Archive for category Medical Malpractice/Risk Reduction
I’d like to highlight two blog posts that essentially summarize the problems with malpractice and the current culture of medicine.
The first: $11,000 hospital bill from the emergency department from KevinMD. A quick summary: Mike, unemployed 29 year-old guy struggling to get by goes to the ED with indigestion after wife has read that this can be a sign of a heart attack. Patient gets an EKG, chest x-ray, CT scan of the chest, labs, and admitted for possible acute coronary syndrome (after declining to leave AMA), get stressed, goes home. Later, the $11,000 bill arrives. No one is happy.
First thing’s first: who knows what this patient said to the EP to get this workup. Maybe it involved pleuritic chest pain, or maybe he had an abnormal EKG. I don’t think anyone should question the EP’s workup unless they were there. Admittedly, it sounds like a pretty exhaustive chest pain workup (and admission), but we’ve all see dead 29 year-olds, and we’ve all seen patients who look very ill or give a very concerning story that you can’t ignore, despite their age. Who knows.
The comments are really where it gets juicy, and where it easily gets spun in either direction: Mike should have left AMA, Mike should have taken Maalox at home, Mike called 911 for indigestion, and yes, this costs money. The doctor scared Mike into staying, the doctor was scared of litigation. I like this quote particularly:
Bottom line, I went to medical school to treat the probably. Now I spend much of my clinical day ruling out the improbable. Not by choice. But lawyers ad [sic] patients want that. So as a result unfortunate souls like the patient end up paying the bill.
I guarantee you no one is happy with this situation: certainly not Mike, who isn’t a medical professional and has to listen to the doctor standing in front of him, who probably himself/herself estimates Mike’s risk of acute coronary syndrome as low, just given his age. And certainly not the doctor, who thinks the risk is probably low, and doesn’t want to really admit Mike or work him up, but now he’s here in the emergency department after calling an ambulance for “indigestion.” And so now both parties end up with an unwanted outcome (big expensive workup for indigestion in Mike’s case, working someone up and admitting them because you’re not allowed to miss a single cardiac event as an EP).
And next up is Inevitable Malpractice by my colleague-in-blogging, WhiteCoat. The post is worth a read yourself, so I won’t spoil it for you, but it’s the not-too-uncommon situation we run into in the ED all the time: damned if you do, damned if you don’t; rock and a hard place; insert your own cliche here.
As I’m heading soon into attendingship, I’m starting to think more about these issues (especially having just applied for my state license that will soon be practiced under while I’m supervising residents). I can only come to a few generic conclusions:
- The system is broken.
- The system has changed the fundamentals of the doctor-patient relationship. It’s not teamwork; it’s not “shared decision making;” it’s not us helping them. Or us guiding them. It’s us versus them. And in a system where that’s increasingly becoming the norm — where doctors are scared of their patients and their lawyers — we’re all in trouble. The perverse incentives of medicine today are probably destroying us all in the process.
- I wonder if the data can help us at all here. You run Mike’s info through the GRACE ACS Risk Calculator, or the Duke Risk Calculator, or the TIMI Risk Score for UA/NSTEMI, and you can give Mike a pretty realistic estimate of his risk of MI. You talk with Mike, explaining we can’t rule out cardiac badness in the Emergency Department, but that his risk is approximately 2%, say, and see if that’s a risk Mike is comfortable with or not. It’s shared decision making, it’s educational, and who knows, it might make both parties happier with a well-documented discussion in the chart and discharge with close primary-care followup.
Yes, it’s just an N of 74, but I think this data is pretty fascinating, and highlights why it’s so hard to estimate how much defensive medicine we “practice,” and why it’s so hard to define it: we can’t even agree on what it is. (If you’re confused, see this.) A quick review of the scenarios, followed by some beautiful graphs (thanks, Numbers App!):
- Scenario 1: 50s lady with a few cardiovascular risk factors with a few minutes of chest pain and a normal EKG. You admit for rule-out ACS.
- Scenario 2: 40yo guy with a history of PE on coumadin, therapeutic INR, with 3 weeks of chest pain. You scan for a PE despite adequate anti-coagulation.
Both of these were pretty split down the middle, which I thought was surprising. I thought fewer people would have wanted to scan the guy with the PE.
- Scenario 3: 4yo kid banged the side of his head on a door. Brief LOC, has a 2cm hematoma, looks like a normal kid here, no other concerning signs/symptoms. You CT the kid.
- Scenario 4: 26yo woman with vomiting and abdominal pain but a non-tender belly. You accidentally get labs with a WBC of 25. Feels better, belly’s still not tender, but you scan anyway, since the white count’s so high.
Apparently we don’t like scanning kids and non-tender bellies, since most people felt like these scans were unnecessary–but still a good 20% felt that the plan was reasonable.
- Finally, Scenario 5: 36yo female with a history of anemia with a story of heavy vaginal bleeding, but normal vitals and asymptomatic of anemia/blood loss, and some pooling in the vault. You send a CBC.
This seemed to be the least “defensive,” maybe because it’s just a lab test and doesn’t expose the patient to significant risk (just the cost of waiting in the department and the cost of a CBC.)
I also ran one more stat — were people who took the survey consistent in their values? (Obviously the scenarios are quite different, and everyone has their own issues, but were people likely to say most scenarios were defensive, or likely to say most scenarios were not?) Here’s a breakdown of how many respondents answered Yes to 0, 1, 2, 3, 4, or all 5 of the scenarios. This surprised me the most: most people were in the middle. I thought more people would be skewed toward the extremes.
I’d love to see ACEP or someone do this with a larger sample and more validated. But I think it’s a fascinating look into practice patterns and just more evidence that there’s no such thing as a “standard of care;” no one person can say what’s “right” or what “should” be done for a patient. We all have different ideas of what’s overly cautious or not cautious enough — and different ideas of what we should worry about. (And I’d hazard a guess that what we’re worried about for our patients is different from what we’re worried about for our patients’ lawyers.)
Just a reminder–my Defensive Emergency Medicine Survey closes tomorrow. 58 responses so far, but I know we can get more! The results, so far, are fascinating. Takes about two minutes to read the scenarios, and 30 seconds to click your responses.
So I read all the time that defensive medicine costs all this money (and depending who you talk to, it’s a lot of money or not that much), but I still don’t know when I’m practicing it or when I’m not. So I came up with a few scenarios and want you to vote on what you think. I’ll leave the poll open for the next week, and then post the results after that. Real cases we all see daily (I don’t necessarily practice this way, just giving examples!):
52 year-old woman with hypertension and dyslipidemia, got in an argument with her daughter, had 3 minutes of left-sided chest pain and “my left arm was numb,” with maybe some shortness of breath (“sometimes,” she says, which doesn’t really answer your question), self-resolved. Now in the ED feels fine, EKG unchanged and unremarkable from the last one. No prior stress test. You admit her for rule-out ACS. “This could be unstable and new angina!”
40 year-old male with a history of PE on coumadin, with three weeks of non-pleuritic 1/10 chest pain and shortness of breath. Gradual onset. EKG and chest x-ray are normal, and INR is therapeutic and perfect: 2.5! You CT angio the patient for pulmonary embolism. “If it’s a PE and he’s therapuetic on his coumadin, he needs an IVC filter!”
4 year-old male had a brief LOC after his brother opened a door quickly and hit him in the forehead. Healthy kid. Normal vitals, normal neuro exam, no signs of a basilar skull fracture. 2cm hematoma. PECARN suggests observation vs. CT. You CT the kid. “I would hate to miss a subdural in a 4 year-old, that’d be devastating!”
26 year-old healthy female with a day of vomiting, no diarrhea. Says she has abdominal pain, but belly’s not tender. Tachy 106, otherwise vitals are normal and she looks well. Plan is for fluids and reglan and re-assess. Your resident orders a CBC and BMP for some reason, and the WBC comes back 24.8. Patient feels a little better, is tolerating PO, and abdomen is still not tender. You order a CT scan of the belly anyway, “That’s a really high white count! I’d hate to send an appy home!”
36 year-old female with a history of anemia on iron with heavy vaginal bleeding, history of heavy periods. Not pregnant. 2 days of bleeding, says she’s going through 8 pads a day, this is heavier than her normal “heavy” vaginal bleeding. Well-appearing in the ED, BP is 130/66, HR in the 70s, no signs or symptoms of symptomatic anemia. Vaginal exam has some pooling of blood in the vault, no active bleeding from the os. Her prior hematocrit in the computer system from 6 months ago is 34.3. You order a CBC. “Maybe it will be really low and she’ll need a transfusion!”
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.
photo by Rionda
While I sat in the courtroom over the last week listening to a Plaintiff’s attorney chide me for everything from failure to document and time every single time I went into a patient’s room for a follow-up exam to failing to diagnose a condition that even his expert witness had to look up (and who only found one similar case report), I thought back to the “Malpractice Ball” traditionally held every year by the Marquette Medical, Law and Dental Schools. It’s a mixer to help bring the students from the different disciplines together in the hopes of forming friendships, making contacts, and encouraging them to play nice if only for an evening. Too bad we all had to grow up and become like predator and prey; a fox and a hound who though similar are enemies due to circumstance.
If there’s one thing I learned from this whole legal experience – it’s to treat every document I touch as though someone else five years from now will be looking at it. Just like the lab books we kept in organic chemistry, that Someone Else should be able to accurately follow our thinking and be able to draw the same conclusions. They should be able to concede that given those circumstances, they would have gotten the exact same results.
I asked my lawyer what common lawsuits are brought up against Emergency Physicians. He told me that missed diagnoses by far surpass any other suit. He said the suits that are successfully won by the physician are the ones in which it’s clearly documented that the physician ordered the appropriate tests and arranged for the proper continued medical care. He also noted that sometimes families will sue because they have questions about what led to a patient’s situation and just want to know what happened. He states that many times physicians don’t take the time to discuss a lab result, a diagnosis, a patient condition. A few extra moments can save a lot of people a lot of time and money.
Now that I have spent my time being grilled both under direct and cross-examination, I can tell you that I never again want to go through the feeling of having my character, my medical decision-making, my very honesty brought into question and exposed for everyone to see. While a fellow doctor understands that you don’t automatically write down every aspect of a patient encounter, when it’s questioned whether something really happened or not based on a gap in the record, you have to wonder if the store clerk sitting on the jury panel really gets it. We don’t write everything down. If my physical exam hasn’t changed from the prior hour’s physical exam, I’m not going to note it… although now I am considering it. I wonder how much one of those helmet cams costs…?
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.
Sonosite has released a FREE iPhone app that will help improve their ultrasound skills.
The videos are amazing! Containing many tips, pointers on techniques, great sample cases, image gallery.
The app even has an abbreviated manuel for the Sonosite. The app also contains the latest news concerning sonosite machines.
Here are some screen shots:
For a sample video click here
If you do not like the app, you are out time but not money.
One of the key ingredient to running an efficient Emergency Room is good communication. Depending where you work finding charts, immediately finding a nurse or calling radiology can take longer than expected. Huntington Hospital is currently using an Iphone/Ipod device that allows the health care staff better communicate with each other. It does this via VOIP (Voice over Internet Protocol), basically the set up the system in the hospital to call each other using these devices instead of the hospital PBX or screaming across the ER. The Voalte One system provides voice, alarm and text services all on one device. Overall helps reduce the noise level and makes it easier for the staff to text each other or call each other.
Over all points:
- Receive Voice calls, alarms, and text messages all on a single device
- Easily manage multiple text message conversations
- Intuitive user interface and ringtones
- Allows simple alarm acceptance or rejection
- Custom, user-generated “quick messages” facilitate instant messaging of common items to other users or a web-based client
Overall I see both pros and cons, on one side I think it would be useful to have one device to do it all.
On the other side, I worry that it might make it to easy to interrupt us from patient care. In the end it is all about the balance act.
Huntington Hospital is a 636-bed trauma hospital. For more information, visit www.huntingtonhospital.com
Company website: www.voalte.com