Angry Doctor

Saturday, June 24, 2006

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.


  • "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...).
    does that means that when a patient compliant of CHEST PAIN, doctor order ECG, CHEST X-RAY. Looks like most MOs does that. they are doing it because they are not sure, or as u say, TO PLAY SAFE? GIDDY, order GLUOUSE POCT, ECG, or even FBC plus PTINR. late period, HCGU, regarless of age, so long is less than 60 years old.

    By Anonymous Anonymous, At June 24, 2006 9:51 pm  

  • You will notice that the original comment referred to physical examinations, and that I specified that I was referring to clinical examination in our discussion.

    Physical examination differs from radiological and laboratory investigations in that the doctor himself can perform them and have the 'results' he requires there and then. There is no need for the patient to travel to another place for the investigations, no extra costs, and no time lag. There is little excuse for not doing a proper physical examination.

    Even if you extend the arguments I used for requiring a proper physical examination to investigations, the way to be safe is not to do *everything*, but to do *everything you think is clincally indicated*.

    By Blogger angry doc, At June 24, 2006 11:13 pm  

  • my goodness, I very frequently have chest pain and my doc always say it due to stress and did no physical examination nor ECG, just prescribed pain killer.

    Is he being overly confident of himself or just plain lazy?

    By Anonymous Anonymous, At June 25, 2006 2:07 am  

  • regarding your example about the guy with and ankle sprain "ASKING" to have his BP checked.....

    Well I wasn't referring to that in my question or more is better or less is better.

    I find that if you wait until the patient's ask you, it's a bit late already. They have somehow formed some opinions about you along the lines of "this doctor so lousy one, never check BP, I go to other doctors automatic will check BP, this one I have to ask....cheh...."

    So do we go out to "wow" the patient with all kinds of examinations (non offensive type) so that they feel like they are being treated like a king? I think that's what some patients like.

    With regard to examinations that patients don't like. Well if you have been practising long enough as a GP, you'll know that women generally do NOT like to have a male (especially younger and still has a whole head of black hair) doctor do a vaginal examination for them. But somehow they choose to come and see a male doctor for their "irregular menses"?!

    The other thing is the patient who comes in asking for "Something to help me pass motion" because he has been having constipation for many months. History taking detects a change in bowel habits and a per rectal examination with Proctoscopy is offered by the doctor.

    Patient looks at doctor "disgusted" and says he has been having this for very long, everytime take some medicine to put up backside then can BO already, no need to check lah.

    What do you do? Document patient refused DRE?

    Well I had a case where this happened and a few months later the patient came back with hematochezia and finally I convinced him to have a DRE/Proctoscopy (apparently passing out fresh blood is scarier and more convincing for the need to DRE!) and found a tumour.

    Very unfortunate. But somehow I feel bad myself too. But forcing all those "disgusted" looking (especially female) constipated ones with recent change in bowel habits (usually described away as "too heaty" by patients themselves) to undergo a DRE/Proctoscopy will probably drive them away from my business too.

    By Anonymous Anonymous, At June 25, 2006 9:43 am  

  • Dear Anon,

    I think you should go all out and wow the patient lah. It doesn't take very much more to do "everything nice" for the patient right? Better safe than sorry.

    As for the stuff that patients don't like. I agree with angrydoc, it depends on the problem and type of patient.

    If it's an anal patient, then just document they refused it. I wonder if SMC accepts that?

    I mean forcing the patients to do things against their will is never good right? On the other hand the patients might complain later that the doctor did not "explain" to them the consequences well enough.

    Well if they aren't willing to listen, no amount of "explaining" will work right? Another point is whether it is worthwhile trying so hard to explain to these people who are so unwilling to listen? How far do you go to explain?

    "You might have cancer. I need to do a check of your anal region to see if their is a tumour. It involves putting my finger gently into the anus to feel for a tumour as well as inserting this device into the anus to see if there is a tumour"

    "Har? Must ar?"

    "I would recommend it. I need to do that to do a complete examination for you bearing in mind you have symptoms that suggest possible cancer"

    "Can dowan or not? Very 恶心 you know! That thing so big!"

    So do you go on and try to convince someone to go through with something you would not like to have done to yourself too? Or just go the easier option....

    "Ok lor, but then I would not be able to check you fully and cannot exclude a tumour. If the problem persists please come back to see me again. But we might have missed a window of opportunity to detect early cancer"

    "Doc, you just gimme the medicine lah. I don't think is cancer lah"

    *Write down, Explained to patient possibility of colorectal Ca, offered to do DRE/Proctoscope, but patient refused. Explained possibility of a missed diagnosis of colorectal CA and advised patient to return for early review if symptoms persist"

    Is that acceptable?

    By Blogger Dr Oz bloke, At June 25, 2006 10:39 am  

  • anon, I see your point now.

    For the same reasons I gave before (convenient, no extra cost etc.), I don't think there is harm in performing un-indicated physical examination just to 'wow' a patient.

    By Blogger angry doc, At June 25, 2006 11:54 am  

  • We shuld be like banks and have legal disclaimer. If patient refuse p.e or investigations, then they forgo the right to sue in future.

    That way a lot of money can be saved and cost effective medicine can be practiced.

    Problem occurs when patients refuse tests/ pe and still sue in future or family sue. The doctor is in a lose lose situation.

    To do p.e , inv would upset patient and lose business. Not to do would render oneself neglient.

    Woody Allen
    More than any time in history mankind faces a crossroads. One path leads to despair and utter hopelessness, the other to total extinction. Let us pray that we have the wisdom to choose correctly.

    Hopefully we don't have to make such decision in future once the rights of doctors are respected

    By Blogger Game1980, At June 25, 2006 9:51 pm  

  • Very early in my practice, I was asked to render a surgical opinion on a young girl with abdominal pain, already in hospital for a couple of days. Appendicitis was the question. Based on all testing and my exam, I was certain she did not have appendicitis, nor any other surgical illness. But the mom was beside herself with worry, saying that her other daughter (who was present as well) had had abdominal pain which her doctors were certain was not appendicitis, and which had gone on to rupture.

    I was pretty young, and probably didn't have the weight of authority. But I explained in careful and thoughtful detail why I was certain, in this case, that operation was not necessary. The mom remained certain that the child should have surgery, and was clearly and deeply frightened at the prospect of having none. I said I'd come back to recheck later. As I walked out, the mom kneeled to pray, and had the daughters pray as well. What was a young surgeon to do?

    By Anonymous Anonymous, At June 26, 2006 3:24 am  

  • So what did you do Sid?

    Exploratory laparotomy?

    Which brings to mind another question. How far does this patient autonomy go?

    Can a patient order the doctor (surgeon in your example) to do something even if it is not needed and the doctor has explained fully how unecessary it is?

    Can the patient insist that you open up her abdomen and do and "operation" just to make sure that she does not have appendicitis?

    How far can this go? They refuse the most necessary and prudent, and insist on the most unnecessary and wasteful!?

    By Blogger Dr Oz bloke, At June 26, 2006 9:29 am  

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