The senior physician stood at the podium and told us about his patient, a man he had treated for many years. Although the patient suffered from a cancer diagnosis that was typically associated with a short survival, this man defied the odds and lived for years. Slowly, the senior physician outlined the treatments he had prescribed. Most were unconventional.
Although the cancer was metastatic -- and although for this tumor there was no evidence to support it -- the doctor had advised several surgeries to remove the disease. While some medications administered were frequently used to treat the cancer, others were not and were supported only by bio-plausibility. Radiation was administered in a way I had not seen before or since in the care of a patient. The speaker made the case that ultimately you can't argue with results. Indeed, the patient outlived the median life expectancy for the condition several times over. The patient was grateful for the superb care he had received.
As the senior physician was wrapping up the presentation, I heard someone shout from the back of the room. It was a colleague of the physician. The colleague had been typing rapidly on his computer during the talk, looking up from time to time when pathology slides or radiologic images were shown on the screen.
"John, John, John?" He flagged the speaker's attention. "Might I ask a question?"
"Uhh..." the speaker hesitated, irritated by the interruption.
"John, I'm curious," the man continued from the back, as attention turned to him, "I am very curious, very curious, what the patient said when you told him."
"You know when you told him that he lived a long time, yes, most certainly, much longer than expected. But you know, if you hadn't done any of those things you did, he would have lived just as long! How did he feel when you told him that he just has slow-growing cancer, and you've been wasting his time with therapies that are, you know, just along for the ride? What did he say when you told him that?"
The room let out a gasp.
In the years since that episode, I realize the man in the back of the room was not right. He could not know for certain what would have happened without all those therapies. But I also realize that he was not wrong either. It very well could be true that with far less treatment the patient would have lived that long. In fact, for many cancers, illness exists on a spectrum, and while survival might be short, on average, there is always someone who will live a long time.
Inevitably, the medical profession will attempt more therapies for the person who lives long enough to endure them, and naturally one might conclude that it was because of those therapies the person did well. The man in the back of the room could not know for sure that the treatments didn't help, though he could strongly suspect it. His remark was overconfident, but it took away the speaker's steam, and got everyone in the room thinking.
These days, I don't see anyone speak like the colleague did. In the era of Zoom conferences, we are lucky if the audience is still awake at the end of the talk -- expecting them to make a provocative comment is beyond comprehension. But even a few years ago, in the world of in-person interactions, a comment that bold would lead to being chastised. The speaker might not feel comfortable being challenged so directly -- they might even be offended -- and the man in the back of the room might be sent off to complete some punitive modules on collegiality.
At the same time, this sort of dialog is important for our profession. We never know the counterfactual for an individual patient -- what would have happened had we acted differently, and without this it is easy to tell ourselves a story that suits us. If things go poorly, it was despite our most valiant efforts. If things go well, it was because of us. When we tell the story of our practice, we are always the hero. Sometimes, it is good to be reminded that the man in the back of the room doesn't think so. He thinks we are deluding ourselves, and we're just along for the ride. Is he wrong? If so, how do we know?
Medicine has always, and will always, draw upon the experiences of groups of people to guide the path for the person in front of you. Even if we could sequence every last bit of intracellular stuff, we will still not be able to predict an individual's future, and we will face this limit of inductive reasoning. We need not be paralyzed by this limitation, but we should be humbled by it, and far more willing to subject our practices to empirical testing.
Many of the most popular books in medicine portray our field as a succession of heroes, but the truth is that for every two steps forward, we often take one step back, and we have a tremendous capacity to fool ourselves. After years of practice in cancer medicine, I revisit the case presented by the senior physician that day. I tend to think the man in the back of the room was correct in his assessment, but these days when I look back, everyone is quiet.
is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .