CHICAGO -- Fear of malpractice lawsuits lurks in the back of just about every emergency physician's mind.
At the American College of Emergency Physicians annual meeting here, several sessions looked at ways to navigate around difficult situations in patient care to avoid tort mines.
One featured Christopher B. Colwell, MD, chief of emergency medicine at Denver Health Medical Center, who addressed how best to handle combative, arrested, and threatening patients -- and not get sued. He consulted 10 attorneys, including an MD/JD. The main take-away: Judges and juries often give emergency physicians wide latitude, with one big "if."
"Judges and juries bend over backwards to support physicians," Colwell told the audience. "If they're trying to do the best thing for the patient. Credible doctors are allowed to make mistakes."
But it gets dicey when there's even a hint of malice or ill will. Colwell's "don't get sued" pearls:
- 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.
Of course, there's only so much physicians can do to protect themselves. Over the last decade, EM physicians watched a much heralded experiment in tort reform with much anticipation that began in Texas in 2003, but the spread to other states.
We also checked in with David H. Newman, MD, author of the regular "Newman's Notes" column atMedPage Today, who is attending the ACEP meeting. He gave us his take on "The Effect of Malpractice Reform on Emergency Department Care," published earlier this month in the New England Journal of Medicine. This report examined outcomes of tort reform legislation in Texas, Georgia, and South Carolina as they affected emergency medicine.
From Newman, in his own words:
"This was a big splash. And the reason everybody is talking about it is partly because it's the New England Journal of Medicine and everybody tends to talk about the New England Journal of Medicine. But the other reason is because it's a malpractice study and it's about emergency medicine. This is something that we don't see enough of: a real focus on the emergency department and the trends in care and the trends in practice patterns when we look at malpractice and malpractice reform.
"So in this study, what they did, it was a sort of quasi-experimental design, a very interesting study. What they looked at was three different states. And the three states were South Carolina, Georgia and Texas. And emergency physicians who know something about public policy will know that those are three states where there was serious tort reform in the last 15 years.
"In one of those states, 2003 in Texas, they actually got tort reform, the kind of tort reform that emergency physicians would love to see in their states. And the reform was basically changing the standard for what [defines] malpractice from a deviation from standard of care to a standard in which you had to commit basically gross negligence in order to be considered to have committed malpractice.
"That's a huge potential change. And the effect of that change in 2003 over the next 7 or 8 years or so for Texas was about a 70% decrease in claims, a 60% to 70% decrease in payouts, so there was a real impact on malpractice from that tort reform. That was in 2003. Very similar legislation in 2005 [passed] in South Carolina and Georgia."
The Hope
"So this was a quasi-experimental study in which they looked at all of the states surrounding those states and those states to see what happened .... not just malpractice and the claims made and the payouts but whether or not there was a change in practice in the emergency department.
"Because if you ask most emergency physicians and most physicians, they'll tell you that malpractice and the fear of medical legal claims is a big defensive medicine spur for them. It's the reason that they order so many advanced imaging tests, the reason that they admit so many patients, the reason that they take a lot of measures that in general they might not take in the emergency department setting.
"The authors of this study very smartly noted that this is an information-poor, resource-rich setting. In other words, the emergency department is a place where we often don't know that much about our patients. We often don't have access to great background information, we don't have continuity of care information, but we do have access to almost every hospital resource there is. We can get a CAT scan, we can get an MRI, we can admit anybody we want, and all of those things make us resource-rich but information-poor.
"The question is, when you change malpractice laws in that kind of a setting, does it change the actual practice patterns of physicians? So they looked at whether or not costs of emergency department care and charges changed over the 7 to 8 to 10-year period after malpractice and tort reform came into being in those 3 states compared to the outlying states."
Surprise!
"And what they found was something that is, I think, both a little disappointing but a little bit of a kick in the butt for emergency physicians. What they found was that, in fact, it didn't change our practice patterns almost at all. Everybody thought -- both the policymakers and the emergency physicians thought -- that this was going to reduce our utilization of advanced imaging. It was going to reduce our admission rates, it was going to reduce our utilization of diagnostic testings.
"And it had very little impact on all of those things. In fact, in most cases it had no impact at all. In Georgia, there was maybe a 3.6% decrease in overall costs (95% confidence interval, 0.9% to 6.2%) and that was the best in the various states that anybody looked at. So for the most part there wasn't any change, and it meant that we didn't really change our practice patterns after malpractice reform, tort reform came into being."
So What Does This Mean?
"Well, there are a couple of things it could mean.
"One, it could mean that we haven't really gotten to the place where we're comfortable enough even in those states with what ... reform means for us on a practical basis. It could mean that it's going to take another 10 or 15 years for the mentality to change. But if that is the case, that also suggests that it's hard to get a policymaker or anybody who writes policy or considers policy to get on board with the idea that we're going to save a lot of money in any kind of a short-term way with tort reform.
"So it's hard to make an argument once we have these data published that there is going to be any kind of a real financial windfall from changing the tort system. In the tort system in those states, they changed everything. There was a substantial decrease in the lawsuits and payouts, and it still didn't change practice.
"The second thing it probably means is that we have a culture of medicine issue that we need to deal with that's internal to us. And that culture of medicine issue has to do with the culture of never miss. The culture of professional embarrassment. The culture of oversight -- such that administration and other departments in the hospital look over emergency department practice and they point fingers and we feel that. We feel it as a potential threat and a potential professional threat rather than a real malpractice threat.
"And if that's the threat, we may need to deal with that on an internal basis. We may need to talk to administration, we may need to start talking to other emergency departments and communicating across the country about what we can do to start changing utilization and over-utilization and the over-utilization of advanced imaging -- what we can do to affect those outcomes in such a way that we address the culture problem rather than blaming it on the malpractice problem."
Don't Blame the Tort
"Malpractice is a broken system. It doesn't really serve patients well, it doesn't serve physicians well, but it turns out it's probably not the biggest stimulant in why it is that advanced imaging and other costs in the healthcare system for emergency medicine at least are ramping up over the last 10 or 15 years. And that's something we're going to have to deal with internally."
This is a special ACEP 2014 edition of Newman's Notes, which is a regular column by David H. Newman, MD, the director of clinical research in the department of emergency medicine at Icahn School of Medicine at Mount Sinai. Newman, who also co-founded the NNT and authored "Hippocrates' Shadow: Secrets From the House of Medicine," reviews a variety of recently published studies. MedPage Todaylightly edits his comments, adding links and additional sources.
Không có nhận xét nào:
Đăng nhận xét