{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,7]],"date-time":"2026-02-07T16:56:13Z","timestamp":1770483373657,"version":"3.49.0"},"reference-count":66,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2013,12,10]],"date-time":"2013-12-10T00:00:00Z","timestamp":1386633600000},"content-version":"vor","delay-in-days":9,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Milbank Quarterly"],"published-print":{"date-parts":[[2013,12]]},"abstract":"<jats:sec><jats:title>Context<\/jats:title><jats:p>When elderly patients face a terminal illness such as lung cancer, most are unaware that what we term in this article \u201cthe Lake Wobegon effect\u201d 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>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\u2019 claims for the outcome of medical treatments.<\/jats:p><\/jats:sec><jats:sec><jats:title>Findings<\/jats:title><jats:p>We recognize that a desire to instill hope in patients shapes physicians\u2019 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\u2019 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.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>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.<\/jats:p><\/jats:sec>","DOI":"10.1111\/1468-0009.12030","type":"journal-article","created":{"date-parts":[[2013,12,10]],"date-time":"2013-12-10T05:34:40Z","timestamp":1386653680000},"page":"690-728","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["The Lake Wobegon Effect: Are All Cancer Patients above Average?"],"prefix":"10.1111","volume":"91","author":[{"given":"JACQUELINE H.","family":"WOLF","sequence":"first","affiliation":[{"name":"Ohio University"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"KEVIN S.","family":"WOLF","sequence":"additional","affiliation":[{"name":"Kevin Wolf &amp; Associates"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2013,12,10]]},"reference":[{"key":"e_1_2_16_2_1","unstructured":"Adjuvant! Online. n.d.Adjuvant! Online: Decision Making Tools for Health Care Professionals. Available atwww.adjuvantonline.com(accessed July 18 2013)."},{"key":"e_1_2_16_3_1","volume-title":"SEER Cancer Statistics Review, 1975\u20132007","author":"Altekruse S.F.","year":"2010"},{"key":"e_1_2_16_4_1","first-page":"733","article-title":"Response of Radiotherapy in Brain Metastases and Survival of Patients with Non\u2010small Cell Lung Cancer","volume":"14","author":"Antoniou D.","year":"2005","journal-title":"Oncology Reports"},{"key":"e_1_2_16_5_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa031644"},{"key":"e_1_2_16_6_1","first-page":"1021","article-title":"Discussing Disease Progression and End\u2010of\u2010Life Decisions","volume":"13","author":"Baile W.F.","year":"1999","journal-title":"Oncology"},{"key":"e_1_2_16_7_1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1136\/thx.2007.086215","article-title":"Inoperable Brain Metastases from Non\u2010small Cell Lung Cancer: What Part Does Whole Brain Radiotherapy Play in Standard Treatment?","volume":"63","author":"Barton R.","year":"2008","journal-title":"Thorax Journal"},{"key":"e_1_2_16_8_1","volume-title":"Understanding Health Policy: A Clinical Approach","author":"Bodenheimer T.S.","year":"2009"},{"key":"e_1_2_16_9_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2000.18.3.623"},{"issue":"5","key":"e_1_2_16_10_1","first-page":"12","article-title":"Five Communication Strategies to Promote Self\u2010Management of Chronic Illness","volume":"6","author":"Boxer H.","year":"2009","journal-title":"Family Practice Management"},{"key":"e_1_2_16_11_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2012.476"},{"key":"e_1_2_16_12_1","unstructured":"CDC (Centers for Disease Control and Prevention) National Center for Health Statistics.2010.United States Life Tables 2006 and National Vital Statistics Reports. June 28 (all males from table 2 all females from table 3 white females from table 6)."},{"key":"e_1_2_16_13_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.320.7233.469"},{"key":"e_1_2_16_14_1","doi-asserted-by":"publisher","DOI":"10.1634\/theoncologist.10-7-467"},{"key":"e_1_2_16_15_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpainsymman.2006.10.010"},{"key":"e_1_2_16_16_1","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.39.6.789"},{"key":"e_1_2_16_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(06)70804-X"},{"key":"e_1_2_16_18_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2008.16.2727"},{"key":"e_1_2_16_19_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2005.05.1474"},{"key":"e_1_2_16_20_1","unstructured":"Genentech.2013.Tarceva Fact Sheet. Available athttp:\/\/www.gene.com\/download\/pdf\/tarceva_prescribing.pdf(accessed May 28 2013)."},{"key":"e_1_2_16_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.lungcan.2013.01.008"},{"key":"e_1_2_16_22_1","doi-asserted-by":"publisher","DOI":"10.1089\/pop.2009.0010"},{"key":"e_1_2_16_23_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2008.20.9114"},{"key":"e_1_2_16_24_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2005.11.138"},{"key":"e_1_2_16_25_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF02782192"},{"key":"e_1_2_16_26_1","article-title":"At the End, Offering Not a Cure but Comfort","author":"Hartocollis A.","year":"2009","journal-title":"New York Times"},{"key":"e_1_2_16_27_1","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.11548"},{"key":"e_1_2_16_28_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2005.02.840"},{"key":"e_1_2_16_29_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2009.04.012"},{"key":"e_1_2_16_30_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjmed.2010.11.009"},{"key":"e_1_2_16_31_1","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.20.4.188"},{"key":"e_1_2_16_32_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2009.127"},{"key":"e_1_2_16_33_1","doi-asserted-by":"publisher","DOI":"10.1002\/cncr.24761"},{"key":"e_1_2_16_34_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.seminoncol.2011.03.007"},{"key":"e_1_2_16_35_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-009-1058-x"},{"key":"e_1_2_16_36_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2011.772"},{"key":"e_1_2_16_37_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2004.06.114"},{"key":"e_1_2_16_38_1","volume-title":"A Darker Ribbon: Breast Cancer, Women, and Their Doctors in the Twentieth Century","author":"Leopold E.","year":"1999"},{"key":"e_1_2_16_39_1","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1097-0215(20000220)90:1<37::AID-IJC5>3.0.CO;2-7"},{"key":"e_1_2_16_40_1","unstructured":"Lovenheim S.2009.New Study: Bankruptcy Tied to Medical Bills.Washington Post June 4."},{"key":"e_1_2_16_41_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2012.42.4564"},{"key":"e_1_2_16_42_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2003.06.142"},{"key":"e_1_2_16_43_1","unstructured":"MedPAC and Centers for Medicare & Medicaid Services.2009.Hospice Services Payment System and Wage Index. Available atwww.medpac.gov\/documents\/MedPAC_Payment_Basics_09_hospice.pdfandwww.cms.gov\/Medicare\/Medicare\u2010Fee\u2010for\u2010Service\u2010Payment\/Hospice\/Downloads\/FY2010_Hospice_WI.zip(accessed July 20 2012)."},{"key":"e_1_2_16_44_1","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1017\/S0098858800010121","article-title":"The Exclusion of Pregnant, Pregnable, and Once\u2010Pregnable People (a.k.a. Women) from Biomedical Research","volume":"19","author":"Merton V.","year":"1993","journal-title":"American Journal of Law and Medicine"},{"key":"e_1_2_16_45_1","doi-asserted-by":"publisher","DOI":"10.1097\/JTO.0b013e3181b6b6f4"},{"key":"e_1_2_16_46_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2007.13.9030"},{"key":"e_1_2_16_47_1","first-page":"3","volume-title":"Care at the Close of Life: Evidence and Experience","author":"Quill T.E.","year":"2011"},{"key":"e_1_2_16_48_1","doi-asserted-by":"publisher","DOI":"10.1097\/JTO.0b013e3181f1c7b0"},{"key":"e_1_2_16_49_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2000.18.1.122"},{"key":"e_1_2_16_50_1","doi-asserted-by":"publisher","DOI":"10.1093\/jnci\/djg059"},{"key":"e_1_2_16_51_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa050753"},{"key":"e_1_2_16_52_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.suponc.2010.12.005"},{"key":"e_1_2_16_53_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMe1211160"},{"key":"e_1_2_16_54_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2011.38.5161"},{"key":"e_1_2_16_55_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2009.427"},{"key":"e_1_2_16_56_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2008.19.4522"},{"key":"e_1_2_16_57_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1000678"},{"key":"e_1_2_16_58_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0025-7125(03)00066-X"},{"key":"e_1_2_16_59_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.294.3.359"},{"key":"e_1_2_16_60_1","unstructured":"U.S. Nuclear Regulatory Commission.2011.Fact Sheet on Biological Effects of Radiation. Available athttp:\/\/www.nrc.gov\/reading\u2010rm\/doc\u2010collections\/fact\u2010sheets\/bio\u2010effects\u2010radiation.html(accessed May 28 2013)."},{"key":"e_1_2_16_61_1","unstructured":"U.S. Preventive Services Task Force.2013.Lung Cancer Screening Recommendation Statement. Available athttp:\/\/www.uspreventiveservicestaskforce.org\/3rduspstf\/lungcancer\/lungcanrs.htm(accessed August 22 2013)."},{"key":"e_1_2_16_62_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejcts.2004.03.041"},{"key":"e_1_2_16_63_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1204410"},{"key":"e_1_2_16_64_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2007.15.2280"},{"key":"e_1_2_16_65_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0169-5002(02)00030-2"},{"key":"e_1_2_16_66_1","doi-asserted-by":"publisher","DOI":"10.1001\/archinternmed.2008.587"},{"key":"e_1_2_16_67_1","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.2012.48.1911"}],"container-title":["The Milbank Quarterly"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2F1468-0009.12030","content-type":"unspecified","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/1468-0009.12030","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,10,2]],"date-time":"2023-10-02T14:08:36Z","timestamp":1696255716000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/1468-0009.12030"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2013,12]]},"references-count":66,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2013,12]]}},"alternative-id":["10.1111\/1468-0009.12030"],"URL":"https:\/\/doi.org\/10.1111\/1468-0009.12030","archive":["Portico"],"relation":{},"ISSN":["0887-378X","1468-0009"],"issn-type":[{"value":"0887-378X","type":"print"},{"value":"1468-0009","type":"electronic"}],"subject":[],"published":{"date-parts":[[2013,12]]},"assertion":[{"value":"2013-12-10","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}