Unreasonable expectations are at the heart of most medical malpractice
lawsuits. It is important not to overstate the benefits of a proposed treatment,
most critically 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 infants have some type of birth
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 bad information drives out good information by increasing 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.
Complications of 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 lifestyle 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.