A Tool to Strengthen the Doctor-Patient Relationship

Though Congress passed the American Recovery and Reinvestment Act earlier this year, debate continues to swirl around the provision of funds for comparative effectiveness research. Critics warn that government bodies could use such research to dictate "appropriate" care and impose third-party oversight so intrusive it would impinge upon the interaction between doctors and their patients.

On the contrary, I believe that comparative effectiveness has the potential to strengthen the patient-doctor relationship. How? By keeping all of us from being blindsided by our own best intentions.

Dr. G was a senior surgeon and teacher of mine. What set Dr. G apart from his colleagues was an extraordinary ability to sympathize—empathize, even—with his patients. As I trailed him on rounds, I watched him, a former college football player, fold his body into a small bedside chair in order to better listen as patients spoke. With certain patients he seemed so moved that his emotions reflected theirs perfectly. He smiled when they did; his eyes welled up as great tears fell from theirs; his face flushed with anger when they spoke of mistreatment by another clinician. Once outside the room and unlike some of his other colleagues, Dr. G's sentiments did not evaporate. Instead, he translated them into care so conscientious that he routinely put the efforts of younger and more energetic doctors to shame.

For a young surgeon who wanted more than anything to retain all of my compassionate ideals beyond my training, Dr. G was a beacon of light at the end of a very long tunnel. He represented what I someday hoped to be.

Until I saw him care for Carolyn.

Carolyn was stay-at-home mother who had been diagnosed with inflammatory breast cancer, a rare but extremely aggressive tumor. Her primary care doctor had used the term "locally advanced" in his referral note; but his descriptor, we would soon learn, put it mildly. Carolyn's left breast was covered with fungating, necrotic tumors. One of the tumors extended upwards, throwing off pebble-sized satellite lesions that burrowed into her left shoulder. Left uncovered, the tumors reeked of rotting flesh, an odor so strong that the doctors and nurses in the clinic's hallway donned surgical masks.

In Carolyn's room, the other resident and I tried to keep our breathing shallow. Dr. G, however, remained unphased, sitting next to Carolyn for half an hour and touching her tumors with ungloved hands. He asked questions and listened quietly as she responded. He nodded when she talked about her children and frowned when she recounted her failed attempts at radiation therapy and the less-than-fruitful discussions with medical oncologists who had thrown up their hands.

I watched Dr. G begin to lean forward as he heard about the other doctors who had turned their backs on Carolyn. I could see lines appear on his forehead as his lips pursed together in deep thought. Then I heard Carolyn's final entreaties. Could he as a surgeon do something? Could he operate and take all the tumor away?

Dr. G stood silent, looking for a moment like a man suddenly thrown in turbulent waters and struggling to keep afloat. The look soon passed, his brow smoothed over, and, looking straight into Carolyn's eyes, he answered quietly, "Yes, we can." He passed his hand once more over the tumorous terrain of her left chest and shoulder. "We would have to do a mastectomy and a forequarter amputation. That is, we would need to amputate your arm and your shoulder because the tumor extends all the way there." He paused again, then added, "You would lose your arm, but we would take all that tumor away."

I looked at the other resident. The muscles along his mandible had tightened; this was the only thing that prevented his jaw from dropping. Both of us knew that such radical surgery was unheard of in patients with advanced inflammatory breast cancer. But we also knew that there was no comparative effectiveness research available on aggressive surgical therapy with this disease. There was no data comparing...