Posts Tagged malpractice

Fantastic Lecture on Risk in EM and an EMCrit Rant on the same

Warning-This is not an ED Critical Care Podcast, it is a rant.

I recently listened to an incredible lecture by Dr. David Schriger given at the most recent All LA Conference. You should go and listen to this lectureASAP (it’s free):

Link to Dr. Schriger’s Talk at alllaconference.com

In this brief rant, I discuss three additional points that occurred to me as I was listening. But remember, you will be far better served using your time to listen to his lecture than my rant.

[Click here to read more and hear the rant]

photo by Rionda

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Trade Pay for Debt?

Mostly for residents (but attendings as well!): would you accept a theoretical pay cut as an attending for a reduced amount of medical school debt (say, half or none), and some malpractice changes? Vote now and add a comment.

http://answers.polldaddy.com/poll/2646892/

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Doctoring Like A Lawyer

courtesy wikimedia commons

courtesy wikimedia commons

A bunch of good thoughts, stories, and controversy about malpractice this week that are worth a look:

  1. If you’re not reading Trial of a WhiteCoat, you’re missing out. WhiteCoat’s Call Room, probably my favorite EM blog out there, stuck his neck out by deciding to post his account of his malpractice trial. It’s fascinating, nerve-racking, and well-written. It all starts here, and the next installment looks like it’ll reveal who won the case.
  2. KevinMD features Robert Ricketson, a former neurosurgeon involved in a high profile malpractice case in 2003 where Dr. Ricketson gives his side of the story, minus all the sensationalizing from the media. Not surprisingly, it’s not “evil, reckless neurosurgeon puts patient safety at risk.”
  3. And finally, Stuart Swadron talks about Teaching to the Tort, at an up-and-coming EM blog with a bunch of big names, appropriately named, *ahem*, EM Blog. The point is this: should residents be learning about the latest evidence, and how to, as far as we can tell, best care for patients, when the “classic teaching” says otherwise, because of malpractice concerns? Are academic programs freer to practice in ways that community physicians aren’t? Dr. Swadron gives the example of pretreating children with atropine for intubation: while the “available evidence contradicts” its use (and note: the latest version of Ron Wall’s airway bible does not recommend it), is not using it going to be a red flag in a malpractice case for an expert witness?
    I asked a similar question to several colleagues and was told this: “Do what you think is right and best for your patients. Malpractice cases come down to one expert versus another: yours will support you, and the plaintiff’s will support the plaintiff. Your job is to do right by your patients as well as you can; while our books certainly provide expert guidance and management strategies, Tintinalli is not “the standard of care” for the patient in front of you. You are.”
    I don’t know if “medico-legal” was part of the curriculum 10 years ago, but I certainly feel it today. I know to document, how to communicate with families and patients, and how to discuss medical decision-making. I can’t help but feel some level of angst that not only am I going to make a mistake that will harm someone, but I’m also going to make one that may cost me my personal, professional, and financial lives. I think I’m more of a fatalist about it, and perhaps my generation is the same: I’m going to be sued sometime. It’s out there. Be prepared for it, do your best, but don’t spend all your time worrying about it. Document well, work hard, think and care, but it’ll happen, no matter how perfect you are. Am I wrong?

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Healing Our Health Care: Doing Less

Often in Emergency Medicine, we have multiple influences pushing us to do one thing, when we know the other is right for the patient. Part of it might be fear — of lawsuits, of bad outcomes — part of might be a demanding patient who “knows antibiotics always work for me,” part of it might be access to a new CT scanner, so “I might as well check.” But we all know of patients who’ve had one workup, which has led to another, which has led to some complication — a botched cath, a nosocomial infection — and you can’t help but wonder what if that workup had never been done, and was it really necessary in the first place? What if we were just chasing our tails with incidentalomas? What was our pre-test probability before the test, and even if the test is positive, how much did it really increase our post-test probability, anyway?

We’re in a tough place in the Emergency Department. People have come to us for evaluation, and our job is to Rule Out Badness ™. They’re in the Emergency Department, so we need to make sure they’re not having an emergency. Sometimes, however, I wonder if many patients weren’t better served at a walk-in clinic instead of a walk-in ED, where the mere lack of access to instant lab results and imaging studies might make for a better course of action (combined with watchful waiting as the workup progresses over days to weeks).

In last month’s EMRAP (2 hours of Emergency Medicine I look forward to every month), Jerry Hoffman, NEXUS Criteria creator and EP at UCLA-Oliveview talks about how he approaches these influences, and I think it’s absolutely worth 3 minutes and 53 seconds of your day:

[wpaudio url=”http://thecentralline.org/wp-content/uploads/2009/08/jerryhoffman-doless.mp3″]

(Thanks to Jerry and Mel Herbert of EMRAP for their permission to use this clip!)

Sometimes Jerry’s methods don’t work — but for most people, most of the time, they will. Sure, it’s easier to write the script for cough medicines or order the CT scan than have a discussion, “teaching moment” or even argument with a patient or his parent — but if the two minute discussion saves the patient from a medication side effect they may come back for, or allows us a faster discharge with less brain radiation, then it’s probably worth it for both doctor and patient, right?

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