Medical Decision Making and Perceived Risk.

Dr Wes talks about how even the perceived risk and  threat of litigation drives medical decision making. I want to come out and say. Absolutely.  100%.  No doubt in my mind.

The threat of litigation, perceived to be real by reason or not, rational or irrational, drives decision making. It is without a doubt at the front of many, if not most physicians' minds when they formulate a plan. It is the threat of delayed diagnosis. It is the threat of a missed diagnosis.

Physicians do not walk into a day of work wondering if they are going to get sued for chopping off the wrong leg. Physicians do not walk into work thinking they are going to get sued for administering a lethal dose of heparin.

Physicians do walk into work with a daily fear of missing a deadly diagnosis. Of missing that case of nonspecific headache that turns out to be meningitis or an aneurysm. Physicians do walk into work daily with a fear of missing that case of chest pain that turns out to be Prinzmetal's angina. They do walk into work on a daily basis with a fear of missing that case of a C1 fracture.

Physicians walk in fear daily with the fear of the unknown. Medicine is a big unknown. How unlikely is it that the old man with chest pain has a ruptured aortic aneurysm? How unlikely is it that the young lady with atypical chest pain is having a massive MI? How unlikely is it that the asymptomatic old lady who fell out of her hospital actually has a subdural hematoma?

The answer to the question is: It doesn't matter.

In our current state of health care, the standard of care is the perceived standard of perfection. And until that community standard changes, Dr Wes and I will always error on the side of caution rather than the side of comfort or the side of expense. The legal standard is the community standard. And the community standard is an impossible standard of perfection.

Example in point. I took care of a woman found unresponsive at a local park. It was unknown how long she was down. She was resuscitated from a PEA arrest and was admitted to my ICU with severe anoxic brain injury, status seizures, ARF, cardiogenic shock with an EF of 5% and recurrent VTach. I determined that this 79 year old lady's chances of survival was 0% for discharge from the hospital alive.

No known family. No DNR. No guidance on what to do. Except my clinical judgment. I wanted to withdraw medical care to allow natural death but ran into concerns by other physicians regarding Happy's Hospital's futile care policy. The simple act of trying to do the right thing and let this lady die peacefully was interrupted by an overwhelming concern for the correct legal interpretation of Happy's state laws. Death should be natural, not legal.

In this situation, like so many, the legal ramifications will trump the right medical decisions. But it happens. And it happens on auto pilot all across this country. Every day. Every single day.

I would even say that so much of medicine is legally driven, that if you have ever been a patient, you will have been exposed to unnecessary tests and prolonged evaluations to protect a physician from the possibility of preventing a missed or delayed diagnosis, no matter how unlikely the probability.

It shouldn't have to be that way.