Intended for healthcare professionals

Rapid response to:

Endgames Statistical Question

Survival (time to event) data: median survival times

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4890 (Published 10 August 2011) Cite this as: BMJ 2011;343:d4890

Rapid Response:

The median is not the message

Sedgwick and Joekes sensitively describe the difficult balance
between statistical correctness and explanations of survival data that may
be understood by patients. These discussions are always tough but the
late Stephen Jay Gould left us valuable advice in his compelling essay
'The Median isn't the Message.' The title was a play on Marshall
Mcluhan's famous 1964 phrase that the 'medium is not the message',
referring to the way that media characteristics affect how we interpret
messages.

Gould, an evolutionary biologist, was brilliant at explaining science
to the public. When diagnosed with abdominal mesothelioma he read that
the 'median mortality' was eight months and concluded that most people
would read such a statement as 'I will probably be dead in eight months.'
Having gathered his composure he used his knowledge as a biologist to make
sense of this to himself as a patient. Doctors learning how to have these
discussions with patients would do well to read his essay in full but
there were two core messages. Firstly that, biologically, it is variation
that is the hard reality rather than imperfect measures for a central
tendency. Secondly, that even with knowledge of prognostic features it is
often difficult at diagnosis to know whether any individual is going to be
to the left or right of the median. As many curves are right-skewed some
patients will survive a long time, which was the case with Gould who died
of another cause some years later.

Gould's analysis helped him to deal better emotionally with the
information and, although never an excuse to give false hope, his insights
can sometimes still be a useful aid for doctors in these fraught
discussions. I gave his essay to a frightened relative at the time of her
diagnosis with the same condition years afterwards when the published
median survival was still eight months; she expressed gratitude to Jay
Gould until her death 5 years later.

Competing interests: No competing interests

12 August 2011
David Levine
Retired Physician
Sennen Cornwall