Callousness and Legalism: Two Bad Behaviors in Medical Practice
Christy A. Rentmeester writing in the Winter 2008 ASBH Exchange, a bioethics newsletter, discusses the tendency for students and young physicians to be exposed to and learn from their mentors callousness and legalism as the way to evaluate and treat patients. Callousness is apparent when a physician does not “..recognize features of his patient’s situations that configure what they need from him.” In addition, he does not "define what the patient needs and deserves from him broadly (instead of narrowly) and generously (instead of meagerly)."
Think for example of a male patient who needs to consistently take a heart medication to prevent angina, a medicine to lower cholesterol and a blood pressure medicine to control the blood pressure. Suppose the physician simply writes the prescriptions and gives no attention to the financial and social status of the patient and whether the patient also has a wife who is also needs medication for her own high blood pressure and gout so that both, with limited income, will not be able to afford purchasing all the necessary medications. That behavior of the physician represents only consideration of the most narrowly defined needs (the written prescription) and no concern regarding how the patient is going to pay for the medications and whether the patient will not be compliant in taking the medications because of trying to support the medical needs of his wife and himself on that limited income. This behavior of ignoring the patient’s full needs represents a form of callousness.
Legalism is a form of practice in which the physician “orders tests, requests consultations or does procedures that are unlikely to benefit the patient or generate new clinical information that would help in caring for the patient more effectively. Such orders, consultations and procedures are done with the idea that doing these actions will make the healthcare professional appear ‘covered’ from an imagined legal point of view.” As Rentmeester suggest, “ …clinicians trained to think and see legalistically are taught to fear their patients and see them as threats.”
I would say that in both callousness and legalism, the there is the underlying behavior by the physician of only being minimally involved with the patient and making self-interest, not the patient’s interest, the major goal. Both Rentmeester and myself might be looked upon as being too harsh in our consideration of physician training. However, in view of the known “hidden curriculum” informally taught by those who train students and physician in their clinical years, there is a need be aware of distortions of clinical moral perception that can lead to callousness and legalism as the new doctors go beyond training. ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:17:00 PM
5 comments
5 Comments:
As Rentmeester suggest, “ …clinicians trained to think and see legalistically are taught to fear their patients and see them as threats.”
And how do you suppose this makes the patients feel when they pick up on it? What a wonderful foundation for a "trusting" provider/patient relationship.
TT, I agree that legalistic thinking on the part of the physician is not at all a constructive way of maintaining a doctor-patient relationship which is therapeutic but also caring and understanding in both directions.
However, the responsibility to get rid of the legalistic thinking is also two sided. The patient and society has to make the malpractice system work better and fairer for all concerned. If the threat for malpractice law suit was reduced and patently frivolous suits were eliminiated and the doctors were educated about the need to practice medicine, order tests, perform procedures based on clinical evidence and not because of malpractice threat, legalistic thinking (and behaving) on the part of doctors would be out the window and doctor-patient trust in eachother would return. ..Maurice.
Dr. Bernstein,
I agree that tort reform has to be a part of the solution and that the litigious society that we currently live in needs to change. Patently frivolous actions need to be quickly dismissed. and those that bring them need to be held accountable, particularly those attorneys that actively promote them. I also think the entire concept of punitive awards needs to be rethought.
Some studies have shown that patients are much less likely to bring legal action against a doctor they have a good relationship with. Common sense says this should encourage doctors to establish those relationships, and to me at least, both callousness and the legalistic approach would seem to be counterproductive in this effort.
Physicians also need to recognize the changing role of the doctor patient relationship and adapt accordingly. The old "paternalistic" model is fast becoming a thing of the past, and as patients become more knowledgeable the "informative" and "collaborative" models are becoming more the standard.
It may be true that legalistic thinking is not always best for the doctor-patient relationship, but it is difficult to avoid the creeping tendency of tests and consultants to leave the person who requested the test or consult on the hook.
How often has a scan come back with a 'cannot rule out pneumonia' on it? Just the other day a nurse saw a bit of ST-elevation on a tele strip and there is no way to avoid an EKG and serial troponin measurements.
In practice it seems difficult to avoid legalistic thinking.
To the fourth year medical student: To label a physician's thinking as legalistic requires that one understand the intent the physician has used to order the tests or consultation. We may not always really know the intent. In fact, in these days of evidence-based medicine with documented procedural guidelines and more tests as part of the guidelines, physicians may find that equivocal results appear. The intent to clarify the equivocal results for the best interest of the patient may be a rationale for ordering even more tests or consultations. If a good history was taken and an appropriate physical exam performed and appropriate testing done with results which clearly lead to a likely diagnosis and treatment, the intent of further testing to be medical legally complete (physician's own interest) is the wrong intent. Testing and consultation should never be a substitute for initial proper history taking, physical examination and taking time to think out the clinical issue. ..Maurice.
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