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The More, The Murkier
Victor R. Cotton MD, JD
It is commonly said that patients file medical malpractice lawsuits as a search for answers that their physicians did not provide.
"They never told me what was happening,"
"If I had only known," and
"All I want are answers,"
are frequently offered by exasperated patient-plaintiffs as the reasons for their lawsuits. To address these apparent communication failures, it is commonly recommended that we share more and more information with patients.
The effect of this recommendation can be seen throughout the healthcare system. Most informed consent forms now resemble rental car agreements, and patients leave our facilities with stacks of paper. Yet, despite all the effort, patients still sue because they are "looking for answers". Given the lack of progress, it is worth examining the validity of our methods.
Although many patients testify that they filed a lawsuit "to obtain answers", most of these responses are coached. The truth is that filing a lawsuit is the worst way to find an answer. People who are sued shut-up, coordinate everything through their attorneys, and testify only after many hours of witness preparation. In most cases, answers must be "beat" out of the defendant.
If it is answers that patients want, what their attorney should do is just the opposite of suing. Instead of filing a lawsuit, he should offer the involved persons immunity in return for sharing what occurred. This process, which is demonstrated nightly on a television program, is a much better way to obtain information. So, the idea that lawsuits are a search for answers is flawed, and providing patients with more information is therefore unlikely to prevent them.
But, even if lawsuits were a search for answers, providing patients with more information would still not reduce our risk of being sued. The fundamental problem is that patients' memories are finite; their ability to comprehend is often limited by illness; and, they cannot recall much of anything.
Alexander studied patients after they received informed consent for coronary angioplasty. She found that, six weeks later, 42% could not identify any risk and 41% could not identify any benefit of the procedure. Paradoxically, 89% felt that they had been adequately informed (1).
Kessels found that up to 80% of information is immediately forgotten (2). Anderson found that half of the information that patients recall is remembered incorrectly, and that the more information presented, the lower the proportion that can be recalled (3).
Luterman noted that patients remember unimportant details such as the color of the doctor's shirt or the kind of glasses he or she wore. They always vividly remember the date and can describe the trip to the hospital in explicit detail. But, they usually fail to retain any of the important information (4).
Despite their limitations, patients who accurately remember important information have better clinical outcomes and greater satisfaction (5). It is therefore worth pursuing strategies that improve patient recall. Unfortunately, the current approach of providing ever-increasing amounts of information is actually counterproductive.
In terms of imparting knowledge, Margolis recommends the following approach:
- Present only the information that is important for the patient to remember;
- Use short words and sentences;
- Present the most important information first and stress its importance;
- When possible, supplement verbal information with written materials; and,
- Repeat the most important information (6).
Although this approach gives us the best chance of success, it is currently out of vogue as a form of "medical paternalism" from a bygone era. Some might even characterize it as "withholding information" and violating "patient autonomy". However, it is scientifically sound, nonetheless.
Communication experts are constantly trying to remake the 5000-year-old relationship between doctor and patient in accordance with their abstract theories. And, none of them ever work. Their latest involves overwhelming sick patients with more information than healthy college students can comprehend. But, this adversely affects patient care and thereby increases the risk of a malpractice lawsuit. The approach must therefore be rejected.
1. Alexander K. Poster 52nd annual scientific sessions of the American College of Cardiology in Chicago, IL.
2. Kessels RPC (2003). Patients' memory for medical information. J Roy Soc Med 96:219-222.
3. Anderson JL (1979). Patient information recall in a rheumatology clinic. Rheum Rehab 18:18-22.
4. Luterman DM (2001). Counseling Persons with Communication Disorders and their Families. (4th Ed.) Austin: Pro-Ed (p. 76-77).
5. Thomson AM (2001). A comparison of information retention at an initial orthodontic consultation. Eur J Orthod 23:169-178.
6. Margolis RH. Informational Counseling in Health Professions: What do Patients Remember? http://www.audiologyincorporated.com/PDF%20files/RecallMSLongVersion.pdf
Medical-legal education with a passion for medicine
and compassion for patients. | 
