Sunday, July 26, 2009

Discussing bad outcomes in medicine

Most doctors are not very good at discussing possible bad outcomes. Actually I think this is the most important skill of a good doctor. There is very little point in discussing good outcomes. When everything goes well, both the doctor and patient are happy . They pat themselves on their backs - the doctor for good a job and the patient for selecting a good doctor - and then move on with their lives . However, things are completely different when the outcome as bad.

We need to look at this from 2 different perspectives – before the bad outcome ; and after the bad outcome.

When there is a complication, patients are understandably upset ; and doctors get very defensive. This starts becoming a confrontational situation. The patient feels that the doctor has done a bad job and has been negligent; while the doctor is worried that the patient may sue for malpractice. Rather than trying to work together to ensure a good outcome, they often spend their energies battling each other. Ironically, this means that when the patient needs the maximal support from the doctor , he is likely to get the least attention ! In case there has been a screwup, the medical staff will often try to cover this up, as a result of which the problem continues to fester , and future patients are also likely to be harmed.

This is why it so important to discuss possible bad outcomes before they occur. This is a central part of getting informed consent from the patient. However today getting an informed consent has become a mere legal formality, rather than being an occasion to discuss the possible risks and benefits of the procedure. Good doctor have always discussed the pros and cons well before informed consent became legally compulsory. Today , it is just seen as a form which must be filled out, before any treatment can be offered to the patient.

Doctors are understandably reluctant to discuss possible complications. They want to treat the patient; and are scared that if they tell the patient the unvarnished truth , the patient may back out of the procedure because he is worried about possible risks. This is why many of them gloss over possible complications; why others leave this unpleasant task to their juniors, who perform this very inadequately by ticking the check boxes on a long form , and getting the patient to sign this.

Patient are also often willing accomplices, because they too are quite reluctant to talk about possible complications. Patients are often scared and worried that they may die; and most human beings are not very good at confronting their own mortality. They just want a doctor who will make all their problems go away and make them completely well again. This is why bad outcomes are often not discussed adequately before the procedure is performed; which is why when the complication does occur, the patient is completely unprepared , both emotionally and mentally.

As an IVF specialist , I make it a point to emphasize to patients that while IVF treatment does have a high success rate , it also has a high failure rate ; and patients need to be prepared for this. I recommended that they prepare for failure; and have a Plan B ready , in case the cycle does not succeed. Some patients get very upset when I talk about failure. They have come to me for a baby; and they feel that if I discuss the possibility of failure, this means that I am not confident that I will be able to give them one. These patients will often find another IVF clinic, which is willing to present a much rosier picture , so they can go ahead with the treatment. Patients who are more mature and realistic, understand the importance of preparing a contingency plan before the cycle starts , and are quite happy to work with me. This is why, in case the IVF cycle does fail , our patients are much more prepared to take this in their stride, and move on. In other clinics , on the other hand , patients get extremely frustrated when the doctor stonewalls and refuses to discuss why the cycle failed, in spite of the fact that he assured them that it would work. Because we have such a transparent approach , we often end up treating a lot of these patients who have failed IVF cycles elsewhere.

Everyone is good at dealing with IVF successes. I think the hallmark of a good IVF doctor is how he manages the IVF failures !

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