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Striking a Balance – Defensive Medicine & Reassurance

As a family medicine doctor, I get a lot of vague patient complaints, all of which could be something sinister. Got a little tingling on your lower jaw? It could be your snaggle tooth, or it could be Giant Cell Arteritis — defensive medicine vs reassuring the patient. Blame the tooth or go in for the bedside temporal artery biopsy?

Imagine being an ER doctor or trauma surgeon or GI/Rheum specialist. I would imagine that these decisions are exponentially more complex.

Scientists, researchers, and policymakers don’t understand defensive medicine. In fact, here is a review article written by 4 researchers from Iran. WTF do they know about practicing defensive medicine in the US?

Defensive Medicine

Remember, defensive medicine is a made-up term, and we’ve all been conditioned to practice this style of medicine. Nobody explicitly tells us that we cannot miss a single diagnosis or order multiple tests for the vaguest of symptoms. We put this pressure on ourselves because Dr. Mo doesn’t want to blame himself if and when he gets sued.

It’s like when you yell at your kid for doing something even though you know it likely will backfire. But you’d rather yell at the kid to assuage your fears. Should something bad ever happen to your kid you’d still be devastated but at least you could tell yourself that you did something.

Defensive medicine is an aphrodisiac that doesn’t work. It’s the viagra you take that you don’t even need. It’s the ultimate placebo that doesn’t work.

The Medical Establishment

Defensive medicine results from learning about a colleague who got sued.

Okay, so the next time some old lady comes in with dysphagia I’ll send her for a CT and endoscopy and get a chest x-ray. I don’t ever wanna be sued so by not missing a bad diagnosis I’m protected.

Of course, patients also sue when they have an unexpected outcome. We also get shit from our bosses when we have a patient complaint. In essence, it’s for things we didn’t do than the things we did.

By definition, doing more should protect us. Getting the CT, laying eyes on the post-op complication, taking that case to the OR, ordering blood tests, starting the IV antibiotics, and transferring the patient to the ICU.

The medical-legal system won’t look at all the nec fasc cases you ruled out visually without taking the patient to the OR. They will look at that one case that was questionable and had a bad outcome.

Or, so it seems, to us.

The Value of Reassurance

The bad news is that you cannot provide reassurance to someone you don’t know; to someone with whom you never built a bond. That kind of faceless reassurance is worth nothing.

Listen, trust me, that elevated heart rate is totally fine and if the EKG is normal and your heart sounds good, you should be fine, I wouldn’t worry.

But, don’t get it twisted, reassurance is one of the most precious things we can offer patients and they know it. It’s like getting a velvety hug from a microwaved marshmallow. You know it, they know it, and everyone is happy.

But there is more to reassurance which we’ll get into later.

Building Patient Rapport

In the perfect medical world we would never take care of patients with whom we cannot build rapport. When I went saw my first surgical consult for my hand, I knew that this was a very knowledge, well-respected hand surgeon and he even immediately diagnosed me with an arterial thrombosis of the hand. Never mind that he was wrong; I just didn’t have any rapport with him.

The next surgeon did a thorough exam and said he didn’t know what was going on but that I needed surgery and he’d likely figure it out after taking some biopsies and looking around in there. I would have given up my virginity to that dude, that’s how much rapport we had.

In the current insurance model you are forced inside a room with someone who communicates differently from you. They have different values and expectations and there simply isn’t enough time to build rapport.

Even worse, sometimes you think you built rapport but the patient walks out in disbelief wondering how such a shitty doctor can have a license to practice medicine. The same interaction, the same dimension, but two completely different perspectives.

Now, once you do build that rapport and get the right feedback that the patient trusts you at least as much as you trust them, that’s when you reassurance carries a lot of weight. And that’s still just the beginning, they are still waiting to see if your reassurance will let them down.

Reassurance Is a Time Extension

When I reassure a patient I’m just buying more time. Not just free, unstructured time but tightly regulated time with bookens and boundaries. I want my patient to closely monitor what is going on and have a place to report their findings to should something go unexpectedly.

I think this pain will disappear over the next 1-2 days if it’s just gas pains but if it really is some obstruction we’ll know quickly because you’ll get nausea, worsening pain, perhaps a fever, and definitely vomiting. I need you to right away go to the ER and also notify my office. Now, let’s review, what are the best options for you at this time moving forward and what remains unclear?

I had a patient whom I saw in the urgent care frequently, he just built a rapport with me and I genuinely loved him too. Just a lovely older man who fully trusted me with his health. I did his knee injections, managed his diabetes, and took care of a small pinky toe infection.

Well, he did trust me but I reassured him prematurely. Unfortunately, the last time I saw him he likely was septic though I didn’t recognize it and I suspect it was that little pinky toe. I found out a couple of days later he passed away.

Designing the right guardrails for your patients is your responsibility. You must consider not only the patient’s health but also their psychosocial state, environment, day of the week, healthcare system, health literacy, and support structure. It’s a lot, it really is. But, according to society, it’s our job.

You Will Get Sued

I say, “You will get sued,” not to scare you or because it’s true, but because it’s important to be the kind of physician who understands the inherent risk of being a doctor.

We do crazy shit to people who are often seemingly healthy before coming to us. Our actions, decisions, advice, and treatments can have life-changing consequences. And the outcome of that must at times be bad because that how statistics and entropy works.

If I am the best doctor in the world, by definition, there will be times when random chance, the medical system, or some other factor will result in a terrible outcome for my patient. If not terrible, at the very least, a very pissed off patient who knows how to wield a bulldog attorney.

Fortunatly, your wellbeing and your peace isn’t tied to a lawsuit. Why? Because you have very little control over it. There are so many moving parts to a lawsuit that it’s best to just have it take you for the ride. Like surfing, sometimes the waves takes you down and tumbles you around for a while before letting you up, right before you think you’ll have to inhale a gallon of whale piss.

What Practicing Medicine Means to You

I can’t practice your medicine and you can’t practice mine. In fact, the last thing medicine needs is a bunch of doctors practicing the same thing. Deversity brings life to the party and is more likely to meet the needs of all healthcare consumers.

What does medicine to you?

  • Do you love it for the science?
  • Are you all about the patient-doctor relationship?
  • Is it the power and prestige?
  • The money?
  • Mastering the art?

It’s different for each and every one of us. For me, it used to be about mastering the art. Then I thought it was because I wanted to put patient healing ahead of everything else.

Now, so many years later, I realize that medicine is a good profession that earns me a stable income. If I don’t drink the Kool-Aid too much I can even do some good but know that most of my patients prefer the quick fix; no judgement there, just how things are.

Things will change from the first decade to the last decade you’ll practice medicine. In the beginning, you want to be better than the other brown doctor. The next decade you want to just earn a good income without killing too many patients. Later, you might want to give back to the profession.

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