To avoid being sued for malpractice, many authorities say, a doctor should mainly try to be the conscientious, caring doctor we all want. But physicians are also being told some tricks that don't fit the picture of the concerned, friendly doctor.
Patients ought to know about these, too.
To start with the more positive suggestions:
Dr. Raymond Scalettar, a Washington internist, member of the American Medical Association board of trustees and vice chairman of National Capital Underwriters (the D.C. doctors' own malpractice insurance company) recently told fellow physicians:
"I do not believe any encounter with a patient should end without a physician asking, 'Are there any further questions, and do you understand what we have been discussing?' The physician should always leave the door open for the patient to telephone or return to the office . . .
"One cannot ignore even the most insignificant of complaints with a patronizing and reassuring comment. If it is significant enough for the patient to complain about, it is significant enough for the physician to pursue even though it may require observation over a period of time . . .
"Objective technological skills alone will not prevent lawsuits . . . A dedicated relationship will cause many patients to think twice before seeking litigation . . .
"We can never ignore the potential mischief that a physician's office staff or hospital surrogates can induce . . . They should not be making decisions beyond their sphere of competence or training when they speak for you . . .
"There is no excuse for leaving your practice uncovered without a back-up physician taking calls or seeing patients when you are gone . . . It is a breach of responsibility to have one's answering service tell the patient the physician is away for the weekend and if there are any problems to go to the emergency room except when the patient may be facing a true emergency ." Scalettar points out that a doctor must judge a patient's competence: "Will he or she follow through with instructions? . . . The chart must be documented as to the recommendations and the patient's responses . . . A useful technique I have found successful is to dictate one's evaluation in the patient's presence. I then encourage any questions . . . Patients appreciate this kind of openness."
The patient whose questions go unanswered is the one whose anxiety and anger are unalleviated, says Dr. Harry Rein, an Orlando, Fla., physician and attorney. "If anything goes wrong, they'll want to find someone at fault, they'll want to get even."
Dr. Dan Tennenhouse of the University of California at San Francisco -- another physician-attorney quoted, like Rein, by International Medical News Service -- urges doctors to give a realistic, not just a rosy picture of what to expect from care, since "a lot of expectations are based on TV soap operas, and almost invariably they show the perfect result."
In many malpractice cases, says Dr. Richard Ruley, a Mississippi surgeon writing in Medical Economics, "it's obvious that surgical egos interfered with obtaining informed consent. Some specialists won't concede any chance that their treatment might fail, or that they might achieve less than 100 percent improvement."
He adds this admonishment: "When the patient is led to believe the surgeon will operate while the resident assists -- and then the opposite occurs -- that's outright fraud."
How does a patient know exactly who will be at the operating table, and who will do what? It's worth asking.
Now, here are some less friendly things doctors are being told by at least some advisers:
*Avoid admitting mistakes.
*If a patient has an adverse reaction to a drug, it's better to say, "Your biochemistry differs from most," rather than, "I guess I should have given you a different drug."
*Don't state theories on causes of injury if there is uncertainty. It is better to say the cause is unknown, and "blaming nature" is very effective.
*Keep your thoughts on other physicians' capabilities private.
*Avoid emotionally disturbed, belligerent or over-questioning patients, and "beware of doctor-shoppers."
To that last point, I'd say: How can we patients find a doctor we like unless we doctor-shop a bit?
I realize that some physicians are being hard-pressed by rising malpractice insurance premiums. But it seems to me that a doctor who follows too much such negative-sounding advice might soon win a reputation as too slippery to merit any real patient trust.
Lawyer-doctor Tennenhouse, though he offers some of these points, also says: "Patients can detect the least amount of avoidance. If they think you're dodging, then up goes the index of suspicion and assumption of your guilt."
And: "If a complication occurs, it should be promptly acknowledged, since the patient eventually will discover it and be angry about not being informed sooner."
The American Academy of Family Physicians tells its members: "If your patient develops complications or if there are untoward events, be completely honest."Next Week: How much must doctors tell us about prescription drugs to avoid malpractice?