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The Patient's Expectations

Unreasonable expectations are at the heart of most medical malpractice lawsuits. It is important not to overstate the benefits of a proposed treatment, most critical if the treatment is for a minor condition or if there are effective alternative treatments. It is simple enough for a physician to avoid overstating the benefits of a treatment in talking with the patient. It is much more difficult to combat the unreasonable expectations that patients get from the constant news about medical breakthroughs. With patients treated to the spectacle of routine heart transplants and perfect test-tube babies on the evening news, it becomes very difficult to explain that heart disease is a chronic illness without a quick fix and that a certain percentage of all babies have some type of birth defect.

A physician must assume that every patient has an unreasonable expectation of the benefits of medical treatment. Whether these unreasonable expectations arise from overly optimistic news reports or medical advertising, they must be rooted out and dispelled. The physician must specifically ask the patient what the patient expects the treatment to do and believes the risks to be. This will allow the physician to deal explicitly with the patient's misinformation rather than blindly giving the patient more facts to confuse. In a variant of Gresham's law, it is clear that good information does not drive out bad information; it increases a patient's misperceptions. Patient misperceptions should be documented and a notation made about the correct information given.

Even when the physician and the patient agree on the severity of the complaint and the risks of the treatment, they will not necessarily make the same decision about undergoing the treatment. Physicians and patients have different risk-taking behavior, and patients differ in their risk-taking behaviors. Some are gamblers, and some keep their money under the mattress.

One patient will present with chronic pain and be satisfied to find out that it is only a bone spur, having assumed it must be cancer. Another patient with the same problem will want the physician to try to correct the spur surgically, despite the risks of anesthesia and potential disability. Patients who do not like to take risks are poor candidates for treatment if their untreated prognosis is good and the available treatments are risky. Patients who are aggressive risk takers may want "kill-or-cure" treatments, but they may also be more aggressive about suing when the treatments fail.

The patient's occupation and avocation can strongly affect his or her tolerance of certain risks. People who engage in activities that involve fine motor skills are susceptible to subtle injuries that might not be noticed by other patients. A routine arterial blood gas sample drawn from the radial artery could diminish the coordination of an accomplished violinist. The same injury in an attorney whose hobby was gardening would go unnoticed. Accommodating treatment to the patient's life-style should be part of medical decision making but is sometimes overlooked. Moreover, for esoteric skills, the patient who is an expert in the skill will be a better judge of its demands than the physician who may never have encountered the problem before. In this situation, the patient may teach the physician, if the physician is careful to listen to the patient.

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