Physician Insecurity and Patient Expectations Drive Medical Excess

by Ean Tam, December 8, 2021

In 2008, a seven-year-old boy complained that his stomach was in such pain that he could not sleep. The boy’s parents took him to see his pediatrician. In due time, the boy found himself in a hospital in Long Island. He was missing an entire school day, which would have otherwise been a happy occasion if it were not for the IV in his arm and the impending endoscopy—a procedure in which a small camera is inserted down his esophagus and into the stomach to check for gastrointestinal issues. The doctors could not find any explanation for the stomach pain. 

Eventually, the boy’s parents brought him to a specialist in Manhattan, who did his own tests. When all the tests seemed to be futile, the specialist asked if lactose intolerance had been considered as a possible cause. After a few days of avoiding milk, the boy’s stomach pain went away. In the end, he had no gastrointestinal issues, no infections, no serious complications; he simply could not digest dairy. Silly, right? I know. The boy was me.

Lactose intolerance is not only very common, but it also runs in my family. All my signs and symptoms indicated lactose intolerance. The evidence was there. As the saying goes, “When you hear hoof beats, think horses, not zebras.” It should not have taken three doctors and a camera down my throat to reach the proper diagnosis. So why did it?

Did my parents’ urgency for their child create a dramatic flare for the doctors? Was there a desire to take action so quickly and intensely? Maybe the doctors thought a simple answer was not satisfactory enough for my concerned parents? Maybe the multiple lab tests and procedures done on me were just the doctors’ gesture that they were trying their hardest to get an answer, no matter how convoluted and unnecessary the gesture. While this may seem ridiculous that a doctor would  offer excessive medical services just to make patients happy, it is not unheard of. In fact, it is quite common. To the detriment of the medical profession, the interpersonal dynamics of the clinic can become tangled with a physician’s fear of lawsuits.

The Power of Patient Expectations

“[W]e overprescribe antibiotics, but my own view is that I don’t really care… your goals at the end of the conversation is for both you and the mother and the baby to be satisfied.”

Anonymous doctor 
(qtd. in Butler et al. 639)

Some doctors find symbolism in providing medical services they know are unnecessary. The doctors see their actions as doing everything they can for their patient (Rowe et al. 5). To them, the issue of overtesting and overprescribing their patients can be overlooked. Doctors have even reported that if their patient left an appointment without some kind of prescription, the doctors felt as if they had not done their job (Butler et al. 639). 

More often than not, patient expectations for their medical care are communicated to doctors implicitly rather than explicitly (Stivers 1127). Since patients are not always making their wishes clear, doctors decide to follow their gut instinct on what they believe their patients want. University of Newcastle researchers Jill Cockburn and Sabrina Pit found that if a doctor perceived their patient to be expecting medications, then the patient was ten times more likely to get a prescription (Cockburn and Pit 521). 

Now, one may say, ‘Maybe the doctor is correct. Maybe the doctor is just really perceptive, and they can tell what the patient wants without the patient saying it.’ Unfortunately, doctors are frequently wrong on this occasion. A study published in Patient Education Counseling observed that when doctors predicted a patient’s expectation for medication, the doctors were correct only 53% of the time (Jenkins et al. 276). Medications can have harmful side effects and high costs. Lab tests also bear negative consequences, especially if the tests involve radiation or high risks of false-positives. Medical services should not be given on gut instinct just to make patients happy.

However, the demand to meet patient expectations is both compelling and draining for doctors. In the short term, doctors may receive some relief in believing their patient walked away feeling fulfilled, but in the long term, the reality of not complying with standards of their medical training may kick in. In interviews with Dr. Theresa Rowe et al. of Northwestern University, doctors spoke about prescribing unnecessary antibiotics because they felt the patients desired them. One doctor remarked, “You spend 15 minutes trying to educate [patients], when they will go out disillusioned, come back the next day and see someone else, making you feel 5 minutes would be better spent just giving them a prescription and getting rid of them.” Another doctor admitted, “I do feel as though I’ve been slightly used. Sometimes slightly abused as well” (639). 

When doctors put an emphasis on patient expectations, they lose the motivation to limit medical excess, preferring to cater to customer satisfaction. Ironically, the physician makes the medical profession more mentally taxing for themselves. Now, they must walk a fine line between customer service and patient wellness. And to keep customers coming back for business, sometimes it pays to think of zebras, not horses.

Looking for Liability

“Malpractice attorneys like to say they save more lives than physicians.”

Eric Katz, MD, MBA (329)

When we think of the healthcare we receive, we hope physicians run their medical practice faithfully, not defensively. However, an unfortunate reality is that the threat of malpractice lawsuits and mentalities such as “more is better” have made doctors weary of acting according to their medical training. Doctors would prefer to safeguard themselves with defensive medicine, ordering multiple tests or procedures that do not always make the patient feel better, but will definitely make the doctor feel better. Doctors can use tests or prescriptions as evidence that they did their job correctly and were extensive in their examination of a patient. 

At times, some of these numerous tests may alert doctors to a hidden, life-threatening illness. If we think in terms of “more is better” or “earlier is better,” then maybe the cost of defensive medicine is acceptable. However, if we prioritize the moral integrity of the medical profession, then we should not accept that some doctors direct our medical care by threat of lawsuit. Then our treatment plans are not designed exclusively for patients. Rather, doctors will begin to merge the clinic with the court, and legal opinion with patient outcome. As Johan Bester, director of bioethics at the University of Nevada Las Vegas, writes, “[Defensive medicine] represents an egregious breach of professionalism and of ethical obligations to the patient and to society” (418-419).

We should hold doctors liable for their mistakes, but we should be mindful of where the threat of liability is steering doctors’ decisions. Current trajectory suggests more defensive medicine. It would be ironic if the tool we use to hold doctors responsible for isolated incidents encourages doctors to have an irresponsible approach to treating every patient.

Conclusion

If we would like to have patient-oriented medicine, we should consider the realities in which doctors exist today. There is no magical wand to stop doctors from engaging in defensive medicine. This is more than just a patient-doctor issue. It is one that affects our economy and healthcare system: from longer wait times to more expensive medical bills. Bill Clinton said he wanted to get rid of defensive medicine in 1992. So did George Bush in 2004. And Barack Obama in 2009.

But there are realistic steps that we can take to clarify the line between patient and customer. We should be more upfront with our doctors: let them know what we expect, what our presumptions are, and what we would like done. We should not be worried about sounding stupid or wasting the doctor’s time with questions. Doctors undergo many years of medical training to give you an answer. So ask away and be frank. We cannot risk our doctors making an inaccurate assumption of our needs and then treating us accordingly. Not all of us are doctors, but all of us at some point will be patients. We do not need to be over-tested nor overprescribed. We should take up our side of the effort to prevent medical excess and preserve our doctors’ attention to us.


Works Cited

Bester, Johan C. “Defensive Practice is Indefensible: How Defensive Medicine Runs Counter to the Ethical and Professional Obligations of Clinicians.” Medicine, Health Care and Philosophy, vol. 23, no. 3, 2020, pp. 413-420.

Butler, Christopher C., et al. “Understanding the Culture of Prescribing: Qualitative Study of General Practitioners’ and Patients’ Perceptions of Antibiotics for Sore Throats.” BMJ, vol. 317, 1998, pp. 637-642.

Cockburn, Jill and Sabrina Pit. “Prescribing Behaviour in Clinical Practice: Patients’ Expectations and Doctors’ Perceptions of Patients’ Expectations—a Questionnaire Study.” BMJ, vol. 315, no. 7107, 1997, pp. 520-523.

Jenkins, Linda, et al. “Developing and Using Quantitative Instruments for Measuring Doctor–Patient Communication About Drugs.” Patient Education Counseling, vol. 50, no. 3, 2003, pp. 273-278.

Katz, Eric D. “Defensive Medicine: A Case and Review of Its Status and Possible Solutions.” Clinical Practice and Cases in Emergency Medicine, vol. 3, no. 4, 2019, pp. 329-332.

Rowe, Tiffany A., et al. “Examining Primary Care Physician Rationale for Not Following Geriatric Choosing Wisely Recommendations.” BMC Family Practice, vol. 22, no. 95, 2021, pp. 1-6.

Stivers, Tanya. “Participating in Decisions about Treatment: Overt Parent Pressure for Antibiotic Medication in Pediatric Encounters.” Social Science & Medicine, vol. 54, no. 7, 2002, pp. 1111-1130.

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