October, 2017

Charles A. Pilcher MD FACEP

Questions frequently arise in medical malpractice cases about the role played by physician “agents” in the care of a patient. Sometimes those agents are medical or surgical residents in training; sometimes those agents are physician assistants or nurse practitioners. When an unanticipated outcome occurs and such a situation is present, the question of responsibility arises.

Three articles have recently appeared addressing this. Below are summaries and links to the full articles

Nurse Practitioners:
This article by Carolyn Buppert MSN JD appears in Medscape and is based on information from PIAA, which reviewed 351 closed claims involving NP’s  between 2001 and 2010. Such claims are rare, but an associated physician may well bear some of the risk. (Ms. Buppert lists policies and procedures to reduce that risk in a separate article.) She then summarizes the 3 most common models of NP/Physician collaboration and compares the risk.
Model 1. Risk is highest in the employment or independent contractor relationship, but “Whether or not the employer or contractor is ultimately held liable depends on the facts of the case and state law.”
Model 2. Risk is lower in the “designated collaborator” model in which a hospital or other third party requires an NP to have such a supervisor/collaborator. More likely, the facility employing the NP will be liable, but it depends on the involvement of the physician collaborator and (again) state law.
Model 3. Risk is lowest, according to Ms. Buppert, when an NP practices independently but designates a physician collaborator to comply with state law Again, the facts of the case and state law can be determinative.
Case Analyses:
Ms. Buppert analyzes 6 cases in detail in which physicians were found liable. In 4 of the cases, physicians were involved with the actual care of the patient. Two of the cases were related to state requirements for oversight in which the physician was liable for failing to meet required standards. No cases were found in which a designated collaborating physician meeting state law (e.g., for chart review within a specified time frame) – and not involved in the patient’s care – was held liable (although they were sometimes named but later dropped or found not to be negligent.)

Physician Assistants:

The liability of physicians for acts of PA’s was addressed in a May, 2017, article by Brown and Lomurro in the New Jersey Law Journal. (free registration required). The article is based on NJ state law but may provide insight into the general liability of physicians working with PA’s.

NJ law 45:9-27 requires that every PA “be under the supervision of a physician at all times during which the physician assistant is working in an official capacity.” Specific requirements include:

  • Supervision may be physical presence or contact through electronic or other means of communication.
  • The patient must be informed that the medical services are being provided by a PA.
  • The PA must be identifiable as a “physician assistant,” “PA-C” or “PA.”
  • All medical record entries by the PA must be signed and followed by the designation, “PA-C” or “PA.”
  • Scope of practice must be clearly defined for the PA, though that scope may well be quite broad. Specific examples of the scope that may be delegated under supervision are described by the New Jersey Board of Medical Examiners in N.J.A.C. 13:35-2B.4. Medical services of a PA can also be authorized or limited through a signed “delegation agreement” defining the PA’s role “including any specific aspects of care that require prior consultation with the supervising physician” and requirements for record review.

The authors emphasize that in all medical malpractice cases involving a PA, such delegation agreements play a major role. They add that, while there has been no reported case in NJ of vicarious liability of a physician for the actions of a PA, state law says that “a physician assistant shall be conclusively presumed to be the agent of the physician under whose supervision the physician assistant is practicing.”

Resident Physicians:

In August 2017 JAMA published an article by Thiels et al. using Westlaw to summarize med mal lawsuits involving surgical residents. The authors note that “medical malpractice litigation against surgical residents is rarely discussed owing to the assumed legal doctrine of respondeat superior.” They found that “70% of cases involved elective surgery and 69% named a junior resident, while lack of direct supervision by attending physicians was cited in 55% of cases.” During a 10 year period, they found 87 malpractice cases involving surgical trainees, and 77% involved death or permanent disability. Interestingly, the cases more often involved questions of peri-operative, pre-operative and post-operative errors involving medical knowledge and decision making rather than intra-operative errors and injuries. This was especially true for cases involving junior residents. The resident’s failure to evaluate the patient was cited in only 12% of cases while lack of direct supervision by attending physicians was noted in 55%. A plaintiff verdict or settlement resulted in 48%. The authors conclude that education regarding oversight of peri-operative management, particularly among junior residents, and appropriate supervision by attending physicians should be targeted to prevent litigation.

 

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Perspective: Attorneys can improve patient safety faster than physicians

August 27, 2017

By Charles A. Pilcher MD FACEP September, 2017 I need your stories. Let me explain. Over the past 3 years I have occasionally written – some would say ranted – about the sorry state we in healthcare find ourselves when it comes to learning from our mistakes. I’ve written about patients who sue physicians to “teach […]

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Perspective: What is the standard of care for documentation?

July 28, 2017

August, 2017 Charles A. Pilcher MD FACEP An emergency physician colleague recently asked “Is there a standard of care for documentation?” Another physician asked “Is there anything that I should always put in my documentation that will keep me from getting sued?” Here’s how I addressed the questions: Is there a standard of care for […]

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Medical Malpractice Bulletin – March, 2017

July 28, 2017

Electronic Health Records (EHR’s): A “critical” review of “click-tation” By Charles A. Pilcher MD FACEP The purpose of a medical record is to record information about a patient for future reference or to communicate information to other caregivers. EHR’s have failed at both. “Click-tation” has replaced information transfer. A handwritten entry is rare. Within hundreds […]

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Perspective: A skeptic views the medical news

June 25, 2017

By Charles A. Pilcher MD FACEP July, 2017 “Over 20% of patients may be misdiagnosed by PCP’s” Really? That was the headline back in April. The Washington Post and other national media gleefully reported that over 20% of patients are mis-diagnosed by their primary care physicians. This is nothing more than “press release journalism,” aka “fake news” that results […]

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Perspective: When is a diagnosis “wrong” or just “uncertain”?

May 28, 2017

June, 2017 By Charles A. Pilcher MD FACEP In a March 2017 article in Emergency Medicine News, Dr. Justin Morgenstern astutely observes that “Doctors don’t make definitive diagnoses, [but] our patients are certainly under the illusion that we do.” Dr. Morgenstern hits the nail on the head here. Uncertainty is a significant part of the practice […]

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Perspective: Spinal Epidural Abscess & Learning from Lawsuits

April 29, 2017

Dr. Pilcher addresses both topics at AALNC National Forum in Portland May, 2017 I was honored to be invited by the American Association of Legal Nurse Consultants to speak to over 200 of the brightest minds in legal nursing at their national educational conference in Portland on Saturday April 8. The morning session covered the standard of care for […]

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Perspective: Cholesterol lowering drug: When a breakthrough isn’t

March 27, 2017

April, 2017 By Charles A. Pilcher MD FACEP The media were all a-twitter on Friday, March 17, about the “dramatic” results from a study of evolocumab (Repatha), a new cholesterol-lowering drug that – allegedly – reduces the chance of heart attack and stroke by 20%. The drug lowers “bad cholesterol” or LDL, and the placebo-controlled study of over 26,000 […]

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Medical Malpractice Bulletin – February, 2017

January 30, 2017

Perspective: Why do orthopedists get sued? By Charles A. Pilcher MD FACEP February, 2017 In 2014 approximately 18% of orthopedists insured by The Doctors Company were named in a claim or a suit. To better understand what causes patient harm, what motivates a patient to pursue a claim and to learn from the analysis, Darrell […]

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Why do orthopedic surgeons get sued?

January 30, 2017

By Charles A. Pilcher MD FACEP February, 2017 In 2014 approximately 18% of orthopedists insured by The Doctors Company were named in a claim or a suit. To better understand what causes patient harm, what motivates a patient to pursue a claim and to learn from the analysis, Darrell Ranum, David Troxel and Robin Diamond studied and […]

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Medical Malpractice Bulletin – January, 2017

December 27, 2016

In this issue: Perspective: When the patient is a VIP – or a plaintiff attorney Thunderclap headache: When it’s not a ruptured cerebral aneurysm Differential diagnosis of neck pain Endovascular (clot retrieval & stenting) approaches to stroke treatment Thunderclap headache: What’s the worst it could be – or not. “Thunderclap headache” is defined as a […]

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Perspective: Don’t bend the rules for VIP’s

December 27, 2016

By Charles A. Pilcher MD FACEP January, 2017 A prominent medical malpractice plaintiff attorney presents to the emergency department of his local hospital. Only months earlier this attorney represented a client in a well-publicized case against this hospital. The attorney is pale, sweaty and complaining of chest pain. ED staff, some of whom gave testimony in the earlier case, […]

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Medical Malpractice Bulletin – September, 2016

December 27, 2016

September, 2016 Perspective: How do patients feel about medical error? By Charles A. Pilcher MD FACEP “I told them about my fever and pain ever since I went to the hospital, and no one paid attention to my symptoms.” “The patient suffered a severe postoperative infection that was not diagnosed for 5 days resulting in a […]

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Medical Malpractice Bulletin – December, 2016

December 27, 2016

In this issue: Perspective: Pearls from the “Diagnostic Errors in Medicine” conference Do blind radiologists miss important findings? Diagnostic Error for Dummies: The “dirty dozen” ways to avoid mistakes  Is “medical error” really the third leading cause of death in the US Perspective: Pearls from the “Diagnostic Errors in Medicine” conference Charles A. Pilcher MD […]

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Perspective: Diagnostic Errors in Medicine 2016

November 28, 2016

By Charles A. Pilcher MD FACEP December, 2016. Over 300 physicians, educators, insurance companies executives, risk managers, quality & safety specialists, patient advocates and medical society representatives assembled at the 2016 Diagnostic Error in Medicine (DEM) Conference in Los Angeles November 6-8 hosted by the Society to Improve Diagnosis in Medicine. The common goal of […]

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Medical Malpractice Bulletin – November, 2016

October 30, 2016

Perspective: The role of electronic records (EHR/EMR) in med mal lawsuits By Charles A. Pilcher MD FACEP Last year Dr. David Troxel of The Doctors Company published an analysis of the role that the Electronic Health Record (EHR) has played in closed medical malpractice claims. This report and an earlier one on the topic by […]

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Electronic Records & Med Mal Lawsuits

October 30, 2016

By Charles A. Pilcher MD FACEP November, 2016 Last year Dr. David Troxel of The Doctors Company published an analysis of the role that the Electronic Health Record (EHR) has played in medical malpractice claims. There are few surprises in this report, or an earlier report on the topic by Dr. Troxel, for the experienced med […]

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Medical Malpractice Bulletin – October, 2016

October 6, 2016

October, 2016 In this issue: Panelists invited: Are non-disclosure clauses medically or legally ethical? Guest Perspective: Grief lessened by disclosure of medical error American Association of Legal Nurse Consultants (AALNC) national conference, Portland, OR, April, 2017 Spinal Epidural Abscess talk to AALNC Dr. Peter Rosen censured for breach of expert witness guidelines Panelists invited: Are […]

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Guest Perspective: Grief lessened by disclosure of medical error

September 30, 2016

By Doug Wojcieszak, Founder, “Sorry Works!” October, 2016 This article first appeared on the blog site of “Sorry Works,” August 28, 2016, and is republished with permission. When most people lose a family member or close friend, they go through the “classical” stages of grief: Denial, anger, bargaining, depression, and, finally, acceptance. Grief counselors often […]

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Perspective: Medical error from the patient’s viewpoint

August 29, 2016

September, 2016 By Charles A. Pilcher MD FACEP Last year Dr. Frederick Southwick et al. published the results of their ongoing survey of patients’ perspectives on medical error in BMJ Quality & Safety. According to the authors, the study “highlights the potential efficacy of patient-initiated surveys for providing meaningful feedback and for guiding improvements in […]

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Medical Malpractice Bulletin – August, 2016

August 3, 2016

Perspective: Who is responsible for the ED “boarder”? By Charles A. Pilcher MD FACEP August, 2016 A patient in the ED with a GI bleed is awaiting transfer to an inpatient bed. The ED doc has informed the hospitalist and believes the patient now belongs to the hospitalist. When the patient’s condition deteriorates 2 hours […]

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Medical Malpractice Bulletin – July, 2016

July 7, 2016

Perspective: Bob Newhart or CRICO: Who can best reduce medical error? By Charles A. Pilcher MD FACEP July, 2016 If our goal is to reduce medical error and improve patient safety, which approach is better: Analyze “big data” or simply tell physicians to “Stop it!” CRICO, the large Harvard based med mal insurer, believes in […]

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Perspective: Bob Newhart (“Stop it!”) vs. CRICO (“Big data”): Which can best reduce medical error?

June 27, 2016

By Charles A. Pilcher MD FACEP July, 2016 One of my all-time favorite skits is the scene from the Bob Newhart Show in which he plays a psychiatrist whose advice to a patient with a “fear of being buried alive in a box” is to just “Stop it!” Seems simple enough, right? The counterpoint to such advice […]

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Medical Malpractice Bulletin – June, 2016

June 25, 2016

Perspective: What is pain and suffering worth? By Charles A. Pilcher MD FACEP I have occasionally been asked to opine on whether or not a patient experienced pain and suffering as a result of a traumatic injury or a medical procedure with a bad outcome. As I understand it, the presence of pain and suffering […]

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Perspective: Pain and suffering in medical malpractice.

May 29, 2016

Charles A. Pilcher MD FACEP June, 2016 I have occasionally been asked to opine on whether or not a patient experienced pain and suffering as a result of a traumatic injury or a medical procedure with a bad outcome. As I understand it, the presence of pain and suffering has an impact on the amount […]

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Perspective: Body cavity search warrants. Are they enforceable?

May 2, 2016

May, 2016 By Charles A. Pilcher MD FACEP A police officer arrives in the ED with a handcuffed prisoner in tow, a suspected “body packer.” The officer presents the emergency physician with a search warrant signed by a judge authorizing the physician to perform a body cavity search to determine the presence of illicit drugs. If […]

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Medical Malpractice Bulletin – April, 2016

April 9, 2016

Perspective: Spinal epidural abscess – Let’s find a way to stop this epidemic By Charles A. Pilcher MD FACEP April, 2016 Too many spinal epidural abscesses (SEA) are being missed. Too many patients are being paralyzed. Too little is being done to prevent these tragedies. It’s time for the medical and legal professions to figure out how to […]

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Spinal Epidural Abscess: Let’s find a way to stop this nonsense

April 9, 2016

By Charles A. Pilcher MD FACEP April, 2016 Too many spinal epidural abscesses (SEA) are being missed. Too many patients are left paralyzed. Too little is being done to prevent these tragedies. It’s time for the medical and legal professions to figure out how to work together to prevent these tragedies. Suing doctors, then burying the results […]

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Medical Malpractice Bulletin – March, 2016

March 6, 2016

Perspective: I removed the spleen! What do you mean it was a kidney?! More transparency needed in medicine By Charles A. Pilcher MD FACEP March, 2016 What if we didn’t have the NTSB to investigate plane crashes? The medical profession experiences the equivalent of multiple “plane crashes” every day, but what do we do to prevent […]

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Perspective: “I removed the spleen! What do you mean it’s a kidney?!”

March 6, 2016

More transparency needed in medicine By Charles A. Pilcher MD FACEP March, 2016 What if we didn’t have the NTSB to investigate plane crashes? What do we do with the medical or surgical equivalent of a “plane crash”? Why does the airline industry learn from their mistakes but the medical profession does not? Here’s an example of why […]

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Medical Malpractice Bulletin – February, 2016

February 6, 2016

February, 2016 In this issue: Perspective: Posterior circulation stroke – why is this diagnosis missed? UPDATE: Spinal epidural abscess Diverticulitis: Another surgical disease goes medical Why radiologists get sued US health system: Great care if you can get it Perspective: Posterior circulation stroke – why is this diagnosis missed? By Charles A. Pilcher MD FACEP […]

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Perspective: Posterior circulation stroke – why is it missed?

February 6, 2016

By Charles A. Pilcher MD FACEP February, 2016 In the November, 2015, issue of Medical Malpractice Bulletin, “Perspective” covered the issue of missed aortic dissections. Missed dissections result in nearly 200 times more lawsuits than missed MI’s – on the basis of frequency of presentation to the ED. This month I cover posterior circulation strokes, another […]

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Medical Malpractice Bulletin – January, 2016

January 8, 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 […]

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Missed spinal epidural abscess: Why can’t we stop this?

January 8, 2016

Perspective: Missed spinal epidural abscess Are attorneys and insurers as responsible as doctors for this epidemic? By Charles A. Pilcher MD FACEP January, 2016 I am shocked, embarrassed, disappointed, concerned and yes, angry. Last month I learned of a seventh patient paralyzed because a spinal epidural abscess (SEA) was diagnosed too late. And that’s only in the […]

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Medical Malpractice Bulletin – December, 2015

December 12, 2015

Perspective: Radiology discrepancies: What’s the “miss rate”? Who’s responsible? By Charles A. Pilcher MD FACEP December, 2015 How often does a radiologist miss an x-ray finding? What happens when they do? Should ordering physicians view all images themselves? What if there’s a disagreement? Who’s responsible? Can we determine a standard of care? When there’s a […]

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Perspective: Radiology discrepancies: What’s the “miss rate”? Who’s responsible?

December 12, 2015

By Charles A. Pilcher MD FACEP December, 2015 How often does a radiologist miss an x-ray finding? What happens when they do? Should ordering physicians view all images themselves? What if there’s a disagreement? Who’s responsible? And can we determine a standard of care? When there’s a “miss,” what procedures and guidelines should be followed? […]

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Medical Malpractice Bulletin – November, 2015

November 20, 2015

Perspective: Why is a thoracic aortic dissection so often missed? By Charles A. Pilcher MD FACEP What are the first things an emergency physician should think of when confronted with a patient complaining of new onset chest pain? Heart attack? Sure. But given how common heart attacks are and how attuned to that diagnosis most physicians […]

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Perspective: Why is thoracic aortic dissection so often missed?

November 15, 2015

By Charles A. Pilcher MD FACEP November, 2015 What are the first things an emergency physician should think of when confronted with a patient complaining of new onset chest pain? Heart attack? Sure. But given how common heart attacks are and how attuned to that diagnosis most physicians are (or should be), how often does […]

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Medical Malpractice Bulletin – October, 2015

November 13, 2015

Perspective: Diagnostic Errors – SIDM works to eliminate them By Charles A. Pilcher MD FACEP” October, 2015 On September 27-29 I joined over 300 other healthcare professionals in Washington DC for an international conference on “Diagnostic Error.” This is an annual event sponsored by the Society to Improve Diagnosis in Medicine (SIDM). Among dozens of fascinating presentations […]

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Perspective: Diagnostic Errors – SIDM works to eliminate them

October 13, 2015

By Charles A. Pilcher MD FACEP October, 2015 On September 27-29 I joined over 300 other healthcare professionals in Washington DC for an international conference on “Diagnostic Error.” This is an annual event sponsored by the Society to Improve Diagnosis in Medicine.  Meeting attendance has grown rapidly over the past few years and I was […]

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Medical Malpractice Bulletin – September, 2015

September 21, 2015

Charles A. Pilcher MD FACEP September, 2015 [Editor’s Note: As a member of the Society to Improve Diagnosis in Medicine, I will be attending their international conference in Washington, DC, this month. The theme this year is “Diagnostic Error in Medicine: After the IOM Report, What’s Next?” I hope to return with new research and insights to share with […]

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Perspective: Are radiologists blind? They should be.

September 19, 2015

By Charles A. Pilcher MD FACEP September, 2015 Last year in the Journal of the American College of Radiology, Durand et al. published a thorough review of the biases inherent in experts’ review of radiologic images during the course of med mal litigation. They then discussed strategies that might be helpful in mitigating those biases. Most […]

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Medical Malpractice Bulletin – August, 2015

August 19, 2015

Perspective: Acute MI: “Yes” or “No” – Still more art than science By Charles A. Pilcher MD FACEP August, 2015 Body et al. published a study in BMJ’s “Emergency Medicine Journal in which they asked: “Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement?” The fascinating aspect of the study […]

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Perspective: Acute MI “Yes” or “No”- Still more art than science

August 19, 2015

By Charles A. Pilcher MD FACEP August, 2015 A recent article in BMJ Emergency Medicine got considerable press suggesting a new “high-sensitivity troponin T” test would predict who is and who is not having a heart attack – with 100% certainty. Hopefully our skepticism rises whenever we see “100% certainty,” “foolproof,” “game-changer,” “breakthrough” or other […]

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July, 2015 – Medical Malpractice Bulletin

July 17, 2015

Perspective: Pursue? Defend? Settle? Drop? The value of a “case viability analysis” By Charles A. Pilcher MD FACEP July, 2015 Every malpractice case demands thorough review to determine whether it should be pursued/dropped (plaintiff) or defended/settled (defense). In order to determine the best course of action, attorneys do a thorough analysis. In this “Perspective” the […]

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Pursue? Defend? Settle? Drop?

July 17, 2015

Case viability analysis crucial to prevent costly decision errors By Charles A. Pilcher MD FACEP July, 2015 “Charles, making decisions is easy. It’s getting the information that’s hard.” These words from my father have stuck with me since I first heard them decades ago at a crucial decision point in my own life. They are particularly appropriate when […]

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Medical Malpractice Bulletin – June, 2015

June 4, 2015

Perspective: If you’re a “nice” doctor, you won’t get sued By Ryan Padgett MD FACEP & Charles A. Pilcher MD FACEP June, 2015 Do hospital ratings matter? Is a “nice” physician with good behavior less likely to get sued than others? Physicians have long been skeptical of the value of patient satisfaction ratings but a recent study […]

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“Nice” doctors don’t get sued (as often)

June 3, 2015

Ryan Padgett MD FACEP and Charles Pilcher MD FACEP June, 2015 “Patient satisfaction scores for your department dropped last quarter. What are your plans to bring them up?” asks a hospital CEO of his ER director. This question irritates physicians more than the patient with an “emergency” wart at 3 AM. Press-Ganey, Healthgrades, Leapfrog, US News, RateMD.com […]

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Medical Malpractice Bulletin – April, 2015

April 28, 2015

Perspective: Why physicians make mistakes – deja vu all over again By Charles A. Pilcher MD FACEP April, 2015 This newsletter has frequently posted articles and “Perspectives” on what leads to physician error. Now a fascinating JAMA editorial on physician mistakes sheds light on the progress we are making (or not making) in improving patient […]

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Perspective: Why physicians err – deja vu

April 26, 2015

By Charles A. Pilcher MD FACEP April, 2015 Over 100 years ago Dr. Richard Cabot reported that autopsies showed a remarkable lack of correlation between the pre-mortem diagnosis and the actual cause of death. The findings were shocking and embarrassing, but the house of medicine anticipated that they would lead to improvements in the diagnostic acumen of physicians. But […]

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March, 2015 – Medical Malpractice Bulletin

March 10, 2015

Perspective: Physicians are learning nothing from med mal lawsuits. Time for a change. By  Charles A. Pilcher MD FACEP I am upset that physicians (other than defendants) are learning nothing from medical malpractice lawsuits. In this month’s “Perspective” I share my strong feelings on this issue and describe a project that I have begun to change that and improve […]

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Can we work together to improve patient safety?

March 10, 2015

By Charles A. Pilcher MD FACEP March, 2015 DISCLAIMER: In the January “Perspective” I presented Medical Malpractice Insights, a new publication for physicians which helps them learn from medical malpractice lawsuits. Because this is so important, I am continuing my “rant” in this post and seeking your involvement. I expect differences of opinion and am interested in your […]

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January, 2015 – Medical Malpractice Bulletin

January 4, 2015

Perspective: It’s time for doctors to LEARN from malpractice suits By Charles A. Pilcher MD FACEP January, 2015 After 35 years of working as an expert in medical malpractice, I continue to see presumably competent colleagues make the same mistakes over and over and over again. We docs are learning nothing from the unfortunate experiences/mistakes […]

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Medical Malpractice Insights – Learning from Lawsuits

January 4, 2015

By Charles A. Pilcher MD FACEP January, 2015 New Publication: Medical Malpractice Insights – Learning From Lawsuits Physicians are learning nothing from the outcome of medical malpractice lawsuits. That must change. Now. Seeing the same mistakes being made again and again by presumably competent physicians is frustrating. We physicians don’t have a clue – unless we […]

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Medical Malpractice Bulletin – November, 2014

November 3, 2014

Perspective: Interruptions lead to mistakes in patient care The ER is a busy place. So is the office of almost any physician. Having  uninterrupted time to address a patient’s problem is critical. Eliminating as many sources of interruption as possible is key to achieving that goal. Interruptions can lead to a lack of focus, a […]

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Perspective: Interruptions put patients at risk

November 3, 2014

By Charles A. Pilcher MD FACEP November, 2014 Last February in Emergency Physicians Monthly Dr. Jeremy Tucker wrote a column titled “The No-Interruption Zone.” Dr. Tucker, a busy ED physician at MEP/St. Mary’s Hospital in Leonardtown, Maryland, talked about the effects of physician interruptions on  patient flow and safety, and the ways in which interruptions lead to […]

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Perspective: Who’s in charge of ED “boarders”?

October 13, 2014

By Charles A. Pilcher MD FACEP August, 2016 An ED patient with a GI bleed and a hematocrit of 28 has been evaluated, the hospitalist has been contacted and initial orders for admission have been written by the night shift ED physician. No inpatient bed is available, but the hospitalist assures the ED doc, “I’ll come […]

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Medical Malpractice Bulletin – September/October, 2014

September 29, 2014

Perspective: Alert fatigue – a pitfall of the EMR By Ryan Padgett MD FACEP [Editor’s Note: This month’s “Perspective” is contributed by my colleague, Dr. Ryan Padgett, who provides services as a Consulting Expert with PilcherMD.com. / CP] As experience with EMRs increases, new challenges are discovered. One of the most critical is “alert fatigue,” an […]

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Perspective: Alert fatigue – a pitfall of the EMR

September 29, 2014

By Ryan G. Padgett MD FACEP September, 2014 [Editor’s Note: This month’s “Perspective” is contributed by my colleague, Dr. Ryan Padgett, who provides services as a Consulting Expert with PilcherMD.com. / CP] Mention the word “EMR” (Electronic Medical Record, aka EHR for Electronic Health Record) to a health professional and you can expect a strong […]

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Perspective: A critical review of “click-tation” in EHR’s

September 6, 2014

Electronic Health Records (EHR’s): A “critical” review By Charles A. Pilcher MD FACEP March, 2017 The purpose of a medical record is to record information about a patient for future reference or to communicate information to other caregivers. EHR’s have failed at both. It’s been 2 1/2 years since Neil Chesanow, Senior Editor of Medscape Business of […]

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Medical Malpractice Bulletin – August, 2014

August 25, 2014

Perspective: “Black Box” drugs raise red flags By Charles A. Pilcher MD FACEP “Black Box Drugs” are those that require the strongest available warning used by the FDA for an approved drug, because they carry “a significant risk of serious or even life-threatening adverse effects.” The warning is placed at the top of the PDR […]

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Perspective: Black box drugs raise red flags

August 25, 2014

By Charles A. Pilcher MD FACEP August, 2014 “Black Box” drugs: Open the box with care In the past few years I have been involved with 3 cases related to drugs with a “black box warning.” All 3 involved the accidental arterial injection of a low pH medication that caused severe vasospasm, arterial and arteriolar […]

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Medical Malpractice Bulletin – July, 2014

July 15, 2014

In this issue: Perspective: Is a “draft” report the “final” report? Canadians say “Yes.” Jumping to conclusions: Little time spent in differential diagnosis Vertebral Artery Dissection May Initially Cause No Noticeable Symptoms The other side of the stethoscope: Injured ED doc finds treatment lacking Malpractice claim may be modified after medical panel decision Must I […]

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Perspective: Is an expert’s “draft” report final?

July 15, 2014

By Charles A. Pilcher MD FACEP July, 2014 As an expert witness, I am occasionally asked to write a report, affidavit or declaration for an attorney client. When I do so, must my initial draft be the only and final say on the matter? May my attorney client accept it as a “draft” and suggest […]

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Medical Malpractice Bulletin – June, 2014

June 5, 2014

In this issue: Perspective: More tests ≠ “standard of care” Opportunities and challenges for attorneys in the ACA 1 in 20 outpatients misdiagnosed Alabama: Brand drug manufacturers liable for claims of generic knockoffs The fraudulent medical record: Anonymous ED scribe admits to over-documentation, over-billing Perspective: More tests ≠ “standard of care” By Charles A. Pilcher MD FACEP […]

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Perspective: More tests ≠ “standard of care”

June 5, 2014

By Charles A. Pilcher MD FACEP June, 2014 Sometimes doing nothing is the best care. There is an increasing body of medical literature illustrating the limits – and dangers – of excessive testing. Too often our legal system assumes that if a doctor had done just “one more test,” the outcome would have been different. Yes, […]

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Medical Malpractice Bulletin – February, 2014

February 23, 2014

Perspective: Can plaintiff attorneys prevail in stroke cases? By Charles A. Pilcher MD FACEP This newsletter assiduously monitors the medical literature on the subject of stroke, as well as news of malpractice suits resulting from the care of stroke patients. In the past 3-4 years there has been almost zero news about lawsuits for failure […]

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Perspective: Can plaintiffs prevail in stroke cases?

February 23, 2014

By Charles A. Pilcher MD FACEP February, 2014 This newsletter has published 4 previous “Perspective” essays on the standard of care for management of acute stroke. One of those standards is the use of tPA (alteplase, or tissue plasminogen activator), the “clot-buster drug,” in those patients presenting within the (now) 4 1/2 hour window from […]

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Medical Malpractice Bulletin – January, 2014

January 6, 2014

Perspective: How do I find a good doctor? By Charles A Pilcher MD FACEP January, 2014 One of the toughest challenges for any health care provider is being asked by a friend or family member with a medical problem, “Who should I see for this?” I have an answer. My fellow physicians have an answer. […]

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Perspective: Finding a doctor – I know. You know. But the patient doesn’t have a clue.

January 6, 2014

By Charles A Pilcher MD FACEP January, 2014 One of the toughest challenges for any health care provider is being asked “Who should I see for…?” by a friend or family member. I have an answer. My fellow physicians have an answer. My nurse colleagues have an answer. Attorneys involved in medical malpractice, both plaintiff […]

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Medical Malpractice Bulletin – November/December, 2013

November 29, 2013

Perspective: How busy was the doc? Overwork can lead to errors By Charles A. Pilcher MD FACEP November/December, 2013 The harder and faster one works, the more prone one becomes to mistakes. That’s no different for physicians than for anyone else. And it matters to med mal attorneys. An increasing body of research is beginning […]

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Perspective: How busy was the doc? Physician workload impacts patient care, leads to mistakes

November 28, 2013

By Charles A. Pilcher MD FACEP November, 2013 The harder and faster one works, the more prone one becomes to mistakes. That’s no different for physicians than for anyone else. And an increasing body of research is beginning to substantiate the magnitude of the problem with actual numbers. This became an issue over a decade […]

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Perspective: Stop! Think! Listen! “Cognitive pause” will reduce medical errors

October 12, 2013

By Charles A. Pilcher MD FACEP October, 2013 What kind of medical error accounts for most malpractice payments: Surgical mistakes? Overdoses? Obstetrical errors? No, no and no. The most common cause of paid claims for malpractice is diagnostic error, accounting for 28.6% of claims and 35.2% of payouts, according to a 25 year summary of […]

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Perspective: Stroke and tPA – ACEP’s Clinical Policy Fuels The Debate

September 10, 2013

By Charles A. Pilcher MD FACEP September, 2013 I am often asked to evaluate the medical records of stroke patients, almost always to address the issue of whether or not the provision of tPA, the “clot-busting drug,” would have provided a patient with a demonstrably better chance of an improved outcome following a stroke. There […]

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Medical Malpractice Bulletin – October, 2013

July 30, 2013

Perspective: Stop! Think! Listen! “Cognitvie Pause” can reduce medical error By Charles A. Pilcher MD FACEP October, 2013 Most medical errors are caused not by lack of knowledge or an obvious mistake, but rather by thinking errors. These result in mis-interpreting the patient’s presentation as something more common, when unusual symptoms should give the physician […]

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Medical Malpractice Bulletin – July/August 2013

July 29, 2013

Perspective:  Electronic Health Records (EHRs): Can we trust them? Media, government and most of organized medicine view the EHR as the answer to much of what is wrong with medical care in America. In part, that may be true. But the past year has seen a flurry of studies and articles pointing out that there […]

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Perspective: Electronic Health Records (EHRs): Can we trust them?

July 29, 2013

July/August, 2013 By Charles A. Pilcher MD FACEP We’ve all seen the hoopla about the benefits of the EHR: standardization, easy communication between providers, reduction in paper, no need to re-enter the same data, better tracking of medications, etc. The EMR or EHR (as the Department of Health and Human Services prefers) has become the standard […]

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Medical Malpractice Bulletin – June, 2013

June 9, 2013

Perspective: Consults and Handoffs Part II: Handoffs By Charles A. Pilcher MD FACEP June, 2013 As introduced in the last issue of this newsletter, all too often the responsibility for a patient becomes unclear when an emergency physician requests a consult or transfers care to another doctor, i.e., a “handoff.” Both “handoffs” and “consults” – if […]

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Medical Malpractice Bulletin – September, 2013

May 6, 2013

Perspective: The Role of tPA in Stroke – ACEP’s Clinical Policy Fuels Ongoing Debate By Charles A. Pilcher MD FACEP September, 2013 How valuable is tPA in stroke? While tPA has become the standard of care for patients who qualify, the numbers are less than impressive and the benefit marginal. Studies generally show that patients […]

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Medical Malpractice Bulletin – May, 2013

May 5, 2013

Perspective: Handoffs And Consults: Who’s In Charge? By Charles A. Pilcher MD FACEP During transitions in patient care, a lot can go wrong. Almost all of the potential risk in these situations is the result of poor communication. But why is the communication so poor? Much of it is the result of misplaced assumptions, unrealistic […]

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Handoffs and Consults: Who’s in charge? Part II

May 5, 2013

Part II: Handoffs By Charles A. Pilcher MD FACEP June, 2013 As introduced in the last issue of this newsletter, all too often the responsibility for a patient becomes unclear when an emergency physician requests a consult or transfers care to another doctor, resulting in potential catastrophe for the patient and physician. In last month’s […]

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Handoffs and Consults: Who’s in charge? Part I

May 4, 2013

By Charles A. Pilcher MD FACEP May, 2013 Part I: Consults [Editor’s Note: This “Perspective” covers “Consults.” Part II on “Handoffs” will appear in the next issue of Medical Malpractice Bulletin. All too often the responsibility for a patient becomes unclear when an emergency physician requests a consult or transfers care to another doctor. The […]

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Medical Malpractice Bulletin – March/April, 2013

March 30, 2013

Perspective: 1/3 of physicians miss test results Charles A. Pilcher MD FACEP One third of physicians surveyed admit to missing a test result because of information overload linked to their Electronic Health Record (EHR). It’s called “Alert Fatigue,” and it’s a growing challenge. Most EHRs have built in alerts, designed to keep physicians from making […]

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Perspective: 1/3 of physicians miss test results

March 30, 2013

Charles A. Pilcher MD FACEP March/April, 2013 One third of physicians surveyed admit to missing a test result because of information overload linked to their Electronic Health Record (EHR). It’s called “Alert Fatigue,” and it’s a growing challenge. Most EHRs have built in alerts, designed to keep physicians from making mistakes: Examples: “Patient due for […]

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Perspective: Why do doctors make mistakes? Part II

March 30, 2013

Charles A. Pilcher MD FACEP March/April, 2013 A study published in JAMA Internal Medicine reveals that the most common causes of medical error resulting in delayed diagnosis and patient harm are “cognitive errors” completely within the physician’s control. Problems with doctor-patient encounter cause most primary care diagnosis errors. On retrospective review of patients requiring an […]

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Medical Malpractice Bulletin – December, 2012

December 20, 2012

Perspective: Must physicians do a lumbar puncture on every suspected subarachnoid hemorrhage? Charles A. Pilcher MD FACEP Classic medical training has been to do a lumbar puncture (LP) on every patient with a new, sudden onset headache if a CT scan does not show a suspected subarachnoid hemorrhage (SAH), usually from a ruptured cerebral aneurysm. […]

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Perspective: Must physicians do a lumbar puncture on every suspected subarachnoid hemorrhage?

December 20, 2012

December, 2012 Charles A. Pilcher MD FACEP At the 2012 ACEP Scientific Assembly, Dr. Ashley Shreves and Dr. David Newman presented statistics showing the number of lumbar punctures (LP) that must be done to find a single subarachnoid hemorrhage (SAH) in a CT negative patient with sudden onset of headache. The answer: 700. Emergency physicians […]

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Medical Malpractice Bulletin – July, 2012

July 22, 2012

Perspective: The chart is my witness. Make sure it tells the story. Guest Authors: Andrew Koslow, MD, JD, and Diana Nordlund, DO The medical record can become a missed opportunity for communication between providers and  a dangerous medico-legal pitfall. Physicians should be certain that it communicates an encounter clearly. EMRs and template charts are particularly […]

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Perspective: The chart is my witness

July 22, 2012

July, 2012 Guest Perspective, by Andrew Koslow, MD, JD, and Diana Nordlund, DO [Editor’s Note: This article first appeared in ACEP News June 5, 2012, and is reprinted from the original with permission of Dr. Koslow] “Doctor, let me see if I understand what you’re saying. You just told the court that Melanie was febrile, […]

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Medical Malpractice Bulletin – May, 2012

May 28, 2012

Perspective: Cauda equina lawsuits: Gambling or litigating? By Charles A. Pilcher MD FACEP May, 2012 Pursuing or defending a case of cauda equina syndrome (CES) is as much a matter for the daring gambler as the skilled litigator. If it were your nerves being pinched off by a herniated disk, would you want to wait […]

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Cauda Equina Syndrome: Gambling or litigating?

May 28, 2012

Perspective: Cauda equina lawsuits: Gambling or litigating? By Charles A. Pilcher MD FACEP May 2012 The March issue of the journal Orthopedics presents a study by Daniels et al on the outcome of litigation for cauda equina syndrome (CES). The study was retrospective and used Lexis Nexus reports from 1983-2010. [Editor’s Note: One must be […]

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Medical Malpractice Bulletin – March 2012

March 22, 2012

Perspective: What is a “reasonable and prudent” physician? It seems such a simple question: Given a specific set of facts concerning the presentation of a patient in the ED, what would the prudent and reasonable physician do? In this month’s guest “Perspective,” Dr. Mark Plaster takes a look at why the “best” care need not […]

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Perspective: What is a “prudent and reasonable physician”?

March 22, 2012

March, 2012 [Editor’s Note: This month’s “Perspective” comes from Mark Plaster MD, Editor of Emergency Physicians Monthly. It was first published December 5, 2011, and is edited for brevity.] It seems such a simple question: Given a specific set of facts concerning the presentation of a patient in the ED, what would the prudent and […]

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Medical Malpractice Bulletin – January, 2012

January 17, 2012

As we begin a new year, I want to thank each you for your encouragement and support of the Medical Malpractice Bulletin, now entering its 4th year. I have enjoyed sharing this information with you and look forward to continuing to assist you in resolving issues related to medical malpractice and personal injury. Charles A. […]

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Perspective: Who’s to blame when bad things happen?

January 17, 2012

This month’s guest “Perspective” is by Mark Plaster, MD, and was first published in Emergency Physicians Monthly, June 14, 2011. It is edited and reprinted with permission. The opinions expressed are those of Dr. Plaster and reflect his experience with a specific case example. Generalization is discouraged./CP Over the years I’ve gotten many calls like […]

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Medical Malpractice Bulletin – September/October, 2011

October 10, 2011

Perspective: Door-to-needle times for tPA in stroke hard to meet By Charles A. Pilcher MD FACEP September/October, 2011 Under current guidelines from the American Stroke Association, tissue plasminogen activator (tPA, commonly known as a “clot buster” drug) should be administered within 3-4.5 hours of “last seen normal” – and 1 hour of patient arrival – […]

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Medical Malpractice Bulletin – July/August, 2011

August 20, 2011

Perspective: Emergency Department discharge instructions: “Sign right here and your good to go.” ———- By Charles A. Pilcher MD FACEP So you’re not having a heart attack like your wife thought. That’s the good news. But what **is** wrong, what **did** cause that pain, and what should you do from here on out? That’s the […]

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Medical Malpractice Bulletin – June, 2011

June 16, 2011

You receive this newsletter because I have had prior contact with you or a member of your firm on a matter of personal injury or medical malpractice. If you wish to subscribe to or be removed from the mailing list, please call 206-915-8593 or email me. I consult with both plaintiff and defense attorneys in […]

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Medical Malpractice Bulletin – May, 2011

June 16, 2011

Perspective: Black, white or gray: Post-hoc knowledge alters opinions of care quality By Charles A. Pilcher MD FACEP Medical malpractice is a field where opinion matters. That’s why attorneys hire experts. But how valid are those opinions? On what are they based? Does one’s opinion of the quality of care change when one knows the […]

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Are you getting “value” from your experts?

June 16, 2011

June, 2011 By Charles A. Pilcher MD FACEP What is value? Based on the repeat business I get from numerous defense and plaintiff attorneys, I must be providing you with value. “Value” is defined as quality divided by cost. When I read depositions, it’s apparent that attorneys are not always getting uniform value from their […]

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