Students — TMLT: Medical Liability Coverage for Texas Physicians

2010 scholarship recipients

Douglas S. Lewis is a third-year student at Baylor College of Medicine. Read Mr. Lewis' essay.
Robert G. McAtee is a second-year student at the University of Texas Medical Branch in Galveston. Read Mr. McAtee's essay.
Scott McIntyre is a fourth-year student at Baylor College of Medicine. Read Mr. McIntyre's essay.
Nathan Wright is a fourth-year student at the University of Texas Medical School at Houston. Read Mr. Wright's essay.

The $10,000 scholarships were awarded to Texas medical students based on each student's financial need and written essay.

2010 winning essays

For the essay portion, applicants for the 2010 scholarship were asked to write risk management considerations for a closed claim study provided by TMLT. The case study and the winning essays follow.

The case study — failure to properly monitor patient

Presentation and physician action

A 20-year-old man was taken to the emergency department (ED) of a local hospital after he began to have difficulty walking. The patient was also foaming at the mouth. The patient reported that he had no history of seizures. The ED physician's work up did not reveal any abnormalities. The ED physician admitted him with a diagnosis of new onset seizure disorder.

While in the hospital, the patient experienced a seizure and a neurologist provided care. The results from a CT scan were normal and an EEG showed no seizure activity. The neurologist suspected genetic or idiopathic epilepsy. He prescribed phenytoin sodium with a plan to maintain the medication "over next day or so," and change to an oral anticonvulsant, possibly topiramate. The patient was discharged one day after admission.

Two weeks later, the patient visited the neurologist's office. The patient had been experiencing drowsiness and headaches since his hospital stay. The headaches were associated with photophobia and phonophobia. His phenytoin serum level was 20.9 with a reference range of 10-20. The neurologist ordered: phenytoin sodium 100 mg once in morning; 200 mg phenytoin sodium at night; and topiramate 25 mg at night. He also asked the patient to keep a headache diary, and to return to the office in two weeks.

One week later, the neurologist received an after-hours phone call from the patient's mother. She reported that the patient had a "red rash that developed all over his body that itched somewhat." The neurologist told the mother to take the patient to a dermatologist. The neurologist did not order tests or see the patient at this time.

Four days later, the patient saw the neurologist in his office. The patient's mother reported that she did not take the patient to a dermatologist, and instead took the patient to see a pharmacist. The pharmacist suggested the patient treat the rash with calamine lotion. The neurologist made no medication changes.

The patient returned with his mother to the neurologist days later and reported that he was not eating, was vomiting, and was excreting yellow urine. He was also jaundiced. The neurologist discontinued the patient's phenytoin and increased topiramate to 50 mg at night.

The neurologist referred the patient to a family physician, who prescribed metronidazole and cefdinir. The family physician ordered a blood test that revealed extremely elevated bilirubin, drastically high aspartate transaminase and alanine transaminase, and high phenytoin. The family physician told the mother to take the patient to the ED.

The patient was admitted at a local hospital after evaluation in the ED. The ED records reported that the rash was gone, but the patient was very weak, lethargic, and nauseated. The patient reported using acetaminophen for headache for the past two weeks. The results of a test for illicit drugs were negative.

The family physician found that the patient's liver panel values were trending downward. Phenytoin sodium level was at 24.9 (normal 10-20) and acetaminophen was less than 10 (normal 10-30). He ordered a liver transplant work up. The patient was found to be a candidate for a liver transplant, and he was placed on the transplant list two days later.

The next day, the patient's temperature increased to 103 degrees, and he became increasingly agitated and lethargic. It was determined that he had stage III encephalopathy. He became unresponsive. Four days later, the patient went into renal failure and developed acute respiratory distress syndrome. Due to his multi-organ failure, he was no longer a candidate for a liver transplant. The family implemented a "do not resuscitate" order and the patient died.

According to the autopsy report, the liver exhibited signs of severe autolysis. The pathologist was unable to determine the cause of the liver failure.

Allegations

A lawsuit was filed against the neurologist, alleging failure to properly monitor and timely discontinue the patient's phenytoin sodium therapy. This led to liver failure and the patient's death.

Legal implications

The plaintiff's expert stated that the neurologist should have discontinued phenytoin sodium therapy as soon as the patient's rash appeared. Failure to do so was a deviation of the standard of care. According to the plaintiff's expert, the Physician's Desk Reference and the FDA-approved packaging for phenytoin sodium state that the medication should be discontinued if a rash occurs.

The plaintiffs were also critical that the neurologist's notes never indicated a plan to take the patient off phenytoin sodium. He was also criticized for failure to see the patient to determine what type of rash he had. It was also noted that the neurologist's documentation was difficult to read.

Defense consultants were not supportive of the neurologist's actions. One consultant said that, "there's no question that as soon as the rash occurred, phenytoin sodium should have been discontinued. To do otherwise is a deviation of the standard of care." Another consultant was critical that the neurologist did not see the patient in his office to determine the type of rash.

The defense was able to locate experts supportive of the neurologist based on causation. These experts questioned whether it was the phenytoin sodium or the acetaminophen that damaged the patient's liver. Reviewers also commented that if the patient's mother had taken him to a dermatologist as instructed, the dermatologist may have spotted the phenytoin sodium reaction. Finally, the defense argued that the standard of care did not require taking the patient off phenytoin sodium therapy, but required the physician to watch the rash and stop phenytoin sodium therapy only if he felt it was necessary.

Disposition

This case was settled on behalf of the neurologist.

Risk management considerations by Douglas S. Lewis

Pharmacotherapy developed over the last half century has done wonders for the medical treatment of human disease. Unfortunately, neglect of a drug's adverse effects can lead to unintended consequences. While the unfortunate outcome of this case cannot be solely blamed on the physician, a more specific plan for treatment and assessment of adverse effects may have prevented the tragic fatality.

The vagueness and inconsistency of the neurologist's original plan was the first thing that caught my attention. " . . . phenytoin over the next day or so, then change to an oral anticonvulsant." In reality, the patient continued the phenytoin for at least 2-3 weeks before switching exclusively to topiramate — an obvious change from the documented plan. While it is true that patient management is fluid and constantly changing, any departure from the original plan needs to be clearly documented. The neurologist would have been better protected from a legal standpoint had he written a more specific plan and documented changes to this plan as they arose.

The use of phenytoin in this case is not inappropriate. However, I question whether the neurologist appropriately considered all of phenytoin's known adverse effects. Monitoring parameters for phenytoin include: BP, vitals, phenytoin levels, CBC and liver function tests (LFTs). Baseline LFTs may have indicated a pre-existing hepatic disease that would preclude phenytoin treatment or at least heightened awareness of adverse hepatic effect. LFTs at the two-week follow up may have revealed hypoalbuminemia and a corrected phenytoin level that was actually much higher than 20.9 mcg/ml. In addition, medical literature suggests measurement of phenytoin levels 2-3 days after initiation to ensure proper metabolism and then adjustment of dose if necessary. From the presented facts, it appears as though the neurologist did not properly monitor phenytoin therapy. All health care providers administering new pharmacotherapy need to ensure proper follow up and evaluation for adverse effects, especially those drugs known to be bad actors.

The neurologist's response to the patient's rash was also concerning. Rash is a common side effect of phenytoin and can vary from a benign hypersensitivity rash to the potentially fatal Steven's Johnson Syndrome. While such fatalities are rare, the general consensus in the medical literature is that phenytoin should be discontinued after the appearance of a rash until the rash can be further evaluated. After report of the rash, the neurologist responded appropriately by referring the patient to see a dermatologist. However, he should have also advised discontinuing the phenytoin immediately until the rash could be evaluated under close scrutiny by a physician. Not only did the patient fail to see a physician, but he ended up continuing the phenytoin for almost a week after the rash first appeared. Health care providers need to be extra vigilant and have a low threshold for investigation when starting new medications.

While it is true that excessive acetaminophen may have been the real culprit behind the patient's liver failure, the proper use and monitoring of phenytoin may have precluded acetaminophen use and led to a much more favorable outcome for the patient.

Risk management considerations by Robert G. McAtee

The progression of this case is a metaphorical representation of Newton's 1st Law of Motion: an object in motion remains in motion, unless acted upon by an outside force. A speeding train will continue speeding down the tracks until the conductor intervenes and slows the train or brings it to a halt. If, however, the conductor fails to take control at a series of sharp curves, the train may succumb to Newton's physical laws and catastrophically derail. In this medical case, the physician had several opportunities to apply the brakes, but his irresponsibility and lack of action led to dire consequences.

The neurologist's initial mistake was one of self-imposed limitation. Instead of thoroughly evaluating his patient to develop a differential, the neurologist immediately constrained his diagnosis to one of idiopathic epilepsy. Although this diagnosis might have been correct, the neurologist should have evaluated all possible causes of the seizure prior to starting the treatment regime. Whether or not to even treat a first seizure with medication is highly controversial due to the toxicity of most anticonvulsants. The neurologist should have documented all supporting tests and his rationale behind his diagnosis and decision to initiate treatment.

After thoroughly evaluating the patient, if the neurologist still decided to prescribe phenytoin, he should have done so in a much different manner. He originally documented that phenytoin would be maintained for "a day or so," and then would be switched to topiramate. He should have instituted a much more concrete plan, especially since phenytoin exhibits zero-order kinetics and is consequently eliminated slowly. The neurologist should also have counseled his patient and provided written information about potential side effects, allergic reactions, drug-drug interactions, and instructed the patient to call him immediately if any serious side effects emerged. This counseling session should have been documented.

When the patient returned to the neurologist's office two weeks later, which was too long given the experienced side effects, the neurologist should have discontinued the phenytoin and switched medications as originally planned, or made note of legitimate reasons to alter his original medication plan. The following week, when the neurologist received the emergency call about the rash, he should have instructed the patient to immediately discontinue the medications and either come to his office the next day or proceed to the emergency room if deemed necessary. This conversation should have been documented. After this encounter, the neurologist should have followed the patient extremely closely and referred him to his family physician much sooner for a liver panel workup.

As medical professionals, we are trained to critically evaluate clinical evidence, compile thorough differential diagnoses, and utilize scientific and practical judgment to make treatment decisions. The process of providing quality care must be dynamic and evolve as each clinical case unravels. In this case, the physician had many opportunities to modify his approach and slow his out-of-control "train," but because of his ineffective communication, lack of documentation, and ultimate irresponsibility, his train left the tracks.

Risk management considerations by Scott McIntyre

The education that comes with experience is a powerful attribute that infuses doctors with confidence, and is thereby reassuring to patients. Unfortunately, it is a universal human fault to allow over-confidence to lull one into complacency.

Physicians cannot know everything about every drug, but for any drug commonly used, the physician must be a walking desk reference. If the neurologist in this case made a list of the drugs that comprise 90% of his prescriptions, he can know those drugs extensively, and be current with research. He likely had prescribed phenytoin hundreds of times before and clearly knew about the drug's potential for hepatotoxicity. With such severe consequences, one must maintain a low threshold for alarm when confronted with early warning signs. Compared to other hepatotoxic drugs, phenytoin is more likely to begin with a hypersensitivity reaction, most commonly within the first two months of treatment. It is understandable that when called about the skin rash, he referred to a dermatologist, and the patient should have gone to the dermatologist rather than be diagnosed by the pharmacist. However, on the follow-up visit the alarm bell should have been blaring. A mildly pruritic full body skin rash shortly after beginning a new drug cannot simply be ignored without proper investigation.

The neurologist originally had the plan to terminate the phenytoin and use topiramate instead. What happened to the plan? Topiramate can be an effective drug for seizures, and can also be effective for migraine headaches. It would be appropriate to detail in the medical record the reasoning for continuing the phenytoin, as well as demonstrate that proper consideration was taken when dosing two interacting drugs.

Phenytoin induces the metabolism of topiramate, which may have resulted in uncontrolled migraines, encouraging what may have been excessive acetaminophen use. Also, some evidence suggests that topiramate may inhibit metabolism of phenytoin in some patients, resulting in elevated serum levels.

After-hours calls are often inconvenient, unexpected, and blind. They also occur when the patient is the most concerned, so it is critical to have good systems in place. Developing routines to simulate normal care as closely as possible is necessary to avoid errors and miscommunication. One way to help is with electronic medical records. With mobile devices widely available, online access to a patient's record could help prevent mistakes, and may have made it easier to recognize the hypersensitivity reaction. They would have also been helpful in reminding the neurologist of the previous plan of treatment. In any case, there is no reason to have documentation that is difficult to read. If the neurologist preferred a pen, then the legibility must be commensurate with a keyboard.

It is easy to be critical when blessed with the benefit of 20/20 hindsight, but more helpful to be receptive to the lesson of how to improve our own processes. Extensive knowledge about commonly prescribed drugs, a systematic approach to after-hours calls, and EMRs to improve continuity of care could have increased patient safety.

Risk management considerations by Nathan Wright

Every doctor makes mistakes. The physician-patient relationship is the most important relationship in medicine and is a protection for both parties. When that relationship degenerates or fails to materialize, physicians become negligent and patients often suffer — two issues at the heart of this case. Fortunately, training that begins as early as medical school can help physicians keep the physician-patient relationship strong and avoid malpractice. Good planning, accepting responsibility to provide optimal care, and timely face-to-face patient interaction are three such lifelines.

Good planning demonstrates concern for the patient and is essential for the physician. A thorough, legible treatment plan focused on the patient's needs should have been documented as part of the neurologist's initial evaluation. Simply writing to start phenytoin and maintain "over the next day or so" was insufficient and as a result, the patient's drug levels were beyond therapeutic at two weeks with subsequent life-threatening organ damage. Though the neurologist had additional documentation, how much defense can it provide if no one else can read it? Good plans are clear and sufficiently detailed. The neurologist's was neither.

In medical school, if we don't know an answer, we are taught to say "I don't know" and look it up. Not only does this increase our knowledge, it is also our duty to our patients and helps us provide the best care possible. Because of this patient's history and previously high drug levels, when a rash developed, a red flag should have been raised in the neurologist's mind. The neurologist either missed the diagnosis or neglected his responsibility by referring the patient. Either one is wrong. Although it is impossible to memorize all the side effects for all medications, it is always possible to look them up. A pocket-book or electronic pharmacopeia could have been a literal lifesaver. Had the neurologist spent a few moments reading about phenytoin on his iPhone or Blackberry, he may have been able to save his patient's life.

A picture is worth a thousand words. Translation: see the patient! The most important way to strengthen the physician-patient relationship is through one-on-one interaction. Sometimes the physician must take the initiative and encourage the patient to come in. This is essential for proper treatment and diagnosis. No amount of clinical know-how can compensate for failure to see a patient. The neurologist should have seen the patient soon after he left the hospital and immediately after the rash appeared, but it was neglected. Clinical consults may have been appropriate second steps, but follow up with the neurologist was the first. At both of these potential visits, simple treatment corrections could have been made (adjusting medications, discontinuing phenytoin, etc . . . ) that would have had a dramatic impact on patient outcome.

In short, there were many things the neurologist could have done differently in this case. At the heart of all of them is the fact that he failed to foster and prioritize a strong relationship with his patient and drifted into seemingly innocent neglect. Unfortunately, the outcome was disastrous.

2009 scholarship recipients

Joseph H. Childs is a fourth-year medical student at the University of Texas Medical School at Houston. Read Mr. Child's essay.
Wilbur Dattilo is a third-year medical student at Baylor College of Medicine. Mr. Dattilo's essay.
Cliff Hampton is a third-year medical student at Baylor College of Medicine. Read Mr. Hampton's essay.
Ravi Kumar is a fourth-year medical student at Texas A&M University System Health Science Center College of Medicine. Read Mr. Kumar's essay.

The $10,000 scholarships were awarded to Texas medical students based on each student's financial need and written essay.

2009 winning essays

For the essay portion, applicants for the 2009 scholarship were asked to write risk management considerations for a closed claim study provided by TMLT. The case study and the winning essays follow.

The case study

Presentation and physician action

A 25 year-old-man came to his family physician complaining of two to three months of dizziness, near syncope, decreased appetite, fatigue, and thirst. The patient also reported a 45-pound weight loss over the last six months. The family physician examined the patient and noted that his height was 5'11"; weight was 139 pounds; blood pressure was 90/74 mm Hg; and pulse was 84. He made one note under skin assessment: "Palms? Pale." This was the only note made regarding skin pigmentation in the patient's medical record.

The family physician diagnosed syncope, nausea, GERD, and conjunctivitis. He ordered a CBC, urinalysis, TSH, complete metabolic panel, and hemoglobin A1C. He recommended that the patient eat a bland diet and follow up in several days.

The patient called the family physician's office the next day. He complained of syncope, nausea, and vomiting blood. The patient was directed to the emergency department (ED) of a local hospital.

The patient came to the ED with complaints of nausea, vomiting, fever, and dizziness for the last two days. His vital signs were recorded as temperature 92.2 degrees; pulse 101; respirations 16; and blood pressure 82/58 mm Hg. He reported a family history of diabetes and that he smoked one pack of cigarettes a day. Labs were drawn and IV fluids were administered. The patient's blood pressure fluctuated from 70/48 to 104/59 mm Hg.

The ED physician diagnosed nausea and vomiting, and contacted an internal medicine physician who admitted the patient. The internal medicine physician — who was not aware of the earlier treatment by the family physician — examined the patient and noted that he was weak and fatigued and his vital signs were stable. He also noted positive bowel sounds and that the abdomen was soft and tender. The internal medicine physician planned to check for diabetes, cholesterol, and thyroid problems. He ordered a GI consult.

The gastroenterologist examined the patient. He found no signs of diabetes, dysphagia, odynophagia, or malabsorption syndrome. A drug screen was negative. The gastroenterologist's impression was anorexia and weight loss most likely secondary to psychophysiological disturbance. He recommended ruling out GI malignancy or metabolic disorder. He agreed with the internal medicine physician's work-up recommendations and also ordered a CT of the abdomen and an EGD.

An abdominal CT scan was conducted, and a radiologist read the results as negative. The radiologist noted that the patient's adrenal glands were normal. The gastroenterologist performed an EGD and no abnormalities were found. During his hospital stay, the patient's sodium and blood pressure remained low. The low sodium levels (129 at admission and 132 at discharge) were attributed to dehydration.

After two days in the hospital, the patient was discharged with instructions to follow a soft diet. He was also told to see the internal medicine physician in two to four weeks.

One month passed and the patient returned to the family physician. He reported that he was still nauseated and was depressed. He told the family physician that his work up at the hospital was normal. The family physician noted that the patient's eyes appeared cloudy. The family physician diagnosed nausea and depression. He prescribed fluoxetine and told the patient to return in two weeks. He did not personally contact the internal medicine physician about the hospital care. The patient did not return to the family physician.

Two weeks later, the patient was involved in a one-vehicle auto accident. Reportedly, he became lightheaded and dizzy while driving and struck a guardrail. By the time EMS arrived, the patient was unresponsive and lying face up. The patient was taken to the ED where a CT of the head showed hypoxic brain injury. He died a short time later.

An autopsy revealed bilateral adrenal atrophy with lymphoid infiltration, consistent with Addison's disease. The pathologist noted the adrenal glands were small and resembled an empty adrenal capsule. The pathologist stated that the cause of death was Addison's disease.

Allegations

Lawsuits were filed against the family physician and the internal medicine physician. The allegations included failure to diagnose Addison's disease; failure to provide appropriate treatment; and failure to order diagnostic tests necessary to evaluate the patient's condition.

Legal implications

The plaintiff's expert stated that both the family physician and the internal medicine physician fell below the standard of care. He stated that the standard of care required the physicians to investigate why the patient had lost 30% of his body weight and to test for Addison's disease with an ACTH stimulation test or 8 AM cortisol test. According to this expert, the patient exhibited classic signs of Addison's disease: skin pigmentations, malaise, low sodium, and low blood pressure. In particular, the patient's low sodium during hospitalization should have prompted the internal medicine physician to order an inexpensive cortisol test.

The plaintiff's expert concluded that if the appropriate tests had been conducted, the disease would easily have been diagnosed. This would have led to proper treatment and normal life expectancy for the patient.

The defense argued that the patient's symptoms could have been caused by hundreds of conditions, and that it was not within the standard of care for the defendants to suspect Addison's disease. According to an internal medicine physician reviewing this case for the defense, Addison's disease is typically diagnosed by specialists over a period of time as symptoms recur. It is not typically diagnosed on an initial visit or in the ED.

This defense of this case was weakened by the lack of communication between the family physician and the internal medicine physician. The internal medicine physician was not aware that the patient had received treatment from the family physician before the hospitalization. The family physician did not contact the internal medicine physician when the patient advised that his work up during the hospitalization was normal. Additionally, defense consultants stated that the defendants' records did not reflect adequate consideration of or an adequate plan to address the patient's rapid weight loss, hypotension, elevated AST, hyperkalemia, and hyponatremia.

Disposition

Due to the communication and documentation issues, this case was settled on behalf of the family physician and the internal medicine physician.

Risk management considerations by Joseph H. Childs

Primum non nocere — 'first do no harm'; also known as nonmaleficence. What does this mean, how can we avoid harming the very people that come to us in search of healing solutions? Harm, although never intentional, results either from misguided physician action or an abstinence of action.

Specific to the case provided, a few key factors ultimately brought about malpractice allegations. If the following three considerations had been adequately addressed, these allegations would likely never have come to fruition. First, the obvious lack of communication between the family physician and the internal medicine physician. Second, the paucity of documentation without providing rationale for the actions taken and not taken. Third, a failure to entertain a comprehensive differential diagnosis.

Communication is an integral part of practicing safe and effective medicine regardless of specialty. Knowingly sending his patient to the ED, the family physician should have forwarded all recent and relevant medical records to the hospital and made an effort to communicate with the internal medicine physician to convey any medical concerns and/or special needs of the patient. Conversely, it is not realistic to expect any patient to convey the important medical details of their own hospital stay; the hospitalist should have contacted the patient's family physician. Both parties ought to have made an effort to communicate with reference to this patient's admission after his discharge from the hospital. Efficient communication becomes extremely difficult if the physician fails to carefully document patient encounters.

In the world of documentation, perception is reality; the recorded information is all there for the reader. For physicians, it is vital to thoroughly document all patient encounters lacking care to convey specific thought processes. Carefully documenting observations through use of pertinent positives and negatives encompassed in the history and physical exam will guide the reader through the author's thought process, making it clear which diagnoses are being considered and ruled out. Careful assessment of the patient and a detailed plan are essential, documenting all evidence, reasoning, and decision-making that leads to the differential diagnosis while providing rationale for diagnostic and therapeutic actions — or lack thereof.

The quintessential assumption in this case is that the involved physicians are knowledgeable about various disease processes and up-to-date with current literature and current standards of care. It is a plain reality that "the eye will not see what the mind does not know." Without the ability to form a broad yet focused differential diagnosis, the utility of history taking, documentation and communication is by-and-large lost. An effective physician needs to be able to consider various diagnoses and be keenly aware of the standards of care for each of these, including proper diagnostic and therapeutic strategies.

In summary, to 'first do no harm' and to increase a physician's defensibility, it is imperative for physicians, present and future, to be properly trained and able to generate comprehensive differential diagnoses. Physicians must document completely and accurately, and hastily communicate documented findings with other physicians involved in the patient's care.

Risk management considerations by Wilbur Dattilo

Even though primary care physicians may not see Addison's disease every day, they certainly become familiar with its features during medical school. Yet, when a distressed patient with a textbook case of Addison's disease presented repeatedly over the course of several months, nobody in this scenario recognized it. Certainly there were problems with documentation, communication, and follow-up, but the real problem was much more fundamental — intelligent and dedicated professionals did not have that "ah-ha" moment that would have allowed them to pair this young man's symptoms with an entirely familiar disease entity.

A simple glance at reference material during this patient's first visit is the most effective step that doctors could have taken to ensure that less-common but treatable conditions like Addison's disease were considered. Even the most brilliant physicians cannot maintain a complete differential diagnosis for every possible combination of symptoms in their heads. Fortunately, there are many easily accessible, quick, and inexpensive reference resources. Because the patient unintentionally lost 45 pounds in six months, his doctors should have been alarmed for a long list of serious conditions including malignancy and HIV. If the family doctor had taken just five minutes to look up this symptom alone in an online database or textbook index, he would have seen a differential diagnosis that included Addison's disease. Perhaps if he simply saw "Addison's Disease" he would have had enough insight to make the preliminary diagnosis immediately. When a patient's condition is serious, and the diagnosis elusive, it is foolish to rely wholly on memory. A few minutes with reference material refreshes memory and facilitates inspiration.

Even if a quick look at reference material was not enough to spark an "ah-ha moment," it could have led to other risk management behaviors that would have increased the probability that this patient would have eventually been diagnosed and treated appropriately. If the family physician had started by referencing a complete differential for unintentional weight loss, for example, he could have documented more efficiently. With a list of possible causes for the patient's symptoms, he could have more easily documented pertinent positives and negatives from the history and physical exam. Furthermore, he could have easily developed and documented a plan to address all of the diagnostic possibilities with the most likely and serious being addressed in first visit, but the others to be pursued thereafter. If he had a complete plan, he would have wanted to communicate with the internist about his patient's hospital care and upon discharge would have more likely coordinated with the internist about diagnostic possibilities that still needed to be pursued. He would have been able to communicate with his frustrated patient about his plans, and this may have helped the patient be more compliant with follow up. Finally, he would have been less likely settle on a diagnosis of depression until other possibilities had been ruled out.

In short, a five-minute investment into abundantly available reference material could have prevented this lawsuit and saved a young man's life.

Risk management considerations by Cliff Hampton

Primary adrenal insufficiency is a rare disorder (35-140 per million prevalence) that presents insidiously with vague signs and symptoms. It would be easy for a family practitioner (FP) to ascribe the dizziness, anorexia, and fatigue with which this patient presented to more common etiologies. While it is true that an ACTH stimulation or cortisol test would have ascertained the diagnosis and set the patient up for proper management, the true challenge was for the physicians to reach a level of clinical suspicion for Addison's disease that would have prompted ordering these tests. Therefore, risk management in this case is most effectively focused on developing and following good practice habits to recognize and develop plans to address potentially serious clinical situations.

Good clinical habits begin with the basics. For all patients, the FP must always pay attention to the vital signs and document a complete history and physical. In this case, the vital signs showed low-normal blood pressure and BMI, the H&P brought out the chronic nature of the symptoms, and the review of systems drew attention to the weight loss. Use of a standard H&P form may have helped prevent key elements from being overlooked, although these forms are only useful if they are filled out completely and accurately for every patient. A disciplined approach to building a comprehensive differential diagnosis must be followed with rigor in all patients, especially those with vague presentations.

Physicians can keep current on the medical literature pertinent to their field and participate in relevant CME. Informed physicians will more likely include rare disorders in their differential. It is essential that documentation of the assessment and plan always include discussion of the differential diagnoses and a plan to address each unclear element of the presentation. FPs should feel comfortable referring patients to the appropriate specialist if they are unclear about their patient's situation.

A specific plan from the internist to examine the etiology of the hyponatremia was a tragic omission. It was not necessary that the cause of the hyponatremia be uncovered during the hospital stay, but it was imperative that the internist document a plan for its investigation. Even a first-rate H&P with a well-documented assessment and plan is of little consequence if not communicated to other physicians. The internist should have called the FP upon the patient's hospital admission. Better communication with the patient was also needed; the internist should have expressed concern for the lab values and emphasized follow up with the FP. The patient's report to the FP that everything was "normal" evidenced the lack of concern conveyed by the internist to the patient. Likewise, rather than listen only to the patient's report, the FP clearly was remiss in failing to obtain, review, and document the hospital record. The FP also should have a routine in place for the office staff to contact the patients by phone to check on the patient and remind him of the importance of the follow-up appointment.

Risk management considerations by Ravi Kumar

This is an unfortunate case. People are fallible by nature, and the patient in this case paid the ultimate price for multiple errors in judgment. But I hesitate in pointing a finger at anyone. As long as people are engaged in health care, mistakes will be made. Medicine is a humanistic art and science. Computers or robots will never replace doctors, because people want to be touched and cared for by another person.

There is no computer program that can equal good judgment or reasoning based on ethics, intuition, or years of experience. So if you ask me what I would have done differently in this case, I'd say, "I would have ordered an 8am cortisol and diagnosed the patient with Addison's disease." But . . . maybe I wouldn't have. Maybe on that day I would have been "off my game," just as the family practitioner, internist, ED physician, gastroenterologist, and radiologist were. Maybe on any given day, any one of these physicians might have recognized the signs of Addison's disease or done something different that would have led to the diagnosis. But none of them did. And because there were no signs of blatant negligence, the errors in judgment made by these physicians were completely within their rights as fallible human beings.

But saying, "I made a mistake," is not good enough. It's not good enough for averting liability, and it's not good enough for patient safety. I propose safety mechanisms as a solution to preventing errors made in health care. I recognized two major errors that could have saved the patient's life and spared the internist and family practitioner liability.

1) The lack of communication between the two physicians was an error. The internist should have known about the patient's pertinent history, and the family practitioner should have had access to the inpatient workup. A universal electronic medical record (UEMR) would be the ideal solution to this problem. It would have given both physicians access to the patient's pertinent medical history and studies. Implementation of a UEMR is more of a long-term solution. In the meantime, physicians should insist that patient's PCPs be notified upon admission, a request for medical records be made, and that hospitals and transcription services send medical records to the patient's PCP upon discharge. Although inefficient, such policies could save lives.

2) All physicians in this case clearly missed the diagnosis. This is a situation in which a computer program could have patched a hole made by our fallible nature. The VA has an electronic medical records system that alerts its users to possible drug interactions. It never overrides a physician order, but seeks to catch possible oversights. In this case, a computer program in conjunction with an EMR could have identified the signs of a possible Addisonian crisis and made suggestions.

Human beings will make mistakes. And in health care, this may cost lives. I believe that it is our duty to put systems in place that protect us from our mistakes.

2008 scholarship recipients

Alexander J. Alvarez is a third-year medical student at the University of Texas Southwestern Medical School. Read Mr. Alvarez's essay.
Megan Gentry is a third-year medical student at the University of Texas Health Science Center at San Antonio. Read Ms. Gentry's essay.
Douglas James Heiner is a third-year medical student at the University of Texas Medical Branch at Galveston. Read Mr. Heiner's essay.
Michael Merrick is a fourth-year medical student at the University of Texas Medical School at Houston. Read Mr. Merrick's essay.
Ana Nguyen is a fourth-year medical student at the Texas Tech University Health Science Center School of Medicine. Read Ms. Nguyen's essay.
Kyle Piwonka is a fourth-year medical student at the University of North Texas Health Science Center's Texas College of Osteopathic Medicine. Read Mr. Piwonka's essay.
Jenny Van Winkle is a fourth-year medical student at the Texas A&M University System Health Science Center College of Medicine. Read Ms. Van Winkle's essay.
Ajit Vyas is a fourth-year medical student at Baylor College of Medicine. Read Mr. Vyas's essay.

The $5,000 scholarships were awarded to one student at each Texas medical school. Scholarship recipients were chosen based on each student's financial need and written essay. The TMLT Memorial Scholarships were created to recognize Texas medical students who are interested in finding creative ways to enhance patient safety and who can communicate their ideas in a short essay.

2008 winning essays

For the essay portion, applicants for the 2008 scholarship were asked to write risk management considerations for a closed claim study provided by TMLT. The case study and the winning essays follow.

The case study — failure to treat septic joint

Presentation

An 8-year-old girl was brought to the emergency department (ED) of a local hospital. She had fever and right knee pain. The mother reported that the child had fever for four days and had swelling and redness of the right knee, with streaking up the leg. The patient's history was notable for a hospital admission 18 months earlier for septic bursitis in the left ankle that was successfully treated following orthopedic surgical debridement.

Physician action

Emergency Physician A saw the child at 7:45 p.m. She noted that the knee was red and warm, but the child had full range of motion and was able to walk with a limp. The area was non-tender and there was no fluid appreciated. The girl's vital signs were temperature of 104 degrees; heart rate of 130-140 bpm; blood pressure 106/65 mm Hg; and respiratory rate in the 20s. Laboratory data indicated a white blood cell count of 11.5 with 46% Polys, 40% bands, 13% Lymphs, and 1% Monos. C-reactive protein was elevated at 8.1.

Plain x-ray films of the right knee were non-diagnostic. An MRI of the right knee was ordered, and the results were obtained after Emergency Physician A went off shift. Emergency Physician B took over. The MRI showed a moderate joint effusion and extensive lateral soft tissue swelling. Emergency Physician B discussed the case with Orthopedic Surgeon A at 1:25 a.m. Orthopedic Surgeon A told him to "hold off antibiotics " and that she would perform an arthrocentesis early in the morning. Emergency Physician B's final diagnosis included "right knee effusion/pain; concern for septic joint."

The patient was admitted to the hospital under the care of Pediatrician A. She had a temperature of 101.6 degrees at 2:30 a.m., and 102.3 degrees at 4:40 a.m. Pediatrician A saw the patient at 8 a.m. She saw Orthopedic Surgeon A in the hallway outside the patient's room, and asked Orthopedic Surgeon A if she had completed the arthrocentesis. When she stated that she had not done the arthrocentesis, Pediatrician A invited her to examine the patient. Orthopedic Surgeon A refused, stating she had an emergency to attend and could not perform the arthrocentesis. She told Pediatrician A that she would ask her partner, Orthopedic Surgeon B, to perform the arthrocentesis. At 9 a.m. Orthopedic Surgeon A called her office to let her partner know that this patient was in the hospital, needing an arthrocentesis of the knee. Since Orthopedic Surgeon B had a clinic full of patients when he was notified about the patient, he decided to complete the clinic and then go to the hospital.

Orthopedic Surgeon B saw the patient a 1 p.m. He noted that she had a pulse rate of 135, a temperature of 102 degrees, and that she looked sick. The patient's left lower leg—previously uninvolved—appeared dusky, and the patient exhibited a petechial rash around the knees. Orthopedic Surgeon B felt the patient either had an embolic event from endocarditis or was manifesting signs of sepsis. He transferred the patient to the ICU, and consulted an intensivist, infectious disease specialist, and cardiologist.

At 1:50 p.m., the pediatrician ordered a repeat CBC, blood culture, a DIC and renal panel, and an echocardiogram. The child was started on Vancomycin and gentamycin. At 2:35 p.m., her blood pressure dropped to 82/42 mm Hg. The infectious disease specialist ordered a fluid bolus of normal saline and an empiric dose of Rocephin 500 mg IV. The patient's blood pressure improved, but dropped again to 73/40 at 3:30 p.m., prompting an additional fluid bolus of 500 cc normal saline. From 3 p.m. to approximately 6:15 p.m., the patient's blood pressure remained in the 90s/30s. Dopamine infusion was started, and the patient received multiple fluid boluses. She was intubated at 5:15 p.m., and one hour later large amounts of blood came through the endotracheal tube. A chest x-ray showed bilateral fluffy infiltrates, consistent with a pulmonary hemorrhage. The patient received platelet and red cell transfusions. At 7 p.m., the patient became bradycardic and required chest compressions. She was given bicarb, calcium, insulin, glucose and epinephrine. Although she was briefly stabilized, she coded again at 7:40 p.m. Resuscitation efforts continued, but they were not successful. The patient was pronounced dead at 8:55 p.m.

An autopsy was performed and the pathologist concluded that the patient died from Group A Beta hemolytic streptococcal sepsis that resulted in acute infectious purpura fulminans and marantic endocarditis.

Allegations

Lawsuits were filed against the hospital, Emergency Physicians A and B, Pediatrician A, and Orthopedic Surgeons A and B. The allegations included:

failure to institute antibiotic therapy after receiving the first lab results (Emergency Physician A);
failure to call in the orthopedic surgeon on a "stat" basis and failure to stress the septic condition of the patient sufficiently to prompt Orthopedic Surgeon A to come in immediately (Emergency Physician B);
failure to obtain an emergent consult from another physician when Orthopedic Surgeon A failed to come in (Pediatrician A and Emergency Physician B); and
failure to make themselves present in a case where a patient had labs indicative of a septic joint and developing septicemia (Orthopedic Surgeons A and B).

Legal implications

The plaintiffs were able to obtain support for their allegations from a pediatric infectious disease specialist. He stated that the ED physicians should have considered septic arthritis as the first diagnosis in their differential diagnosis and arranged urgent orthopedic consultation for aspiration of the child's right knee. Once the fluid was sent for culture, the standard of care required that the child be started immediately on IV antibiotics pending the results of the culture and rheumatologic studies. The ED physicians and the pediatrician should have insisted that Orthopedic Surgeon A or another orthopedic surgeon perform an arthrocentesis, and failure to do this was a violation of the standard of care. Further, this failure was a direct cause of the child's bacteremia, septic shock, and death. If antibiotics had been started in the ED, this patient likely would have survived.

An orthopedic surgeon who testified for the plaintiffs stated that the orthopedic standard of care for a possible infected knee joint is either to come in and aspirate the joint, or if the ED physician feels competent, have that physician aspirate the joint for culture and sensitivities. Antibiotics should then be promptly started until the culture growth can be established. Aspiration of the joint before starting antibiotics in a possible infected joint is the standard of care, rather than empirically starting antibiotics without this culture. Doing a blood culture alone, is not the standard of orthopedic care. According to this expert, Orthopedic Surgeon A did not meet the standard of care.

Several consultants reviewed this case for the defense. The orthopedic surgeons blamed Pediatrician A and Emergency Medicine Physicians A and B. The pediatric consultants blamed Orthopedic Surgeon A. The emergency medicine physicians who reviewed this case were critical of everyone. They felt that had antibiotics been started in the ED, and had the ED physicians been trained to do arthrocentesis, they could have prevented the death of this patient. The pediatric infectious disease consultants who reviewed the case were all concerned that with a severe left shift, antibiotics should have been started sooner. Only one physician who reviewed this case stated that the patient's survival was unlikely, and the addition of antibiotics early in the morning would not have made much difference in the outcome.

Finger pointing among the physicians further complicated the defense of this case. Emergency Physician B stated that if asked, he would testify that he spoke with Orthopedic Surgeon A twice between 1:30 and 2:30 a.m. During the first conversation, he said the patient had a severe left shift in her labs and looked to have a septic joint. He asked Orthopedic Surgeon A to do an arthrocentesis immediately. Orthopedic Surgeon A said she would perform it in the morning, and she ordered that no antibiotics be given so the culture would be accurate. Orthopedic Surgeon A told Emergency Physician B not to call her back. After obtaining the results of the MRI, Emergency Physician B called her back to give her the results. She still did not come in.

Emergency Physician B then alerted Pediatrician A to this fact, but Pediatrician A did not order an arthrocentesis from another physician. She agreed to wait until morning. When Pediatrician A arrived at the hospital at 8 a.m., she expected that the tap had been completed. When she learned that it had not, she was concerned. Orthopedic Surgeon B testified that had Pediatrician A or Orthopedic Surgeon A stated that he was urgently needed, he would have seen the patient sooner. Orthopedic Surgeon B was surprised that Pediatrician A and the nurses waited so long to call him and failed to involve an intensivist and infectious disease specialist earlier.

Disposition

This case was settled on behalf of Pediatrician A and Orthopedic Surgeon A. The hospital also settled their case. The case against Emergency Medicine Physicians A and B and Orthopedic Surgeon B were dismissed.

Risk management considerations by Alexander J. Alvarez

As was outlined in the case allegation, there were multiple factors that contributed to this patient's unfortunate death. Emergency Physicians A&B clearly acted according to the standard of care, as was stated in the Orthopedics surgeon testimony. He stated that standard of care for a possible septic joint is either (1) for the orthopedic surgeon to come in and aspirate the joint or (2) for the ED physician to aspirate if he feels competent to do so. According to the statements of the ED physicians, they were not trained to properly perform arthrocentesis, so only option (1) followed standard of care. Emergency Physician A ordered an MRI to work up a suspected diagnosis of septic joint after seeing a left shift in the labs of a non-diagnostic plain film. The results didn't come back until Emergency Physician B was on duty, at which point the diagnosis was correctly was made as "right knee effusion/pain; concern for septic joint." Emergency Physician B immediately contacted Orthopedic Surgeon A to perform an arthrocentesis. He said he would come in the morning, and not to call back. However, Emergency Physician B called again an hour later to reiterate the need for the procedure, and Orthopedic Surgeon A still did not come in. Pediatrician A, whom was assigned the case, was surprised to arrive at 8 am and find the arthrocentesis was not performed. He saw Orthopedic Surgeon A outside the patient's room at this time, and requested he come in to perform the tap. Orthopedic Surgeon A again declined, stating that he had an emergency and would refer the case to his colleague, Orthopedic Surgeon B. However, as Orthopedic Surgeon B testified, it was not made clear to him by Orthopedic Surgeon A that this was an urgent situation, so he decided to come after clinic. By the time he arrived, the patient had suffered was septic, and expired soon after admission to the ICU.

It is clear that Orthopedic Surgeon A was negligent in her care. Both Emergency Physicians ordered the appropriate tests, made the correct diagnosis, and consulted a specialist to perform a procedure that was out of their scope of skill. Pediatrician A trusted the specialists interpretation and decided to wait until 8 am for the procedure to be performed, and when that had not occurred, made a good faith effort to have the procedure done by again requesting it from Orthopedic Surgeon A. Orthopedic Surgeon A then failed to reiterate to Orthopedic Surgeon B the urgency of the situation, and left without performing the procedure. In the end, Orthopedic Surgeon A refused 3 times to do the procedure, and failed to insure continuity of care with Orthopedic Surgeon B. The situation could have been avoided in a number of ways: (1) ED physicians could be trained to competently perform necessary procedures that may need to be done on an emergent basis (2) Orthopedic Surgeon A was negligent on his duty to perform the arthrocentesis on 3 occasions despite indications that this was a septic joint and antibiotic therapy was necessary (3) Orthopedic Surgeon A could have exercised better communication to his colleague to insure an accurate picture of the patient's status was reflected, so that the proper care would be received (4) Any of the physicians in this case could have been more proactive in getting someone to perform the arthrocentesis, instead of relying solely on Orthopedic Surgeon A. Though Orthopedic Surgeon A is the specialist, this does not shirk the responsibility of the other physicians to insure care is received in an appropriate and timely manner.

Risk management considerations by Megan Gentry

Blame is easily assigned in hindsight, but applying discerning foresight reduces the risk of preventable medical error.

One decision did not lead to the unnecessary death of this patient. Instead, a plethora of missteps allowed simple medical procedures to be ignored while this patient's chances of diagnosis and recovery slipped away.

First, hospital bureaucracy spawned an environment that allowed responsibility to be jostled from doctor to doctor. Even when simple medical diagnostic clues presented themselves, no doctor claimed responsibility and initiated a viable treatment plan, shifting the patient's care onto the shoulders of another. This negligence allowed the patient's life to fall fatally through the cracks.

Secondly, a number of ignored diagnostic flags also contributed to the death of this patient. The patient presented with classic septic arthritis; monoarticular joint pain, fever, erythema, and edema. A history 18 months earlier for septic bursitis should have strongly alerted the physician to this patient's propensity for joint infection. Lab results showing a strong left shift and elevated inflammatory markers gave support to the primary concern of bacterial infection. Lastly, the progression of the infection to the other leg, plus the appearance of the petechial rash, indicated rapid spread from the primary infection site. By the time antibiotics were finally administered, bacteremia was imminent and attempts at resuscitation were futile. The heart of the young patient could not withstand the strain of this fulminant infection. The autopsy revealed the tragedy of hospital bureaucracy and ignored diagnostic flags: this type of bacteria could have been easily treated.

The final and most incriminating contributing factor is human error. Disregarding the severity of her presenting symptoms and failing to initiate antibiotic therapy in a timely manner cost this child her life. As different physicians noticed nothing was being done, no one deemed this case an emergent stat situation. Busy physicians make mistakes. But does being overworked, understaffed, exhausted, and stressed excuse the loss of life? That is the question that has plagued the medical profession for years.

In medical school we're taught that every patient deserves to receive the highest standard of care. The physicians involved in this case forgot that simple mantra. Am I naive enough to think I will not make a similar mistake in my practice? No. But the tireless pursuit of perfection is what makes the difference between a good doctor and a great doctor. May I strive to be the latter.

Risk management considerations by Douglas James Heiner

The death of this child is all the more tragic because she was in a hospital, surrounded by medical professionals that could have delivered the highest standard of care. The hospital had all the necessary equipment and was fully staffed with component medical personnel, many of whom in some way contributed to this failure. Because of the number of medical professionals involved, this case invites a "systems failure analysis" from which much can be learned. Risk management is about managing a "system" to reduce risk. With demands on our medical system exceeding supply, that system must prioritize those patients posing the highest risk and requiring the most expeditious application of system resources.

Appropriate patient prioritization requires: (1) effective communication; (2) clear lines of accountability; and (3) a "back-up" system enabling one professional to immediately challenge another professional's decision that may breach the standard of care of fail to correctly prioritize a patient.

This case involves numerous failures to communicate effectively, e.g., many of the physicians appear unaware that the patient was hospitalized for a similar condition 18 month earlier; Emergency Physician B fails to communicate the urgency of the arthrocentesis; Pediatrician A fails to demand that Orthopedic Surgeon A see the patient when the procedure has not been performed by morning; and Orthopedic Surgeon A fails to communicate to her partner the urgency of the arthrocentesis.

There were also numerous occasions where no physician accepts clear accountability for this patient. Whether Orthopedic Surgeon A refused to come in and perform the requested procedure, there were multiple ways that the tap could have been accomplished: Emergency Physician B could have performed it himself; another affiliated orthopedist could have been called in; or a hospital administrator could have required Orthopedic Surgeon A to respond earlier. Perhaps most surprising is that

Pediatrician A did not see the patient until morning, did not require the arthrocentesis to be performed immediately, and failed to frequently evaluate this patient's condition and demand treatment.

Some circumstances that appear to be failures to communicate may in fact be failures to challenge the poor decision of another professional. Orthopedic Surgeon A decides to "hold off antibiotics" and to perform the arthrocentesis in the morning, over 12 hours after the child is initially admitted to the ER. Emergency Physician B's failure to challenge these decisions results in a breach of the standard of care for a septic joint which mandates arthrocentesis and early antibiotic therapy with possible surgical debridement. (If the tap could not be completed in a timely way, empiric antibiotics should have been initiated.)

The failures of individual physicians in this case to communicate effectively, accept accountability, or challenge poor medical decisions are "systems" of broader system weaknesses that need careful, system-wide improvement to meet the evolving standard of care in a system that is increasingly more sophisticated, complex, and specialized. Although specific improvements are beyond the scope of this brief essay, they are necessary for our extraordinary medical system to deliver the medical "miracles" we all work for.

Risk management considerations by Michael Merrick

This case is an example of poor patient management and inadequate communication. There are a number of ethical dilemmas in this case, and not many of them were handled appropriately. Although the lawsuit that was filed is an important issue to discuss, it is a distant second to the expiration of the 8 year old girl. A patient's life was lost because of violations in appropriate care and because inconvenience took precedence over timely management.

The first fault in this case begins with Emergency Physician A's lack of response to the initial presentation of the patient. It is clear from the patient's physical exam and striking laboratory values that this was a surgical emergency. The appropriate response before ordering an MRI would have been to immediately contact the Orthopedic surgeon. In such a situation, time is of the essence and more than a few hours were lost due to this error in judgment.

The next and most crucial mistake in this case was the decision by Orthopedic Surgeon A to hold antibiotics and wait until the morning to perform an arthrocentesis, and the acceptance of this decision by Emergency Physician B and Pediatrician A. If we assume that the surgeon has no other acute issues to attend and that she simply made the decision to wait until the morning based on convenience, then this is a completely unacceptable management decision and one that ultimately led to the death of the 8 year old girl. The physician had the duty of beneficence, to make decisions that were in the best case of the patient's health. This duty is independent of the hour of the day or convenience of the procedure.

The remainder of the case is an example of the danger of passing on a problem without thorough follow-up. Referring a patient to another physician is a completely acceptable practice, even when it occurs within the same specialty. However, there is a responsibility of the referring physician to make certain that the next practitioner is fully aware of the patient's situation and is capable of providing adequate treatment. In this case we get the impression that Orthopedic surgeon A informed Orthopedic surgeon B of a patient's need for arthrocentesis without adequately explaining the severity of the patient's condition. This same responsibility falls on Pediatrician A, who is the primary manager of the patient's medical care. It is the failure of these two physicians that lead to the case being settled on their behalf.

The final issue that struck me upon reading this case is the apparent lack of communication with the family. Although not described in detail, the description leaves the reader with the impression that the child's family was not kept up to date with the medical plan. There are enough mistakes in the care of this patient that better communication with the family may not have had an impact on the family's decision to file a lawsuit, but the possibility of a better outcome is certainly plausible.

Risk management considerations by Ana Nguyen

The malpractice case presented here clearly demonstrates the importance of taking personal responsibility for patient care and the need for a proactive approach to treating patients. As one reads such a case, it is very easy to just focus on the issue of standard of care and to determine on the basis of those standards which physician the blame should be place upon. However, the more important issue here is whether or not each physician involved has done all he/she could do to provide the best care for the patient. It is, therefore, appropriate to discuss the importance of the physician's responsibility to his/her patients and the role that a proactive approach to patient care plays in malpractice risk reduction.

Medicine is one of the fields where teamwork plays such a crucial role, and teamwork requires that individual players take full responsibility of their roles. It is clearly evident in this case that several players are involved in the care of the 8 year-old patient: the ER physicians, the Pediatrician, and the two Orthopedic Surgeons. Due to the time limit coupled with heavy patient load, physicians are often tempted to perform the work-up accordingly to the standard of care for a specific differential diagnosis and consult the appropriate party without making extra effort to follow-up on the patient. In the case presented, even though the ER physician had already consulted the Orthopedic Surgeon, he/she has the responsibility of treating the patient accordingly to his/her own clinical judgment instead of waiting and following the orders of Orthopedic Surgeon A, who has not even seen the patient. The same goes for the Pediatrician, who should have taken the full responsibility of making sure that all the steps have been taken to treat the patient instead of waiting for the arthrocentesis to be performed by the Orthopedic Surgeon. Furthermore, the Pediatrician should have followed the patient closely to ensure that the patient is seen by the Orthopedic Surgeon in a timely manner.

As physicians, we often have to ask ourselves the question of whether or not we have done everything we can for the patient based on what we have available at the moment, that is, taking a proactive approach to patient care. As mentioned above, the time limit coupled with the heavy patient load often tempts the physician to settle for the minimal amount of work on each patient. Every physician, either primary or specialist, should approach each patient as though he/she is the patient's primary care physician and advocate. This is one of the main principles of teamwork in the health care setting. A proactive approach to patient care allows each physician involved in the care of the patient to feel as though he/she is maximizing all options to provide the best care for the patient.

Lastly, the importance of proper documentation cannot be ignored, for it forms the cornerstone for all malpractice cases. Without proper documentation, it is often difficult to objectively determine whether the physicians involved have done all that they could to provide the best care for the patient. Without proper documentation, all proactive approaches will not be apparent to the patient, his/her family, and those involved in the litigation. The concept of the physician whether primary or specialist, taking full responsibility for the patient, a proactive approach to patient care, and the proper documentation of all the steps taken are crucial in evaluating all malpractice cases and are clearly apparent as risk management considerations in the case presented here.

Risk management considerations by Kyle Piwonka

The 8-year-old-girl in this closed claim study lost her life to a systemic infection that began in her right lower extremity. This deadly infection could and should have been treated and managed vastly differently by all the physicians involved. The infection in question, acute septic arthritis, is a medical and surgical emergency and must be diagnosed and treated as soon as possible. The goals of treatment are to prevent destruction of the articular cartilage and to retain motion, strength, and function of the extremity. (1) Although this can occur in any joint in the body and at any age, children are particularly susceptible and must be diagnosed and treated rapidly.

In light of this information, this patient's serious infection was hardly given the care and immediate attention it so desperately needed. The emergency physician's roles are to rule out life threatening pathophysiology and establish a differential that could explain the patient's presenting symptoms. When Emergency Physician A first received the chart for a young child that had a temperature of 104, a left shift in presently drawn lab work, and a red and warm knee, septic arthritis should have been first on his/her differential. Knowing that septic joints are most adequately diagnosed by performing a needle aspiration of the affected joint for fluid cultures and WBC count, Emergency Physician A should have immediately notified the orthopedic surgeon on call, Orthopedic Surgeon A, to let him know his suspicions for the case, the work-up that was currently in place (x-ray and MRI), and his lack of training and knowledge in diagnostic joint aspiration.

In addition to septic arthritis, Emergency Physician A should have established a differential diagnosis that included viral arthritis, toxic synovitis, traumatic arthritis, periarticular cellulitis, osteomyelitis, Henoch-Schonlein purpura, juvenile rheumatoid arthritis, acute rheumatic fever, Lyme disease, postinfectious reactive arthritis, leukemia, and diskitis, and begin a rule-out process for those to which were life threatening to this young child. The child's pediatrician, Pediatrician A, should have been consulted immediately at this time. A hospital admission here seems to be inevitable due to the symptoms displayed by the patient, the complicated nature of the above differential, and his/her close ties with young girl, parents and medical history.

If all of the above consultations were established earlier in the case (before midnight), early morning phone calls could have been avoided and a contingency plan initiated that all could agree on. Given the above diagnostic information, if Orthopedic Surgeon A felt as though his/her availability could not be provided at an early enough time, his partner could have been notified much earlier in regards to the joint aspiration and patient examination. Knowing that antibiotics were critical for the patient's prognosis, Pediatrician A and incoming Emergency Physician B could have both pressed the orthopedic team to see the patient immediately.

Especially recognizing that before the discovery of antibiotics, there was a fifty percent mortality rate for children with septic arthritis. (2) It would also be important for the physicians to assess this child's temperament, coping strategies, and how she may have handled previous hospitalizations or medical procedures, if applicable, to design an appropriate teaching method for her about septic arthritis. The parents should also be included in the child's preparation for surgery to decrease anxiety and elicit their cooperation and cooperation in the care of their child.

For children with septic arthritis, an early diagnosis and immediate treatment is directly correlated with a good prognosis. Hospitalization is mandatory so that they can be monitored and care can be given quickly to prevent serious complications. (3) With proper care this 8-year-old child may have survived with mild residual knee deformity or may not even have had any permanent damage to her knee because she received care immediately, was in surgery as soon as the diagnosis was made, and received excellent continuity of care.

Bibliography:

(1.) Canalem Operative Pediatric Orthopaedics, 1050.
(2.) R M Barkin, Pediatric Emergency Medicine: Concepts and Clinical Practice (St Louis: Mosby-Year Book, 1997) 1038.
(3.) Soud, Rogers, Manual of Pediatric Emergency Nursing, 296.

Risk management considerations by Jenny Van Winkle

This closed claim study is one of many ill-fated examples of how the practice of medicine has become subject to our legal system. Unfortunately, stories such as this exhibit how often physicians are at fault for the adverse fate of a patient. However, as students of our profession, we should learn from these experiences, further our delivery of care and hopefully avoid others' pitfalls.

Communication is essential to the practice of medicine, especially in today's age of specialized medicine. This is the principal issue presented in this case. Without details of the physicians' conversations, it is difficult to assign responsibility, however I speculate that the gravity of the patient's condition was lost in translation, as her case was shuffled among specialists. The lack of communication is evident throughout this case: Emergency Medicine Physician B did not effectively communicate with Orthopedic Surgeon A; Orthopedic Surgeon A apparently does not know or does not communicate the entire situation to Orthopedic Surgeon B; and Orthopedic Surgeon B claims to not have been informed of the urgency of the situation by Pediatrician A or the nurses. Such failures were implicated in a number of the allegations by the plaintiff. More frequent and explicit communication may have prevented the outcome of this case and would have increased the defensibility of the physicians involved.

As a medical community, we are trained to follow procedures that adhere to a standard of care. In this case, an arthrocentesis should have been performed, followed by the immediate administration of antibiotics. Protocols are followed to ensure adequate care. If Emergency Medicine Physician B believed the patient had a septic joint and that the situation was emergent, he should have consulted another Orthopedist to ensure an immediate arthrocentesis. Since Emergency Medicine Physician B was not trained in performing arthrocentesis and considering the patient's condition and his apparent concern, another option for Emergency Physician B was to begin antibiotics despite Orthopedic Surgeon A's advice and the standard protocol. Either of these actions would have corresponded to considering patient safety first and likely would have increased his defensibility.

Defensibility of all physicians involved would be improved with documentation of actions, reasoning, and communication. Not only does this aid in obtaining facts surrounding the case, accountability can be accurately placed. Aside from the aforementioned, I would have initiated antibiotics sooner, whether or not an arthrocentesis had been performed, and I would have followed up despite transfer of care.

Part of becoming a physician is learning one's limits, capabilities and comfort level. Adapting to situations is essential to the practice of medicine. Orthopedic Surgeon B's actions surrounding his arrival at the hospital demonstrated the importance of timely adaptation. As an aspiring physician I can take many principles from this case study: communication is essential, protocols are in place to aid in care but treatment sometimes takes precedence over protocol, accurate documentation is a necessity, and honesty should not be avoided for fear of liability.

Risk management considerations by Ajit Vyas

Whenever a tragedy occurs, one's first instinct is to look back with hindsight and assign blame. A much harder task is fixing the underlying systemic problems that led to the tragic outcome. How does one accomplish this? The key is not merely to focus on the actions of the physicians, but rather how they communicated those actions to each other. Furthermore, their actions should not be considered in isolation, but rather in the framework of the established processes in the Emergency Department (ED). The physicians' cognitive errors were borne not from malice or indifference but rather from a system whose processes did not foresee the potential for these types of errors. To change the outcome, one must change the culture of this particular hospital.

Much focus these days is placed on patient-physician communication. This case though highlights the importance of physician-physician communication. The primary care physicians (Emergency Physicians A & B, and Pediatrician A) clearly failed, in one way or another, to stress the importance of this particular case and the necessity of an arthrocentesis to Orthopedic Surgeons A & B. One could argue that Orthopedic Surgeon A knew enough about the case and should have done the procedure, but given that he was unwilling, Emergency Physician B should not have let him go without strongly urging that the procedure be done immediately, and then listing the potential adverse outcomes if Orthopedic Surgeon A refused to act. Sometimes, the hierarchical nature of a hospital prevents physicians from speaking openly. However, when one thinks about the patient's care first, language that is clear, bold, and even possibly confrontational is at times necessary.

Still, going beyond the failures in communication, this girl's death was ultimately a failure in the system as a whole. The emergency department and the orthopedics department should have a unified protocol for how to deal with such cases. If a child presents with a clinical picture of a septic joint and suspicious initial laboratory findings like increased white blood cells with a left shift, an arthrocentesis should be done immediately. Having a protocol in place increases the likelihood that important procedures will be performed in a timely manner and will not be neglected simply due to one particular physician's discretion. The protocol also improves a physician's defensibility if that physician follows the steps outlined by the protocol. To further reduce the chance of error, the ED physicians themselves should be trained to do arthrocentesis, decreasing their dependency on the orthopedic surgeons. Such simple modifications may well have prevented this unnecessary death.

Failures of communication and lack of an appropriate protocol compounded the initial error in this case. Instead of merely focusing on the individuals' actions, one must take a holistic approach in order to better manage the risk inherent in patient care and prevent future adverse outcomes.

2007 scholarship recipients

John Chiara is a fourth-year medical student at Texas Tech University Health Science Center School of Medicine. (Mr. Chiara also won the scholarship from Texas Tech in 2006.) Read Mr. Chiara's essay.
Paul Chin is a fourth-year medical student at the University of Texas Southwestern Medical School. Read Mr. Chin's essay.
Julie Cummings is a fourth-year medical student at the University of Texas Medical Branch at Galveston. Read Ms. Cummings's essay.
Stanford T. Israelsen is a fourth-year medical student at Baylor College of Medicine. Read Mr. Israelsen's essay.
Jason R. Pearce is a fourth-year medical student at University of Texas Medical School at Houston. Read Mr. Pearce's essay.
Eric South is a third-year medical student at the University of North Texas Health Science Center's Texas College of Osteopathic Medicine. Read Mr. South's essay.
John Wilkinson is a fourth-year medical student at Texas A&M University System Health Science Center College of Medicine. Read Mr. Wilkinson's essay.

The $5,000 scholarships were awarded to one student at each Texas medical school. Scholarship recipients were chosen based on each student's financial need and written essay.

2007 winning essays

For the essay portion, applicants for the 2007 TMLT Memorial Scholarship were asked to write risk management considerations for a closed claim study provided by TMLT. The case study and the winning essays follow.

The case study — failure to evaluate and test

Presentation and physician action

A 63-year-old man came to a new family physician primarily for the treatment of hypertension. The patient continued seeing this physician for routine medical care over the next four years. Documentation in the medical record for these visits was extremely limited. Vital signs were not documented for more than 30 visits with this patient. Though the physician was treating the patient for hypertension, there is only one recorded blood pressure measurement.

In April 2003, the patient came to the physician with an infected mole of the left upper arm. The physician prescribed Tetracycline with a note: "excise or hyfercate later." This is the first documented reference to an upper arm mole. The patient later testified that he had shown the mole to the doctor in September 2001 when it started changing colors. He also testified that he showed the family physician the mole in September 2002, and that the physician told him it was nothing to worry about. The physician testified he was not made aware of the mole until April 2003.

The patient returned in May 2003. The left arm mole was still infected. The physician prescribed Keflex. After little improvement with two rounds of different antibiotics, the patient was referred to a general surgeon for excision of the mole.

A general surgeon saw the patient. He told the surgeon that the mole had been gradually increasing in size for several months, becoming more irritated, brittle, and had been bleeding. Examination revealed a two-centimeter raised ulcerated lesion consistent with a basal cell carcinoma versus irritated keratosis. The lesion was excised and sent to a lab. The pathologist's initial opinion was poorly differentiated carcinoma, likely squamous. The slides were sent to another lab for subsequent review. Further evaluation revealed a stage IIIA malignant melanoma, differentiated, completely, but narrowly excised.

Two months after the excision, the patient returned to the general surgeon. The surgeon believed the patient would need a wide excision and sentinel node biopsy. A CT scan of the head, chest, and abdomen revealed a tiny nodule on the right middle lobe of the lung. MRI of the brain did not show any significant findings. A PET scan revealed malignant disease of the lymph nodes in the left axilla.

The patient returned to the general surgeon to undergo a wide excision and left axillary node dissection with skin grafting at the excision site. Pathology revealed that two of the 22 lymph nodes were positive for metastatic neoplasm consistent with metastatic malignant melanoma.

Over the next several months the patient underwent chemotherapy treatment for a new mass in the right middle lobe of the lung. The patient exhibited good response from the chemotherapy and a CT of the abdomen and pelvis showed the lungs free of infiltrates or masses. One year after the original excision the patient showed no evidence of disease progression.

Allegations

A lawsuit was filed against the family physician, alleging that he failed to properly evaluate, test, and diagnose the patient's mole and refer him to a dermatologist for evaluation. The plaintiffs questioned whether it was within the standard of care for the physician to prescribe antibiotic treatment for what he thought was a squamous cell carcinoma, rather than referring the patient to a surgeon for biopsy.

Legal implications

The plaintiffs were able to locate an expert who testified that the malignant melanoma went undiagnosed for 31 months and subsequently decreased the patient's life expectancy.

Physician consultants for the defense were critical of the family physician's poor documentation. Most of the entries made no reference to a reason for the visit, physical exam and findings, or a plan of care.

The physician did document the presence of the upper arm mole in April 2003. However, the lesion was first documented two years after the patient claims he first brought it to the physician's attention.

Another family physician consultant pointed out that the defendant's documentation was poor and often illegible. However, the documentation indicated that from the time the mole was first documented in the chart, there was reasonable treatment. Additionally, besides the poor documentation, it appeared that the defendant practiced within the standard of care with regular office visits, appropriate prescriptions, and lab work ordered at each visit.

Defense consultants also pointed out that the mole was felt to be either a basal cell carcinoma or an irritated keratosis; both of these are easily curable. On exam, the mole did not look like a melanoma, supporting the physician's slow timeframe for biopsy. The pathology report after excision was also confusing, suggesting an atypical lesion.

Disposition

A significant weakness for the defense was the conflict between the patient and the physician about when the upper arm mole was mentioned. It was believed that a jury might conclude that an earlier diagnosis was possible. This factor, along with the inadequacy of the physician's documentation, led to the decision to settle this case on behalf of the defendant.

Risk management considerations by John Chiara

This case illustrates the consequences of failing to fulfill one of the primary responsibilities of any physician: complete and timely documentation. While in any examination of a liability case it can be tempting to concentrate on the appropriateness of care, such a discussion becomes impossible without an adequate treatment record. Since it is obvious that incomplete documentation was a key factor in the assignment of liability in this case, a discussion of how documentation affects both care and liability management is valuable.

One of the principle purposes of documentation is facilitating continuity of care. Medical liability aside, inadequate record keeping made it impossible for this physician to provide even effective treatment. An example taken from this case is the management of hypertension, which requires that the physician develop an individualized understanding of the patient and the status of the disease process. It is unrealistic to imagine that the physician remembered the patient's vital signs from the previous visit, much less the trends he should have observed during the patient's 30 visits spanning a period of four years.

Documentation and proper care both require time, a commodity often in short supply in a busy practice. Given the importance of the medical record a system that ensures its accuracy and completeness is a priority. Simple practices such as patients filling out their own review of systems or the nurse documenting vital signs can serve to both save time and direct the physician's course of treatment. While handwritten notes are time consuming and often illegible there are viable alternatives, like electronic medical records or dictation, which facilitate brief and precise documentation. These, and myriad other approaches can help provide improved documentation, but it remains the responsibility of the physician to select and implement their use.

Without documentation this case became nothing more than a question of whether the jury believed the physician's or the patient's version of the events. The physician's course of treatment may or may not have reached a minimum standard of care, but this question is impossible to resolve because of his failure to keep proper records. The remedy for this situation is to choose and commit to a system of timely and accurate documentation, possibly facilitated by delegating some of this process to both the patient and office staff. Even with limited time the medical record is one of the pillars of both proper care and risk management.

Risk management considerations by Paul Chin

Given the current view that primary care physicians are directors and coordinators of care and subsequent unrealistic patient expectations for that care, any failure or delay in evaluation, diagnosis, and treatment can be grounds for litigation. Thus, implementation of several proactive techniques can insure the achievement of standard of care and reduction of risk and liability.

First and foremost, the outcome of this claim demonstrates the absolute necessity of proper documentation. Did this physician fail to document the two previous references to a mole, or did this patient fabricate the two previous references? Given over two dozen omissions of vital signs in this hypertensive patient's medical record, how difficult do you think it would have been for a plaintiff's attorney to persuade a jury that this physician clearly did not document two earlier references to this mole? Although some feel that documentation has become a bane of modern medicine, always remember that proper documentation is protection. It is protection from the mind's tendency to forget and distort the past, and it is protection from the 20/20 hindsight of expert witnesses.

Furthermore, it behooves all physicians to act quickly if a medical decision is out of their realm of expertise. In these situations quick referrals to experts can avoid potential conflicts such as the one in this claim. This patient would most likely have benefited from an earlier referral to a dermatologist to evaluate his condition. Nevertheless, in a common scenario such as this involving a skin lesion, records such as photographs are as the saying goes "worth a thousand words" and should be kept in a patient's medical record.

Finally, it is vital to assess the health literacy of patients including their understanding of their medical conditions and treatments plans. Implementation of these simple techniques will help guarantee excellent patient care, safety, and confidence.

Risk management considerations by Julie Cummings

I am overbooked in clinic today and need to be home by 5:30 to take my son to his soccer tournament. My next patient is Mr. Rogers, one of my regulars. I have been following him for the past year for hypertension. I go into his room and record his vitals in the chart. Just as I expected, his blood pressure is 128/76. He has no symptoms, and just needs refills of his medications. I look through his chart, noticing his blood pressure has been well controlled at all previous visits and he is current on labs. I also notice that three months ago he was concerned about a mole that was changing colors on his left upper arm. I examine Mr. Rogers and measure his mole at 6 mm x 4 mm. At his last visit the size of the mole was recorded at 4 mm x 2 mm. I inform Mr. Rogers that his mole has changed and needs further evaluation. I give him the options of performing a biopsy or referring him to a dermatologist. He says "I am more comfortable with you than a stranger." I am proud that he has confidence in me, but I am running out of time. I scheduled a follow-up appointment for him next week to biopsy the mole.

The next week, I explain to Mr. Rogers that clinically the mole looks like basal cell carcinoma, which is a type of skin cancer that rarely spreads and has a very high cure rate. I also tell him about squamous cell carcinoma, actinic keratosis, and melanoma. I tell him that pathology is necessary for diagnosis.

The pathology reveals melanoma in situ. I call Mr. Rogers and schedule a follow-up appointment to discuss the results. At the appointment, I tell him the lesion was not what I thought originally. I ask him if he would like to know the results and he agrees. I tell him he has melanoma localized to the skin. He says, "that's the bad kind we talked about, right." I tell him it is and I am sorry to be giving him such bad news, but it is still localized to the skin, and it is good that we caught it in such an early stage. I ask him if he needs to call anyone for support or if he needs help telling his wife. He says he is okay. I refer him to a surgeon and his melanoma is removed with negative margins.

Five years later, I see Mr. Rogers at one of his regular clinic visits. I reflect back on how accurate evaluation and documentation prevented Mr. Rogers from having a higher staged melanoma. I recall how busy my clinic was that day and am relieved that I always kept precise documentation and take time to review it. I have the responsibility to be a good physician that spends time to obtain a full health history, documents it properly, educates the patient, and discusses treatment options. By practicing responsible medicine I am practicing defendable medicine.

Risk management considerations by Stanford T. Israelsen

Allegations of malpractice in this case center on two claims. The first is that from September 2001 to April of 2003 the family physician failed to properly evaluate, test and diagnose the patient's mole according to accepted standards of care. The second allegation is that once the physician did suspect skin cancer he failed to follow the standard of care in deciding to initially treat with antibiotics rather than make an immediate referral to a specialist for further care. The plaintiff contends that either or both of the above actions by the physician may have caused the cancer to progress undiagnosed and untreated resulting in decreased life expectancy.

Regarding the first accusation, the physician claims he first examined the mole in April 2003 when first noted in the medical record, while the patient claims it was pointed out in September of 2001. Assuming the physician is correct, his position is nevertheless greatly weakened by his failure to establish a pattern of regularly recording physical exam findings and plans of care. Knowing the physician only once documented a blood pressure in the chart while treating the patient's hypertension for four years, a jury would be likely to assume that if the physician had examined the mole earlier than 2003, he would similarly have failed to document that. Also of note is that entries found in the chart were often illegible. One of the most important risk management practices for physicians is keeping accurate, thorough, regular and legible records. His lack of doing so was the principle factor leading to the physician's loss. To his credit he made no additions or changes to his charts, which would have further damaged his credibility.

Also at issue is professional competence. If the patient did bring the mole to the physician's attention prior to 2003, it was likely not properly evaluated. Given its large size and ulcerated state, it is reasonable to assume the mole appeared suspicious prior to 2003. If the physician was unsure about the mole he should have referred the patient to a dermatologist. For a 63-year-old man an annual skin exam is reasonable, and had that been performed and well documented prior to 2003 the physician would have had a much stronger defense.

As for not referring the patient immediately to a surgeon in April of 2003, one could argue there was no good reason for delay. If the physician did suspect cancer (as a reasonable physician arguably would) he should have recorded specific plans to diagnose and treat, including the date of a future visit to remove the lesion in office or record of referral to a specialist. Characteristically, the chart was vague, with a plan described only as "excise or hyfercate later."

Risk management considerations by Jason R. Pearce

In an era of increasing litigation, it has become the physician's responsibility to not only treat patients, but to also protect against legal culpability at the same time. In my own experience and from talking to other physicians the two most commonly practiced methods of protecting oneself from being sued are good patient-doctor communication and proper documentation. In this case the physician appears to be at fault with both these principles.

The particular difficulty in this case seems to be in trying to prove that something did not happen, in particular that the physician had not seen the patient's skin lesion until April of 2003. The physician's best argument is that the mole wasn't seen until April, and at that point he then took the appropriate actions. If the physician was to have shown a history of both consistent and thorough documentation of each patient encounter, it becomes more difficult to argue that the physician somehow failed to mention this skin lesion, but was then thorough in every other aspect of his documentation. There are several techniques the physician could have employed to help in this situation. First, the doctor should have made a comment at the end of each note that the patient had the chance to ask all of his questions and that before exiting the patient understood the plan until his next visit. This would have been more evidence that the doctor went out of his way to allow the patient to mention any concerns about the skin lesion. Next, if the doctor would have had his nurse/staff ask the patient what the reason for the office visit was and then documented it in the chart, it would have been more difficult to argue that he actually mentioned his mole during the visit, yet no one wrote it in the chart. Also the doctor could have drawn a picture of the lesion when it was first mentioned noting the location and size of the lesion; if for no other reason than to monitor any change over time, but at the same time to illustrate a start point to visualization and treatment of the mole. Another technique that may have been very helpful would be to have his existing patients undergo a full physical exam every 1-2 years, this would have most likely revealed this skin finding or any other problems that had gone unnoticed by the patient or doctor. With this exam documented in the chart it would provide more evidence of the doctor's overall quality of care.

The other concern is appropriate communication between the two parties. There appears to be confusion about why the doctor was using antibiotics for a possible malignancy. The patient should have been told why he was being given antibiotics and the physician's differential diagnosis. There isn't any reason not to tell the patient if the physician has concerns about malignancy.

Unfortunately, for this physician it didn't matter how well the patient had been treated. With such poor documentation it became impossible to prove the quality of care given, thus leaving this doctor in the powerless position of he said, she said.

Risk management considerations by Eric South

In my medical training, I have been taught that "if it isn't written in the chart then it wasn't done." The patient in the case visited the physician 30 times yet there was only one instance of vitals documented. To diagnose hypertension, the minimum is two instances observed over a period of time. While I hope someone took the patient's blood pressure every visit, without it documented, others must assume that it was not performed. In addition, the physician cannot chart the effectiveness of the treatment plan for hypertension without documented blood pressure. This is an unacceptable level of documentation that leaves the physician exposed legally and prevents proper care.

Regarding the mole on the patient's arm that was found later to be a malignant melanoma, the past medical records give the impression that the doctor was sloppy and careless whether or not this was true. As a family physician he was trained and able to treat skin lesions such as this or to refer if the situation is more complex. Based on the fact that the skin lesion was atypical this situation may have been handled correctly from April 2003 onward. When the lesion was unresponsive to antibiotic treatment, he properly referred the patient to the surgeon for excision. Questions arise from the documentation to "excise or hyfercate later." If the lesion needed to be excised, he should have made arrangements to do so. Writing in the chart "reevaluate later" would have been more acceptable if he felt the lesion was likely not skin cancer. This raises the question presented in the case of whether antibiotic treatment was the standard of care for suspected skin cancer. This calls the physician's practice into question in addition to his documentation.

The major problem was whether or not the physician was aware of this skin lesion as of September 2001. If he was aware in 2001 and did nothing, the physician also needs to be referred to the state medical board in addition to the legal proceedings. The physician in question has allowed himself to be set up for disaster. His failure to thoroughly document details from patient visits leaves him at the mercy of the legal system. The case in question comes down to the patient's word against the physician's medical records. Based on past medical records that were reviewed by others, the notes were poorly written, but the physician did practice within the standard of care by ordering appropriate tests, etc. Had the physician properly documented everything from the visits and set a high standard of doing so, this case would have no strength. It is unknown whether or not this lesion was brought to the physician's attention much earlier so the issue that needs to be addressed is the level and quality of charting patient visits. Better documentation is necessary to provide the highest quality of care for other patients and allow the physician to defend himself in future legal situations.

Risk management considerations by John Wilkinson

Thirty visits to a primary care doctor, two ineffective antibiotics, one bleeding mole . . . zero documentation of possible skin cancer.

Melanoma is a frustrating disease to diagnose and treat. With appropriate precautions and proper record keeping, however, this type of malignancy can be caught before it spreads. With a personal history of over 10 excisional and shave biopsies, numerous lab reports, two re-excisions, and countless skin checks, I have learned first-hand about the screening process for melanoma. As I read this closed claim study, many alarms went off in my head. The patient is concerned. The mole is changing shape and bleeding. The infected appearance did not improve with antibiotics. But were these alarming symptoms also concerning to the patient's practitioner? We do not know because the physician's thoughts were not documented in detail.

When a person finds out that they have cancer, it is a traumatic experience. It may be one of the most difficult situations in their life. They feel frightened, alone, worried, frustrated, angry, depressed, and, likely overwhelmed.

Understandably, a common question might be, "Was this preventable?"

In this case, we do not know if the patient's cancer would have been avoided if it had been discussed, treated, and followed-up at an earlier stage. The central issue in this case is documentation. The following steps that I would have taken to change the course of this patient's care:

Asked patient to complete a review of systems form — this would have included the patient's chief complaint and any worrisome symptoms for discussion during the visit.
Taken a picture — digital photography is an inexpensive and easy medium to use which, in this setting, would have given clear understanding of what the lesion looked like on initial presentation and how it changed over time.
Completed an electronic medical record — checkbox-based entries can quickly document which parts of a history and physical are completed during a problem-focused clinic visit. This EMR could have been used and supplemented with a dictation-based system to record the assessment and plan.
Distributed handouts on skin cancer signs and symptoms
Personally called the patient to follow up after the clinic visit
Hired a physician extender — this person would have assisted with follow-up for this patient's care.
Organized a meeting — a meeting would allow local doctors to share best practices on how to manage a busy clinic schedule while completing necessary documentation.

Although it is sometimes difficult to find time in a busy practice, documentation of a doctor's actions not only records details of an office visit but, more importantly, provides the treating physician with a plan of action for subsequent visits. It may be debatable whether the suggestions listed above would have made a difference in the patient's outcome. Ultimately, however, we have an obligation to our patients to fully document clinic visits so that we can take their care and our overall profession to a higher level.

2006 scholarship recipients

D'Andrea Michelle Anders is a fourth-year medical student at the University of Texas Medical Branch at Galveston. Read Ms. Anders' essay.
John Spencer Chiara is a third-year medical student at Texas Tech University Health Science Center School of Medicine. Read Mr. Chiara's essay.
Jessica Dalby is a third-year medical student at Baylor College of Medicine. Read Ms. Dalby's essay.
Tara Hagopian is a third-year medical student at the University of North Texas Health Science Center's Texas College of Osteopathic Medicine. Read Ms. Hagopian's essay.
Chad D. Housewright is a fourth-year medical student at Texas A&M University System Health Science Center College of Medicine. Read Mr. Housewright's essay.
Eric Jon Larsen is a fourth-year medical student at University of Texas Medical School at Houston. Read Mr. Larsen's essay.
Joshua Delbert Mitchell is a third-year medical student at the University of Texas Southwestern Medical School. Read Mr. Mitchell's essay.
Stephanie Watson is a third-year medical student at University of Texas Medical School at San Antonio. Read Ms. Watson's essay.

The $5,000 scholarships were awarded to one student at each Texas medical school. Scholarship recipients were chosen based on each student's academic achievement, financial need, and written essay.

2006 winning essays

For the essay portion, applicants for the 2006 TMLT Memorial Scholarship were asked to write risk management considerations for a closed claim study provided by TMLT. The case study and the winning essays follow.

The case study — delay in diagnosing epidural abscess

Presentation

Upon referral from his family physician, a 41-year-old man came to a freestanding diagnostic center for an MRI of the lumbar spine. The patient had a history of chronic back pain that was not responding to conservative measures. The technician completed the MRI after the center's two radiologists had left for the day.

Physician action

The next morning, a Friday, radiologist 1 reviewed the MRI and described a mass consistent with an epidural hematoma or osteomyelitis. Based on the fact that the fluid collection in the epidural space was well defined, the radiologist believed it was more likely a tumor in the bony area. The radiologist was further swayed by the patient's history of "chronic" back pain, which favored a tumor rather than an acute infectious process. Radiologist 1 filled out a request for additional views, as well as a Gadolinium study to examine the bony structure, all to be taken within 72 hours. He instructed staff at the center to contact the patient, and have him return for the additional studies. Radiologist 1 did not directly contact the patient or the referring physician. At noon that day, radiologist 1 went home with the flu and did not return to the office on Saturday.

The diagnostic center staff attempted to contact the patient at the phone numbers supplied by his referring physician, but were unsuccessful. They then called the family physician's office, and were told the telephone numbers that had been provided to them were the only numbers they had for the patient. Interestingly, the patient information sheet completed by the patient when he registered at the diagnostic center contained his current working telephone numbers. Staff never checked that sheet or attempted to contact the patient at those phone numbers.

At 10 a.m. on Saturday, the patient came to the emergency department (ED) of a regional hospital with complaints of back pain with radiation down his legs. ED staff called the radiology center for the results of the MRI. Radiologist 1 was called at his home by a center employee. He advised this employee to locate the films and have his partner on duty, radiologist 2, review the films. Radiologist 2 reviewed the films and testified that he prepared a handwritten, preliminary fax report to be sent to the ED. In this report, he said there was a heterogeneous cystic mass located from L4 to S1 on the left and that a Gadolinium study was needed. Radiologist 2 then gave the report to an employee who faxed it to the ED and later called to confirm it had been received. This preliminary report is not in the files at the diagnostic center and is not in the hospital chart. The ED physician and ED personnel deny receiving a faxed report from the center. They allege receiving only an oral report of an MRI with findings of degenerative disease and a mild diffuse posterior disc bulge, along with foraminal stenosis and a compression fracture. Based on his evaluation of the patient and the results of the MRI, the ED physician diagnosed back pain and herniated disc. The patient was discharged home from the ED.

The patient returned to the ED at 9 a.m. on Sunday complaining of not being able to move or feel his legs. The patient was treated by the same ED physician, who ordered a lumbar spine MRI. The MRI was read by the hospital radiologist, who reported a "hematoma (spinal) epidural." A neurosurgeon was consulted, and took the patient to the OR. He performed an emergency decompression of the epidural space and noted a "large collection of what appeared to be an organized clot on the posterior aspect of the thecal sac" and a "well organized and fibrous-type clot of blood . . . also associated with this some pockets of what appear to be purulent matter and a material consistent with epidural abscess with hematoma."

When radiologist 1 returned to his office on Monday morning, he became aware that the patient had not returned to the diagnostic center for additional testing, had been seen at the ED, and had undergone surgery. It was at this time and with this information that radiologist 1 dictated his MRI report. The MRI report is dated Thursday (indicating the date of the study) with a transcription date of Monday. He then called in the report to the referring family physician. The patient was ultimately diagnosed with cauda equina syndrome and secondary incomplete paraplegia. He has limited motor function in his legs, but can walk with the help of a walker. The patient was also diagnosed with neurogenic bowel and bladder, and does experience nocturnal incontinence.

Allegations

A lawsuit was filed against the two radiologists, the diagnostic center, the ED physician, and the hospital.

Legal implications

The plaintiff retained a credible expert who testified that the lesion radiologically appeared to be an abscess, which represented an emergent condition requiring immediate communication with the patient and referring physician.

During his deposition, radiologist 1 testified that he believed that the patient had a neoplasm. Because the patient had not reported any neurological symptoms, and because the patient reported the problem to be chronic rather than acute, radiologist 1 did not consider the patient's condition "emergent." Further, radiologist 1 testified that he would have called the family physician directly to inform him of the results if the additional studies had been completed.

Defense radiology experts were supportive of radiologist 1's interpretation of the MRI. Both experts testified that the findings on the MRI were not emergent, and that radiologist 1 was not required to call the family physician on Friday to alert him that he found something suspicious for which he was conducting additional studies. One expert, who has written extensively on American College of Radiology's practice guidelines for communication, supported radiologist 1's decision not to call the referring physician. Radiologist 1 felt the study was incomplete and that there would be no danger to the patient in waiting a couple of days to obtain additional contrast studies.

Other defense radiology consultants were not entirely supportive and felt the lesion represented an abscess instead of a solid lesion. One expert pointed out that a note contained in the patient information sheet completed by the patient when he came to the diagnostic center indicated "history of chronic back pain, weakness in left leg, no trauma." To this expert, "weakness in the left leg" indicated neurologic compromise. When coupled with the finding on the MRI, the radiologist should have called the family physician immediately. Another radiologist, who was supportive of the interpretation of the MRI and the belief that it was neoplastic disease, believed radiologist 1 should have advised the family physician of the finding because radiologists never know the full clinical picture of a patient.

The family physician testified that if radiologist 1 had called him on Friday to report the preliminary findings, he would have agreed with the decision to obtain additional studies. However, the family physician said he would also have called the patient to inform him of the findings and check on his condition. He further testified that had he been contacted on Friday, he would have arranged for a neurosurgical consultation for the patient, but not on an emergent basis.

Disposition

This case was complicated by communication errors committed by staff at the diagnostic center, a "lost" radiology report, and finger pointing among the defendants. Based on these factors, the case against radiologist 1 was settled before trial. Radiologist 2, the diagnostic center, and the hospital settled their cases before trial. The outcome of the suit against the emergency physician is unknown.

Risk management considerations by D'Andrea Anders

One of the most frightening things about becoming a physician stems from the fact that we must accept the reality that lawsuits are inevitable. No matter how exemplary our performance is as physicians, there will come a time when we miss a diagnosis or just make the wrong decision as it relates to a patient's condition. As future physicians, we will be expected to serve as team leaders regardless of what field of medicine we choose to pursue. This is one of the greatest advantages to being a physician, but if the team doesn't function efficiently, it can also be one of the greatest disadvantages.

A hardworking dependable staff can help a good physician be an excellent physician, but the opposite is true of a nondependable staff. The staff at the diagnostic center failed to contact the patient when his contact information was readily available and may have even failed to fax the second radiologist's preliminary report the emergency department. These actions are totally inexcusable and because the two radiologists trusted that these things had been done, they became liable for things that were in a sense beyond their control.

The outcome of this case may not have been so tragic if the physicians involved had used better judgment when they were given the opportunity to make decisions about the patient's care. The first radiologist's initial interpretation of the films indicated that the patient's condition was serious enough to warrant further studies; therefore, until the worse case scenario had been ruled out, he should have had a heightened level of concern for the patient. I do feel that he should have contacted the referring physician to obtain information about the patient that would have helped him make a more informed decision. It is difficult to comment on the second radiologist's role in this case because there is a question of whether a report was ever really generated. If in fact he did review the films and prepare a handwritten preliminary fax report to be sent to the emergency department, I find no fault with him. If I were the emergency department physician, again, I would have wanted to rule out worse case scenarios before I discharged the patient home. If I were not able to obtain the films from the outside diagnostic center or talk to the radiologist myself, I would have re-ordered studies.

This case clearly demonstrates how a breakdown in the team structure can lead to disastrous consequences for patients. Consequently, there are a number of lessons to be learned. Worse case scenarios should always be ruled out, and the members of medical teams should try to make informed decisions to ensure that the welfare of patients is not compromised. It's unfortunate that the patient in this case suffered permanent disability. My only hope is that the defendants learned as much as I have learned and will make wiser decisions when caring for future patients.

Risk management considerations by John Spencer Chiara

This case represents two types of errors that can lead to medical mistakes: systems breakdowns that lead to communication failure and misdiagnosis. While the latter often assumes the limelight, it is difficult to eliminate and, at least in this case, is not as serious as might be assumed. The former is completely avoidable and in this case led to both the damages and assignment of liability. Failure to communicate findings in a timely fashion is the crux of this case.

Initially, although the family practice doctor provided a short explanation, it would have been preferable for him to include a detailed list of the symptoms that led to the referral for an MRI. This would have better guided Radiologist #1, who is not a clinician, in understanding both the severity of the condition and urgency of timely diagnosis and treatment.

The next error, and without any question the most critical, was made by Radiologist #1. Failure to dictate his report of the MRI the day the study was made, regardless of his impression of the urgency of the condition, is the key to this case. If he had dictated the report when he reviewed the study he could have substantially reduced his liability, because the ED physician would have had easy access to a report indicating some type of mass lesion. Even with the mistaken diagnosis of a neoplasm, the ED physician would have known that there was a potentially expanding lesion threatening the spinal cord. The ED physician would have then been able to seek a neurosurgical consult and saved at least some of the patient's function. Misdiagnosing an abscess as a neoplastic lesion is probably a pardonable error, but no when that diagnosis, as flawed as it was, was not made available to the ED physician.

The true harm in this case occurred because the ED physician did not have access to the information regarding the previously identified lesion. It is debatable whether the patient or family physician should have been contacted, since it is unclear how their actions would have been different or contributed to a better outcome. The best way to have protected the patient and reduced liability would have been for the first radiologist to dictate and report his findings at the time they were made. Making information available to subsequent doctors would have enabled each of them, in turn, to apply their knowledge and experience as the events unfolded.

Misdiagnosis will occur from time to time and is a product of an imperfect science being practiced by imperfect people. Nevertheless, with proper and timely communication of findings, the diagnostic error would have been of much less consequence and may not have resulted in tragedy for the patient.

Risk management considerations by Jessica Dalby

This case report, rife with problems, demonstrates the consequences of human fallibility. Threats to patient safety are often covered up, rather than discussed, in our culture of blame and shame. Such behavior only builds huge obstacles that impeded the creation and implementation of safer protocols. Creating an environment in which professionals can freely discuss problems and prevention methods is the key for risk management.

The greatest failure of the physicians implicated in this case lies in poor communication skills. The lack of communication between radiologist 1 and the referring physician and the failure of radiologist 2 to speak directly with the ED physician are both examples where a five minute phone conversation could have greatly improved the patient's outcome. Good medical practice is deeply rooted in effective communication, both in the doctor-patient relationship, between doctors, and among other professionals. As a medical student, you toil for hours to prepare the perfect patient presentation for your attending because you know that the differential a doctor considers is heavily influenced by the way in which the case is presented. Thus, effective communication is a vital skill learned in medical school that must be practiced effectively throughout a physician's career. Effective communication is comprised of two parts, what is spoken and what is heard. Thus an effective communicator must not only speak clearly, but must ensure that his words are interpreted correctly. The conversation between the diagnostic center and the ED clearly failed to meet this definition.

Several different scenarios in this case would have benefited from improved protocols, providing additional safety checks. Specifically, a policy needed to be in place in which no MRIs were done at the diagnostic center without at least preliminary review by a radiologist the very same day. Also, the failure of the diagnostic center staff in contacting the patient, when his current phone numbers were listed in their files, could have been avoided had the staff followed a set protocol to actually look at their paperwork. The next preventable failure is seen when radiologist 2 prepares a hand-written preliminary report for the ED, yet doesn't file it with the patient's chart. A simple protocol to ensure better record-keeping, such as saving all faxed reports, could have saved the physician from a hearsay battle with the ED, who would also have benefited from better record keeping, Finally the failure by radiologist 1 to dictate his report immediately allowed subsequent events to sway his dictation, which is ethically questionable. Had a protocol existed requiring dictation within 48 hours, the physician would have avoided this sticky situation.

To ensure patient safety requires a lot of effort by everyone involved, from the office assistant to the technician to the physician. Therefore, patient safety reviews, in which staff can point out problem areas and plans can be made to correct those issues, are critical to the smooth operation of a practice. We should strive to create a medical culture in which everyone learns from mistakes of the past to ensure a higher quality of patient care in the future.

Risk management considerations by Tara Hagopian

In retrospect, the risk management considerations in this case seem reasonably apparent. Lack of communication, poor attention to detail and dated documentation procedures by the physicians and their staff gave rise to the malpractice lawsuit. While hindsight is 20/20, physicians must practice medicine in an anticipatory manner to mitigate risk to themselves and to their patients. An opportunity was present at some point for each physician to change the outcome of this case, however reliance on the dependability of other people contributed to the ineffective treatment of the patient. Had modern technology designs been applied here, as well as in many other cases, there is a chance that the patient would have experienced enhanced continuity of care and the burden on the physicians to provide this level of care would have been reduced.

This case was plagued by simple mistakes from the beginning. Radiologist 1 should have initially contacted the referring physician even though he felt the study was incomplete due to the fact that he did not know the patient's complete history and also to simply reduce his liability. Had the radiologist and his staff paid closer attention to the patient's chart they may have first, noticed the weakness in left leg coupled with back pain which would have necessitated immediate action including contacting the referring physician, and second, the staff would have been able to contact the patient at his current phone number. To prevent this type of error the clinic could implement procedures that include entering patient information to an electronic chart upon arrival where the new phone number and patient history may not have been so easily overlooked.

Other mistakes include the failure of Radiologist 2 to document the fax he sent and failure of the ED physician to request the MRI from the clinic or request a new one the first time the patient was presented at the ED. Electronically sending the fax, or at least making a copy of it as well as a transmission report for the patient file would have greatly reduced liability for Radiologist 2. The ED physician in an effort to reduce his liability should have requested the MRI, which could have very easily been emailed had new technology been in place, or at the very least should have checked for weakness in the patient which would have prevented the patient from being discharged so that he could be treated immediately.

In times such as these when medical malpractice suits are high, physicians must take extra care in treating patients to reduce personal liability. This case demonstrates how anticipatory action, attention to detail and good communication and documentation are essential elements in the practice of medicine. The use of technology to facilitate better communication and documentation could have provided improved continuity of care as well as decreased the risk to all parties involved.

Risk management considerations by Chad D. Housewright

We are simply a sum of our decisions. Often in medical malpractice claims a trail of poor decisions can be observed. The essential elements of establishing medical malpractice are summarized by the "4 D's" which can assist in navigating this trail. The physician has a duty to provide adequate care for the patient. There must be an obvious dereliction of this duty. Furthermore, damage must be suffered that is directly caused by the physician's derelict actions. This closed claim case serves as a model to demonstrate these elements.

Although not a pursuant in the claim, some would argue that the family physician failed in a few areas. He could have provided the patient with anticipatory guidance and education on possible outcomes, warning signs, and agreed upon instruction to contact the physician in the event these were noted. This would have been helpful since the physician was familiar with the patient and could assist emergency physicians in directing care. The family physician should also be well versed on the practice patterns of referral institutions utilized and be aware of the possibility that diagnostic testing may be performed in the absence of a radiologist and thus interpretation of such tests would be delayed.

On the other hand, radiologist 1 may have been a victim of distraction as he unfortunately succumbed to the flu. Life events will occur in medical practice, but pre-established guidelines can act as a safety net in these circumstances. Radiologist 1 could have notified a covering physician of pending diagnostic interpretations of issues that may need prompt attention in his absence. Also a set of protocols should have been in place to directly contact the patient and the referring physician in the event that further evaluation would be needed. Guidelines should have been enforced to dictate diagnostic reports in a timely fashion. Furthermore, the staff should have verified several methods for communication and contact numbers prior to performing diagnostic studies.

One must note that poor documentation was paramount in this case. Some physicians live by the adage "if it was not documented, it was not done." The written medical record must reflect the date, time, involved parties, actions taken, and the results of any events. Radiologist 2 should have submitted a written preliminary report to the medical record with a summary of his or her transmission of the report to the emergency physician. The radiology staff should have also documented the verbal conversation with radiologist 1, the transmission of the report to the emergency department, ad verification of receipt including the name of the person spoken with and the time received.

Although defense experts testified that there were no derelict proceedings, few would argue against the fact that the physicians had a duty to this patient. Several acts of commission and omission led to this unfortunate trail of events. These actions could have been avoided and may have been directly related to the damage suffered by this patient.

Risk management considerations by Eric Jon Larsen

All of the problematic situations presented by this case represent times when the people most responsible, the physicians, have not performed and/or deferred duties to their staff and peers which they should have performed themselves.

The first chronological error that took place in this patient's care was made by Radiologist 1. By not including the referring physician and/or patient in the discussion of the initial radiological findings, he/she restricted the use of a wealthy resource of background knowledge that may have shifted his/her thinking away from an initial exclusion of an infectious process. The first mistake that many doctors make is thinking that their patients can't understand what is happening to them, thus excluding them from discussions of the findings until they have read the studies and an "educated" diagnosis is agreed upon beforehand. By having the patient brought into the discussion, they can add clarification to the sensory information needed to pinpoint the diagnosis (eg. — weakness in his left leg in this case).

The second error made by Radiologist 1 was that he/she did not read the Patient Information Sheet filled out during registration at the diagnostic center. By filling out this initial form, most patients feel that any concerns marked on this form have been addressed and they forget to re-mention it during their interaction with the physician. Since Radiologist 1 did not read this form before trying to interpret the MRI, he/she missed a vital clue that would have prevented an infectious process from being erroneously excluded from the list of possible diagnoses. This critical error caused the patient's illness to be categorized as non-emergent and placed the patient at risk for improper management. Also, since staff did not read the Patient Information Sheet either, contact with the patient was further compromised.

Where Radiologist 2 came under criticism in this case was regarding the missing report that he/she gave to an employee to fax to the ED. Instead of handing over the master copy of any document to someone not responsible for the patient's care, the doctor should have provided multiple copies to be placed in the chart, given to the patient, to be faxed and for the diagnostic center's permanent files. Without this written proof that the physician was acting in the patient's best interest, there is no support for his/her actions when under scrutiny by the legal system. Radiologist 2 also stated that they called to verify that the faxed document was received, but never stated by whom. He/she should have talked to the ED physician directly and given an oral report to corroborate the written findings. This would have relieved any legal responsibility regarding inadequate care by Radiologist 2.

While it may be cumbersome and time-consuming for doctors to micro-manage every aspect of a patient's care, this is the expectation placed on them by their patients as well as society. We are entrusted with their health and it is what we would expect if/when we ever become patients ourselves.

Risk management considerations by Joshua Delbert Mitchell

"You can delegate authority, but you can't delegate responsibility," is a mantra that the army has long expressed to remind its leaders that they are ultimately accountable for results. It is an awesome responsibility to be a leader in the military where you can routinely make decisions that affect your soldier's lives. It is very similar to the responsibility of a physician, in whose hands a patient places his life and well-being. Similar to the battle drills and operating procedures the military uses to minimize risks and casualties in peace and war, established and rehearsed protocols can also help minimize risks and litigation in medicine. The current case study poignantly points out the medical and legal consequences of deficiencies in established protocol and lack of proper management accountability.

Prior to any patient treatment, a standard system for managing patient information and communication of diagnostic imaging findings should be established and disseminated to all office workers, to include physicians, of the referral center. A copy of the protocol should always be readily available, and a radiologist or office manager must routinely re-evaluate the standard courses of action to ensure they are understood and followed. If such a system were in place, the referral center could have avoided many of the unfortunate mistakes in this case.

Specifically, a standard protocol should include promptly inputting patient information into a central database and routinely double-checking the patient's most recent information sheet when attempting patient contact. It should include notifying the supervisor if, after following these guidelines, the patient still cannot be reached. It should include meticulous record keeping of all findings as well as the time, place, and person to which the findings were relayed. It is especially important to record the person that received diagnostic communications transmitted through facsimiles, which do not readily ensure that the intended party received the information sent.

Poor supervision added to the problems of the diagnostic center. The radiologist instructed his staff to contact the patient for follow-up studies, but the patient would have been better served through direct notification by the radiologist. The radiologist knew best the nuances of the patient's case, could answer the patient's questions, and could confirm with the patient the chronicity of his symptoms that were key to the preliminary diagnosis. The radiologist also arguably has an ethical responsibility to keep the physician and patient informed, even prior to follow-up studies, since the differential diagnosis includes processes that can be severe and debilitating.

While mistakes will always be made in patient care, the physician should strive to eliminate those that are due to a simple lack of precision and oversight. Litigation will only be minimized if one combines standard communication procedures and record keeping with good diagnostic and medical management skills. It is the duty of the physician to ensure all of these things happen, for it is the physician that is ultimately responsible for the patient's well-being, just as military leaders are ultimately responsible for their soldier's lives.

Risk management considerations by Stephanie Watson

This case represents a regrettable end to a common problem in medicine. With no less than 12 people involved in handling this patient's information in only 3 days, one can easily see the room for error in communication. The major problem is with hand-offs of information, when a physician or their staff transfers information to each other. Richard Croteau, JCAHO's executive director of strategic initiatives states, "2/3 of our sentinel events (leading to patient morbidity and mortality) are due to errors in communication, and most of that is at hand-offs."

This case is not an isolated event in which punishing these physicians will solve the problem. At many points in this patient's weekend, these physicians and their staff made mistakes in judgment about how to proceed, but I do not believe they did so maliciously, as most physicians do not. They acted in ways that made their day easier, by making less phone calls, writing less notes, and having co-workers take over responsibilities. This is human nature and must be prevented by systems in place to make it harder for us to make these errors.

The first communication breakdown comes when radiologist 1 read the initial MRI, but did not call the family physician with the abnormal result. Even though it was read as non-urgent, a policy should be in place to be sure the reading is documented and the FP knows about the abnormal MRI and the plan for follow up studies. Next, when radiologist went home sick, someone else in the office could have been informed of the patient's status and could have read and dictated a report on the initial MRI instead of the report being dictated after the weekend of ED visits revealed the true diagnosis.

When the staff of the diagnostic center could not reach the patient and the FP's office was called, the new contact information provided by the patient could not be used because it was not entered into the patient's chart. The FP's office needs a system to ensure this information is promptly entered. If the patient was informed of the abnormal MRI he could have used this information at the emergency department. Furthermore, since the FP's office was called, the physician could have been informed at that time.

When radiologist 2 prepared the MRI report and his staff faxed it, another breakdown of communication occurred. The ED physician claims he got an oral report of DJD and disc herniation, which he used as grounds to discharge the patient, but radiologist 2 claims he sent a report of cystic changes. Somehow the diagnostic center's fax did not get to the ED and the ED got the wrong report orally. Nothing is in writing, no one followed up his or her reports, and this miscommunication contributed to the patient's current condition. Systems to double check names, ID numbers, and receipt of reports as well as physician read-backs of reports and redundancies in retrieving and submitting information could have changed the outcome of this case.

2005 scholarship recipients

Danielle T. Burkett is a third-year medical student at the University of North Texas Health Science Center's Texas College of Osteopathic Medicine. Read Ms. Burkett's essay.
Jesse Lee Even is a fourth-year medical student at the University of Texas Medical School at Houston. Read Mr. Even's essay.
Jedidiah J. Grisel is a fourth-year medical student at Texas A&M University System Health Science Center College of Medicine. Read Mr. Grisel's essay.
Bradley Lega is a fourth-year medical student at Baylor College of Medicine. Read Mr. Lega's essay.
Rodolfo Jose Oviedo is a third-year medical student at the University of Texas Medical School at San Antonio. Read Mr. Oviedo's essay.
Erin K. Shiner is a third-year medical student at Texas Tech University Health Science Center School of Medicine. Read Ms. Shiner's essay.
Rebecca Wald is a third-year medical student at the University of Texas Southwestern Medical School. Read Ms. Wald's essay.

The $5,000 scholarships were awarded to one student at each Texas medical school that participated in the competition. Scholarship recipients were chosen based on each student's academic achievement, financial need, and written essay.

2005 winning essays

Applicants for the 2005 TMLT Memorial Scholarship were asked to write a 1000-word essay answering this question: "What can individual physicians do to ensure patient safety and minimize the risk of medical malpractice suits?"

by Danielle T. Burkett

Law X: "If you don't take a temperature, you can't find a fever." —The House of God.

Although this statement seems obvious, it appropriately points out that a physician with incomplete information cannot arrive at the proper diagnosis. This lack of information puts both the patient and the physician at risk. In today's complex medical environment, maintaining and increasing patient safety, and thereby reducing the risk of malpractice suits, is a daunting yet crucial task for physicians. However, the benefits of undertaking this task accrue not only to the patient through decreased preventable and unnecessary risk, increased efficacy of treatment, and improved quality of life, but also to the physician through decreased malpractice risk and increased ability to provide quality health care. Creating such benefits requires that physicians take initiative to assure accuracy of information through meticulous history-taking, thorough education, and careful clarification of all aspects of a patient's care.

The physician must first ensure that the patient accurately communicates all pertinent health information. In order to elicit a reliable history, a doctor should create an atmosphere of trust by assuring the patient that the interview is confidential. He or she should put the patient at ease and approach the patient in a manner that conveys genuine concern but also respect for the individual. Taking these steps will make the patient more likely to reveal sensitive information relevant to their overall health.

Observation also plays a crucial role in the assessment of patients. Careful attention to the patient's demeanor, dress, speech, body language, and movement may reveal critical details about the presentation. Overlooking such information could lead to erroneous conclusions and misdiagnoses.

When beginning the interview, the physician should first allow the patient to explain their situation without interruption in order to acquire what a patient feels is relevant history. They may relate details about which the interviewer might fail to ask. More importantly, however, by allowing the patient to express their history uninterrupted, the physician can avoid the trap of leading a patient to a presupposed diagnosis.

Following this initial narrative, physicians must be prepared to ask detailed questions regarding the patient's medications. Inquiries related to medications have generally been included as part of taking the patient's history, but because the scope of prescription medication, over-the-counter medication, and herbal supplements has increased dramatically, the physician must now question the patient more completely to ensure that conflicts do not arise between current and future treatments the patient may undergo. Patients often forget or do not find it necessary to include their use of over-the-counter medications and herbal supplements in their histories, so inquiries must be made about these substances in particular. Dosage, frequency of use, compliance with directions, and reactions and side effects of these medications must also be obtained. Furthermore, the doctor should ask about previous treatments and reactions.

Unfortunately, physician inquiries into the patient's lifestyle, habits, and emotional state have been less frequent and less detailed than similar attempts to learn about the patient's medications. Physicians do not want to offend patients or make them uncomfortable, or they make the mistake of assuming they know the answer. While these may be uncomfortable to discuss, issues such as sexuality, illicit drug use, and depression can be of utmost importance, giving the physician insight into risk factors that must be addressed in the patient's treatment plan. Patients are far more reluctant to voluntarily divulge such information, making it imperative that the physician bear the responsibility for incorporating such information into the patient interview in a professional and respectful manner.

The information that the physician communicates to the patient is equally vital to the patient's health care. There are several areas that the physician must address. First, the patient should receive an explanation of their current illness including associated risks and what they can expect in the future. Second, the physician should address treatment options with the patient. It is imperative that the patient understands the risks and benefits of all options, including the choice to not take action. Together, the patient and physician should weigh these options and decide on which approach will best serve the patient. A thorough discussion should include not only medical and surgical options, but lifestyle modifications that will improve the patient's overall health and decrease risk of future disease or complication. Failing to properly educate the patient can result in a lack of compliance from the patient which would most certainly decrease the patient's safety and increase the physician's exposure to malpractice claims.

Finally, the physician has a responsibility to clarify all information. During the interview, this requires confirming key aspects of the history of the patient. When giving treatment plan instruction, the physician needs to ensure that the patient completely understands all instructions. While it is important to ask the patient if they have questions, one should be sensitive to the fact that the patient may be unwilling to openly admit a lack of understanding. Overcoming these hurdles to patient safety can largely be accomplished by simply speaking slowly and clearly in terms that the patient can understand and asking the patient for feedback to assess their comprehension of any instructions or explanations. Trying to anticipate any questions is helpful. Writing instructions down is another way to assure compliance. Often, instructions that seem common or simple to the doctor may be more complicated to the patient who will be likely to forget such complicated details. Providing written instruction prevents this problem. Finally, the physician should reassure the patient that if any problem arises or they think of questions later, they can contact the office for further information.

Increasing patient safety begins with increasing the quality of information flow between the patient and the physician. It is a dynamic process requiring diligence and flexibility to continually improve the quality of medical care. Although time consuming, the value of obtaining complete information will prove to outweigh the cost by increasing the overall level of patient safety and reducing the risk of malpractice litigation.

by Jesse Lee Even

To ensure patient safety and reduce the risk of medical malpractice lawsuits, physicians today must first recognize that they will likely face legal liabilities if they don't take steps to safeguard their practice. Many of these liabilities can be minimized with easily implemented daily habits. This essay will explore a few straightforward preventative measures, and will focus on the need for greater physician/patient communication, the need for physician delegation of medical responsibility to the patient, the importance of physician utilization of technology to ensure patient safety, the need for physician-led communication between medical staff members, and finally the importance of continued medical education.

The simplest way physicians can promote patient safety and minimize medical malpractice lawsuits is to take the time to communicate with their patients. Taking a history and physical is one of the first lessons taught to students when they enter medical school. Medical schools teach physicians to ask the right questions, but also to listen to the patient's answers instead of reading down a laundry list of boilerplate questions. However, in the time-sensitive medical market of today, this art form has been long lost along with important medical information about the patient. This gap in the physician's knowledge of their patient could compromise the patient's safety and could ultimately result in a finding of negligence in a court of law. If physicians take the time to simply listen to and converse with their patients, many important aspects of the patient's medical history will be revealed, helping the physician determine the most appropriate care. In addition, when physicians effectively communicate with their patients it shows the patient that their physician is truly concerned with their medical issue. This in turn creates an environment wherein the patient feels their physician is doing everything within their power to solve the patient's medical issue, thus promoting a relationship that is less likely to result in litigation.

Along with listening to their patient's complaints, physicians must also take the time to discuss their prescribed medical treatment with their patients in an understandable manner. All too many times physicians try to speed the patient through the office or send them off to surgery, but forget to empathize with and dispel any lingering fears of the patient. One way to solve this problem is for the physician to assume the patient has never heard of the prescribed procedure or treatment. The procedure or treatment should be explained to them on an introductory level, and then to be certain of their comprehension, the physician should ask the patient to recapitulate it to the physician. Finally, the physician must remember to ask their patients if they have any questions in a manner that invites inquiry. Physicians sometimes assume patients understand, when in reality many are confused but are too intimidated by medical terminology to ask questions. When a patient is unsure of what medical actions are being taken and why, they begin to develop feelings of distrust. This distrust could lead to legal action if a procedure or treatment doesn't turn out the way the patient expected.

Encouraging patients to feel responsible for their own care is another habit physicians can practice to ensure patient safety and reduce medical malpractice lawsuits. This is an important aspect of patient compliance, but it also fosters the notion that medical care is a team effort between the medical professionals and the patient. When a physician cultivates this type of environment the patient will feel more in control, and will therefore be more likely to take at least partial responsibility if a treatment doesn't work and less likely to sue.

Another important tool that should be utilized by physicians to ensure patient safety and minimize legal actions is the use of medical technology such as digital records and integrated pharmacologic programs. Digital medical records need to be made readily available to promote the sharing of patient information between physicians, which would increase the continuity of care. Imagine if a physician could pull up every visit their patient ever had in his or her lifetime and learn every medication they were ever prescribed. Not only would these records be extremely helpful in charting the care of the patient, but it would also increase the safety of the patient because the physician could access information the patient may have forgotten or never knew about. Such technology would also be helpful when prescribing patient medication. The technological accuracy would reduce the amount of incorrect doses and negative drug interactions caused by human error.

Physicians in the practice of surgery have a particularly simple yet under-utilized method in which they could increase patient safety. Because of the numerous lawsuits filed against surgeons who have performed operations on the wrong patients or amputated incorrect limbs, a system of identifying the patient and site of surgery has been implemented in most hospital settings. This identification consists of naming the patient and the procedure to be done verbally before the procedure begins. However, this procedure is often taken lightly, or not completed at all. In most cases, it is the nursing staff members who have initiated these identification procedures. The patient is the physician's ultimate responsibility and physicians should take full command of these identification procedures to ensure the patient's safety and to prevent medical malpractice suits. This quick identification process is a valuable preventative measure that must be utilized.

The final way physicians can ensure patient safety and minimize the risk of medical malpractice suits is through continued medical education. Physicians have an obligation to their profession, and especially to their patients, to be up-to-date with the most accurate medical information available. It should be the goal of every physician to read an article daily that will further their medical knowledge. This simple task will not only convey to colleagues and patients that the physician takes his or her profession and patient care seriously, but it also serves to prevent medical mistakes.

There are many avenues that physicians can take in our daily practice of medicine to ensure patient safety. Increasing physician/patient communication, physician delegation of medical responsibility to the patient, physician utilization of technology, physician-led communication between medical staff, and continued medical education are only a few ways patient safety can be protected. And when physicians position the safety of the patient as their top priority, the amount of frivolous lawsuits will decline automatically.

by Jedidiah J. Grisel

The reasons why patients bring lawsuits against providers are a variegated as patients themselves. However, underlying almost all litigation is a sense of distrust; for some reason the patient feels that the doctor's actions are inconsistent with their best interest. Since litigation is often the result of a breakdown in trust, physicians can prevent and reduce unnecessary lawsuits by strengthening the doctor-patient relationship. Researchers at the Mays Business School at Texas A&M University and Scott & White have shown through ongoing research that physician behaviors are the most powerful predictors of patient commitment. Patients who trust their doctor and are committed to the relationship are more likely to forgive mistakes, accept poor outcomes and seek understanding before turning to legal options.

There are many things that physicians can do to strengthen the doctor-patient relationship. Three important examples are providing patient-centered access, cultivating a spirit of transparency and implementing evidence-based guidelines. In addition to strengthening relationships, these strategies also ensure that patients receive care that is safe, effective, patient-centered, timely, efficient and equitable.

Every patient has expectations about when and how they should be able to access their doctor. Trust is diminished when a patient's important health problems (whether perceived or real) are put off for weeks because the doctor's schedule is packed. The message sent in such situations is that the patient's problem is not important or, worse, that the doctor just does not care. Careful scheduling techniques as well as providing the patient a variety of access options can remedy this patient backlog problem. Many practices are currently implementing an "open-access" scheduling system where a certain percentage of each day is left available for office visits. When used appropriately, this system can help meet the needs of more patients without leaving precious office-visit slots unfilled. Additionally, many patients do not need or want an office visit for every medical problem. Oftentimes, a variety of nontraditional access options may more appropriately meet these patients' needs. Telephone and email consultations are becoming more accepted as legitimate means of communicating with patients. Many clinical situations, such as emergencies or new patient visits, do not lend themselves to these types of communication. However, judicious use of telephone and email cannot only save patients a trip to the doctor's office, it can also open up more clinic time for those who can be served in no other way. Patients who obtain access to health care when and how they want are more likely to feel satisfied with their doctor and trust that their care is appropriate.

Cultivating a spirit of transparency is another way in which physicians can strengthen trust with their patients. This standard of honesty should permeate every aspect of the physician's practice, including relationships between staff, nurses, doctors and patients. The threat of legal involvement tempts many providers to hide mistakes from colleagues and patients. Intuitively, one may think that full disclosure of all wrongdoing may leave a physician vulnerable to increased litigation. There are several reasons, however, why maintaining a policy of complete transparency is the better choice, even in a litigious society. Unless mistakes are reviewed and examined in the light, there is no way to prevent these errors from occurring in the future. Doctors can promote a spirit of non-punitive error reporting in their practice by admitting to their own errors and praising others for doing the same. The ultimate example is for doctors to fully disclose medical errors to patients without reservation. Most patients are willing to forgive even the most grievous errors, but they are not willing to overlook dishonesty. Nothing destroys trust more than dishonesty and secrecy in the doctor-patient relationship. Therefore, patients should be given complete access to their record, without fees or hassles, and they must always feel that the doctor is being open and candid. When legitimate breeches in the standard of care have been made, doctors should provide restitution. It is understood that this strategy will not eliminate all lawsuits, but it will strengthen trust with patients, open lines of communication before litigation is sought and provide a means to examine errors so that they can be eliminated in the future.

Finally, when patients receive clear, consistent messages from multiple health care sources, their trust in the validity of their care is increased. Medicine is often complicated and confusing, and when patients receive information that is contradictory or conflicting, they become more confused. As a profession, physician and specialty associations should (and many do) make it a priority to establish evidence-based guidelines that reflect the most current research. By implementing such guidelines, physicians can be confident that their recommendations are in the best interest of the patient according to the current state of scientific knowledge. This principle has been applied in many other industries with much success. For example, airline pilots are governed by strict guidelines to ensure a certain level of performance during flight. Customers can expect the same degree of safety regardless of who is flying the plane, so long as a licensed pilot is in the cockpit. Similarly, patients should be able to depend on health care that is up-to-date and accurate, no matter who is providing their care. As more physicians implement evidence-based guidelines, patients will come to expect and rely on the improved quality.

The thought of influencing medical litigation can seem daunting for physicians when one considers the size and complexity of the issue. However, interacting with patients is something that every doctor does every day. By using these interactions to strengthen trust, physicians can create bonds with patients that become safeguards against litigation in the face of unfortunate events. Despite the complexities of modern medicine, we still find ourselves in a profession that requires not only intellectual knowledge, but emotional and interpersonal skill as well. The words of Sir William Osler ring true today when he said, "Our fellow creatures cannot be dealt with as a man deals in corn and coal; 'the human heart by which we live' must control our professional relations."

by Bradley Lega

Hunter S. Thompson, the author of Fear and Loathing in Las Vegas and Fear and Loathing on the Campaign Trail, recently shot himself. This is a shame for many reasons, but one of them is that he never had the chance to write a book called Fear and Loathing in a White Coat: A Chronicle of Doctors, Lawyers, and Malpractice. Fear and loathing seem like two most appropriate concepts to describe the average physician's view of malpractice: fear of being sued, loathing for the wolfish lawyers that patrol the flanks of medical practice looking for the weak and the old. The fear begins early in training as professors emphasize points about disease management with phrases like: "And if you don't do this, start finding a lawyer." The loathing comes from many sources, including unending TV ads for Jim Adler the Texas Hammer, an over-exposed malpractice attorney who evidently takes advice from professional wrestlers.

After starting clinical rotations, I noticed that loathing associates itself with malpractice in another, more subtle form. Stories of lawsuits become a way for residents to express their dislike for their peers. During my medicine rotation, the team's intern complained about how lazy one of the surgery residents was, and then added, "He's already been sued twice." The story is petty, but it shows that physicians often think that their less competent and careful peers are the ones being sued, that a lawsuit is something like a professional scarlet letter. The advice these physicians give about malpractice reflects their attitude — I can't count how many times I've heard the sentence "If you do what's best for the patient, you won't be sued."

I call this method of malpractice avoidance the Edwards method, after the Puritan preacher whose sermon "Sinners in the Hands of an Angry God" has some legendary metaphors about the consequences of immorality. In the Edwards method, if a physician does what she's supposed to, she can live with a clean conscience and without fear of legal reprisal. The method theoretically ensures infallible patient care: if a physician always does what's best for the patient, then patient safety should be one of her prime concerns. But what's best for the patient? The conventional term "standard of care" is a fluctuating and nebulous concept, especially for unusual cases. Plus, bad things happen to good people: innocent women were drowned as witches, pious Franciscans caught the plague, and good doctors suffer lawsuits.

This last point leads to a second often-repeated prescription for avoiding malpractice: documentation. If a physician carefully documents what she does and her reasoning behind difficult decisions, her defense lawyers will have powerful weapons to keep the wolves at bay. I call this the Nixon method, since Nixon's tapes illustrate how documentation can caused problems for people who aren't doing what's right. The Nixon method's emphasis on documentation implies that a physician must maintain constant vigilance, thinking of each page in the patient's chart as a piece of evidence of her own defense. It also contributes to the adversarial nature that pervades too many doctor-patient relationships, a trend that can't be good for patient safety no matter how artful the argument. Finally, in my limited experience, mistakes often occur when doctors forget to do things that they normally would do — forgetting to recheck a patient's potassium level after ordering an ACE inhibitor, for instance. But the Nixon method does nothing for these types of errors, since a physician can't document something she forgets to do.

It appears then that serious flaws weaken both the Edwards method and the Nixon method, even though they are the basis for 70% of the advice that medical students hear about malpractice. I think an approach that I call the Aristotle method solves some of these problems and could serve as a model for how physicians avoid malpractice and promote patient safety. The Aristotle method is built around virtue, as is Aristotelian ethics. It stems from the observation that physicians-in-training learn their habits by emulating some of their superiors, especially residents, attendings, and other students that have won the respect of their peers. Co-workers attribute virtues such as "hard-working," "sharp," "strong," and "efficient," to these role-models, but the Aristotle method doesn't mean that physicians can avoid malpractice by being stronger and sharper. It means that when taking care of patients, students should imagine themselves verbalizing their analysis and decision-making to one of their professional heroes. This mental exercise finds potholes in reasoning, and the act of forcing oneself to construct a coherent narrative helps identify things that the physician may have initially forgotten to do.

The Aristotle method is not the same thing as asking inane self-questions like "What would Osler do in my position?" It advocates mental recapitulation, not simple mimicry. We may find that we disagree with our role models' imagined opinion, but we should then be able to offer good reasons for doing so. And if we honestly don't know what he or she would think, then it might be time to consult the literature. This idea may initially seem similar to the Edwards model, in which physicians practice in constant fear of judgment for deviating from some standard, but I think it's more positive since most of us want to win recognition of the people we look up to and we're willing to work hard for it. And by thinking about what a specific person's thoughts or criticisms might be, it avoids the vagueness inherent in "standard of care." It may also look similar to the Nixon model, since documenting one's reasoning generates the same kind of narrative as imaginary verbalization. But I think it's less cynical since it creates habits from virtue rather than lawsuit avoidance, and it actively helps prevent errors of omission.

As with any good practice, the Aristotle method could be instituted if the professionals we respect tell us that it's a good idea. I think it's a way that avoiding lawsuits and promoting patient safety can converge.

by Rodolfo Jose Oviedo

It shall be for the good of the sick

"I do solemnly swear, by whatever I hold most sacred . . . That into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power . . ." The Physician's Oath of Hippocrates is still recited with devotion and pride by the privileged ones who enter the most beautiful and fascinating profession in the world, the one profession that was born when human beings began to care for each other and that continues to be practiced by fragile but determined people who have sworn to dedicate their efforts and sacrifices to the assistance of the ill: medicine. Nonetheless, in spite of the selfless character of this way of life that society still regards as one of its noblest professions, it is disconcerting to know that physicians are being treated with distrust by those to whom they have sworn to protect and save from illness, their own patients. On the twenty-first century of the modern era, the term "defensive medicine" has come to acquire an almost official validity and is being used by doctors from all specialties as though by saying it they felt more secure and aware of the fact that the potential for a legal suit is always imminent, awaiting them on any given day of their practice.

It is amazing to realize that in this great country, where the technological advances of medicine have put physicians on the summit of patient care in terms of procedures and treatments that were unimaginable some decades ago. Patients are losing their trust in their doctors and have lost respect for many of them after numerous unfortunate experiences in which they have felt mistreated or ignored; when their right to autonomy has been violated; and their need to know about their diseases has not been addressed by the medical professionals, either consciously or unconsciously, by negligence or on purpose. What can we do, as a rational and organized society, to understand the nature of this critical problem of our time and commit ourselves to the quest for a solution that surges from the very roots of the problem? The safest way to do it is by humbly admitting that we, as doctors in training and consecrated professionals with years of experience, have made a terrible mistake by distancing ourselves from a reality that has been known for centuries: that physicians must learn to be, above all things, excellent communicators and protectors of the mind and soul of their patients. Human beings have many needs, but one of their most fundamental needs is meaning. We as medical students and physicians should emphasize personal communication and public relations skills in our training and daily lives so that we can fulfill our patients' need to understand their diseases and their meaning to their lives with dignity and freedom to choose their destiny.

As a concrete solution to the problem of patient safety and the risk of malpractice suits, medical students and residents should receive formal training on ethics and humanities, not just as a class taken for a semester or two, or as a number of credits that must be met, but as a permanent and familiar philosophy during the entire medical school and residence experience. Future doctors of Texas and this nation will know how to prioritize their patients' dignity and right to know about their diseases and treatment options. If we learned how to consider our patients' questions as hints about their deeper needs and provided them with enough information for them to make their own informed decisions, the situation would be different and a more favorable one for our health care system. Individual physicians who are already practicing can sacrifice some time by spending a few more minutes discussing their diagnosis and treatment modalities with their patients so that the latter learn how to take care of themselves and begin to practice preventive medicine on their own before it is too late and their diseases have advanced to a point where intervention is required. Physicians can always spend a few more minutes to counsel their patients and advise them to join support groups in their communities or hospitals where other people in their situation share their experiences on how to control their chronic diseases, such as hypertension or diabetes, with lifestyle changes.

In addition to implementing communication, ethics and humanities curricula in all our medical schools and residency programs, we as Texans and Americans should make these areas of human understanding official requirements for certification of our licenses so that we may prevent arguments with our patients and future malpractice suits because of lack of communication. Sometimes it does not take a complication from a procedure or the wrong choice of antibiotic to upset a patient. Rather, it takes the patient's realization that his or her doctor did not care about explaining the possible outcomes and treatment alternatives. Of course, the potential for a lawsuit will always be there, but we can certainly minimize that potential by practicing a more human type of medicine.

It is not an impossible task. If our physicians committed themselves to ensuring that their patients learn how to cope with their diseases and prevent others, and provided them with enough information so that they decide what to do, the patients would not feel that they need to sue their doctors should an unfortunate complication develop. It would simply be unnecessary, and hopefully, unthinkable, for them to take their doctors to court because they would know that those physicians took their time to treat them with respect and practice their profession "with uprightness and honor." We should always try to educate our patients and heal them instead of focusing on treating diseases that pose challenges to our intellect. To ensure patient safety, we as doctors should indeed practice "defensive medicine," but not to defend ourselves. The ones that we have sworn to defend from illness and suffering are the patients.

by Erin K. Shiner

In the United States, medical errors are estimated to lead to nearly 100,000 preventable patient deaths and to cost $9 billion in injuries annually (1). In the midst of this dilemma, the U.S. is also experiencing a medical liability insurance crisis. A report from the General Accounting Office designated losses incurred from malpractice claims as the primary contributor to increased medical liability insurance premiums (2). A recent survey of physicians practicing in rural Florida uncovered that the mean increase in their insurance premiums was 93.5% from the previous year (3). Thus, there is an urgent need for improvement in the health care system that would lead to increased patient safety and reduce the risk of malpractice.

To address the role that the physician can have in improving patient safety, I have developed a model that I call RAPPORT (Read, Advocate change, Patient communication, Participate in research, Open collaborations, Report it, Technology). This essay will address each of these areas in the RAPPORT model and how the utilization of this system can improve patient safety at the level of the physician.

Read: An important task of every physician is to stay abreast of current scientific and medical literature in his/her area of medicine. Besides subscription to medical journals, physicians can browse current literature easily through specialized search engines (i.e. PubMed, MDConsult). Furthermore, online subscription to news alerts from various medical networks can keep the physician current on changing medicine.

Advocate change: Changes at the hospital, state and national levels are quite necessary for improving patient safety. Through membership in medical organizations (i.e. TMA, AMA), caregivers can be aware of what issues are under review by lawmakers. The individual physician should practice making his/her voice heard by writing letters to state and national legislative representatives on issues, such as regulation and health care reform. In addition, a physician can participate in change within a health care organization by sitting on planning committees or assisting in coordinating change in some other way that his/her time allows.

Patient communication: Good rapport with patients can itself promote patient safety and reduce malpractice, and rapport is the very root of this model. Patients who are at ease with their physicians are more likely to relay important information to their doctors. By educating patients on the importance of taking their prescribed drugs and going in for clinical tests, it is more likely that the patients will be compliant. Furthermore, understanding the financial capabilities of patients will enable the physician to prescribe accordingly and to increase compliance as well. Because of time management constraints, it is very tempting for caregivers to manage several different tasks at a time, but multitasking will inevitably lead to errors and should be avoided. The University of Colorado School of Medicine utilizes a communication skills technique that is referred to as Invite, Listen, and Summarize. This method is used to create rapport, collect good data, and improve compliance during the medical interview through active listening in which the practitioner makes eye contact, avoids distractions during the interview, and summarizes the patient's words to allow for corrections and elaborations (4).

Participate in research: Health services research is a vital tool for improving the health care system. It is through research that problem areas can be identified and mechanisms can be developed to correct weaknesses and enhance strengths. If an opportunity presents itself for a physician to participate in a research survey/study on patient safety or malpractice issues, the physician should definitely take part.

Open collaborations: One of the most powerful patient safety tools at the hands of every physician is the ability to form strong collaborations with other health are workers, including nurses and providers of end-of-life care. During an invitational conference in 2001 sponsored by the Agency for Healthcare Research and Quality and the ABIM Foundation, the point was made that the focus of health care needs to shift from acute to chronic care, which bears complex morbidities, and so a team approach to treating the patient will need to be well established (5). Referrals and collaborations formed between physicians and other health care workers are a necessity for optimal patient care.

Report it: One strategy of health care systems to reduce medical errors is the use of a reporting system to identify and learn from errors made by caregivers. Reporting of medical errors is concerning, however, because of the potential consequences of reporting, including greater frequency of lawsuits, negative repercussions on the reporting practitioners, and frightening the public unnecessarily (6). Realistically, though, errors have a tendency to have a recurrent pattern in which a set of circumstances can provoke similar mishaps, thus it is imperative that practitioners report errors so that procedures can be modified to lower the risk of recurrence (7). Furthermore, physicians should make a point to report near-misses (events that could have had adverse consequences but did not) because the benefits of these data could lead to discoveries of procedures with imminent risk and enable focused improvements in training, organization, management of work, and the design of systems without carrying the liability of full-fledged medical errors (1).

Technology: Electronic patient management tools can reduce errors by alerting physicians of abnormal test results or past due or noncompliance with tests in addition to freeing up some valuable time for physicians (8). Physicians should learn how to utilize the electronic tools available to them at their particular health care institution. Also, handheld devices are a valuable and easily portable electronic tool that can store a number of medical software programs that can assist the physician in providing top quality care to patients in order to reduce the frequency of medical errors.

Overall, the RAPPORT model was designed in order to address the need for improvement in patient safety and reduction of medical malpractice risk. There is a critical need for intervention in health care systems at a national, state, and institutional levels; however, the physician also has a very active role in improving patient safety. The items outlined in this model are all areas in which the individual physician can be active.

References

Barach, P, S.D. Small, Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000.320(7237): p. 759-63.
Office, U.S.G.A., Medical Malpractice Insurance: Multiple Factors Have Contributed to Increased Premium Rates, in Report No. GAO-03-702. June 2003.
Brooks, R.G., et al., Impact of the medical professional liability insurance crisis on access to care in Florida. Arch Intern Med. 2004. 164(20): p. 2217-22.
Boyle, D., B. Dwinnell, and F. Platt, Invite, listen, and summarize: a patient-centered communication technique. Acad Med. 2005. 80(1): p. 29-32.
Goode, L.D., et al., When is "good enough"? The role and responsibility of physicians to improve patient safety. Acad Med. 2002. 77(10): p. 947-52.
Weissman, J.S., et al., Error reporting and disclosure systems: views from hospital leaders. JAMA. 2005. 293(11): p. 1359-66.
Reason, J., Human error: models and management. BMJ. 2000. 302(7237): p. 768-70.
Poon, E.G., et al., "I wish I had seen this test result earlier!": Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004. 164(20): p. 2223-8.

by Rebecca Wald

For the holidays this year, I received the gift of time with my father. My dad was diagnosed with prostate cancer in October, and I will never forget his voice saying, "Rebecca, they found cancer." The emotions began to flood, and I realized that my "invincible" Dad might not always be there for support and love. As I sat by his hospital bed, the importance of patient safety was not just a medical record number on a chart, it held the face and name of someone so dear to me. In an ever- changing and advancing health care system, it is more important than ever to ensure patient safety and satisfaction. I believe there are several simple measures that each individual physician can do to ensure patient safety and minimize the risk of medical malpractice suits. These measures can be broken down into four areas: a physician's clinical communication, their relationship with the patient, interaction with the nursing staff, and the physician's own health maintenance. Working with these four areas will help each individual physician ensure patient safety and decrease malpractice suits.

As the numbers of physicians and nurses seeing each patient increases, the importance of each physician's communication is critical. Proper and pertinent information must be shared between medical personnel to efficiently treat each patient in a timely manner. An easily overlooked way a physician can improve patient safety is by writing legibly. If one's handwriting is not legible in the chart, the orders may be misread, the following physician may miss key findings, and the patient may be placed in harms way. Each physician should also summarize in progress notes daily: an overview of the medical history, the current hospital course, treatment plan, preventative care, current medications and doses, and if they have spoken with a family member.

The second area a physician can improve patient safety and decrease malpractice suits is in their interaction with the patient. Thorough hand washing, relentless glove usage and proper isolation precautions should be followed to decrease infectious spread. The physician should also keep up-to-date on the latest medical information. Patients are now more informed with greater access to sources like the internet, and the physician must be ready to explain why certain measures are being taken versus those that the patient may have researched on-line. Most important of all concerning patient safety and satisfaction is establishment of a good rapport with the patient. This is a lesson that was taught to me by my sister who is an obstetrician/gynecologist, a specialty in which malpractice rates are high. A physician must care for their patients, cry with them, be joyous with them, and express that they are in the battle together. A patient that feels their physician is genuinely concerned for their health and well-being will be more satisfied with their patient care and more compliant with treatment and follow-up plans.

Establishing a good rapport starts as soon as the physician first interacts with the patient. The few minutes one has to spend with each patient should be quality time that expresses one's concern for the patient. Little things like eye contact, smiling, and sympathizing with the patient go a long way. Also, to decrease confusion, physicians should introduce themselves and give the patient a business card with their specialty written on it. For example, a nephrologist may write "kidney doctor." When an additional doctor sees the patient, they may also introduce themselves with a card and say whom they are covering for. This will allow the patient to feel less overwhelmed by the large amount of individuals in charge of their care. Additionally, work with the family to help them understand the procedures, results, and make them feel involved. Finally, explain results and reasons for treatment in words the patient can understand, and be sure to ask if they have any questions.

The third area a physician can increase patient safety and decrease malpractice suits is by good relationships with the nurses who are also key to patient safety and satisfaction. My mother, who has been a registered nurse for almost 40 years, always taught me one important lesson: nurses are invaluable. Listening to their input and recognizing them as part of the team can dramatically improve the level of health care provided and patient safety. Each physician should get to know their nurses, thank them for their help, respect their opinions, encourage suggestions and keep an open line of communication. Many nurses have a great deal of knowledge and intuition from experience and can help the physician better treat the patient and often avoid inappropriate or misunderstood orders. Also, the respect a nurse has for a doctor is easily viewed by the patient and influences patient satisfaction and compliance with care.

Lastly, the physician's personal health maintenance is often overlooked, but vitally important. If the physician is not at their highest mental capacity due to lack of sleep and exhaustion, the patient's safety is in jeopardy. Recent measures to decrease resident weekly hours are a step in the right direction to improving patient safety. In addition, each physician should realize that the advice they give to their patients holds true for themselves as well: eating healthy, exercise, and getting adequate rest. Of course, universal precautions should be second nature to ensure the health of the physician against injuries or transmission of diseases.

By taking measures toward improving patient safety in the four mentioned areas: clinical communication, relationships with the patients, interaction with the nurses, and one's own health maintenance, each physician can work to improve safety and decrease malpractice suits. Every patient is someone's father or mother, sister or brother, son or daughter, husband or wife. Each deserves the best we have to give. When we treat each patient as if we were treating our own family member, we will be stepping towards better health of each patient and will allow the gift of more time, like I had with my father, to be given to all.

2011 TMLT Memorial Scholarship

2011 winning essays

The case study — Failure to diagnose myocardial ischemia

Presentation

Physician action

Allegations

Legal Implications

Disposition

Risk management considerations by Duane Akwar

Risk management considerations by Elizabeth Rossmann Beel

Risk management considerations by Clay Buchanan

Risk management considerations by Charles Willnauer

2011 scholarship recipients

2010 scholarship recipients

2010 winning essays

The case study — failure to properly monitor patient

Presentation and physician action

Allegations

Legal implications

Disposition

Risk management considerations by Douglas S. Lewis

Risk management considerations by Robert G. McAtee

Risk management considerations by Scott McIntyre

Risk management considerations by Nathan Wright

2009 scholarship recipients

2009 winning essays

The case study

Presentation and physician action

Allegations

Legal implications

Disposition

Risk management considerations by Joseph H. Childs

Risk management considerations by Wilbur Dattilo

Risk management considerations by Cliff Hampton

Risk management considerations by Ravi Kumar

2008 scholarship recipients

2008 winning essays

The case study — failure to treat septic joint

Presentation

Physician action

Allegations

Legal implications

Disposition

Risk management considerations by Alexander J. Alvarez

Risk management considerations by Megan Gentry

Risk management considerations by Douglas James Heiner

Risk management considerations by Michael Merrick

Risk management considerations by Ana Nguyen

Risk management considerations by Kyle Piwonka

Risk management considerations by Jenny Van Winkle

Risk management considerations by Ajit Vyas

2007 scholarship recipients

2007 winning essays

The case study — failure to evaluate and test

Presentation and physician action

Allegations

Legal implications

Disposition

Risk management considerations by John Chiara

Risk management considerations by Paul Chin

Risk management considerations by Julie Cummings

Risk management considerations by Stanford T. Israelsen

Risk management considerations by Jason R. Pearce

Risk management considerations by Eric South

Risk management considerations by John Wilkinson

2006 scholarship recipients

2006 winning essays

The case study — delay in diagnosing epidural abscess

Presentation

Physician action

Allegations

Legal implications

Disposition

Risk management considerations by D'Andrea Anders

Risk management considerations by John Spencer Chiara

Risk management considerations by Jessica Dalby

Risk management considerations by Tara Hagopian

Risk management considerations by Chad D. Housewright

Risk management considerations by Eric Jon Larsen

Risk management considerations by Joshua Delbert Mitchell