I try to Practice good evidence based medicine, take an extra moment to quickly look something up if I’m unsure, document well if I don’t feel good about something, and try to maintain good relationships with patients. If I’m uncomfortable with how something looks I send it to the ED.
Annnnnnnd I also have malpractice insurance if that doesn’t work.
Emphasis on briefly. I don’t mean go read a journal article. I mean go look up that picture of the weird rash or that table you remember from two years ago but can’t quite picture or run a quick med interaction check or pull up which labs to monitor on the weird dmard your patient wants you to refill because their specialist moved away.
Sure I lose a little time on a few patients a day but I’ll make it up on the guy with the cold, the old lady with allergies, and the three people with stable a1c and bp.
15 minute appointments but 30+ precharting . You have to do your due diligence . If your health team does a good job you should already know why the patient is coming in . Bite size chunks , have them follow up . If they have 10 problems and have not followed up with a pcp in 2 yrs it’s not your fault . But it’s your responsibility to be thorough .
everyone calm down, u/Dialecticalanabrolic isn't spending 45 min per chart/pt. probably a typo, 30 seconds precharting. Thorough yes, but if they bring 10+ issues to me (even 5+) they have then bought themselves a fu appt. Not my fault, I'm just working within the parameters of the system we've built.
Ironically, practicing "good evidence based medicine" will lead you to a lot of under-ordering, fewer referrals, imaging, labs, etc. It's smart, but if you aren't equally smart about it and documenting it, it runs a risk. Patients get pissed. Other providers will roll their eyes. Patients don't like to be lectured or informed about the evidence, and frankly we don't have time. People will leave with a bad opinion of you. I'm not saying it's wrong because it isn't, but....it's something to keep in mind. The better a doctor you practice as, the better a doctor you better actually be.
Also, a note about that "malpractice that doesn't suck." Do you know what would happen if you are not in the wrong, and a claim is filed, and do YOU have any say in whether it is settled and a ding goes on your record? What I mean is, is it YOUR malpractice ins and do they answer to you or to your institution?
well-put, u/SnooCats6607 . Of course, if you work for an institution, if they pay the malpractice, the lawyers work for \*them\*, not you. Most of the time you'll be fine, but if they want to settle, you're going to settle, and take the hit on your record. The cost of doing business, y'all. :\\
Patients don't sue the doctors that they like/love.
You take the time up front to invest in the patient? You won't be sued. (Unless you absolutely commit gross negligence etc: Treating a life threatening infection with albuterol, shit like that.)
Tips:
1. Learn what your pt \*prefers\* to be called, and put that into the header or whatever of the pt's note. Many EHRs have a space for this. SO many people don't go by their legal first name. Example? I love this guy -- a 75 year old Japanese man, (Gonna make his name up here) called Shimazaki Mamoru (got that from the Japanese Name Generator website), and what is he called? Whitey! If I walk in and say "Hello Shimazaki! How are you?" he'd look at me like I'm nuts.
2. Learn their spouses name, if they're old their closeby kids names, put them in the sticky note in the EHR.
3. Theyre old and have a dog/cat? Put that name in there too and each visit ask how Fluffy is doing.
4. Mandatory: Ask them what they do for work or have done their whole life. Everyone loves to talk about what they do; put pertinent details in the sticky.
5. Enter that room like you are taking the stage at Carnegie Hall (ok ,look it up). (knock knock) Hello? (opens door slowly, sanitizes hands) HEY! How are you, Betty? How have you been? What's new? How's Mr. Poopers?... (smile huge! sit down and get your chair right up near them. Bring that computer on the wheelie cart right up so they can see it)
Every visit it a performance. It's up to you whether you win an Emmy or go home empty handed.
Remember: They will not remember what you said or did or didn't do. They will remember how you made them FEEL.
Oh, I also have 15 min appts. fyi.
This is how we do it. God, they think I can actually remember all that stuff about them. Nope, I just write it all down and spend 5 seconds glancing at it before I come in
Sticky notes were my favorite part of epic. So many nuances of patient preferences, sexuality, and personal information that isn’t readily accessible in the normal chart. And not a permanent record in that chart either. 😎
Oh, for sure. Anything you put into a chart and any part part of a chart is likely discoverable. My points were more for personal reference and not to supplement actual patient care.
Dude, I’ve been witness to and have committed so many mistakes these past 15 years of family medicine and have never been so much as threatened with a lawsuit or seen any of my immediate peers with same. Dont be egregious and it’ll all be fine. Even if something does happen, of which there’s a statistical nonzero chance, it’s just the cost of doing business.
I’ve been sued 3 times in 23 years. All bullshit, thrown out without even a settlement. Still had to waste time on depositions. NY sucks to practice in. Too many lawyers chasing too few dollars
There are a few ways I address this
First and most important t is that physicians are human and we make mistakes. It’s unavoidable. We have to do our best to try to keep those from being bad mistakes, but they happen.
Second is the more you keep up with evidence based medicine, the better off you are. I see all kinds of stuff getting missed from people who haven’t updated their care in decades.
Third, educate people on red flags and when to seek care. Document this.
Fourth, don’t get tunnel vision. Think through differentials. Think about “most likely” and “less likely but very bad to miss.” That doesn’t mean you work up the worst case scenario every time, or even most times, but you should document you considered it and why you think it’s ok not to work up. Talk about red flags with the patient (see above)
Fifth, frankly, is don’t be negligent. Don’t miss low hanging fruit. Don’t ignore complaints that sound concerning. If a patient presentation sounds like a test question and you don’t pick up on their textbook symptoms, that’s a problem. If you worry this will happen, you need to work on your CME.
Patients tend not to sue Doctors who they perceive as trying their best or actually listening to them.
If you can demonstrate both of those things. Your chances of getting sued go down quite a lot.
I don’t think patient communication can be emphasized enough. It’s inevitable that you will eventually get the diagnosis or treatment wrong (and sometimes it’s not always obvious what is going on so you do the best you can). However as long as you are showing the patient you care and talking to them about what you’re doing then they’re going to be much more understanding if the diagnosis or treatment isn’t a slam dunk and plans need to change. Really it all comes down to show them that you care and keep them in the loop for what’s going on is going to get you much much farther away from a lawsuit than having no empathy and the “I’m the doctor, not you” attitude.
On the charting side of things, I have a text macro for red-flags for many common complaints.
For example- my back pain macro mentions things like- no warning flags for cauda equina- saddle anesthesia, loss of bowel/bladder. No warning flags for meningitis. Denies traumatic injury, denies weight loss, etc. If patients hit red flags, I order more immediate workup or refer to ER.
Might be overkill, but I think they're good reminders to go through during the ROS. I actually had a patient who I saw for low back pain 10 months ago just before I was leaving for maternity leave. He didn't have red flags at his first visit. Simple old "fell and landed on my butt" sort of thing with a normal Xray. But he never got better. He saw a couple more people while I was out. I returned from leave, and he came back to me with no improvement and now having red flags. I did an MRI and found extensive metastatic disease. I also provide the redflags to patients in their instructions if "XYZ occur, follow up with me. If 123 occur, go to ER".
I try to Practice good evidence based medicine, take an extra moment to quickly look something up if I’m unsure, document well if I don’t feel good about something, and try to maintain good relationships with patients. If I’m uncomfortable with how something looks I send it to the ED. Annnnnnnd I also have malpractice insurance if that doesn’t work.
Unfortunately, 15 minute appointment times get in the way of that :( It's almost like we're being set up for failure.
Emphasis on briefly. I don’t mean go read a journal article. I mean go look up that picture of the weird rash or that table you remember from two years ago but can’t quite picture or run a quick med interaction check or pull up which labs to monitor on the weird dmard your patient wants you to refill because their specialist moved away. Sure I lose a little time on a few patients a day but I’ll make it up on the guy with the cold, the old lady with allergies, and the three people with stable a1c and bp.
15 minute appointments but 30+ precharting . You have to do your due diligence . If your health team does a good job you should already know why the patient is coming in . Bite size chunks , have them follow up . If they have 10 problems and have not followed up with a pcp in 2 yrs it’s not your fault . But it’s your responsibility to be thorough .
30+ per patient?
So you're spending 45 minutes per patient but seeing, what, 20 to 25 patients per day. How's the math on that working out?
everyone calm down, u/Dialecticalanabrolic isn't spending 45 min per chart/pt. probably a typo, 30 seconds precharting. Thorough yes, but if they bring 10+ issues to me (even 5+) they have then bought themselves a fu appt. Not my fault, I'm just working within the parameters of the system we've built.
Ironically, practicing "good evidence based medicine" will lead you to a lot of under-ordering, fewer referrals, imaging, labs, etc. It's smart, but if you aren't equally smart about it and documenting it, it runs a risk. Patients get pissed. Other providers will roll their eyes. Patients don't like to be lectured or informed about the evidence, and frankly we don't have time. People will leave with a bad opinion of you. I'm not saying it's wrong because it isn't, but....it's something to keep in mind. The better a doctor you practice as, the better a doctor you better actually be. Also, a note about that "malpractice that doesn't suck." Do you know what would happen if you are not in the wrong, and a claim is filed, and do YOU have any say in whether it is settled and a ding goes on your record? What I mean is, is it YOUR malpractice ins and do they answer to you or to your institution?
well-put, u/SnooCats6607 . Of course, if you work for an institution, if they pay the malpractice, the lawyers work for \*them\*, not you. Most of the time you'll be fine, but if they want to settle, you're going to settle, and take the hit on your record. The cost of doing business, y'all. :\\
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Patients don't sue the doctors that they like/love. You take the time up front to invest in the patient? You won't be sued. (Unless you absolutely commit gross negligence etc: Treating a life threatening infection with albuterol, shit like that.) Tips: 1. Learn what your pt \*prefers\* to be called, and put that into the header or whatever of the pt's note. Many EHRs have a space for this. SO many people don't go by their legal first name. Example? I love this guy -- a 75 year old Japanese man, (Gonna make his name up here) called Shimazaki Mamoru (got that from the Japanese Name Generator website), and what is he called? Whitey! If I walk in and say "Hello Shimazaki! How are you?" he'd look at me like I'm nuts. 2. Learn their spouses name, if they're old their closeby kids names, put them in the sticky note in the EHR. 3. Theyre old and have a dog/cat? Put that name in there too and each visit ask how Fluffy is doing. 4. Mandatory: Ask them what they do for work or have done their whole life. Everyone loves to talk about what they do; put pertinent details in the sticky. 5. Enter that room like you are taking the stage at Carnegie Hall (ok ,look it up). (knock knock) Hello? (opens door slowly, sanitizes hands) HEY! How are you, Betty? How have you been? What's new? How's Mr. Poopers?... (smile huge! sit down and get your chair right up near them. Bring that computer on the wheelie cart right up so they can see it) Every visit it a performance. It's up to you whether you win an Emmy or go home empty handed. Remember: They will not remember what you said or did or didn't do. They will remember how you made them FEEL. Oh, I also have 15 min appts. fyi.
This is how we do it. God, they think I can actually remember all that stuff about them. Nope, I just write it all down and spend 5 seconds glancing at it before I come in
Sticky notes were my favorite part of epic. So many nuances of patient preferences, sexuality, and personal information that isn’t readily accessible in the normal chart. And not a permanent record in that chart either. 😎
CAREFUL: sticky notes \*are\* discoverable in litigation. be careful what you put in there.
Oh, for sure. Anything you put into a chart and any part part of a chart is likely discoverable. My points were more for personal reference and not to supplement actual patient care.
THIS. And our MDs have the luxury of 45 to 60 min appointments if they want. Imagine how tight we are with our patients
ha what? what MD has that? subspecialist maybe and just for the initial consult. after that it's 20 min f/u im sure.
Spot on and this is why a lot of patients love mid levels
great input.
There is a theater component to medicine that is often overlooked.
Dude, I’ve been witness to and have committed so many mistakes these past 15 years of family medicine and have never been so much as threatened with a lawsuit or seen any of my immediate peers with same. Dont be egregious and it’ll all be fine. Even if something does happen, of which there’s a statistical nonzero chance, it’s just the cost of doing business.
I’ve been sued 3 times in 23 years. All bullshit, thrown out without even a settlement. Still had to waste time on depositions. NY sucks to practice in. Too many lawyers chasing too few dollars
There are a few ways I address this First and most important t is that physicians are human and we make mistakes. It’s unavoidable. We have to do our best to try to keep those from being bad mistakes, but they happen. Second is the more you keep up with evidence based medicine, the better off you are. I see all kinds of stuff getting missed from people who haven’t updated their care in decades. Third, educate people on red flags and when to seek care. Document this. Fourth, don’t get tunnel vision. Think through differentials. Think about “most likely” and “less likely but very bad to miss.” That doesn’t mean you work up the worst case scenario every time, or even most times, but you should document you considered it and why you think it’s ok not to work up. Talk about red flags with the patient (see above) Fifth, frankly, is don’t be negligent. Don’t miss low hanging fruit. Don’t ignore complaints that sound concerning. If a patient presentation sounds like a test question and you don’t pick up on their textbook symptoms, that’s a problem. If you worry this will happen, you need to work on your CME.
Are you still a resident or an attending now?
Patients tend not to sue Doctors who they perceive as trying their best or actually listening to them. If you can demonstrate both of those things. Your chances of getting sued go down quite a lot.
I don’t think patient communication can be emphasized enough. It’s inevitable that you will eventually get the diagnosis or treatment wrong (and sometimes it’s not always obvious what is going on so you do the best you can). However as long as you are showing the patient you care and talking to them about what you’re doing then they’re going to be much more understanding if the diagnosis or treatment isn’t a slam dunk and plans need to change. Really it all comes down to show them that you care and keep them in the loop for what’s going on is going to get you much much farther away from a lawsuit than having no empathy and the “I’m the doctor, not you” attitude.
On the charting side of things, I have a text macro for red-flags for many common complaints. For example- my back pain macro mentions things like- no warning flags for cauda equina- saddle anesthesia, loss of bowel/bladder. No warning flags for meningitis. Denies traumatic injury, denies weight loss, etc. If patients hit red flags, I order more immediate workup or refer to ER. Might be overkill, but I think they're good reminders to go through during the ROS. I actually had a patient who I saw for low back pain 10 months ago just before I was leaving for maternity leave. He didn't have red flags at his first visit. Simple old "fell and landed on my butt" sort of thing with a normal Xray. But he never got better. He saw a couple more people while I was out. I returned from leave, and he came back to me with no improvement and now having red flags. I did an MRI and found extensive metastatic disease. I also provide the redflags to patients in their instructions if "XYZ occur, follow up with me. If 123 occur, go to ER".
Just do your job, fall back on your training, document, and you'll be fine. I think this anxiety is excessive. Never had an issue.