Defensive medicine and the pandemic of fear- stricken doctors

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Healthcare has transformed over the last four or five decades revealing a gradual shift in the practice of medicine from patient-centred care to one of systems, algorithms, and guidelines-based practices. There appear to be various contributing factors, the most obvious being the push for a corporate model of medicine by various global and national organisations with conflicting interests. Sadly, a large part of it is supported by ignorant and terrified doctors subservient to the system of medicine, rather than its practice.

With the advent of this modernist technocratic medicine came the phobia of litigation and the birth of a new field of medicine – Defensive Medicine. While this is not a subspeciality of any recognition, it is practised in full scope by all modern-day doctors regardless of their speciality. The drive to this dark side was and is happening at a rapid pace unbeknown to the majority of doctors who are busy working long hours and managing families and personal responsibilities.

Practices have evolved in time as a consequence, which use fear-based tactics to steer patient decision-making. Patient feedback suggests doctors engaging in a pattern of fear-based information sharing advising the undertaking of treatments that if not done, could lead to catastrophic consequences. Some have also been given deadlines to live if their advice was not followed through. It’s a case of working on the back foot rather than the front foot. This is quite contrary to the Hippocratic oath and medical principles that emphasise on shared decision-making with the doctor only being a facilitator of the outcome. Fear disillusions and creates a state of confusion and alarm. Under these circumstances, it cannot be expected of a patient to make a rational and sound decision regarding their health in an informed manner. There’s only one choice left for them and they have just been told what that is.

While the foundation of medicine is based on full informed consent and freedom of choice, the modern-day doctor ensures he or she has instilled enough ‘information’ (mostly ignorantly and driven by their own fears) into the patient that they will have no choice but to do what they were advised to.

I was approached recently by a family who were vaccine-wary and came to me after spending many months reading through available literature including ones contrary to public health advice. Despite my repeating verbatim what the guidelines are on the issue, they only wanted certain vaccines out of the entire schedule. The yellow road sign flashing ‘caution before you proceed’ kept flashing at me as though warning me of the dangers ahead. As this was a perplexing situation for me, I called up my defence organisation for guidance. I was advised that in the end, two things matter in this context – what is the patient’s choice after discussion, and what is written in the consultation notes? I had the answer to the first and as for the second, I had to ensure my words (and every alphabet) did not in any way affirm their decision and aligned with the mainstream approach. Though it seemed odd that I was a family doctor working for the patient and their family, I had to learn the most important step of self- defence in my career.

Every medical treatment (including a procedure) has risks and where there is a risk, there has to be a choice. Clinicians today practise the art of self-defence (much like a martial art practitioner), holding straight faces, avoiding eye contact and honest opinions, and deflecting responsibility. The fear of saying something that is going to run a risk of litigation and likely not be accepted by their peers at a tribunal hearing weighs heavily during consultations. Veering off guidelines is practically an inconceivable sin carrying with it tremendous implications and a heavy cost burden. These fears are also propagated by the discreet hook-up of medical defence organisations and medical teaching institutions and regulatory bodies. The ‘teamwork’ ensures compliance from the culprit doctor through biased and unfair processes that could go on for years. Undoubtedly, this leaves the doctor emotionally traumatised and scarred, financially disadvantaged with a loss of reputation and eventually self- confidence. It’s little wonder doctors ensure compliance just like primary school children, not challenging the orthodoxy.

In the recent past, I got caught up in the above whirlwind and got tossed around from the medical board to my defence organisation and I finally conceded defeat. It came down to a legal breach even though I cared for my patient and kept her safe all along. I wasn’t applauded for the good I did but I sure spent ‘time’ repenting my sins. The trauma from this experience lingered for a long time and created in me a fear of not messing with the system, a merciless bureaucracy that has lost its soul. Once bitten, I will always be twice shy.

As it is for patients, fear muddies the processing of information and sound judgement for a doctor and invariably breeds coerced conformity. A petrified and cornered medical practitioner (frightened of both the medical board and of their patient) is undoubtedly a great risk to the public. If it is so, they are best served by stepping down from their medical duties to protect their patients and the public and last but not least, for their own safety. We do this for all professions like police and law enforcement, education etc if a threat to the public is identified. Healthcare has to be at the top of that list and deserves utmost priority.

Transparency and openness are the two bridges upon which a patient travels to make informed decisions relating to their healthcare needs. In healthcare, adopting a broad treatment approach or making decisions to safeguard the broader community is an uncommon occurrence and it departs from standard practice. Such an approach is only employed with considerable caution taking into account personal choices and circumstances, medical conditions, and other relevant histories such as genetics and family. Free will is paramount and non-negotiable.

This is due to the age-old inherent principles of bodily autonomy, sovereignty, and freedom of choice for individuals. Health-related decisions should always be made in conjunction with a medical practitioner and should be free of any coercion, threats, fear of reprisal, and last but never least based on unbiased information disclosure. With everything that has transpired during the last 3 years, can the modern 21st- century doctor can practise freely in a democratic society without the barrage of bureaucracy weighing on them? In other words, the question to be asked is ‘Can a doctor today be a doctor?’ The verdict unfortunately eludes discussion and should be initiated by the public. I say ‘Let doctors be doctors.’

This article first appeared in The Spectator Australia here.

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