Doctors in no win situations: Damned if you do or don’t

Here’s a little story from the early days of my first job as a chairman of surgery.

Shortly after I assumed the role of surgical chairman in a community teaching hospital at the ripe old age of 40 and having absolutely no administrative experience, I visited a mentor of mine whom I had known since I was a medical student. He had been serving in a similar role at a larger hospital than mine, and I thought he might be able to share some wisdom about how to be a good chairman.

He was dispensing sound advice for most of the hour or so I spent with him. Then he said something that struck me. Sometimes the unexpected happens and there’s no simple solution. He told me that among the challenges he was facing were two lawsuits.

One was from the family of a patient who had died after a carotid endarterectomy that had been performed by a surgeon in his department. The plaintiffs were suing the hospital and my mentor, the surgical chairman, for allowing what they alleged was an incompetent surgeon to do complex vascular surgery.

The other lawsuit was by a surgeon in his department who had requested privileges to perform carotid surgery, which had been denied by my mentor on the grounds that in his opinion, the surgeon was not adequately trained in carotid surgery.

I never heard the outcome of either case, but it certainly seemed like a no-win situation.

Although that encounter occurred some 25 years ago, the problem persists today. For example, patient advocates are concerned that pain is not being adequately addressed. Yet there is an epidemic of abuse of narcotic prescription drugs that is sweeping all parts of the country.

We also are being criticized for runaway healthcare spending and being encouraged to reduce things like unnecessary testing, while a recent jury verdict for $6.4 million in Philadelphia went against two physicians for failing to order certain tests on a man who had a fatal heart attack 3 months after an emergency department visit for pneumonia.

Some say too many CT scans are being ordered for the work-up of appendicitis with worry that radiation will cause future increased cancer rates. However, in my experience, patients prefer accuracy in diagnosis over a theoretical increased risk of cancer 30 years from now.

Not long ago I was called by an emergency physician who said he had a 17-year old boy with a textbook case of acute appendicitis. He felt a CT scan was unnecessary. I examined that patient and agreed. I explained to the boy’s mother that I was convinced he had appendicitis and needed surgery. She said, “What about a CT scan?” After a lengthy discussion, I convinced her that the CT scan was not needed. As I made the incision, I said to the OR team, “I sure hope this kid has appendicitis.”

I can think of many more such situations. How should we resolve them?

It seems to be the mantra for modern medicine. “Damned if you do and damned if you don’t.”

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • NewMexicoRam

    “Ain’t it the truth? Ain’t it the truth?” — Lion, somewhere in Oz.

  • Dike Drummond MD

    Thanks for this post SkepSkal – it only seems like a Mantra because these situations can really get under our skin as physicians and especially if you have chosen to take on a leadership role.

    If you take a look at your day … I would wager there are only rare situations when you feel damned both ways. It is just that they feel so bad they dominate your feelings and stand out in your mind over and over again when we are stressed. You are also naming a stress that is unique to physicians

    We hear population based statistics – listen to opinions that judge us collectively – and then make the natural leap to allow these thoughts and feelings to intrude upon decision making with an individual patient. You quote increased cancer risk from CT and the opinion that “doctors order too many CT’s” – we all have heard it and felt it. AND that critique and population based statistic has no place in an individual patient care decision — like whether or not your patient needs to go straight to the OR.

    All of this contributes to the stress and burnout epidemic – and some of it we can see as tricks our brain and the conditioning of our medical training plays on us. And PLEASE drop the other shoe. Did your patient have a hot appy? (inquiring minds want to know)

    Dike Drummond MD

  • Carol Levy

    “For example, patient advocates are concerned that pain is not being adequately addressed. Yet there is an epidemic of abuse of narcotic prescription drugs that is sweeping all parts of the country.”
    The DEA has taken out the ‘war on drugs’ on those with chronic intractable pain. No one has proven that this epidemic is the result of patient abuse, misuse or that of most pain management specialists. This is a damned if you don’t, damned if you do only because we, responsible chronic pain patients and their responsible doctors are being scapegoated.
    As to the lawsuits it is not Darned if you do, darned if you don;t. Public citizen has said 85% of all malpractice os caused by 15% of recidivist doctors. It is the patient who is darned because neither the state nor medical societies go after these doctors.
    In your example do you know that those tests were unnecessary? You are, it appears making that assumption. I would assume that the tests should have been done, proof available in order for the court/jury to come to its decision.
    I agree with you about people wanting unnecessary tests, they hear it on TV, House, shows like that and have become convinced more is better. That is an issue, by the expert doctor, this test should be done and this one not. Often the outcome makes 20/20 hindsight the only way to know if maybe it should have been ordered.
    Carol Levy
    author A PAINED LIFE, a chronic pain journey

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