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'The enemy of good is great'

Article-'The enemy of good is great'

There is an old adage that surgeons pass from one to another. Whenever the need arises, they remind each other that, "The enemy of good is great."

It is a reality that every surgeon has encountered, sometimes five hours into a two-hour surgery and sometimes moments after the first incision. Perfection in medicine is often unattainable. Moreover, as the adage implies, the surgeon must strike the delicate balance of treating the patient without harming that patient.

Creating expectations

Unfortunately, in our media-centric society, patients have come to expect the "ideal" outcome. Pharmaceutical companies, as well as medical device manufacturers, now target the general public with images of happy patients, free of acid reflux, dancing with their new hips.

Only in a short voice-over towards the end of these commercials is the patient informed of the potential risks and side effects of treatment.

As it stands now, patients' expectations regarding their medical treatments are not aligned with what really happens. Why is this concerning? It is this disconnect between perception and reality that has fueled the malpractice crisis.

Anatomy of a lawsuit

In fact, Linda Crawford, a legal researcher who has taught at Harvard Law School and devoted her career to analyzing medical malpractice suits, says, "It is clear to us, 22 years into this research, that lawsuits are not about bad outcomes ... they are about expectations."

We can no longer hold onto the mistaken belief that the medical malpractice system weeds out those doctors practicing inappropriate medicine. Currently, at least five out of every six medical malpractice lawsuits involve doctors practicing "good medicine." Shockingly, then, the medical malpractice industry is not about medical negligence. Ms. Crawford also rightfully points out that the healthcare industry is victimized by its own success.

"The more medical advances we make, the higher the (patient) expectations. And the higher the expectations, the greater number of lawsuits regardless of the quality of our medicine."

After all, why would a patient ever expect anything but an excellent outcome from surgery that is touted as "minimally invasive" or "bloodless?"

In July of 2002, the journal Surgery published an article that concluded that a surgeon's tone of voice was associated with his or her malpractice claims history. The article found that those surgeons whose voice tones connoted dominance (e.g. deep, loud, fast) were more likely to be sued than those whose tones conveyed concern or empathy.

One truly concerning point that is made in the article is that the surgeon-patient encounter is often characterized by technical explanations; therefore, there may be a greater opportunity for the surgeon, rather than other types of physicians, to be perceived as dominant.

Surgeons recognize that the practice of medicine is both an art and a science. The American Society for Healthcare Risk Management understands this duality when they describe informed consent as a "process, not a form."

However, it is difficult for the surgeon to embrace the process (that is, to be an exceptional communicator) given the pressures and responsibilities of running a modern office. Studies now show that the typical surgeon has less than nine minutes per patient consultation. Arguably that is too little time to adequately explain the technical aspects of the surgery and post-surgical care, the emotional aspects of being a patient, the risks of surgery and the realistic expectations of the surgery. Also, it is too little time to listen to the patients' specific concerns and anxieties. Yet active listening is one of the most important aspects of effective communication.

Addressing the issues

Technology, in the form of current, accurate and compelling online educational tools, can be used to help improve the patient education process and ensure a better approach to informed consent.

Most importantly, these tools can set the tone for the surgeon-patient communication and start the process of managing expectations.

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