More or Less

A reader asked me this in a comment on my previous post, and I thought it was a topic worth discussing:


Angrydoc, do you find yourself doing certain procedures and examinations just for the sake of satisfying the customer's pre-conceived expectation that the doctor should be checking this for me and that for me even when it isn't necessary?

Or like doing more is good and less is bad?

On the other hand, do you also find yourself doing less sometimes because the patient's pre-conceived expectation is that he should not have certain unpleasant procedures done on him?

Eg patient complains of constipation/abdominal problems and you don't complete the physical examination by looking at the groin for hernia or perform a digital rectal examination? Patients give me the "funny look" when I want to check their groins for hernia and perform DRE.

So which is better? Having a patient walk out the door with a happy smiling face because the doctor has done what he wanted? Or having a patient walk out the door thinking, "Basket the doctor sick or what want to see my down there and stick finger in my ass!"

I think in the former the possibility of lawsuits and complaints to SMC are actually lower!


The issue of patient expectations as to what constitutes necessary and unnecessary examination is an important one. Ideally a doctor should be able to manage a patient's expectations and educate him on whether and why an examination is required or not. In reality we all know that it can be difficult. Still, it's something a doctor should think about.

Over the years I have come to form some opinions over this issue, some of which have come from reading of the MPS Casebooks.

As usual when it comes to discussion of clinical situations, a lot depends on the specific patient and clinical condition, but in generally I would say more is better than less when it comes to clinical examination (laboratory and radiological and other investigations are another altogether...).

Say you are sitting in an orthopaedic clinic and this healthy young man who is seeing you for an ankle sprain asks you to check his blood pressure. Certainly there is no real indication to do so, but it will take only a minute of your time and you might (just might) pick up a case of secondary hypertension. I find it hard to say 'no' in cases like this one.

You might get a complaint if you refused to check his BP, even if his BP was perfectly normal. It's something a reasonable person (and perhaps doctor too?) would expect a doctor to check and a simple examination that takes little time and costs, and is non-invasive. (If he asked for his AFP to be checked even though he has no risk factor, then it would be a different situation altogether.) And if he did turn out to have hypertension and suffered real damage as a result of a delayed diagnosis because you didn't check his blood pressure for him, he might even succeed in a suit against you.

In the reverse scenario of a patient refusing an examination which I think is required, I make it quite clear that without the examination I consider the consultation incomplete and that due to that I may decide not prescribe a treatment. I usually offer the patient the option to see another doctor or to refer the patient to a relevant specialist, but I never 'just give medicine' without completing an consultation properly. Always offer an option and a follow-up or referral, but never force a patient to undergo an examination.

The possibility of missing important diagnoses if you prescribe treatment without a proper examination is always there. An 'ezcema' which you don't bother to look at before you prescribed some steroid cream might turn out to be a skin cancer. An 'irregular menses' for which you did not perform a vaginal examination before you prescribed the woman some hormones may turn out to be a cervical cancer. The possibility of a complaint to SMC or even a lawsuit in such cases is of course very real. If you looked and made a wrong diagnosis, it's a case of error in judgement. If you didn't even look, it is negligence.

Now even if the examination revealed benign conditions or produced a negative findings and the patient filed a complaint, I seriously doubt any court or the SMC will find you guilty, as long as you did not force or coerce the patient into the examination (in which case it becomes battery, if I have my law right).

It is true that patients tend to complain when they are unhappy (for whatever reason) rather than for real negligence or damages, so by not acceding to their request for or refusal of an examination you will be setting up yourself for more complaints. However, if your reasons for requesting or refusing to perform an examination are sound, then it is likely that these complaints will not stick. On the other hand, if you agree to not performing an examination when it is clinically indicated simply because the patient would rather you did not and you missed an important diagnosis, then the complaint when it comes may possibly end your career.

I'd rather be safe than popular.