Do surgeons’ (mis)perceptions of risk play too big a role for patients’ good?
A globally renowned seismologist, weary of recent scaremongering reports that a major fault in California was “locked, loaded, and ready to roll,” offered a pointed scientific evaluation of risk: “You’re about as likely to be shot by a toddler than die in an earthquake,” she observed. She explained that, in geologic terms with earthquakes, imminent can mean centuries, not milliseconds. Further, over the last 100 years, there have been an average of 40 temblor deaths annually in the Golden State; in 2015 alone, toddlers with guns killed roughly that same number of Americans.
Suddenly, the media fascination with an impending seismic catastrophe receded to more normal concern.
This much publicized discussion of risk underscores the private complexity that many patients confront in harsh, short time spans when they get multiple surgeons’ opinions on whether they should undergo major procedures. Why does one surgeon tell a young patient and his family to wait and try a lot of other treatments for his brain hemorrhages but not an operation? Then why does a second neurosurgeon tell them the boy needs a procedure NOW to save his life?
New research published in the peer-reviewed Annals of Surgery suggests that surgeons’ hugely varied perceptions of risk play an outsized role in their sharply different ways of treating patients. As a story from the online news site Vox says, these disparities about risk─how surgeons perceive it and how they communicate it with patients─make some sense; they’re rooted in physicians’ experience and practice. But doctors are people, and they may be excessively inclined to go with their gut, or intuition, or they can rely on a not well defined, fact-based means to weigh risk and reward. These are far from optimal approaches, as I see in my legal practice.
Risk is ubiquitous in health care, where tough choices need to be made constantly and often. Vox points out that researchers are, for example, developing online risk calculators that can assist both surgeons and patients in gathering a broader, more objective range of information and factors for improved decision-making. There are other ways to get key data, too.
Learning from error
I know we all hear about how doctors and surgeons have become risk-averse, lawyer hating, and resorted to over-testing and other bad practices for fear of litigation by their patients. I’ve also written recently about the important observations by Ralph Nader─one of the great consumer champions of our day─about the critical role that lawsuits, especially in medical malpractice, play in improving and saving lives.
The Wall Street Journal, in fact, has recently reported on how some enlightened hospitals and researchers are scrutinizing old lawsuits to improve diagnosis and care, learning as much from mistakes as successes. Or, as some of my legal colleagues have headlined their views on this story: Good doctors learn from malpractice, bad doctors lobby for new laws.
The Journal says that, based on closed claim reviews:
- Obstetricians might need to be more aware in treating older, overweight mothers of the risks that a large, first baby will get stuck and suffer harm during a difficult vaginal birth.
- Emergency room physicians may need to be more aware of the risks of failing to explore inflamed and infected wounds. Many of these may be cleaned, drained, and sewn up by nurses or physician assistants in ERs without a surgeon examining the patient closely. This can mean a more experienced caregiver fails to detect that a foreign body, such as a stinger or object, remains in the wound, causing major complications later.
- And orthopedists have started to learn the importance of follow-up with patients who undergo knee and hip replacement surgery. They can assist considerably in their own recovery, but a third of the patients who suffered post-surgical injury had failed to keep up with treatments and appointments.