Objectives

2. Objectives At the conclusion of this presentation, the participants will be able to: Describe physician behaviors that impact a patient�s decision to sue. Identify strategies that a physician may use to improve communication with patients.

3. What do we know about physicians who get sued? Patient Complaints and Malpractice Risk Longitudinal Study, Jan. 1992 to March 1998. Unsolicited complaints. Risk management events. 645 physicians accounting for 2546 years of care.

4. Study Data Complaints originated equally between inpatient and outpatient sites. Complaint categories included: communication, humaneness, care and treatment, access and availability, environment, and bill complaints.

5. Study Results Risk management events were significantly related to total number of patient complaints, even when data were adjusted for clinical activity. Complaints and risk management events were higher for surgeons than non-surgeons.

6. Study Comments A relatively small number of physicians generated a disproportionate share of complaints. Physicians� complaint generation was positively associated with risk management outcomes, ranging from file openings to law suits. Patients who saw physicians with the highest number of lawsuits were more likely to complain that their physician would not listen or return phone calls, were rude, and did not show respect.

7. Lessons learned from study Risk is not predicted by patient characteristics, illness complexity, or physicians� technical skills.

8. Lessons learned from study Risk appears related to patients� dissatisfaction with physicians� ability to: Establish rapport, Provide access, Administer care and treatment consistent with expectations, Communicate effectively.

9. What Do Plaintiff�s Attorneys Have To Say? Plaintiff�s Attorneys Share Perspectives on Patient Communication Defense attorneys recommended plaintiff attorneys in LA. Small survey by personal mail. Doctor-patient communication issues identified.

10. Survey Data Poor listening skills. Delegation of critical consent communication. Failure to share timely information with colleagues and nursing personnel. Failure to have meaningful, empathetic conversations when adverse outcomes occur. Defensive behavior when patients seek to learn more by questioning diagnoses and treatment options.

11. Others Lessons Learned Decision to litigate is most often associated with a perceived lack of caring by the physician. 20% sought legal advice to obtain more information about their illness and said physician did not listen or talk openly. History taking was often substandard. Patient�s perception of physician competence is based on professional expertise but also on patience and respect for the patient.

12. Quote From An Attorney �Ineffective communication is a primary cause of substandard medical care.�

13. What Else Do Patients Say Hickson et al. Factors that Prompted Families to File Medical Malpractice Claims Following Prenatal Injuries. JAMA. 1992; 267(10): 1359-1363. 1/3 advised to sue by knowledgeable acquaintance. 1/5 to find out what happened. 1/5 suspected a cover up. 1/5 so this wouldn�t happen to anyone else. 1/15 monetary gain.

14. Case Study #1 Sarah Mathews made an appointment with a new physician when she developed cramps and heavy bleeding. After the exam the doctor told Sarah she had fibroids, and told his nurse to schedule her for a hysterectomy. Sarah, who was 41, asked for an explanation and instead of responding, the doctor gave her a book on hysterectomies.

15. Case Study #1 - continued She asked if she was at risk of ovarian cancer, and the doctor responded, �If you�re concerned about that we can take your ovaries out too.� Sarah left the office feeling humiliated and scared. Risk Management Essentials for Physicians, Gafner 2002

16. What is the Source of the Communication Problem? Sarah: the doctor gave her the info she needed. If she would have read the book, all her questions would be answered. The Doctor: he didn�t give Sarah the info needed. She was specific with her requests but he wasn�t responsive. Both of them: this is a shared problem. She shouldn�t have left until she got what she needed. If he didn�t understand her, he should have clarified.

17. Case Study #2 8 year old overweight boy scheduled for a tonsillectomy/adnoid-ectomy. As part of the pre-op testing a sleep apnea test was performed and the child was diagnosed with obstructive sleep apnea (OSA.)

18. Case Study # 2- continued The ENT Doctor (Dr. A) was aware of this assessment when he performed the pre-op physical. He discussed the �regular� risks of the surgery with the family but did not discuss the increased risks for a child with OSA. Dr. A expected the anesthesiologist to review that increased risk with the family during the anesthesia evaluation and consent process.

19. Case Study # 2- continued Dr. B was the ENT who actually performed the surgery. Dr. A told him about the OSA but not about the recommendations that were made. Dr. B did not talk with the family or with anesthesia before the surgery.

20. Case Study # 2- continued The surgery went well without any complications. While in PACU, the child experienced a laryngospasm. Just as anesthesia was about to re-intubate the patient, the patient stabilized and his oxygen saturations returned to baseline. Nothing was documented about the laryngospasm and the family was not informed.

21. Case Study # 2 - continued Later that afternoon, the child had symptoms of post-obstructive pulmonary edema (POPE), coded for over 5 minutes and sustained a severe anoxic brain injury.

22. Issues with Case Study # 2 Was it Dr. B�s responsibility to evaluate the child prior to surgery and confirm the plan of action for dealing with a child with OSA with Anesthesia? Was it Dr. A�s responsibility to include more detail during the informed consent discussion with the family about the risks of surgery with a diagnosis of OSA?

23. Issues with Case Study # 2 Three different anesthesiologists were involved in the care of this patient. There was no documentation about OSA and there was no documentation of the laryngospasm the patient suffered. Other than the pre-op history, no mention was made of OSA. It was not included in anyone�s treatment plan. Dr. B had authored an article about POPE and, therefore, was well aware of the risks.

24. Outcome Case Study #2 Indemnity of $1.5 M paid on behalf of both ENT doctors. Unknown what hospital paid. Unknown what the anesthesiologists paid.

25. What strategies can we learn from all of this? Work to establish a rapport with patients. Listen to your patients and their families. Always get a good history from your patient. Be accessible. Return phone calls and answer questions. Watch your attitude!

26. What strategies can we learn from all of this? The informed consent process is non-delegable. In a timely manner, communicate with colleagues and nursing personnel. When adverse outcomes occur, be empathetic and do NOT run and hide! When patients and families have questions, take the time to address them in a respectful manner.

27. Summary � Communication is important. Starting from a physician�s first contact with patients, good communication can establish rapport, improve the quality of patient histories, and strengthen the medical partnership where mutual trust engenders better treatment results.� Richard Spector, MD, JD Plaintiff�s attorneys share perspectives on patient communication.

28. Objectives At the conclusion of this presentation, the participants will be able to: Describe physician behaviors that impact a patient�s decision to sue. Identify strategies that a physician may use to improve communication with patients.

29. Thank You! What Questions Do You Have?

30. Disclaimer The information contained herein and presented by the speaker is based on sources believed to be accurate at the time they were referenced. The speaker has made a reasonable effort to ensure the accuracy of the information presented; however no warranty or representation is made as to such accuracy. The speaker is not engaged in rendering legal or other professional services. If legal advice or other expert legal assistance is required, the services of an attorney or other competent legal professional should be sought.