Croup fatality malpratice case aka the scourge of bad EM expert witnesses

[ShockIndex]

I don’t think anyone would seriously suggest most cases are filed to improve the system. I think most cases are filed a) if something bad happens, and patient/family member wants to be compensated and b) lawyer sees something in review of the case that is potentially malpractice so they can get paid. It would be great if the malpractice system weeded out bad physicians and inadequately trained providers, but it definitely doesn’t function that way.

There is only one place within 2 hours of me that doesn’t require midlevel cosignatures. It is a critical access that just staffs 1 doc on 24’s. Agree with many others that it is not possible for everyone to work a place that doesn’t require this.

There is a big difference between actually supervising and becoming a mill by clicking sign on charts that you’re not even reading.

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[RustedFox]

There is a big difference between actually supervising and becoming a mill by clicking sign on charts that you’re not even reading.

Here's the thing; you can't actually supervise them for a few reasons.

At my one gig, we had such an attitude of oppositional defiance with the PLPs that we asked "how can we get rid of them?"

The answer? You can't. They're "employees". You're just "independent contractors". It would be easier to replace the entire physician staff.

 

[DrDrummer]

There is a big difference between actually supervising and becoming a mill by clicking sign on charts that you’re not even reading.

I would be interested in this spinning off into a separate discussion from the expert witness talk. I very much share your concerns about this practice. I work in a group where we co-sign all PA charts. In the state I practice in, the requirements have changed so that (as I understand it) this is not required legally, but we have kept doing it as a group practice. I don't think it actually generates additional RVUs unless there is an attestation that you have independently seen/evaluated the patient, and in the new coding requirements there might even be more nuance. In theory, this should lead to more true 1:1 supervision / staffing of cases, in practice it doesn't seem to.

Has anyone's group has this model, and then abandoned or modified it? Someday we should discuss how different groups structure supervision, it would be interesting. I wonder if there's anyone else out there who has had experience getting these policies changed or if enough objections were raised to this practice in an organized way it would lead to change and help prevent the what-feels-like-inevitable slide into EM turning into anesthesia's model of 1:4 (or worse) "supervision" ratios.

 

[Brigade4Radiant]

Co-signing is required even in hourly places. Also just because you don’t sign a PA/NP chart doesn’t resolve the doctor of liability since during discovery they will find the physician who worked and will say you had a duty to supervise the PA/NP

Also not signing PA charts can get you reported to the national provider database so the option of “just don’t sign the chart.” Is laughable

It’s like not signing a residents chart and thinking the the attending g won’t get named

These lawsuits are about money when OBGYNs drop malpractice insurance in Florida lawyers don’t go through with a lawsuit in a lot of cases

Also CMGs and admin have power but bear no blame

Yet we have a physician thinking that going after doctors “for selling out to rvu”

The not signing charts mantra will get you fired

 

[GonnaBeADoc2222]

Yeah the "just go work elsewhere" or "just switch specialties" arguments are pretty lame.

 

[GatorCHOMPions]

I’d argue that you have a choice. Perhaps you just don’t like the consequences of doing the right thing?

The moment you lost everyone. Incredible arrogance, and out of touch with the job market in a lot of areas around the country. Sounds typical of a plaintiff “expert” witness. The more you write the more you come across as a stereotype. Giving you some benefit of doubt, I can’t help but think some of this is trolling.

 

[NYEMMED]

“just switch specialties”
What? We all trained in EM, you want everyone to just leave? Who’s going to take care of the patients??

“Just move”
To where? 90% of all EM contracts are held by CMGs, they all require signing charts. Some CMGs own whole markets. Some people have families they can’t leave behind.

If you don’t know the above, then you really aren’t an EM doc (as you are not a practicing EM physician) and really should not be an expert witness…

 

[NYEMMED]

I was approached once to be an expert witness. (I know somebody that worked at the law firm) about 4 years ago.

I was “paid” to review a case. I told the lawyer “this is not a case, everything was done perfectly”
Lawyer said “maybe you don’t understand, I am paying you for an opinion I can use”

So I responded again, “it’s not a malpractice case”

Never heard from him again, never got paid either….

My friend at the office told me he had 4 docs after me look at the file until he found one that agreed with whatever he said.

It was at that point I realized the entire system is 💩. They will keep going until they find somebody they can pay off to say whatever they want.

I do expert witness defense work, Its more satisfying than being a paid for hire lier….

 

[HemeOncHopeful19]

I was approached once to be an expert witness. (I know somebody that worked at the law firm) about 4 years ago.

I was “paid” to review a case. I told the lawyer “this is not a case, everything was done perfectly”
Lawyer said “maybe you don’t understand, I am paying you for an opinion I can use”

So I responded again, “it’s not a malpractice case”

Never heard from him again, never got paid either….

My friend at the office told me he had 4 docs after me look at the file until he found one that agreed with whatever he said.

It was at that point I realized the entire system is 💩. They will keep going until they find somebody they can pay off to say whatever they want.

I do expert witness defense work, Its more satisfying than being a paid for hire lier….

I always wonder why they don’t have to report how many docs said the case was fine before they finally found a sellout.

 

[NYEMMED]

I always wonder why they don’t have to report how many docs said the case was fine before they finally found a sellout.

The defense lawyer should absolutely request this in discovery.
Most don’t

 

[ShockIndex]

Here's the thing; you can't actually supervise them for a few reasons.

At my one gig, we had such an attitude of oppositional defiance with the PLPs that we asked "how can we get rid of them?"

The answer? You can't. They're "employees". You're just "independent contractors". It would be easier to replace the entire physician staff.

What follows @RustedFox is an answer to you; not at you. I do not presume to know your motives or background.

What you describe is a small part of the reason why I left EM - the first time. Back in 2008-2009, EMP (now everyone’s favorite USACS) began the process of making life unbearable by changing the comp scheme so that about 1/4 of the monthly salary was dependent on Press Ganey scores being in the top 10% for the most productive physicians. Prior to that PG was in the comp but nowhere near as impactful, at least on the most productive. They also cranked up the mid-level hiring so that we could no longer effectively supervise them (mid-levels began around 2008ish under the condition that we would see every patient with them). The effect was immediate and profound since I spent most of my time in a military hospital that didn’t do this stupid BS and I could see the dichotomization evolve. Suddenly, physicians at the EMP site were writing for 10 percs or norco to every dental and back pain in a misguided attempt to avoid the dreaded 1s, and this was just the tip of the iceberg in terms of maladaptive BS that physicians were willing to do. So, I left the field, took a big pay cut in the process, and very much enjoyed the clean air. And before anyone claims that ApolloMD and TeamHealth were better, if so it wasn’t by much - I’ve worked there too.

So no, I’m not here to persuade. The time for that has passed. Scott Weingart is mostly correct - EM is now a broken and failed paradigm, I just think that we helped break it. Thus, I am here to chime into all these threads decrying the lawyers, administrators, and patients as a reminder to our culpability in this mess. And when I see threads such as this where the prevailing wisdom is effectively that no EP should be sued (the logical conclusion of a system where no expert witness should be allowed to exist), I will chime in to say “that’s insane and stop drinking your own Kool-Aid.”

 

[NYEMMED]

What follows @RustedFox is an answer to you; not at you. I do not presume to know your motives or background.

What you describe is a small part of the reason why I left EM - the first time. Back in 2008-2009, EMP (now everyone’s favorite USACS) began the process of making life unbearable by changing the comp scheme so that about 1/4 of the monthly salary was dependent on Press Ganey scores being in the top 10% for the most productive physicians. Prior to that PG was in the comp but nowhere near as impactful, at least on the most productive. They also cranked up the mid-level hiring so that we could no longer effectively supervise them (mid-levels began around 2008ish under the condition that we would see every patient with them). The effect was immediate and profound since I spent most of my time in a military hospital that didn’t do this stupid BS and I could see the dichotomization evolve. Suddenly, physicians at the EMP site were writing for 10 percs or norco to every dental and back pain in a misguided attempt to avoid the dreaded 1s, and this was just the tip of the iceberg in terms of maladaptive BS that physicians were willing to do. So, I left the field, took a big pay cut in the process, and very much enjoyed the clean air. And before anyone claims that ApolloMD and TeamHealth were better, if so it wasn’t by much - I’ve worked there too.

So no, I’m not here to persuade. The time for that has passed. Scott Weingart is mostly correct - EM is now a broken and failed paradigm, I just think that we helped break it. Thus, I am here to chime into all these threads decrying the lawyers, administrators, and patients as a reminder to our culpability in this mess. And when I see threads such as this where the prevailing wisdom is effectively that no EP should be sued (the logical conclusion of a system where no expert witness should be allowed to exist), I will chime in to say “that’s insane and stop drinking your own Kool-Aid.”

They are also guilty of this. USACS is the worst offender of the group, followed by the others

 

[RustedFox]

What follows @RustedFox is an answer to you; not at you. I do not presume to know your motives or background.

What you describe is a small part of the reason why I left EM - the first time. Back in 2008-2009, EMP (now everyone’s favorite USACS) began the process of making life unbearable by changing the comp scheme so that about 1/4 of the monthly salary was dependent on Press Ganey scores being in the top 10% for the most productive physicians. Prior to that PG was in the comp but nowhere near as impactful, at least on the most productive. They also cranked up the mid-level hiring so that we could no longer effectively supervise them (mid-levels began around 2008ish under the condition that we would see every patient with them). The effect was immediate and profound since I spent most of my time in a military hospital that didn’t do this stupid BS and I could see the dichotomization evolve. Suddenly, physicians at the EMP site were writing for 10 percs or norco to every dental and back pain in a misguided attempt to avoid the dreaded 1s, and this was just the tip of the iceberg in terms of maladaptive BS that physicians were willing to do. So, I left the field, took a big pay cut in the process, and very much enjoyed the clean air. And before anyone claims that ApolloMD and TeamHealth were better, if so it wasn’t by much - I’ve worked there too.

So no, I’m not here to persuade. The time for that has passed. Scott Weingart is mostly correct - EM is now a broken and failed paradigm, I just think that we helped break it. Thus, I am here to chime into all these threads decrying the lawyers, administrators, and patients as a reminder to our culpability in this mess. And when I see threads such as this where the prevailing wisdom is effectively that no EP should be sued (the logical conclusion of a system where no expert witness should be allowed to exist), I will chime in to say “that’s insane and stop drinking your own Kool-Aid.”

I agree with a lot of your points.

The thing that made it *impossible* for us is that we had a group of PLPs that rotated between two sites, while the docs stayed at one site.

At "the other shop", it was a total free-for-all. Nobody supervised the PLPs, and the docs themselves; let's say they weren't exactly up to date on a few things. So, when the PLPs came to work with us at OurSite, they had the same expectation that "nobody was watching" and fast-and-loose was "okay". It wasn't. NOW, when we went to correct them, it was like talking to a child with divorced parents who would defiantly answer: "Mom says I can do THIS over at HER house, why can't I do it here? You must be WRONG, because OtherSite is bigger and has higher acuity overall. Nyahhh."

The hubris was insane.

 

[ShockIndex]

They are also guilty of this. USACS is the worst offender of the group, followed by the others

In today’s standards yes. But remember that I’m posting cases from a decade ago. Back then, it was a race to the bottom but from different angles. ApolloMD was pimping PA carts with no supervision as early as 2009 and the partners loved the extra RVUs. Around that time I had a very direct conversation with Dave Scott (EMP’s Pres) when he came to inform our site that we would be expanding the role of APPs in our fast track to account for the 20% increase in volume over the past year. When I told him that most of that volume was BS caused by our group turning the FT into candy land, and that APPs would only make it worse, I got a lecture about culture, values, and the future. Kinda like people in this thread commenting on my values…

Guess how many physicians were willing to say anything negative about the idea?

 

[allantois]

I was approached once to be an expert witness. (I know somebody that worked at the law firm) about 4 years ago.

I was “paid” to review a case. I told the lawyer “this is not a case, everything was done perfectly”
Lawyer said “maybe you don’t understand, I am paying you for an opinion I can use”

So I responded again, “it’s not a malpractice case”

Never heard from him again, never got paid either….

My friend at the office told me he had 4 docs after me look at the file until he found one that agreed with whatever he said.

It was at that point I realized the entire system is 💩. They will keep going until they find somebody they can pay off to say whatever they want.

I do expert witness defense work, Its more satisfying than being a paid for hire lier….

The lawyers should be on trial for this

 

[Rekt]

I mean you just continue to show you’re out of touch. 90% of the places I interviewed at you blind sign mid level charts. Everyone of my colleagues do it too where they took jobs. It’s essentially “standard of care” now.

Do I think its right? Of course not. It sucks and it’s bad patient care. But I have loans and need a job. Although due to specifics of my current setup I sign single digit cherts at most and sometimes none.

 

[Kryptocoin]

Any policy that solely depends on the ethics of someone with financial incentives to "do the right thing" is a failed policy. Instead we should be advocating for strong tort reform.

A few that I like:

Texas: "willful and wanton negligence" standard for emergency physicians.
Nebraska: Panel of expert witnesses that includes doctors and a lawyer. Prescreen the case and determine if standard of care was met. Findings admissible in court.
Indiana: Prescreening panel of expert witnesses. Admissible findings.
Nevada: $50k (yes, $50K) hard-cap on non-economic damages for emergency physicians.

 

[NYEMMED]

Any policy that solely depends on the ethics of someone with financial incentives to "do the right thing" is a failed policy. Instead we should be advocating for strong tort reform.

A few that I like:

Texas: "willful and wanton negligence" standard for emergency physicians.
Nebraska: Panel of expert witnesses that includes doctors and a lawyer. Prescreen the case and determine if standard of care was met. Findings admissible in court.
Indiana: Prescreening panel of expert witnesses. Admissible findings.
Nevada: $50k (yes, $50K) hard-cap on non-economic damages for emergency physicians.

South Carolina: gross negligence required for any EMTALA bound care. 300k non-economic cap

 

[allantois]

Any policy that solely depends on the ethics of someone with financial incentives to "do the right thing" is a failed policy. Instead we should be advocating for strong tort reform.

A few that I like:

Texas: "willful and wanton negligence" standard for emergency physicians.
Nebraska: Panel of expert witnesses that includes doctors and a lawyer. Prescreen the case and determine if standard of care was met. Findings admissible in court.
Indiana: Prescreening panel of expert witnesses. Admissible findings.
Nevada: $50k (yes, $50K) hard-cap on non-economic damages for emergency physicians.

Is this varied based on specialty?

 

[Kryptocoin]

Is this varied based on specialty?

Yes, the WWN standard is specifically for EM.

 

[BulgeDaTwine]

In today’s standards yes. But remember that I’m posting cases from a decade ago. Back then, it was a race to the bottom but from different angles. ApolloMD was pimping PA carts with no supervision as early as 2009 and the partners loved the extra RVUs. Around that time I had a very direct conversation with Dave Scott (EMP’s Pres) when he came to inform our site that we would be expanding the role of APPs in our fast track to account for the 20% increase in volume over the past year. When I told him that most of that volume was BS caused by our group turning the FT into candy land, and that APPs would only make it worse, I got a lecture about culture, values, and the future. Kinda like people in this thread commenting on my values…

Guess how many physicians were willing to say anything negative about the idea?

Just had to login for the first time in awhile to say that you're exactly the person the rest of us are $hit-talking about behind your back at the water cooler. Falling all over yourself with your haughty self-assuredness, second-guessing things with the luxury of the retrospectoscope... I bet your classmates LOVED you in residency.

The cases that everyone agreed with you on, shouldn't need expert testimony. The ones you selfishly defended lining your pockets with as you sold a colleague out, were probably more a victim of bad luck and whatever crap infrastructure/systemic issue their ER had.

 

[Arcan57]

In today’s standards yes. But remember that I’m posting cases from a decade ago. Back then, it was a race to the bottom but from different angles. ApolloMD was pimping PA carts with no supervision as early as 2009 and the partners loved the extra RVUs. Around that time I had a very direct conversation with Dave Scott (EMP’s Pres) when he came to inform our site that we would be expanding the role of APPs in our fast track to account for the 20% increase in volume over the past year. When I told him that most of that volume was BS caused by our group turning the FT into candy land, and that APPs would only make it worse, I got a lecture about culture, values, and the future. Kinda like people in this thread commenting on my values…

Guess how many physicians were willing to say anything negative about the idea?

I jumped into this thread at this post and thought, hmm kinda reasonable wonder why they're getting so much blowback. Then I backtracked and saw your prior posts. Maybe it's because I'm watching Andor but I see echoes of your proposed strategy in the early Rebellion's plan to make life under Emperial rule so miserable that the Rebellion wins popular support. I can see were you may attach some nobility to your quest to rid the world of unsupervised APPs. I guess my question would be how many pro bono plaintiff's cases have you taken? Cause I find people get really good at justifying their crusades when they're personally profiting from the crusade. Victims of egregious errors should be compensated. The system should protect patients better. Neither of those truths means what you're doing isn't just another person profiting off of someone else's misery.

 

[Kryptocoin]

Legislature approves cap on noneconomic damages in malpractice lawsuits • Iowa Capital Dispatch

Lawmakers sent a bill capping noneconomic damages in medical malpractice lawsuits to the Governor's desk Wednesday.

iowacapitaldispatch.com

Iowa just augmented their own tort reform. Capped at 1M. Just right at the policy limit for most doctors. $1M is still too much for greedy malpractice lawyers. Not enough deterrence in my opinion.

Grade C+

 

[PianoMedic]

Legislature approves cap on noneconomic damages in malpractice lawsuits • Iowa Capital Dispatch

Lawmakers sent a bill capping noneconomic damages in medical malpractice lawsuits to the Governor's desk Wednesday.

iowacapitaldispatch.com

Iowa just augmented their own tort reform. Capped at 1M. Just right at the policy limit for most doctors. $1M is still too much for greedy malpractice lawyers. Not enough deterrence in my opinion.

Grade C+

Better than an entire practice having to declare bankruptcy due to one partner having a lottery malpractice judgement against them and malpractice insurance carrier not wanting to pay out the claim:

Iowa City clinic owing $75M judgment files bankruptcy

An Iowa City medical clinic that owes parents of a newborn who has permanent brain injury files for bankruptcy protection after its insurance carrier hasn’t paid policy limits.

www.thegazette.com

They could have done more, I agree with you there. Better than nothing, but not as helpful as they could have been.