Do I lie in my job as a radiation oncologist? My immediate reaction may be to recoil with a strong "No! That would be unethical." On deeper reflection, however, I've come to realize that the answer is more like, "It depends." It depends on how you define the word "lie." It depends on whether you are only talking about lying to patients. Does it change if I include family members, insurance companies, precertification forms, or even referring physicians? Let's start with the obvious and most important place: patients. I and no doctor I know unabashedly lies to patients. If the MRI shows a new brain metastasis, that information is relayed in the most appropriate possible way. It can be softened or spun as a glass-half-full piece of information, but lying is impermissible. Lies of omission, on the other hand, are enormously common in oncology, in my experience. We are all eager to quote statistics to our patients with hormone-receptor-positive ductal carcinoma in situ (DCIS) but may avoid doing so to our glioblastoma patients unless specifically asked. The unvarnished truth can sometimes interfere with our role as unofficial cheerleader. Breast cancer patients with a poor response to neoadjuvant therapy may have a poor prognosis, but there's still more therapy to get them through postoperatively—maintaining a positive attitude to get them through the next treatment phase may be more important than passing along every bit of the truth. Lies of omission are enormously common in oncology. Perhaps the most difficult situation may be counseling patients with poor insight or lower educational levels. So much of what we recommend and do in oncology is based on statistical benefits seen in trials, but many patients have little to no understanding of what that means. As just one example, most patients understand definitive treatments, but explaining a recommendation for adjuvant chemotherapy or radiotherapy can be slippery. Questions like "Do I need to do this?" or "Will it cure me?" invariably arise. We all have our ways of explaining difficult concepts like the benefits of adjuvant care or the tumoricidal mechanism of radiation, but I think we need to be alert to the fact that we can oversimplify to the point of obfuscation or even untruth. And certainly this is a two-way street: Patients treated with adjuvant chemotherapy after lung cancer resection commonly say they were cured by the chemotherapy. How many of us let them know that statement is true more on a statistical basis than an individual one? You can tell your patient, "At our current level of knowledge we really don't know which patients are specifically helped by postoperative therapy and which may have been cured without additional therapy." Or you can allow the patient their misunderstanding, accept their praise, and move on. Another interesting situation occurs with cultural differences. I trained in a location with a large population of first-generation Asian immigrants. It was not uncommon for adult children to request that we lie to their elderly parents and not tell them they had cancer. Of course, I always declined, but it serves as a good reminder to use independent interpreters rather than family members, who may have their own agendas, lest you end up "lying" to the patient without even realizing it. If lying to patients is forbidden, what about lying about patients to other physicians. We all consider advocacy on behalf of our patients at least a part of our job. And we all accept that we may exaggerate the truth in our role as an advocate. I get frequent calls from referring physicians asking me to sneak a consult in quickly because their patient has debilitating pain from metastatic disease and needs palliation. It's not uncommon that, after squeezing in that extra consult, the patient will appear in my office, comfortable, and describe their pain as a 4 out of 10. Was I lied to? Some might say yes, although I think this is more appropriately described as advocating for a patient than true lying. It's probably something we all do, consciously or not—trying to get our patient in to see colleagues who may be booked out for weeks in advance. Another situation is lying to insurers or their preauthorization representatives. This is clearly a different situation. Patients and other doctors are viewed as being on the same team as the oncologist. In some of the situations described above, you may not be fully truthful at all times, but that's based on a kind of game theory to try to get the best results for the patient. Insurers, on the other hand, may at times be viewed as being on the opposing team. Some oncologists may justify lying to an insurer as a means of helping a patient. Additionally, lies to insurers are more black and white. I've seen a number of patients who had minimal complaints during treatment but were declared intolerant to chemotherapy to allow a switch to immunotherapy. Or a PET scan report written with indeterminate nodal uptake might be called "progression" or "stable disease," depending on what the oncologist wants to do. In the radiation space, a late head-and-neck or gynecologic cancer nodal recurrence may be coded according to the previously resected and controlled primary rather than as a nodal metastasis to allow for insurance coverage of less toxic IMRT. Finally, what about those annoying peer-to-peer authorization calls? Many oncologists would consider these the most overtly adversarial part of their job. The timing always seems to be bad, and the "peer" on the other end of the line always seems to have spent exactly zero time reviewing the case, putting the onus on you to describe why this case is unlike other case. Authorization works well with the straightforward and clearly staged patients, but it breaks down with the complicated, obscure, and unclear cases. In a busy practice, the "unusual" actually gets seen relatively often due to the sheer volume of patients. The overwhelming temptation is to tell the reviewer what you think they want to hear. It's win-win, in that you get to go back to your busy day, and your patient gets what you think they need. Recently, I was on the phone with a peer reviewer about a case of a woman with a large pelvic mass. The site of origin was unclear, and pathology was undifferentiated to the extent that even delineation between carcinoma and sarcoma was impossible. Sending out specialty immunohistochemistry (IHC) labs as well as molecular analysis did not help. As I tried to explain all of these studies and the numerous tumor board presentations on the case, I could almost hear the peer reviewer on the other end urging me to say one of his magic words for IMRT approval. Sadly, we all know that many of these peer-to-peer calls amount to a hunt for one of those necessary phrases for approval, whether it be "4D simulation" or "prior radiotherapy" or "T4 disease." The temptation to lie is great. Personally, I haven't and won't lie in that situation, but I am sure that I have colleagues who do, and I don't really blame them for doing so, as long as the motivation is patient care rather than increased billing. In the end, I think we all realize that oncology does not exist in an idealized world. Out-and-out lying in the oncology clinic is rare and forbidden, but bending the truth is common and even to an extent allowed if the purpose of the fib is to improve patient care. No one wants to lie, but the next time your scheduler says that the surgeon has no openings for routine outpatient consults for 3 ½ weeks, you too may say, "Make it a stat consult," telling yourself in your head, "It's all for the patient." Source
