MEDICO LEGAL EXCLUSIVES

Q.) You are a surgeon taking care of three patients in the ED. One has chronic back pain, one has abdominal pain suspicious for appendicitis, and one has a laceration of her hand requiring sutures. You are seeing your third patient who wants to discuss the possibility of scarring and is quite concerned; however, you are paged by the radiologist regarding the CT results on your abdominal pain patient. Which of the following is the likely best provision of care?

A. Because you are currently with your third patient, continue your discussion with her and answer all of her questions.

B. Tell your third patient, “I will be right back,” and go see your first patient, who has been waiting the longest.

C. Tell your third patient, “Let me go arrange a consultation with plastic surgery after I answer this page” and go to answer the page from radiology.

D. Tell your third patient, “Don’t worry; no one will notice this scar,” and go to answer your page.

E. Tell your third patient, “Don’t worry; no one will notice this scar” and suture her hand.

Ans:  C.

 Despite wanting to form a supportive relationship with this patient, allay her fears, and answer her questions, as a physician it is important to be able to prioritize seriously ill patients above less ill patients. In this scenario, the patient with possible appendicitis is top priority, despite patient number 1 having been in the ER the longest. Thus, when radiology pages you regarding this patient, you should answer this page as soon as possible to determine whether this patient needs surgery. However, there are better ways to excuse yourself from your third patient. If you tell her, “I will be right back” and then do not come back for a long time, she is likely to become annoyed. However, if you acknowledge her concerns by consulting plastic surgery and explain quickly that you have another sick patient who requires your care, she is likely to understand and to feel that her waiting is justified. Telling her,“no one will notice this scar” does not acknowledge her concerns about scarring and is inappropriately paternalistic.

Q. You are an obstetrician providing care for a patient in labor. A nurse informs you that the fetal heart rate is experiencing a bradycardia, and on exam there is an umbilical cord prolapse. The patient is being moved to the operating room for an emergency cesarean section. Which of the following describes optimal documentation of this event?

A. Immediately write down your impression of the situation and your plan of action.

B. Go to the patient’s bedside and facilitate the move to the operating room; after the cesarean, write a note documenting what occurred and when.

C. Tell the nurse your plan of action, then postoperatively ,time your note for when you told the nurse of the plan.

D. Write a quick note, and then postoperatively, make changes to the note that reflect what actually occurred.

E. There is no need to document what occurred because nursing will do the documentation.

Ans: B.

In this setting of an emergent procedure needing to be performed, rapid, efficient action is the most important thing. While in most cases it is best to document events as they occur, a physician in this case should act first and worry about documentation second.

Further, there is never an indication to change prior documentation or adjust timing on notes to make it seem as if they were being written prior to when they actually were written. It is useful to communicate the plan of action to the nurse, who is likely to document at some point what that plan was. However, you cannot rely on other practitioners to do your documentation, as everyone may have a different viewpoint on how events occurred. The best way to document an event of this sort is to deal with the emergency, perform the cesarean section, and move the patient to recovery. Once there, discuss the timing of events with nursing and anesthesia and write a note that reflects your best understanding of what occurred.

Q. A patient you are seeing for the first time has chronic back pain. He wishes to have an immediate MRI and a referral to a neurosurgeon. He tells you this is what his last doctor was going to do. Your best course of action is to:

A. Order the MRI and make the referral.

B. Tell the patient that because this is the first visit, you need to start the work-up of his back pain from the start.

C. Give the patient ibuprofen and order an x-ray of the back.

D. Ask the patient for the name and number of his prior physician and ask him to obtain his prior medical records, and reschedule him in 1 or 2 weeks.

E. Order a CT and refer him to an orthopedic surgeon.

Ans: D.

 It is unclear why this patient has changed physicians. He may have already undergone an extensive work-up for his chronic back pain that you do not need to repeat. If this was a first visit

for this symptom, ibuprofen and an x-ray would be a reasonable way to begin management. However, for this patient, who has likely already used ibuprofen and had x-rays, it is unlikely to contribute to his care. It is also folly to assume that a patient has had the appropriate work-up thus far, as he may have switched providers a number of times and not had good continuity of care. Thus, the most important thing to do is to acknowledge his prior care and attempt to assemble a plan of care with his prior practitioner that is acknowledged as workable by you and the patient.

Q. A physician is caring for a patient with atrial fibrillation and is prescribing medication to anticoagulate her blood. Which of the following actions is most likely to increase the risk of lawsuit.

A. The physician prescribes twice the necessary dosage of medication, but there are no complications and a month later, the dosage is decreased.

B. The physician prescribes the appropriate medication but the patient experiences a stroke despite the treatment. The physician sees the patient daily in the hospital.

C. The physician prescribes the appropriate medication, but the patient experiences a stroke despite the treatment.The physician explains how medication does not always work.

D. The physician prescribes the appropriate medication, but the patient experiences a stroke despite the treatment. The physician allows the hospital team to provide excellent care for the patient and plans to see the patient back in the office after discharge.

E. The physician prescribes the appropriate medication, but the patient experiences a stroke despite the treatment. The physician updates the patient’s family with daily

Changes

Ans: D.

 Answer (A) is the only one that has malpractice. However, because this action did not result in any harm, it is unlikely to lead to a lawsuit. Answers (B), (C), and (E) all involve the physician communicating in an ongoing way with the patient and her family. Although answer (D) results in excellent care, because the physician does not follow up with the patient during her acute event she may feel abandoned. Furthermore, by waiting to follow up with the patient after discharge, if she ends up in a nursing home, goes to a rehabilitation facility, or dies, the physician will not have the opportunity to see the patient at all.