The FTCA and You

1. The FTCA and You (aka How to avoid getting sued before it ever happens)

2. FTCA – The Federal Tort Claims Act

3. FTCA 101 • Provides medical malpractice coverage to providers and staff at community health centers, as well as the VA, IHS, military hospitals and other federal facilities

4. FTCA 101 • Since 1992 • Saves malpractice costs for FQHCs • Provides a degree of legal “immunity” to providers at FQHCs

5. FTCA 101How the game is played… • Jane Doe decides that her chronic back pain is your fault • Jane Doe calls a lawyer that she saw on daytime TV ad • Lawyer files suit in county or state court alleging malpractice

6. FTCA 101How the game is played… • Provider receives subpoena • Provider panics, cusses, etc… • Medical Director notified ASAP • Medical Director contacts FTCA guardian angels at US Department of Justice

7. FTCA 101How the game is played… FTCA coordinators contact local lawyer to clarify certain key issues… 1. Because the provider is covered by the FTCA, all suits must be filed in federal court 2. The provider is represented by the US Department of Justice… and they don’t look kindly upon frivolous lawsuits

8. FTCA 101How the game is played… FTCA coordinators contact local lawyer to clarify certain key issues… 3. They can’t sue the provider or their family… The US government becomes the sole defendant. 4. An independent medical review board will consider the merit of the claim prior to any proceedings 5. If a case is filed and pursued, there will be no jury trial. A federal judge would hear the case. No jury = No sympathy card… and minimal damages for pain and suffering.

9. FTCA 101 Most frivolous lawsuits are dropped within the first week

10. FTCA 101 Even if it proceeds… And Uncle Sam loses or agrees to settle… Your personal assets are protected However… you’d still get a “ding” in the National Practitioner Data Base

11. Practical Advice on How to Avoid Getting Sued in the First Place

12. Cardiovascular Disease • Chest pain should always be investigated. • Assume that it is heart disease until proven otherwise. • Document management of risk factors and adherence (or lack of) to treatment. • Maintain a high index of suspicion in patients with diabetes, the elderly and women.

13. Cardiovascular Disease • Hypertension: enhanced emphasis in reaching goals for selected populations, i.e., diabetes, pre-existing heart disease. • Extremities: document pulses, look for infection in patients with diabetes and those who use tobacco (peripheral vascular disease).

14. Medications • Ask about allergies and the nature of the problem. • Ask again and again (every visit). • Be alert to drug interactions and document your conversation with patients. • Consider the use of an electronic source of pharmacologic information.

15. Medications • Anticoagulants: risk of hemorrhage; drug interactions with antibiotics and others • Narcotics: sedation, risk of falls • Antibiotics: allergies • Digoxin: check dose in the elderly, nausea • Statins: obtain CPK and follow it, tell them about myositis and the symptoms

16. Medications • Lithium: increased levels with dehydration, certain meds and renal failure • Do not refill until you are sure of the dose. • Monitor for adverse effects (consider standing order for blood tests). • Bring medications to every visit.

17. Abdominal Pain • High index of suspicion, particularly in elderly. • If not sure or severe, admit and obtain consultations. • Think abscess, pancreatitis, gallstones, bowel ischemia, appendicitis

18. Infections • Urinary Tract Infections: think pyelonephritis/bacteremia-fever, flank pain, nausea, tachypnea, relative hypotension. • Look for skin lesions, respiratory rate and subtle evidence of severe disease (sepsis). • Skin infections: suspect deep involvement when pain is out of proportion to what you see. • Look for clues that may dictate admission.

19. Back Pain • Look for alarm signals • Recent trauma, history of cancer • Bowel and/or urinary incontinence or retention (cauda equina) • Fever (epidural abscess) • Cancer (epidural met and spinal compression) • Weight loss (malignancy)

20. Cancer • Colon: bleeding, pain, change in bowel habits • Bladder: hematuria • Lung: lung nodule, never assume that it is benign unless you are sure; refer • Ovarian: abdominal enlargement, constipation • Cervical: HSV, HPV

21. Breast Cancer • Investigate all breast symptoms. • Perform mammography. • Palpable lesions must be investigated even with a normal mammogram. • Nonpalpable lesions with an abnormal mammogram should be investigated. • Follow up and tracking if decide not to intervene. • Obtain consultations when in doubt.

22. Pulmonary • Evaluate shortness of breath; think of pulmonary embolism • Treat acute asthma according to guidelines; early use of steroids, monitor, admit, if necessary • Follow up on abnormal chest x-rays, particularly in smokers or former smokers

23. CNS • SAH: severe headache (never had it), neck pain; do CT and LP, if needed, neuro consultation • Headaches: alarm signals: new onset in elderly, progressive, cancer history, neuro signs, papilledema

24. Metabolic • B12 deficiency (elevated methylmalonic acid with low-normal level): neuropathy, cognitive dysfunction, anemia • Anemia: look for iron deficiency and, if present, check for occult GI blood loss • Electrolytes: diuretics (low sodium)-elderly females

25. Extremities • Document your exam (neuro, vascular) during lacerations. • If trauma and a lot of pain, think compartment syndrome. • If there is infection and a lot of pain, think necrotizing fasciitis.

26. Extremities • Trauma: Obtain x-rays to look for a foreign body

27. Referrals • Tracking to prevent lost reports or nonadherence to consultations. • Try to implement for x-rays, mammograms and labs.

28. Patient Communication • One of the most important factors. • Call for follow up when ill and just seen. • Call when new medications are started and you have a concern. • Express empathy and compassion. • Do not make inappropriate or judgmental comments. • Become a good listener. • Do not blame for nonadherence to treatment.

29. Legibility • All prescriptions and medical records must be legible. • Consider use of transcription or other electronic means. • The medical record is to document facts, not criticize other providers (bad idea).

30. Office Environment • Courtesy, respect of staff towards patients • Training and monitoring • Define unacceptable behaviors at the CHC (includes providers)-Performance Management • Define disruptive behavior

31. Preventive Strategies • Communicate with patient. • Show respect and courtesy. • Alert them if they are going to wait more than 15-20 minutes. • Develop referral tracking system. • Do not make derogatory comments toward patients.

32. Mammograms Pap smears PSA’s Chest x-rays CT scans MRI’s Blood tests Tracking

33. ER • Develop good relationships with the ER to facilitate follow up. • Develop protocols to obtain ER records of your patients. • Do not make negative comments about the ER staff or the management.

34. Recommendations • Read daily and develop high clinical knowledge. • Maintain a high index of suspicion when dealing with certain situations. • Call your patients when they are being treated. • Develop referral tracking systems. • Write legibly. • Do not make negative comments about others in the medical record. • Keep in mind common high risk situations.

35. Thanks