Bioethics Discussion Blog: “Watchful Waiting”: Concerns-Patient Satisfaction, Malpractice but Perhaps a Component of Better and Cheaper Medical Care

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Thursday, July 16, 2009

“Watchful Waiting”: Concerns-Patient Satisfaction, Malpractice but Perhaps a Component of Better and Cheaper Medical Care

“Watchful waiting” is an expression used in medical practice for simply monitoring some unknown or simple medical condition without subjecting the patient to multiple testing, multiple procedures or unnecessary and perhaps risky medical or surgical treatments. This relatively inexpensive and unsophisticated method of medical practice for selected medical conditions is one way that the medical profession can maintain beneficence for the patient but also, at the same time, reduce the cost of all medical care in the United States. But it is also something that patients and their doctors must accept.

In these current days where our government is trying to find an answer to fixing or reducing the cost of medical care yet improving all aspects of quality, “watchful waiting” may be a possible solution. After all, not all runny noses and sore throats need antibiotics to resolve, not all isolated mild first time gall bladder attacks need surgery, not all chronic low back pain need spinal surgery and current evidence suggest that mildly elevated PSA values does not require prostate biopsy nor all detected prostate cancer require immediate surgery or radiation and particularly if discovered in the elderly.


So what are the arguments against and for “watchful waiting”? How about patient satisfaction? Will patients accept this decision? Well, there has been a study on this very point published recently in the Annals of Family Medicine where patients with unexplained complaints were either given a blood test at once or given education and observed over a 4 week period before a blood test was taken. The conclusion: “Test-ordering strategy does not influence patients' satisfaction with and anxiety after a consultation. Instead, specific aspects of physician-patient communication are important” What this means is in this one study, delay of testing for the yet unknown cause of the symptoms was tolerated by the patients.


On the other hand, a lawyer’s view of watchful waiting regarding prostate cancer might be one of cautioning potential clients to this decision and encourage them toward litigation if the outcome is unfavorable. Finally, the management of diagnosis and treatment of prostate cancer including "watchful waiting" will be to David Leonhardt, writing in the July 7 2009 issue of the New York Times, his litmus test about whether the Congress and the government is willing to change the basic economics of healthcare. Read his enlightening article and then return with your conclusions.


Are you asking your doctors to do too much, too soon and at too great a cost? Are your doctors doing too much too soon for additional income or because of malpractice worries? Do you see a role for “watchful waiting?” ..Maurice.

3 Comments:

At Friday, July 17, 2009 9:15:00 AM, Blogger Hexanchus said...

Dr. Bernstein,

I believe that "watchful waiting" is a viable course of action in some instances. The main thing I see that needs to happen to facilitate this is "watchful waiting" needs to become formally recognized as a treatment option that meets the "standard of care" for those situations and circumstances. Along with that, physicians are also going to have to do a better job of consistently providing the patient with enough information to reach a truly informed decision.

You mentioned the lawyers view - part of the problem is that the standard of care varies widely from jurisdiction to jurisdiction. This is one area I believe the federal government could truly make a positive contribution to improving the quality of health care. I believe that the standard of care needs to be uniform throughout the US, it needs to be evidence based, and only the feds can make this happen. Further, that treatments engaged with the full informed consent of the patent meet the uniform standard of care should be a prima facie defense against tort claims.

Just my $0.02.....

 
At Friday, July 17, 2009 9:51:00 AM, Blogger Maurice Bernstein, M.D. said...

Hexanchus, unfortunately because of the logistics of providing medical evaluation and treatment across the United States cannot be uniform because of the regional resources which are available or unavailable, there cannot be any standard of practice which can be legislated or otherwise set forth by the national government. Standards of practice is legally related to the community standards which can be expressed. "Standards of care", however is another matter and really follow the ethical principles of beneficence, non-maleficence, autonomy and justice. These principles and their application to the specific patient should be attempted to be carried out by the healthcare providers irrespective of the geographic location of the patient and doctor. ..Maurice.

 
At Sunday, July 19, 2009 11:13:00 AM, Anonymous Anonymous said...

It is time for the medical community to come to grips that the "Prostate Contoversy" is not if PSA testing is good or bad, it is about what happens to the patient once he is diagnosed with prostate cancer. Low Gleason cancer may be over diagnosed and over treated. It is time for the medical community to come up with new guidelines in the treatment of prostate cancer.

PSA results are only an indicator that further testing may be required. It is the biopsy report which triggers procedures. To many men are terrified by the term cancer, and are convinced to proceed with a treatment even if they are "low grade".
Let's put the focus on treatments, when to treat and type of treatment.

Robert

 

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