Medical Malpractice Bulletin – January, 2016

Perspective: Missed Spinal Epidural Abscess (SEA): Who’s to blame? 
By Charles A. Pilcher MD FACEP
January, 2016

We are experiencing an epidemic of missed spinal epidural abscesses – and there is no excuse for it. The diagnosis is easy to make once one includes it in one’s differential for back or neck pain. Yet patients are being left paralyzed when the condition is only recognized when intervention is futile. The same egregious mistake is being repeated because physicians are learning nothing from the outcome of multiple lawsuits. Suing doctors for missing the diagnosis is clearly not working. Is it therefore time for attorneys and insurers to do their part by modifying the confidentiality clauses that have become a roadblock to physician learning? [Editor’s Note: This one challenges the status quo, is controversial and may raise some hackles. I’d appreciate your feedback. /CP]. Read more at your peril ->

How risky is telemedicine?
The field of telemedicine is growing rapidly. Is seeing a patient virtually rather than in person more likely to result in a med mal lawsuit? Such visits may be range from a simple phone conversation between a doctor and a regular patient up to a virtual stroke examination via video conference with  a neurologist hundreds of miles away. Even “Nightshift Radiology” could be considered virtual patient care. Medscape recently produced an excellent review of this issue including interviews with many involved parties including the American Telemedicine Association. Bottom line is that risk appears to remain minimal at this stage but is likely to grow as the field matures. [Editor’s Note: Lots of pearls here if you’re dealing with situations involving such visits. /CP]

Missed diagnosis? What about over-diagnosis?
In an article in JAMA Internal Medicine’s “Less Is More” column, Wegworth & Gigerenzer report the results of a survey of both patients and physicians on possible harms posed by various screening exams. For example, Gøtzsche and Nielsen found that “for every 2000 women invited for [mammography] screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily.” Physicians are poor judges of the risk of over-diagnosis according to the article, while patients are anxious to discuss such risks with their doctors. Also check a short summary of this issue from Health News Review.

How not to get sued
An article in MedPage Today on the ACEP Scientific Assembly last October reported on Dr. Christopher Colwell’s session on how not to get sued. Among his top “pearls” were these:

  • No such thing as “partial restraint.”
  • In the heat of the moment ask: What would you rather defend?
  • Keep intoxicated patients until you feel it’s safe for them to leave.
  • Take a breather before documenting your reaction — plaintiff lawyers look for any evidence of malice.
  • Accuracy counts! Be careful of software macros and templates that lawyers could latch onto as error.
  • Tell a story: Voluntary arrival? List consent/refusals, abuse, threats, and disposition.

Georgia, South Carolina and Texas: Did tort reform change physician practice?
Readers of this Bulletin are undoubtedly aware of tort reform in Georgia, South Carolina and Texas that has changed the standard for medical malpractice to one of “gross negligence.” But has that changed the practice patterns of emergency physicians in those states? The answer is “No” according to a study by Waxman et al. in NEJM. The message here is that emergency physicians have work to do in their own house before claiming that “defensive medicine” is raising the cost of healthcare in the US.

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