COMMENTARY

Are You Honest When Patients Ask, 'What Would You Do?'

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci

Disclosures

May 07, 2020

This transcript has been edited for clarity.

Hello. I'm David Kerr, professor of cancer medicine from the University of Oxford in England. I'd like to share with you a uniquely interesting consultation I had at clinic last week.

It shouldn't be a surprise that, working in a large hospital in a university town like Oxford, we get a lot of academics as patients. They fall into two broad groups, as does all of humanity. The first group trusts that which we tell them and say, "You know best, doc." They're there to be counseled and advised. The other half come armed with tons of information from huge literature searches, which are often, but not always, misinterpreted.

This particular consultation took place with a formidable mathematician, who had gained an extraordinary background in statistics from his senior academic role at the university. The patient had his primary tumor resected 3 years ago, which was early stage IIa colon cancer. The tumor now recurred with a 7 mm metastasis in one of the segments of his liver. He came to us to find out what we were going to do about it.

We are part of a fantastic multidisciplinary team in Oxford, with superb surgery, interventional radiology, ablation, and stereotactic body radiotherapy; you name it, we've got it on the team. We were disappointed to see him back but pleased that it had been caught at an early stage with the PET and MRI scanning we employ as part of a routine follow-up.

He came to us with sheets and sheets of data. We luckily had lots of doctors at the clinic that morning, which allowed for the consultation to last an hour and a half. In a typically busy clinic morning, I see 20 to 30 patients. We normally don't have that kind of time to spare, but here was an opportunity to really go through things together.

We had a statistical debate about Kaplan-Meier plots, confidence intervals, believability, and the number of patients shifting from one category to another that would render treatment, which otherwise seemed positive, null and void. It was a challenging but nonetheless very interesting, technical conversation about how we as medics analyze statistical data.

Then we had a discussion about what endpoints we measured. My patient dismissed progression-free survival as being irrelevant. He was making an investment in the future. He had young children and a life ahead of him. For him, it was overall survival or bust. I had to agree with that. Progression-free survival is a useful estimate of whether a treatment is working. But in terms of making an investment in one's own life, you would want to see that you were curing the cancer, living longer, and so on.

We then looked at the treatment options. That was terribly interesting because he wanted to consider neoadjuvant chemotherapy, adjuvant chemotherapy, or even locoregional chemotherapy. He came with all the relevant literature, which of course, because it's my focus of interest, I knew very well. These were trials that had been performed by our friends and collaborators, so we managed to wade our way through the various elements of it.

'I Wouldn't Volunteer for That Treatment'

Ultimately, he decided that he wanted to take a rather specific approach that's been developed very beautifully, but at a single center. It isn't offered in the United Kingdom or really in Europe either. I thought the evidence base for that was narrow. It drew from a slightly hokey meta-analysis based on a retrospective review that, honestly, as a statistician, I thought he should have, if not seen through, then at least understood its relative weaknesses.

The thing that made this consultation uniquely interesting is that I said, "It wouldn't be me. I wouldn't volunteer for that treatment." In thinking about it, I realize I've never done that before. I've only said that in instances where patients tell me they're considering relatively weird things. When people seek out alternative medicines and therapies, I apply my rule of three: I tell them that if it doesn't cost an arm and a leg, if it doesn't have harmful side effects, and if it doesn't get rid of conventional treatment, then I shrug my shoulders and tell them they can explore these options.

With informed consent, I usually think that I'm there to present the evidence so that the patient can weigh the pros and cons, and we can make a decision together about what would be best for them. My job is to inform and then to support that decision, not to say, "This is what we must do." The old days of paternalistic medicine, I think, have gone. Yet after this prolonged discussion, which felt closer to being interviewed or undergoing an examination as a medical student, I told him that I disagreed with his choice. Despite the quasi-logic up until then, it just felt wrong.

Others may say, "That's absolutely fine. If that's your interpretation of literature, off you pop." That is sort of what I did say, but I added, "I wouldn't go for that treatment." Often patients say to you, "If you were me, what would you do, doc?" My stock answer is, "I don't know. Unless I were in your shoes, unless I were a cancer patient, I can't predict how I'd behave."

Many of my clinical colleagues who are so dismissive of the benefits of chemotherapy when they're well, when they become cancer patients, they behave like cancer patients. It's impossible to predict how you'll react. But here I found myself, in a psychologically interesting moment, saying, "No, I wouldn't do that."

This was unusual for me, and I haven't quite thought through why I felt I should add that rider to it. I didn't feel particularly strongly about it because there was a partial evidence base for it. But it was interesting that I had this reaction.

For those of you reading who have sat beside a patient at a clinical consultation, how often have you heard them ask, "What would you do, doc, if it were you?" Do you ever give a direct answer? This isn't a psychotherapy session for me—far from it—but I'd be very keen to read any comments you may care to post about how you'd answer.

Thanks for listening. For the time being, over and out.

David J. Kerr, MD, is a professor of cancer medicine at the University of Oxford in Oxford, England. He is recognized internationally for his work in the research and treatment of colorectal cancer and has founded three university spin-out companies: COBRA Therapeutics, Celleron Therapeutics, and Oxford Cancer Biomarkers. In 2002, he was appointed Commander of the British Empire by Queen Elizabeth.

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