The Power of Expectations

April 1, 2005

Managing the ambiguity of medicine

When Max, my precious 2-year-old, started wheezing last week, I nervously took him to his pediatrician. She told me he had "an asthma-like condition," noting that "his lungs are tight and his oxygen levels are low" but adding she's reluctant to call it asthma until he has at least two more attacks.

"'Asthma' freaks parents out," she explained.

Turns out, I'm one of those parents, and I was more freaked out by being told he had an "asthma-like condition" than I would have been to learn he had asthma.

I wanted a diagnosis. Logically, I understand there are gradations of disease and that a diagnostic process must be followed.

Emotionally, I want to put a name to what is troubling my boy. A diagnosis offers certainty -- and a specific treatment plan.

The physician was doing her best to communicate honestly, but I didn't want to hear what medicine is really like. I wanted to kiss it and make it all better.

I'm not the only patient -- or nervous parent -- who wants medicine to be more clear-cut than it really is. We expect a perfect science, not a muddy art.

Recognizing this in your practice is important, not only because you'll provide better care when you understand your patients, but also because your patients will be happier -- and thus less inclined to sue you.

You think a patient's decision to get a lawyer is guided only by whether he had a bad medical outcome? Think again: the ones most likely to sue are those whose expectations aren't met -- whose perceptions of what should happen smack up against a different reality.

"Lawsuits are not about bad outcomes ... they are about expectations," says Linda Crawford, a faculty member at Harvard Law School, in Archives of Surgery. In her research, 98 percent of patients who actually experienced malpractice did not sue.

"[R]isk appears related to patients' dissatisfaction with their physicians' ability to establish rapport, provide access, [and] administer care and treatment consistent with expectations," confirms a report in the June 12, 2002 issue of JAMA.

Doctors and patients often think they understand each other, but don't. You might assume, for instance, that a man about to undergo a prosthesis implantation for erectile dysfunction would listen closely to his doctor's explanation of the procedure and risks, and ask plenty of questions. After all, not only is the procedure highly invasive, it also typically renders less drastic therapies useless. But David Sobel, a lawyer and physician finishing his residency in urology, says you'd be surprised how many patients are simply clueless about what they're getting into.

"I'll be wheeling a patient down to the operating room ... and he'll say, 'Well, doc, I guess if this doesn't work I can always have it taken out and I'll go back to where I was,'" Sobel told me. "The reality is that often in my hospital the physicians are getting informed consent the morning of the surgery [when] the patient is incredibly anxious. [Patients] aren't hearing what's said."

For Sobel, solving the malpractice crisis is more about preventing lawsuits through better communication than capping the damages patients can receive once they're mad. He feels so strongly that physicians need a better way to set patients' expectations that he created Emmi, an interactive educational tool for patients that he believes can reduce risk -- and malpractice rates. See how it works at www.rightfield.net/whatisemmi.shtml.

It's a conundrum. As a physician, you need to appear trustworthy, knowledgeable, and safe. Yet succeeding at that means patients are dumbfounded when they think something goes wrong, can't be given a name, or falls into a medical gray area. But the better you get -- the more we patients hear about medical advances -- the less we hear you when you tell us about risks and ambiguity.


As for little Max, he is doing much better -- for now. And our pediatrician was so very reassuring at his follow-up visit. Still, I wince every time he coughs and wonder what will happen next.

How do you manage expectations? E-mail me at pmoore@physicianspractice.com.

This article originally appeared in the April 2005 issue of Physicians Practice.