Patient complaints may worsen defensive medicine

Doctors often have a communication disconnect with their patients.

A recent piece from the New York Times encapsulates the issue, citing a recent New England Journal of Medicine perspective.

According to oncologist Ethan Basch, “Direct reports from patients are rarely used during drug approval or in clinical trials. If patients’ comments are sought at all, they are usually filtered through doctors and nurses, who write their own impressions of what the patients are feeling.”

There are a variety of reasons for this. Some doctors feel they have a better sense of the patient’s symptoms than the patient himself. Biases can affect how doctors and nurses perceive symptoms. For instance, there is a “tendency to downgrade symptoms may be based on the doctor’s knowledge that a patient is in the early stages of an illness and could be much worse. Or the doctor may be making mental comparisons with other patients who are sicker.”

More interesting is how the threat of malpractice can be a factor: “Describing a problem in a chart creates a record that the doctor may have to act on. ‘There may be a defensive lack of documentation,’ [Dr. Basch] said.”

But does every patient complaint need to be acted upon? In the current liability environment, unfortunately, the answer may be yes. Woe to the physician who dismisses a symptom only to miss a life-threatening diagnosis.

Compound that with the lack of time most doctors have, it’s easy to see how there is a tendency to answer every patient symptom with a diagnostic test or referral. It’s another subtle, yet prevalent, variation of defensive medicine.

There’s no question that doctors need to better listen to patients.  That job would be made easier if the malpractice cloud that shrouds the interaction was cleared.

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  • Marc Gorayeb, MD

    It is a mistake to buy the line of the plaintiff’s bar that the defensive practice of medicine is not a major contributor to health care costs. Let me add one more anectdote to the pile. Apparently it is the policy of some emergency departments that all elderly patients on coumadin who fall and hit their head will be admitted for at least 24 hours regardless of the finding of the initial CT scan. If negative, a repeat CT scan must be performed in 24 hours before the patient is discharged. There are many objective reasons why this is a ridiculous rule. (In this case, evidently, evidence-based medicine doesn’t apply). We all know the real reason why a policy like this exists.

    I have an idea. Instead of focusing on limiting damages in tort reform, why don’t we also focus on the issues of negligence and causation? Somehow, lawyers have built for themselves a relatively impenetrable shield against malpractice lawsuits by having a multi-dimensional approach to the problem. It takes more than the word of an “expert,” (i.e. another lawyer), to establish that ‘but for’ the lawyer’s alleged negligence, the client would have won their case. The Supreme Court’s definition of legal negligence over the years has also established that lawyers with vast differences in ability can practice without significant fear of a lawsuit. Just don’t miss that statute of limitations.

  • Edward

    In the US there is little chance of meaningful tort reform as long as our legislative bodies are composed primarily of attorneys.

  • Michael Kirsch, M.D.

    Why does every patient with a stomach ache in the emergency room get a CAT scan?

  • DJ

    Any meaningful health care reform must include tort reform and curtailing medical education costs…you can’t ask doctors to take less and be an employed public servant, to take care of the masses,as their ‘duty’ without taking away the ‘deep pockets mentality’. Amercia can’t have it both ways!

    It must change if they are going to make doctors employees ultimately and severely curtail their earnings, which I believe has been the plan for some time now, as corporate health care, and govenment agencies have been trying to force doctors out of private business and treat them merely as employees, like most everybody else in health care.

    Sorry social engineers, you can’t have your cake and eat it too!.

  • Anonymous

    The first sentence says….
    “Doctors often have a communication disconnect with their patients.”
    They also have disconnect with each other………..

  • WhiteCoat

    “Why does every patient with a stomach ache in the emergency room get a CAT scan?”

    So emergency physicians don’t get badmouthed by the gastroenterologist for not doing one when the patient follows up in their office.

    Why does every patient with a stomach ache in the gastroenterologist’s office get scheduled for an upper and lower endoscopy?

    Don’t start throwing rocks when you live in a glass house.

  • Butch Phelps

    I believe doctors are out under a tremendous pressure to be perfect, not only by patients and their lawyers, but by other doctors themselves. If the average doctor has an average of 7 minutes per patient, according to the AMA, then they can never use their gut feeling. There is only time for ordering tests and writing prescriptions. Gut reactions are hard to defend in court. Doctors are human and in a perfect world, should be given the opportunity to actually save lives. But if that were to happen, all the companies that bank their profits on mass producing medicine would go broke. Until tort reform happens, the costs will continue to escalate.

  • Michael Kirsch, M.D.

    @White Coat, fair point regarding reflex endoscopies, which I have made repeatedly, in writing and under my own name. No glass house here.

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