Clinical Advances in Hematology & Oncology
March 2015, Volume 13, Issue 3
Lies and Truth
If you tell the truth, you don’t have to remember anything.
—Mark Twain
You can’t handle the truth!
—Jack Nicholson in A Few Good Men
Every weekday night at 7 pm, my wife and I used to turn our TV to channel 4 (NBC) to watch Brian Williams give his perspectives on current events. Not only did he have the best ties and great hair, he was a real master of the airwaves, a reliable reporter, and a seemingly worthy successor to the all-time icon, Tom Brokaw. Williams’ recent downfall was upsetting. We relied on him and trusted him. Now there is a void that even the likeable, solid Lester Holt just does not fill.
The articles written about Williams’ sudden fall describe how he got caught up in his own tales and misled those who trusted his every word. I was one of those who trusted him, and now I feel betrayed. It appears that, whether on a helicopter or surveying the ruins of New Orleans following Hurricane Katrina, he had difficulty in distinguishing the singer from the song or, more relevantly, the storyteller from the story. Most suspect that his 6-month unpaid exile is merely a phase-out period. We let politicians get away with massaging the truth, but our newscasters are held to a much higher standard. Does his punishment fit the crime, or was he just spinning a few very costly (given his $10-million-a-year salary) yarns?
Recently, a patient of mine called me a liar. She was a young woman with limited-stage Hodgkin lymphoma whose positron emission tomography (PET) scan was negative for disease after 2 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) chemotherapy. We were all optimistic, but the results of her posttreatment scan were interpreted as concerning for recurrent disease. A biopsy was attempted, but insufficient material was obtained. A repeat scan a couple of months later showed that a new node had appeared, another node had disappeared, and 1 node that had been noted on the previous study had decreased in size but increased in standardized uptake value. I was unsettled by these findings, and the patient and her husband were anxious and scared. In an effort to be both realistic and optimistic, I explained that although a relapse of Hodgkin lymphoma had to be considered, a number of factors made this unlikely. After all, the negative predictive value of an interim scan is greater than 90%, and it was hard to imagine that limited disease would come back so soon. I went through a differential list of inflammatory reactions, infections, and all of the false positives of PET scans.
When I next saw the patient in clinic, I had the unenviable task of presenting the results of a node biopsy that found that she did, indeed, have recurrent (and therefore primary refractory) Hodgkin lymphoma. She and her husband were understandably distraught. I initiated a discussion of the therapeutic options, with autologous stem cell transplant at the top of the list.
I was taken aback when they responded that they could no longer trust what I was recommending, given that I was no more than a liar. I had told them there was a good chance that the brightness on the scan did not represent lymphoma. When the worst case became the reality, the messenger was pummeled.
Had I really lied to them? I was hurt by the accusation, to the point of losing sleep that night and the next. I am rarely one to paint a rosy picture; in most cases I am (overly) blunt when it comes to giving the bad news. I believe it is the patient’s right to know how fast the train is approaching. In this case, however, I had tried to provide a modicum of uncharacteristic optimism to 2 rather fragile individuals. Had I been a Brian Williams? Or had I just been a hoper holding onto an admittedly remote hope? Sometimes the truth is black and white, and other times it is subjective. But whether the person in question is a physician or a news anchor, trust—once lost—is difficult to earn back.
Until next month . . .
Bruce D. Cheson, MD