“Is there any hope I can walk again?”

I looked up to see an elderly man lying in the hospital bed struggling to put on his portable hearing aid. I gently removed his blanket to help untangle the wires, exposing his frail body in the process. His once muscular frame now appeared diminished, his muscles atrophied and limp. His joints were deformed and held at awkward angles—a testament to years of untreated arthritis. As he reached out to shake my hand, I noticed his missing digit. “The docs had to amputate that one because of my diabetes,” Mr. P chuckled dryly.

It was my second day on my internal medicine clerkship. Our rheumatology team had been called for a consult for Mr. P. This was his tenth fall in the past year. His doctors were concerned that his diabetes, arthritis, and declining physical function had been hiding a more insidious disease. Mr. P’s lab results, notable for an uptrending serum creatine kinase more than 75 times the normal limit, prompted a myositis panel and rheumatology consult.

“Is there any hope I can walk again?” Mr. P repeated. “Please don’t give up on me. I won’t give up.”

Dr. G paused, carefully weighing his next words. “I believe you can, sir,” he replied. “I won’t lie to you. It will take a lot of hard work with physical therapists, but I believe there is hope you can walk again.” Dr. G carefully steered the conversation back to the present. “Right now, we’re going to do our best to figure out what’s happening to you and how we can best help you.” He assured Mr. P that we would continue investigating any underlying rheumatological causes of his symptoms alongside his care team and other specialists.

Telling patients the truth is an important aspect of building rapport with patients and ensuring a therapeutic doctor-patient relationship built on trust. However, this was not always the case. In the early days of American medicine, intentional omission of information was the standard in medical practice if a physician believed the information could lead to harm.1 This paternalistic view was rooted in two of the central tenets of medical ethics, beneficence and nonmaleficence, at the expense of patient autonomy. In its 1847 Code of Ethics, the American Medical Association described its stance on physician-patient communication: “The life of a sick person can be shortened, not only by the acts but also by the words or the manner of a physician. It is, therefore, a sacred duty to guard himself carefully in this respect, and to avoid all things which have a tendency to discourage the patient and to depress his spirits.”2

More than a century later, a study of 219 physicians published in JAMA in 1961 showed that the vast majority indicated a preference to not tell cancer patients their diagnosis.3 Just 18 years later, a similar study also published in JAMA revealed that 97% of 264 university hospital medical staff favored telling cancer patients their diagnosis—perhaps because of the development of promising cancer treatments and the social milieu at the time.1,3

In the 1960s and 1970s, there was a paradigm shift in medical ethics that pushed away from therapeutic deception to physician disclosure and a professional commitment to telling patients the truth. Indeed, in 1964, the newly created Code of Ethics of the World Medical Association—commonly known as the Declaration of Helsinki—characterized doctors’ commitment to the health of patients above all else.4 In 1973, the American Hospital Association wrote a “Patient’s Bill of Rights,” outlining how a patient has “the right to and is encouraged to obtain from physicians and their direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.”1 Still, some patient situations may require considering an act of deception, as described by medical ethicists, professional physician society statements, and legal precedent. Even today, physicians encounter many ethical dilemmas, including but not limited to “professional obligations, competition of interests, truth telling, and end-of-life care.”5

In their didactic preclinical years, medical students are exposed to the foundations of clinical ethics and ethical decision making through lectures and standardized patient interactions. The use of simulated patient-based teaching interventions may help trainees develop their physician-patient communication skills and promote ethical attitudes toward telling the truth. Early exposure helps prepare students for when they encounter such situations in their clinical years of education, such as when I met Mr. P.

As a trainee helping care for Mr. P, I had the privilege to learn from Dr. G’s example and his years of experience. When Mr. P asked about walking again, Dr. G simultaneously told the truth and carefully managed expectations—2 critical components of patient care—before redirecting the conversation back to the present. As Dr. G delicately navigated the balance between delivering honest answers and providing hope, a wave of relief washed over Mr. P. His eyes sparkled with a sense of newfound determination and gratitude. “Thank you, doctor,” Mr. P said quietly. “Thank you.”

On the surface, telling patients the truth seems like a simple task. However, I have learned that the art of truth-telling can be complex, characterized by acknowledging uncertainty, managing expectations, and providing a balance of hope and honesty. As I continue my education, training, and career, I aim to use the lessons I learned from Dr. G to foster compassionate and honest communication to help patients heal.

I am grateful to Dr. Vijaya Murthy and Dr. Emilio Gonzalez for teaching me the practice of medicine. Their compassion for patients and their ability to help people heal have shaped my approach to medicine significantly.