Articles and Case Studies

But Doctor - Are You Certain?

13 Jun 2014

by Dr Paul Nisselle

The question, “But doctor, are you certain?” along with “But doctor, can you guarantee…” is a real heart sink one. We know that honesty requires us to say “No” in many instances – and this can be considered by the patient as a reason not to follow our advice. However, there are ways we can turn the question around.
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For example, the answer to the question, “Can you guarantee that immunising my child is safe?” could be, “No – but I can guarantee that not immunising your child is not safe.”

At a community level, there are demands to prove that mobile phones are “safe”, that living under power lines is “safe”, that genetically-modified foods are “safe”, and that dredging Port Phillip Bay (to be parochial) is “safe”.

Scientific probity requires us to give guarded answers, e.g. “All the testing we’ve done so far suggests that [x] is safe.” If you ask a doctor, “Will the sun rise in the East tomorrow?” the reply will never be “Yes”. It might be “Probably” or “I have every reason to expect it to” or “Recorded data going back 5,000 years would suggest it will” – or the reply could use the much loved medical double negative, “It’s not unlikely”.

Sadly, we live in an era consumed by fear, the reaction to which is a demand for certainty when there is none. But uncertainty is inherent in human existence. For at least half (if not three-quarters) of the twentieth century, patients accepted that living was risky; and that health care improved your chances, but was also risky. It appears though that as medical outcomes get better and better, paradoxically, the demand for certainty of a perfect outcome increases.

Failure to meet a patient’s expectations commonly leads to litigation and complaint – even if those expectations were, at least to the doctor, unrealistic. It’s perhaps a good idea to assume the patient will expect a perfect outcome unless you specifically warn them of not just possible complications, but also the limit of what can be achieved. There are always scars. Not every woman will have a perfect child as a result of a perfect labour, even with the very best of care.

Our society is now so frightened of litigation that everything comes with a health warning. Some are simply ludicrous – like the packet of peanuts inscribed with the warning “Caution – may contain peanuts”.

The medical equivalent is the doctor who, having recommended a treatment for very good reasons, proceeds to warn the patient of every possible adverse outcome. If they do have an adverse outcome – well, they were warned. But what if having been frightened by all the doctor’s dire warnings, they choose not to have the treatment and come to harm? Is this their fault?

No, it’s not. “Informed consent” is not just about telling patients everything that can go wrong. It’s our job to give balanced information – summarising the risks and benefits for that patient, and answering their questions with neither positive nor negative spin.

Our patients want us to assume responsibility for protecting them from their vulnerability. We can’t do it. One of our hardest tasks is to encourage patients to accept that there is risk in everything they do – including taking our advice!

Frank Furedi, Professor of Sociology at the University of Kent, has studied the prevailing climate of fear and written many articles on the sociology of fear – these are available at: frankfuredi.com/site/article. He says: Society’s cultivation of fear is really the cultivation of our own vulnerability… Most human experiences now come with a warning, continually reminding us that we cannot be expected to manage the risks we face.

Dr Paul Nisselle AM
Consultant and VIC PMLC 
Member
MDA National

Communication with Patients, Anaesthesia, Dermatology, Emergency Medicine, General Practice, Intensive Care Medicine, Obstetrics and Gynaecology, Ophthalmology, Pathology, Psychiatry, Radiology, Sports Medicine, Surgery
 

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