The Risk of Practicing Medicine

I just got a letter saying that a patient I saw in the urgent care nearly 1 year ago has decided to pursue a lawsuit because I didn’t adequately inform her of the side effects and risks of a procedure I performed. So, let’s talk about the risk of practicing medicine.

This isn’t a surprise since the urgent care is the kind of place that all sorts of random shit happen. I have patients get verbally and physically threatening. I’ve been called a racist, I’ve been accused of sexual harassment and now, of course, battery.

The Risk of Practicing Medicine

The liability in medicine is astronomical. I have made plenty of mistakes and there have been many opportunities when I have come within millimeters of missing something big.

A healthy appearing patient can have something quite serious going on with them. My 12 yo with a septic hip looked and walked quite well, my buddy’s septic teenager who passed away had nothing more than a fever.

We had a recently missed case of a 70-year-old woman who died of a PE after presenting to the urgent care for a cough. She had no typical PE symptoms, yet had an ‘unexplained’ cough.

We had a severe outcome after a missed spinal abscess. This was a drug seeking patient who came in complaining of back pains during 3 different urgent care visits.

I had a patient with respiratory failure admitted to the ICU due to influenza. I was taken through the paces and had to defend my position why I didn’t start her on an antiviral.

A 17-year-old patient of mine went into acute renal failure 2 days after I ordered him a ketorolac injection. This one certainly highlight the risk of practicing medicine. And sadly, like most things, it was unavoidable.

Not Just a Lawsuit

Remember, the medical board can make their own independent assessment regardless of the outcome of the lawsuit and choose to suspend your license, limit your practice hours or force you to be under the supervision of another clinician.

I commenting on my own post because in just a few months from now the medical board will start an investigation on me which I had no idea would happen. Read all about it and see this 2+ year drama slowly unfold.

The medical board can limit the kind of patients you see and they can force you into costly classes or have you get randomly tested. And they can ruin your chance at ever getting a job in the future.

The risk of practicing medicine can suddenly manifest itself by leaving you jobless with a ton of student loan and mortgage debt. Can you imagine that?

Weighing the Risks

When does the risk outweigh the benefit? Naturally, many docs practice medicine despite the risk because they enjoy what they do. Let’s set love and passion and dedication to humanity aside.

From a risk/benefit viewpoint, a physician with sizeable assets in the frontlines is putting their household at risk by practicing medicine.

Though most lawsuits are paid out at less than $1 million per incidence, the risk of a far costlier claim exists and I am pessimistic enough to not trust that my malpractice insurance company will always come through.

Practicing Defensive Medicine

We have been assured by lawyers that defensive medicine doesn’t work. The only way to stave off lawsuits is being kind and respectful to the patient.

Defensive medicine is sending every sick patient to the ED. It’s ordering more tests than its necessary. It’s going through an exhaustive differential on every single patient. It’s ruling out every single potentially life-threatening differential diagnosis before discharging the patient. It’s not performing potentially risky procedures.

So we just take the risk of practicing medicine and offload our fears onto the patient. We drive up healthcare cost and create more work for ourselves.

Protecting your assets

Many doctors have read or heard about establishing trusts which attempt to “hide” or “protect” their assets. Or forming an LLC or FLP’s in order to make it harder for a potential sue-happy individual to find out how much you’re worth.

The risk of practicing medicine is higher in some states. Especially if they have angry medical boards – think AZ, OR, TX.

Some States allow better protection for your retirement accounts. But not all retirement accounts qualify. The devil is in the detail and unless you are going to sit down with a qualified attorney to tease it all out, you are putting your assets at risk.

Though most lawsuits end in a settlement and though many doctors have less in assets than the debt they owe on their primary residence, it doesn’t mean that doctors don’t lose their shirts in certain cases.

If you have sizeable assets, that factor alone will make you quite an attractive victim for the potential client.

Purchasing an umbrella policy and putting your assets in the name of a spouse are some of the tricks used by attorneys to protect their physician clients. However, none of these are fool-proof.

Practicing ‘Safer’ Medicine

To mitigate the risk of a lawsuit, it’s probably better for a financially independent physician to engage in less risky medicine.

Dealing with walk-in patients with shortness of breath and chest pains, back pains and eye complaints – these are risky scenarios.

I sort of get the feeling of “quitting while ahead”. It’s that little voice inside of me saying that further exposure it’s not worth the risk.

Steps Towards Less Risky Medicine

1. Work for a well-run large medical group

Larger groups have ways of addressing poor patient outcomes in a very efficient manner. They have several lines of defense before even having to file a claim with their malpractice insurer. Settling slam-dunk cases before lawyers are involved by using 3rd party mediators is one method.

A larger group will often have more systems in place to prevent a patient from falling through the cracks. Consulting a specialist is easier and arranging follow-up for a recheck can be done better compared to a private practice.

At KP, on multiple occasions I have had certain protocols save my ass. I am not sure how well it would have worked out if I had my own private practice.

2. Avoid Elective Care

Obviously, each specialty has their own limitations. But as an urgent care doctor,  I can avoid an ingrown toenail removal and arthritic joint injections if those can be done by a specialist down the road.

Is it urgent to add on an ACE-I to better control the patient’s hypertension and risk a potential angioedema? Or could the patient perhaps follow-up with their PCP.

3. Avoid acuity

It’s not easy for me to avoid acuity since I have to see whatever patient is put on my schedule. However, I can send higher acuity patients to the ED for further workup or monitoring – things I can’t do in the urgent care.

I can’t tell you the number of times I have put faith in my spidey senses and sent a patient home. It has never bit me in the ass but I’m not sure if it’s a sustainable practice.

4. Arrange Follow-up

Out of the many cases which come across my email for quality assurance or M&M, the lack of follow-up for a patient or lack of a referral to a specialist after the initial visit has been a major factor.

Bringing a patient back for a 24-hour recheck or placing a referral to optho for that acute red eye may seem excessive to some of us but it can add another a layer of safety for the patient regardless of your proficiency with the slitlamp.

An edematous upper lid in a 17-year-old who was given antibiotics for a sinus infection was dismissed by me as an allergic reaction. I decided to bring him in for a 24-hour recheck due to persistent fevers and thankfully the case presented itself as periorbital cellulitis with a brain abscess.

5. Decrease Your Exposure

Working in an urgent care can be even riskier than working in the ED. Patients often present with early symptoms, not enough to warrant more expensive and aggressive intervention. Ordering an MRA in the ED is easier to justify than getting one in the urgent care.

For the time being, I believe virtual medicine carries less risk than in-person medicine, possibly because of patient self-selection. We shall see how that scene evolves.

And if you are going to practice some telemedicine, be sure to avoid excess practice risk there as well.

Seeing fewer patients will statistically decrease your chance encounter with a bad case. However, not seeing enough patients can hurt you in the other direction. I find that 10 hours of clinical practice a week is a good place to start, though I feel much more comfortable if I’m seeing around 100-150 cases a week.

Malpractice Stats

The majority of healthcare mistakes aren’t reported by large medical groups. They aren’t swept under the rug, but they are addressed locally which makes the medical malpractice scene appear much tamer than it really is. Only 10-15% are reported.

You can find all sorts of interesting malpractice stats, often shared by malpractice law groups.

Some patients will wait up to 2 years before bringing the lawsuit to the steps of the clinician or hospital group.

90-95% of lawsuits are resolved out of court. Either they are dropped, dismissed or settled out of court before hitting a jury trial.

Primary care is often in the top 3 of specialties which are involved in patient suits.

The majority of the patients who won lawsuits were female and the majority were <65 years of age.