Good medicine sometimes makes patients unhappy

As physicians, we all strive to practice good medicine. Good medicine means evidence based medicine in the patient’s best interests. In the ideal world this will make patients happy and satisfied. If you are getting the best treatment for your condition you should be happy, right?

In the real world, though, keeping patients or their families’ happy and practicing good medicine might not be possible at the same time. This is true for both inpatient and outpatient physicians.

A recent experience that one of my partners had to go through demonstrates the point. The patient in his mid 80’s came with a massive heart attack. He had a heart attack at home and, unfortunately, wasn’t found until later. He developed muscle breakdown that affected his kidneys. He had to be started on continuous dialysis.

Despite aggressive medical management, his condition had progressively deteriorated. The blood pressure remained low despite the high doses of medications. All major organs started to shut down. The patient was dying.

When his condition suddenly deteriorated and he developed a fatal arrhythmia, the responding physician refused to escalate care and suggested to the family that comfort care was more appropriate in his case.

The family was unable to make a decision, insisting on providing futile care. Subsequently, they became angry with the physician and complained to the hospital administration. This caused the physician emotional distress and an unnecessary headache. The refusal to provide futile care lead to a very unhappy family yet it was the right thing to do. It was the right thing for the patient.

Things might not be as dramatic in the outpatient world, yet the problem, probably, exists on an even bigger scale. Studies have shown that physicians are more likely to prescribe medications and order tests when confronted with a specific request from the patient. Often the request is granted even though it might not be the best treatment for the patient. Some studies have shown that the perception of the quality of care improves once the request is granted.

Some hospitals and clinics are even trying to improve patient satisfaction scores by adjusting the physician’s compensation and bonuses based on the patient satisfaction. Does that encourage physicians to do what the patient wants and not what the patient really needs?

A study published in the Archives of Internal Medicine demonstrated that the request for antidepressant prescription is much more likely to be granted if the patient asks for the medication directly or indirectly. In many cases these prescriptions would be considered unnecessary or even inappropriate by the current practice guidelines.

Any physician ever practicing outpatient primary care knows that patients often expect to be given antibiotics for upper respiratory symptoms, even though, viral infection is the culprit in more than 90% of cases. You might say: “What’s a big deal if the patient takes antibiotics for a few days? Even if unnecessary, it might make the patient feel like he is actually being treated.”

Now, imagine on the national level how much wasteful cost it adds to medical care. The patients are being exposed to unnecessary risks of antibiotics. Antimicrobial sensitivity will be altered in the community with emergence of drug resistant pathogens.

The bottom line is – practicing good medicine and having satisfied patients often means performing a balancing act on the part of inpatient and outpatient physicians. The silver lining, according to the study mentioned earlier, is that effective communication with the patient is shown to improve satisfaction even when the specific requests are not being granted.

Ralph Gordon is a critical care physician who blogs at realICU.

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