Where are these statements…and how/where do I sign!?

Your solution is impractical, as you will learn when you start your clinical rotations in 2 years.

Sometimes your patient will be able to understand your explanations and the choices you’re offering. Sometimes you will have the extra time to explain all the ramifications of the choices. But not all the time, not even most of the time, not even very often.

On top of that, most patients don’t want to make the choice. They want the doctor to decide. Hopefully, within a few years you’ll be experienced enough that your abilities will justify their trust in you.

The costs of a lawsuit would be higher than the cost of the test for that one patient, yes. But not necessarily higher than the sum total cost of that test in the 1000 other similar patients that it takes to find that one patient with a positive result. And possibly one(or more) of those other 1000 patients are harmed in someway(renal failure through IV contrast, future cancer from radiation exposure, actual contrast allergy, some ditzel is seen on the CT that leads to future CTs and/or procedures to further characterize the ditzel which 2 years and countless dollars and lots of worry and maybe a cool new scar later is nothing, etc. All of these f/u procedures have their own risk as well. Where does one draw the risk/benefit line? Does money play a role? Sure. But absolutely also playing a role is the how many people do I cause harm to by doing this test to find the one positive result?

I’m afraid that if I allow the fear of litigation to run my practice, I will cause unnecessary harm and discomfort to my patients (radiation, invasive diagnostics, over medicating, etc). I’m also afraid that if I don’t exhaust my differential, I might miss something and allow harm to come which I was in a possition to prevent. And yes, I’m afraid for myself and my family if I were to be sued.

In reading these comments, both physicians and patients are on both sides of the issue. Some physicians are on the “unnecessary harm” side, and some are on the “don’t miss it” side. Others, I’m sure, are mostly concerned with protecting themselves which is completely understandable.

Some patients want the (perceived) absolute certainty of such and such being ruled out. Others probably avoid getting checked up for as long as possible because they don’t want $1200 scans that everyone knows will likely be normal. And, perhaps, a few patients are looking for a buck.

So what should I do? My default instinct is to cover my own butt and worry about myself before I worry about the patient. But I AM worried about the patient. After some thought, it seems to me that the best option is to present the patient with your knowledge and clinical assessment, then discuss the tests that will rule out the less likely diagnoses and allow the patient to decide.

I’m only 6 months into my medical training, and perhaps I’m missing something, but this seems like a fairly simple solution. Wouldn’t it free the practicioner from liability? Wouldn’t it allow the patient to decide if they want to pay that enormous bill, or if they want to take the chance that something improbable will be overlooked? Shouldn’t they decide if they want to risk the adverse effects of additional diagnostics? Doctors are employed by patients, so it shouldn’t really be my decision at all.

Actually what has changed is the expectation that you do the most cost-effective approach rather than the best approach for the patient.

In most of your examples the additional work-up did benefit the patient by ruling out a possible complicating factor. It may have only been a one in ten or one in a hundred chance that you ruled out, but it was not zero (except in one or two cases).

It used to be that dr’s would want to rule out these possibilities. Now the insurance co’s have so fouled up our ideas of what medicine ought to be that we can’t even see that point of view any more.

As your potential patient, it is certainly my opinion that most of those tests would have been in my best interests.