Expert Witness

[Backpack234]

Anyone here who does expert witness work? Seems like a decent gig and could be a good way out. But I’m sure someone else can tell me why I’m wrong?

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[Dr Mantis Toboggan]

Anyone here who does expert witness work? Seems like a decent gig and could be a good way out. But I’m sure someone else can tell me why I’m wrong?

If you do it too much, the opposing side will paint you as a professional sell out who will say anything for a buck. Plus you lose credibility if you are not still actively practicing. Per hour it’s by far my most lucrative work, but it’s a small % of my overall income.

 

[deuist]

I do some expert witness work from time to time. It's not a job; it is side income only.

 

[Backpack234]

Following up: how do you get started doing this as a side gig?

 

[Jball43]

Following up: how do you get started doing this as a side gig?

Find you a personal injury attorney or someone connected to the legal field who can pimp you out.

 

[CliveStaples]

Most people I have heard that got into it fell into three categories

1) You get sued and your attorney said "I think you'd be good at this" based on how you handle your own deposition. They then use you or refer you to your peers.

2) You get referred by a friend/colleague who is already doing expert witness work to get you your first gig.

3) You register on some kind of database offering your services as an expert witness and a random lawyer finds you this way.

+1 to the idea that this is an interesting side stream of income, and certainly could be a way to cut back on clinical shifts, but maintaining credibility means you have to keep working clinically and many will say you need to work for "both sides" to maintain credibility.

Do too many jobs for the same firm (defense or prosecution) and you risk being perceived as "their guy" who just gives whatever opinion that side wants.

 

[hoot504]

Locums guy I work with seems to do a lot of this. He's always bantering on the phone about it at work.

He writes some of the most medically indefensible notes I've ever seen. No MDM. Blank templates strewn about everywhere. Maybe he knows something I don't?

 

[TooMuchResearch]

Locums guy I work with seems to do a lot of this. He's always bantering on the phone about it at work.

He writes some of the most medically indefensible notes I've ever seen. No MDM. Blank templates strewn about everywhere. Maybe he knows something I don't?

Here is the advice I've heard about documenting for defensible charts:

Write down everything including a 20 item differential.

Write down little including almost no differential.

 

[EctopicFetus]

Reality is there isnt enough of this to go around for you to make this a full time gig. It’s a fun side hustle. Maybe you can make 10k per.. maybe you get 3/yr.. not enough to live on..

 

[Rendar5]

Locums guy I work with seems to do a lot of this. He's always bantering on the phone about it at work.

He writes some of the most medically indefensible notes I've ever seen. No MDM. Blank templates strewn about everywhere. Maybe he knows something I don't?

I don’t include a differential on at least half my notes (and when I do it’s for coding purposes only most of the time). I work expert witness on the side.

Notes need to tell a story that forces the reader to agree with you. They don’t need to say how smart you are. Often times, the less you write, the better. Remember, anything you say can and will be used against you in a court of law. True for cops. True for lawyers.

 

[Rendar5]

I also don’t write MDMs unless it’s not a straightforward case. It’s pretty obvious that the 90yo man PMH CAD with nonexertional nonpleiritic nonradiating chest pain without any associated symptoms with a normal exam is getting admitted for chest pain…. The history, exam, testing pattern, and results spell it out.

 

[Mount Asclepius]

I also don’t write MDMs unless it’s not a straightforward case. It’s pretty obvious that the 90yo man PMH CAD with nonexertional nonpleiritic nonradiating chest pain without any associated symptoms with a normal exam is getting admitted for chest pain…. The history, exam, testing pattern, and results spell it out.

Unless you practice in the community where hospitalists and cardiologists don’t care about your perceived risk. Most chest pain with negative testing goes home anymore.

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

The new billing changes in 2023 also placed increased emphasis on MDM.

 

[EctopicFetus]

Unless you practice in the community where hospitalists and cardiologists don’t care about your perceived risk. Most chest pain with negative testing goes home anymore.

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

The new billing changes in 2023 also placed increased emphasis on MDM.

Increased emphasis on MDM but you can get to a level 5 chart with minimal meaningful MDM..

for the 90 year old chest pain..
Order 3 tests, interpret the CXR with “No pneumothorax”, consider admission.. Level 5 chart even if you dc.

The MDM matters but lets be super clear that its not the depth of the MDM that pays.

 

[southerndoc]

Unless you practice in the community where hospitalists and cardiologists don’t care about your perceived risk. Most chest pain with negative testing goes home anymore.

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

The new billing changes in 2023 also placed increased emphasis on MDM.

Will never forget when I first started how I had a 35 year old with chest pain reproducible with palpation of his sternum. EKG normal. Point-of-care troponin was 70. Went to cath lab and had an occluded circ. I had just told him it's unlikely cardiac given it's worse with me pushing on his chest when the nurse walked in showing me the result on the i-STAT machine.

 

[Rendar5]

Unless you practice in the community where hospitalists and cardiologists don’t care about your perceived risk. Most chest pain with negative testing goes home anymore.

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

The new billing changes in 2023 also placed increased emphasis on MDM.

My “MDM” reads (anything in brackets is text inserted. Everything else is default auto text)
_____________________________________________
CPT coding information
Number and complexity of Medical Problems addressed
[Chest pain, possible cardiac ischemia]

Amount and complexity of data to be reviewed and analyzed.
1. tests/ document/independent historians.
a. External Notes reviewed: _
b. Ordering of Tests: All tests ordered in this chart were placed under ED physician supervision.
c. Reviewing of results: All tests documented in this chart or reviewed by myself.
d. Independent historians: _

2. Independent interpretation of tests: EKG (documented elsewhere)

3. Discussion of management or test interpretation: I discussed case with admitting physician.

Risk of complications and/or morbidity or mortality of patient management
I admitted the patient to the hospital.

____________________________________________



So in essence, my MDM is blank for my above chest pain admission with the exception of an auto text were inserted that there is possible ischemia. Technically, I could even leave that part blank, and there would be sufficient coding for a level five chart with my default admission autotext

When I’m discharging, I have a slightly different auto text with pulldown menus and would have to pick EKG as something I interpreted, under risk I would probably pick admission was offered to the patient but declined.

And if it’s a bull**** chest pain, I will actually write a differential that only includes stuff that I have ruled out because I never had an admission discussion with the patient. It would likely read:

The patient presented with chest pain. The differential diagnosis includes, but is not limited to: pneumonia, pneumothorax, ST elevation MI, NSTEMI, costochondritis.



All of those methods get to a level five chart. None of those methods is actually medical decision-making. My medical decision-making is implicit in the chart and any extra witness could still correctly interpret it. If I am going to be sued for a missed diagnosis, whether it’s consideration is documented or not, the plaintiff attorney will try and claim that I didn’t appropriately consider it for test for it as part of my differential, regardless of what my MDM actually says.

As above, I save my decision-making thought process for only those cases where it is complicated and cannot be written implicitly in my chart. I save documenting ED course to those patients that get multiple reevaluation.

 

[TooMuchResearch]

Unless you practice in the community where hospitalists and cardiologists don’t care about your perceived risk. Most chest pain with negative testing goes home anymore.

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

The new billing changes in 2023 also placed increased emphasis on MDM.

Muscle spasm in my back.
Posterior STEMI.

 

[TooMuchResearch]

Increased emphasis on MDM but you can get to a level 5 chart with minimal meaningful MDM..

for the 90 year old chest pain..
Order 3 tests, interpret the CXR with “No pneumothorax”, consider admission.. Level 5 chart even if you dc.

The MDM matters but lets be super clear that its not the depth of the MDM that pays.

Yes for some reason "MDM matters" for some people means "must write a novel every time." My concise sentence fragments accomplish the same billing.

 

[RustedFox]

I’ve come to the conclusion that history in chest pain is worthless. Burning pain just like my prior GERD relieved by tums. STEMI. Pleuritic pain in hypoxic, tachycardic cancer patient with negative CTA. STEMI. Sore throat with URI symptoms. StEMI. Chest pain following fall with reproducible tenderness. STEMI. All cases I’ve seen. Atypical presentations happen. You can chart what you want with history. That doesn’t defend you.

Honestly this.
My index of suspicion for CAD has nothing to do with anything the patient says but rather my internal monologue of: "How unhealthy does this one look to me ."

 

[TysonCook]

I remember the good old days of an entire chart, *everything*, triage note, RN notes, orders, H&P, MDM, Dx etc *everything* was on one sheet of paper, one sided at that! EMR has us writing Moby Dick every other day... and god forbid there's a typo or Dragonism. Looking at past charts sucked, but it was very streamlined and still billed out level 5's.

 

[RustedFox]

I remember the good old days of an entire chart, *everything*, triage note, RN notes, orders, H&P, MDM, Dx etc *everything* was on one sheet of paper, one sided at that! EMR has us writing Moby Dick every other day... and god forbid there's a typo or Dragonism. Looking at past charts sucked, but it was very streamlined and still billed out level 5's.

Blame the insurers and attorneys.

 

[RustedFox]

Honestly this.
My index of suspicion for CAD has nothing to do with anything the patient says but rather my internal monologue of: "How unhealthy does this one look to me ."

Yeah, I quoted myself. Cope.

The internal monologue goes even further.
It's unpleasant, but I'm also very often not wrong.
I recently caught a case of severe CAD in a young male because my brain said: "This guy looks dumb. Dumb enough to think that pizza rolls and ranch dressing are most of his diet. Admit."
99% circumflex.
HEART score can eff off.

 

[Mount Asclepius]

Yeah, I quoted myself. Cope.

The internal monologue goes even further.
It's unpleasant, but I'm also very often not wrong.
I recently caught a case of severe CAD in a young male because my brain said: "This guy looks dumb. Dumb enough to think that pizza rolls and ranch dressing are most of his diet. Admit."
99% circumflex.
HEART score can eff off.

Decision scores are for learners. This is reflective of experience and judgement.

 

[TooMuchResearch]

Decision scores are for learners. This is reflective of experience and judgement.

I stopped using a lot of the decision tools in the past few years but I thought it was out of laziness. Are you saying I'm just experienced and...judgemental?

I still like a score for pediatric appendicitis.

 

[RustedFox]

Decision scores are for learners. This is reflective of experience and judgement.

He really was "skinnyfat."

Like, my brain said: "This guy never matured beyond thinking that Limp Bizkit was the greatest band of all time and doesn't know how to do anything else food-prep wise beyond "put the pizza rolls on the baking sheet and have a bottle of ranch dressing at the ready when the timer goes off."

 

[Mount Asclepius]

He really was "skinnyfat."

Like, my brain said: "This guy never matured beyond thinking that Limp Bizkit was the greatest band of all time and doesn't know how to do anything else food-prep wise beyond "put the pizza rolls on the baking sheet and have a bottle of ranch dressing at the ready when the timer goes off."

Ahh college. Miss those days.