not mention the cancer concern for now. The follow up X-ray in a few weeks would clarify things.
 
But isn’t he entitled to know everything? Isn’t total honestly and disclosure an essential part of the doctor/patient relationship? Don’t patients deserve to know all the details and possibilities—even the bad ones?
 
And, as was true in this case, what if the patient just happens to be one of my best friends? Does that change the conversation?
 
I didn’t tell. After the call, he was at ease that he had pneumonia, was on the right medication and trusted me to worry about the details and ensure he recovered.
 
I spent two weeks of sleepless nights, anxiety and self doubt…until the new X-ray was done. It was completely clear! My patient/buddy was fine. I can say that I felt a massive weight being lifted off my shoulders. It wasn’t until several months later that I got around to talking to him about what really happened. As I explained the story to him, with all its detail, complete with my moral crisis, emotion and uncertainty, his reaction was an unequivocal, “Thank you for not scaring my wife. She would have been a complete wreck for those two weeks. You did good.”
 
I’m still not so sure. What do you think?
 
 
 
Dr. James DeVore has been a full-time family physician in Santa Rosa since 1980. He’s medical director of St. Joseph Health’s Annadel Medical Group.

 

 

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