The Lake Wobegon effect: are all cancer patients above average?

Milbank Q. 2013 Dec;91(4):690-728. doi: 10.1111/1468-0009.12030.


Context: When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article "the Lake Wobegon effect" taints the treatment advice imparted to them by their oncologists. In framing treatment plans, cancer specialists tend to intimate that elderly patients are like the children living in Garrison Keillor's mythical Lake Wobegon: above average and thus likely to exceed expectations. In this article, we use the story of our mother's death from lung cancer to investigate the consequences of elderly people's inability to reconcile the grave reality of their illness with the overly optimistic predictions of their physicians.

Methods: In this narrative analysis, we examine the routine treatment of elderly, terminally ill cancer patients through alternating lenses: the lens of a historian of medicine who also teaches ethics to medical students and the lens of an actuary who is able to assess physicians' claims for the outcome of medical treatments.

Findings: We recognize that a desire to instill hope in patients shapes physicians' messages. We argue, however, that the automatic optimism conveyed to elderly, dying patients by cancer specialists prompts those patients to choose treatment that is ineffective and debilitating. Rather than primarily prolong life, treatments most notably diminish patients' quality of life, weaken the ability of patients and their families to prepare for their deaths, and contribute significantly to the unsustainable costs of the U.S. health care system.

Conclusions: The case described in this article suggests how physicians can better help elderly, terminally ill patients make medical decisions that are less damaging to them and less costly to the health care system.

Keywords: NSCLC treatment; end-of-life care; hospice; physician/patient communication.

Publication types

  • Personal Narrative

MeSH terms

  • Aged
  • Aged, 80 and over
  • Carcinoma, Non-Small-Cell Lung / diagnosis
  • Carcinoma, Non-Small-Cell Lung / drug therapy
  • Carcinoma, Non-Small-Cell Lung / psychology
  • Carcinoma, Non-Small-Cell Lung / therapy
  • Female
  • Humans
  • Lung Neoplasms / diagnosis
  • Lung Neoplasms / drug therapy
  • Lung Neoplasms / psychology
  • Lung Neoplasms / therapy
  • Neoplasms / diagnosis
  • Neoplasms / psychology*
  • Neoplasms / therapy
  • Palliative Care
  • Physician-Patient Relations
  • Terminal Care
  • Treatment Outcome