East Coast Meets West Coast Two Examples of A Malpractice Curriculum for EM Residents

1. East Coast Meets West Coast Two Examples of A Malpractice Curriculum for EM Residents CORD Academic Assembly 2018 Carlo L. Rosen M.D. Program Director Associate Director, GME Beth Israel Deaconess Medical Center Harvard Affiliated Emergency Medicine Residency Matthew A. Silver, M.D. Program Director Kaiser Permanente San Diego Medical Center

2. Goals and Objectives • Understand examples of malpractice curricula which have worked in two programs • Discuss a QI/PS curriculum developed in collaboration with a malpractice insurance company • Learn about a unique interdisciplinary session co-developed and taught by emergency medicine faculty and law professors

3. Why is this topic so important? • Estimated that residents are named in 22% of lawsuits • < 1% of claims (with a payment) reported to National Practitioner Data Base between 1990-2012 named a resident • Bailey et al, Ann EM 2012 • Residents may get named in suit • Decrease stress/anxiety levels by educating residents about the process

4. Why is this important? • Teach residents about the process in case they get sued as an attending • Methods to decrease chances of being sued • Learn good habits early • Documentation skills • Communication skills • Handoffs • No standard curriculum

5. Background • Do residents get sued? • What types of cases? • What are contributing factors? • What are the differences between resident and attending only cases?

6. Comparison of Emergency Medicine Malpractice Cases Involving Residents to Non-Resident Cases • Controlled Risk Insurance Company (CRICO) • Comparative Benchmarking System (CBS) database (2009-2013) • > 400 hospitals, > 165,000 physicians • > 30% of all malpractice cases in US • > 350,000 claims • 845 EM cases • 13% of cases included a resident Gurley, et al SAEM 2016

7. Characteristics of EM Resident Casesversus Attending only cases • Procedure involved in 32% • Vascular access and LP were involved more frequently in resident cases than attending only cases • Average incurred losses smaller in resident cases ($51,163 vs. $156,212) • Higher injury severity in resident cases • 66% vs. 57% were High Injury Severity (major permanent injury) Gurley, et al SAEM 2016

8. Characteristics of EM Resident Casesversus Attending only cases • Most common diagnosis was cardiac related (19% [resident] vs. 10%) • Most common contributing factors-clinical judgment (71% [resident] vs. 76%) Gurley, et al SAEM 2016

9. Resident vs. Attending Malpractice CasesConclusions • The overall case profiles, including allegation categories, final diagnoses and contributing factors are similar • Patient safety efforts should therefore encompass the entire care team • Most prevalent contributing factors: Clinical judgment, communication and documentation • targets for risk management strategies.

10. BIDMC CRICO Malpractice Curriculum • Based on similar experience in Denver program • Collaborate with malpractice insurance company • Collaborative malpractice curriculum • Controlled Risk Insurance Company • > 12,400 physicians • 34 hospitals • 3,500 residents (100 are EM)

11. BIDMC CRICO Malpractice Curriculum Two components: • Five hour annual seminar put on by CRICO, malpractice insurance company • “Hands-on” closed case review at CRICO offices

12. The BIDMC CRICO CurriculumPart I • 5 hour seminar • EM specific data about malpractice cases • Anatomy of a lawsuit • Role of attorney • Chronology of lawsuit • Attorney/risk adjustor’s perspective • Emergency physician input • Strategies on how to avoid a lawsuit • Review a case as a group

13. The BIDMC CRICO CurriculumPart I Topics covered • Role of CRICO (Controlled Risk Insurance Company)-malpractice provider • Patient safety overview • Malpractice data review • Resident malpractice data • Risk reduction strategies in EM • Closed malpractice case • EM Cases • Case Disposition

14. The BIDMC CRICO CurriculumPart I Topics covered • What to expect as a defendant • Chronology of a malpractice case • Disclosure and apology program • Missed and delayed diagnoses in EM • Top allegations in EM • Contributing factors in EM • Interpretation of diagnostic tests • Consultation management

15. Curriculum • Review EM specific malpractice cases including cost analyses, case rate statistics, allegation, contributing factors and case disposition • Discuss malpractice case trends, their analyses and subsequent implemented risk mitigation strategies • Outline anatomy of a malpractice case presented by an attorney outlining the logistics and proceedings of a lawsuit

16. Presentation Summary • CRICO Cases • N=1,292 cases asserted between 1/1/09-8/31/14 • EM is the 6th specialty in case frequency • 5th in cost • 79 cases resulting in $51.7 million in total incurred losses • (including reserves on open and payments on closed cases)

17. How did the residents respond to this curriculum?

18. Quality And Safety Curriculum For Emergency Medicine Residents • 68% felt it impacted their documentation • 90% increased documentation of consultant discussions • 79% increased MDM documentation • 32% felt it impacted communication skills • 47% said test ordering would increase • 63% said avoiding a malpractice suit impacts their clinical decision-making • 74% impacted communication with nurses • 79% impacted their discharge plans Gurley et al, SAEM 2016

19. CRICO EM Resident Closed Case Review (Part II) • 2.5 hour session at malpractice insurance company • Review a malpractice case-records, depositions, materials, legal materials • Discuss the case disposition with attorney, EP, and risk adjuster • Residents rave about the experience

23. Medical Malpractice: The Anatomy of a Case Richard D. Barton, J.D., Adjunct Professor of Law Procopio, Cory, Hargreaves & Savitch LLP Matthew Silver, M.D. Natalie V. Mueller, Esq.

24. Course Goals • Learn together • Burden of proof and the “standard of care,” • Informed consent • Documentation and communication • The practice of defensive medicine • Procedures for taking and defending depositions • How to prepare for trial • Settlement or verdict • Licensing and regulatory bodies

25. Course Goals • Experience of handling a medical malpractice case from start to finish • Law students: • How to represent a physician • Take a deposition • Prepare for trial • Residents: • Insight into the legal field • Aid in the understanding of the mechanics of a lawsuit • Provide a practical understanding of how the legal system functions

26. Course Schedule • Introduction and Course Overview; Medical Malpractice Basics • Understanding the Practice of Medicine, QI Presentation • Mary Smith v. Tom Jones, M.D.; The Lawsuit is Filed • Perspectives from San Diego Medical Malpractice • Damages in Medical Malpractice Actions • Client Walks In—Plaintiff and Defense Perspectives • Meeting with Your Expert Witness to Understand the Medicine Mary Smith’s Medical Record • Expert WitnessesPreparing to Take and Defend a Deposition • Mock Depositions • Trial—Understanding Trial Procedures and the Jury System

27. The Case Patient: Mary Smith Doctor: Thomas Jones, MD, FACEP San Diego Memorial Hospital June 11, 2016

29. Pictures of mock deposition

30. Conclusions • Joining forces with your malpractice insurance company can facilitate the development of an EM resident curriculum to teach about patient safety and risk management. • Interdisciplinary training in Emergency Medicine need not be limited to critical event scenarios. • Interdisciplinary training between law students and EM residents can serve to expose trainees to a scary, poorly understood, yet frequent occurrence encountered in the practice of Emergency Medicine. • Joint training sessions can help learners better understand the others respective fields, aid in the understanding of the mechanics of a lawsuit and provide a practical understanding of how the tort system functions.