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As anyone who reads this blog regularly knows, I am interested in the doctor/patient relationship and why it seems to be eroding in American medicine.
Perhaps no phenomena are more reflective of that erosion than the malpractice crisis. Discussions with lawyers, patients, physicians, medical students, and risk compliance officers all point to clear and consistent communication and adequate informed consent as key factors in preventing physicians from getting sued.
Physicians are perceived by the public as over-promising and under-delivering when it comes to health care. Perhaps part of the problem is that we have been so successful at treating some acute conditions, that patients live long enough to suffer from the chronic conditions that we do not treat as effectively.
It is revealing that the Dreyfus model of career development for physicians labels the highest level of achievement as the Master Physician who is a humbled, reflective practitioner who is an expert who enjoys surprises and publicly engages in learning from personal professional failures. When physicians over-promise and under-deliver they are perhaps not being so humble. (http://ist-socrates.berkeley.edu/~hdreyfus/pdf/MerleauPontySkillCogSci.pdf
As the podcast interview with Professor J. Scott Armstrong of Wharton revealed, this arrogance is a problem for all experts. Patients want to believe in experts. Joan Didion in her new book The Year of Magical Thinking describes how all her friends believe that they control their lives because they have access to the best, expert physicians. Part of her disorientation and despair from the illness of her daughter and the sudden death of her husband seems to stem from the realization that life can throw situations at you where even the most expert of experts are not much help with the ultimate outcome.
I think part of the cause of malpractice is the public's need to believe in their doctors, and their disappointment when bad things happen. The lack of transparency and communication between physicians and patients only adds to the size of the gap that devastates the family when outcomes are poor.
So many things we depend on to create the illusion of control in our lives seem to be failing us. The local, state, and federal government were not able to protect and save American citizens in the Gulf of Mexico region after Katrina. Accounting audits do not seem to assure investors that large companies are financially solvent. The American intelligence community did not prevent 9/11 and misled the country about the existence of weapons of mass destruction. The food pyramid has been changed. Nothing is secure and reliable anymore, or so it seems.
As a pathologist I have always had a passing interest in forensic medicine, and an article in the Wall Street Journal today (Sharon Begley, Fingerprint Matches Come Under More Fire As Potentially Fallible, WSJ, October 7, 2005, B1) provides yet another example of how the public needs to be wary of expertise. Unlike the CSI television programs which tout the effectiveness of forensic tests, the reality is more disappointing and less certain.
In a classic example of over-promising and under-delivering, the International Association for Identification, the largest forensic organization, says testifying about "possible, probable or likely identification shall be deemed...conduct unbecoming."
And yet forensic science is not 100% certain. Begley in the WSJ article cites error rates of 63% for voice ID, 40% for handwriting, 64% for bite marks, and 12% for hair. She also reports on a small study where three experts said two fingerprints did not match even though they were the same ones that they had previously testified in court definitely did match. And of course there is the case of the Portland Oregon lawyer whose fingerprints the FBI erroneously said were found on evidence from the Madrid bombing. The FBI finally had to apologize in that case even though their handbook states "of all the methods of identification, fingerprinting alone has proved to be both infallible and feasible."
The Master Physician knows not to be as arrogant as the FBI is about the accuracy of fingerprints. We may not all be Master Physicians, but we can emulate them and be as humble as they are. It just might prevent us getting sued. And it just might increase the trust that is so sorely missing from many doctor/patient relationships. It just might improve the level and depth of our conversations with our patients. And it just might help us connect with those we treat.
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