EM malpractice (Communtiy vs Academia)

[Alejandro]

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I feel as a med student it's trivial for me to bring this up (since all of our deans are brainwashing us with, "do what you WANT TO DO." Like some EM docs, I also have a background in the ED as a tech before school, and yes its influencing me to EM to a certain degree. Don't mind the weird/off hours that much, the lack of continuity with the pts i see, and knowing a little over a lot of different specialties, and the thought of being a thorn to consultants upstairs.

That all aside, one big thing that I'm still wondering if I should continue the EM path is med mal, and also its context in academia and community hospital EPs. As other posts have alluded to, there should be more education in schools about malpractice and being sued. Our school said that we will all get sued one day, but never really applied it to specialties and whatnot. What I'm trying to figure out is:

1) The basics of med mal. Where do you guys suggest me to start reading? I'm confused with for example, when does a suit hurt your record (to affect your job prospects and/or qualification to practice?), when you settle, or go to court, do both instances raise your premiums (like car insurance?), what is a reasonable estimate for a malpractice insurance? (although i'm sure this is probably regional, so why am i asking), among many other thoughts.

2) Academics vs. community EPs: I've talked to a fair number of profs about litigation and whatnot, and it seems like the academic institution "covers them," but what does that really mean? Like, do they get settled without them getting called out? or is it because the institution has a squad of 50 lawyers ready to defend your case? Are a lot of these suits more applied to community EPs?

3) So I've heard you guys talk about "the big miss" or the "lightning strike," and how even 99% sens/spec can still screw you over because lawyers can say that their patient does not deserve to be the dispensible 1%. So is there any real value in these statistics other than for your own gratification of feeling more confident in a diagnosis, when it seems like it wouldn't hold well in court?

Sorry for belaboring you guys with this--I've tried to look at other threads but haven't really found anything that answers my questions, and if you guys can find them, i'm all for reading the links. Thanks!

 

[EMIM2011]

Must read:
http://www.epmonthly.com/department...ractice-rundown-a-state-by-state-report-card/

 

[Birdstrike]

First of all, you should do what "you like." You should consider these other factors, but it's not brainwashing. (You will be brainwashed in plenty of other ways, and I'll be the first to call that out when I see it). Second, there are countless academic physicians that have gotten sued. I don't think it protects you at all, unless you're in a state that offers extra protection for academic/state employees (not many; protection may only be partial). In some specialties you may be more likely to get sued in academics, because at a tertiary teaching center you get sent tougher, sicker patients with worse outcomes. Bad outcomes bring suits. Trust me, being an academic "name" in your specialty means jack sh¡t when being sued. I guarantee they'll find some other scumbag in your specialty with just as big a "name" as yours, willing sell his soul and take thousands of dollars, to testify against your sorry arshnickle, while you sit on the witness stand with your bow tie on, sweating. Big academic name get sued and loses:

http://www.rossfellercasey.com/news/6-4-million-verdict-in-wrongful-death-medical-malpractice-case/

Since everyone gets sued eventually, generally it won't effect your ability to work at all, unless you have way more than the average suits, or multiple awards over policy limits. In my state, if you have no awards over your policy limit, your rates cannot go up, even if you're sued 10 times. Rates vary by state and specialty. Yearly premiums could be anywhere from $10,000 per year up to >$100,000 (high risk specialty in judicial hellhole state.)

I think when people talk about it "ruining" them, or "destroying careers," for all practical purposes that's closer to a personal fear and urban myth, rather than the rule. We all get sued, and the lawyers are more than happy to let us keep working, paying premiums, to build up that kitty so they can sue you again. They don't want to ruin you. They want to keep pulling your slot machine lever. Lawyers will spend tens of thousand of dollars to win an award against you, claiming you're a danger to society, but not a penny to get the medical license revoked from your supposedly dangerous doctor self. In fact, med mal attorneys have been know to go first to ERs where they've sued many doctors, when they have their own emergency. I've witnessed it, but HIPAA prevent me from exposing the appalling details.

Some people have been known to get severely depressed over a lawsuit. However, no one says you need to go kill yourself, or drink yourself to death, because some lawyer wants to extract money from your med mal policy, when you did nothing wrong. We need to have a thicker skin about these matters, and see these cases as the fraudulent shakedown that they usually are, totally disconnected from our self worth or lack thereof. I admit that's much easier said, than done.

This breaks it down by specialty (click "figures and multimedia" then "figure 1"):

http://www.nejm.org/doi/full/10.1056/NEJMsa1012370


Here's your career likelihood of getting sued (100% if high risk specialty; 80% if "low" risk specialty):

Above link, "figures and multimedia" then "figure 4"


Another must read article on this:

http://www.medscape.com/features/slideshow/malpractice-report/public#25


Here's a couple things I wrote on this subject if you care (first posted on this forum, which you might have read already) in addition to the related thread on the board right now:

http://www.epmonthly.com/whitecoat/2013/02/it-didnt-feel-like-a-win/

http://www.kevinmd.com/blog/2012/10/death-defensive-medicine.html

Either way, you will not be alone in this. We're all in this goat rodeo together, my friend. Welcome aboard.

 

[Groove]

Many academic centers are protected "somewhat" by sovereign immunity which in general covers most, if not all, federal and state hospitals.

In the end, we will all get (or have been) sued. It's inevitable if you look at the statistics. Thank God, I haven't yet, but I'm sure my day will come. That being said, I had some really good advice from an attending who trained me who recommended researching not only "your perfect job" but the community reputation of the hospital. He said, "It doesn't matter how good you practice emergency medicine... If the public considers you to work in a "bad" hospital, they are more likely to sue." He's probably right. I didn't do this for my previous job, but in my current one... I got my contract lawyer to do due diligence for the hospital where I'm working and she looked to see if there were any active lawsuits or any lawsuits against the ED for the past few years. There weren't and that made me feel much better about taking the job.

 

[Vandalia]

To echo what the previous posters have said:

1) I have ended up spending a fair amount of time on both credential and physician hiring committees. I pay about as much attention to any malpractice history as I do to the physician's undergraduate institution - in other words, none. I can never recall a physician's history of malpractice suits ever being a topic that was discussed in ether venue. Now, obviously, if a physician manages to get 20 suits in one year, that might be a cause for concern, but if so, that would likely also be reflected in the reference letters and/or actions taken with respect to previous hospital privileges. Every physician knows that there is no correlation between ability and being sued, and even less between skill and the amount of judgement. So being sued, or ending up with a large judgement, will have almost no consequences with regard to future employment opportunities. (Although it may change your desire to pursue those opportunities.)

I have also have known people to get very depressed about losing a malpractice jury trial. If you stop and think about that, and try to be objective (far easier if you are not the one sued) it is pretty stupid. Why would you base your professional self-esteem on what a random group of uneducated people (who, to quote one movie, "are so stupid they couldn't even figure out a way to get out of jury duty") think about how you handled a complex medical problem?

2) The advantage of working for a government, or government affiliated institution, is that these generally come with sovereign immunity. There was a long thread about this topic several weeks ago, and it should have all the information you need to know about that.

 

[EMIM2011]

Those of you who work(ed) in academics, how did you feel about the malpractice risk of working with residents - specifically from a documentation perspective? Where I work, one attending sometimes supervises up to 5 residents, with all very high acuity/complexity patients. It is basically impossible to really read through 30 notes per shift, often very long, if you work full-time clinically (12-15 shifts)... I am regularly reviewing malpractice cases, and documentation can really make or break a case.

 

[Vandalia]

I didn't spend a lot of time as an attending in academia, but I never really thought that documentation was a concern. Or let me rephrase that, I never thought under documentation was a concern. With medical students, interns, other residents and students from other disciplines around, if a patient sneezed, it was usually documented at least three times. I always thought the belief that academic physicians were less likely to be sued was a result of the fact that an attorney reading through several medical student H&Ps would set the chart (or monitor) on fire and drop the case.

Maybe it was unique to my era, but I wouldn't trust a student's knowledge of anatomy, or take for granted a young resident's differential for abdominal pain in a fertile female, but I always trusted that things were documented correctly and usually didn't go over it with a fine tooth comb. Maybe I should have... but since the statute of limitations has passed, it really doesn't matter know.