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ONLINE EXCLUSIVE: Billing Expert Explains Why Documentation, Education, and Feedback Are Crucial to Reimbursement
ONLINE EXCLUSIVE: CogentHMG hospitalist explains how hospitalists can prepare for Value-Based Purchasing at hospital, individual level
Click here to listen to Dr. Wright
Click here to listen to Dr. Wright
Click here to listen to Dr. Wright
Accuracy Matters When Compensation for Hospitalists Is at Stake
Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.
The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.
The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.
A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.
When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.
The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.
Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.
Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.
The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.
The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.
A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.
When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.
The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.
Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.
Not long ago, I received an email from a hospitalist group leader who was working with her CMO on a new compensation plan. The CMO, wanting to ensure that the proposed compensation per unit of work was appropriate, had taken the MGMA national median annual compensation for internal-medicine hospitalists ($234,437) and divided it by the national median annual work RVUs (4,185) to arrive at a targeted compensation per wRVU of $56.01.
The hospitalist leader, however, had the benefit of referring to her 2012 State of Hospital Medicine report, in which Table 6.30 reported an MGMA median compensation per wRVU for internal-medicine hospitalists of $58.28. That variance of more than two dollars per wRVU could mean an additional $8,000 or so in annual compensation to her and her colleagues, so she was seeking to understand why the report has a different number than the one calculated by her CMO.
The answer is that the CMO got caught in a common error of logic: The CMO assumed that the compensation median and the wRVU median were derived from exactly the same population, failing to consider that the underlying data sets might be different. Here’s what happened: Compensation data were reported for 3,192 internal-medicine hospitalists, but wRVUs were reported for only 2,389 of those hospitalists. So the analysis of compensation per wRVU can be accurately calculated only for those 2,389 hospitalists for whom both compensation and wRVUs were reported. The other 803 hospitalists for whom no wRVUs were reported had to be excluded from the ratio calculation. The CMO’s error was to calculate a ratio of two medians based on different data sets, rather than calculating the individual comp-to-wRVU ratios, then determining the median for that smaller data set.
A similar thing has happened over the years with nocturnist data. In SHM’s 2007-2008 compensation and productivity survey, and again in the 2011 SHM/MGMA State of Hospital Medicine report, the median compensation reported for nocturnists actually was lower than that reported for all adult hospitalists. In my work with hospitalist practices across the country, I’ve only run into one or two where the nocturnists earned less than the daytime doctors, so I was flummoxed by this finding. Turns out, I was making the same mistake of assuming I was looking at “nocturnist” and “all adult hospitalist” compensation for the same hospitalist groups. But the adult medicine groups using nocturnists are actually a small subset of all adult medicine groups, and the nocturnist data likely included at least a few pediatric hospitalist nocturnists. Because the underlying data sets are different, the two medians aren’t directly comparable.
When all is said and done, we don’t really care whether the average nocturnist earns more or less than the average non-nocturnist hospitalist. What we really want to know is, Do the nocturnists in a given group earn more than the non-nocturnists in the same group? That’s why this year SHM asked groups to report the average percent compensation differential between nocturnists and non-nocturnists in their groups. It turns out that groups serving adults only reported a median of 15% higher compensation for nocturnists, a far different result than users of previous surveys inferred.
The bottom line: Make sure you understand how the State of Hospital Medicine survey results are calculated. Many of the formulas used are described in Appendix B of the report, and if you have questions about others, feel free to contact SHM and ask.
Leslie Flores is a partner in Nelson Flores Hospital Medicine Consultants.
More Hospitalists Opt for Part-Time Work Schedules
An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.
Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.
The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:
- Independent contractor or employee status;
- Compensation;
- Benefits;
- Professional liability (malpractice) insurance; and
- Restrictive covenants.
Independent Contractor vs. Employee
Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.
Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.
Compensation and Benefits
Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.
Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.
Professional Liability (Malpractice) Insurance
While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.
When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.
Restrictive Covenants
Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.
Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.
Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.
The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:
- Independent contractor or employee status;
- Compensation;
- Benefits;
- Professional liability (malpractice) insurance; and
- Restrictive covenants.
Independent Contractor vs. Employee
Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.
Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.
Compensation and Benefits
Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.
Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.
Professional Liability (Malpractice) Insurance
While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.
When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.
Restrictive Covenants
Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.
Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.
Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.
The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:
- Independent contractor or employee status;
- Compensation;
- Benefits;
- Professional liability (malpractice) insurance; and
- Restrictive covenants.
Independent Contractor vs. Employee
Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.
Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.
Compensation and Benefits
Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.
Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.
Professional Liability (Malpractice) Insurance
While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.
When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.
Restrictive Covenants
Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.
Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.
Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].
Hospitalist Edward Ma, MD, Embraces the Entrepreneurial Spirit
Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.
“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”
Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.
“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”
Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.
Question: What do you like most about caring for patients?
Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.
Q: What do you like least?
A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.
Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?
A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.
Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?
A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.
Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?
A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.
Q: What are the biggest challenges you face as medical director?
A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.
Q: What’s the most important thing to know when starting an HM group or fixing a broken group?
A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.
Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?
A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.
Q: What’s the best part of being an SHM member?
A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.
Richard Quinn is a freelance writer in New Jersey.
Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.
“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”
Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.
“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”
Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.
Question: What do you like most about caring for patients?
Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.
Q: What do you like least?
A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.
Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?
A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.
Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?
A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.
Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?
A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.
Q: What are the biggest challenges you face as medical director?
A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.
Q: What’s the most important thing to know when starting an HM group or fixing a broken group?
A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.
Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?
A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.
Q: What’s the best part of being an SHM member?
A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.
Richard Quinn is a freelance writer in New Jersey.
Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.
“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”
Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.
“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”
Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.
Question: What do you like most about caring for patients?
Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.
Q: What do you like least?
A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.
Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?
A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.
Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?
A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.
Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?
A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.
Q: What are the biggest challenges you face as medical director?
A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.
Q: What’s the most important thing to know when starting an HM group or fixing a broken group?
A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.
Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?
A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.
Q: What’s the best part of being an SHM member?
A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.
Richard Quinn is a freelance writer in New Jersey.
Risky to Change Dosing "as a Favor"
An Alabama woman with chronic asthma went to a pharmacy to pick up a refill of 10-mg warfarin tablets, prescribed by the defendant physician. She began to take the medication as prescribed, one tablet bid. Eleven days later, she was hospitalized with shortness of breath. A blood test revealed elevated warfarin levels.
The plaintiff alleged negligence on the part of the pharmacy, the physician, and the family practice with which the physician was associated. The plaintiff claimed that warfarin toxicity had exacerbated her asthma and that she should not have been taking more than one tablet per day. The plaintiff claimed that the prescription was inappropriate and that the pharmacy should have had some system in place to catch excessive prescription dosing.
The pharmacy was dismissed from the action.
The defendant physician claimed that the plaintiff had been given oral instructions regarding dosage, as the dosage had been modified based on blood testing, and the label on the prescription bottle did not reflect the dosage instructions given to the plaintiff. The defendant claimed that the prescription had been written to reduce the required number of trips to the pharmacy, to accommodate the plaintiff’s difficulty in arranging for transportation. The defendant also maintained that the episode had not impacted the plaintiff’s asthma.
OUTCOME
According to a published report, a defense verdict was returned.
COMMENT
Here is a case in which doing a favor nearly turned into a malpractice judgment. Only the defense verdict saved this physician. Warfarin is a dangerous drug, as even a small change in dosing can cause a dramatic and deadly adverse effect. Warfarin level monitoring and subsequent dose modification present an especially rich opportunity for error.
In support of the need to provide clinical summaries of office visits to patients, the Health Resources and Services Administration cites research stating that 40% to 80% of medical information provided by practitioners “is forgotten immediately after a clinic visit.” Of the information that is remembered, almost one-half is remembered incorrectly. (See www.hrsa.gov/healthit/toolbox/HealthITAdoption toolbox/MeaningfulUse/howdoiprovideclinicalsummaries.html). It is important to remember that an office visit may be a stressful event for a patient, and visual or auditory deficits may come into play as well. These deficits may not always be obvious to the provider.
At the very least, this means that a clearly written documentation of the correct dosage of the medication must be provided to the patient. This is especially true when there is an absence of written instructions on the medication bottle or if the instructions are eliminated from the prescription for any reason. The written instruction provided at the office may also act as a safety check for the patient that will confirm the accuracy of the prescription provided at the pharmacy.
How many times have health care providers written a script for a dose different from the dose that the patient was orally instructed to take? This may occur for many reasons, including (as happened in this case) saving the patient difficult trips to a pharmacy. Another reason might be to help a patient to save on copays when a greater number of doses of a medication fall within standard practice parameters. I have often seen prescriptions written with instructions “take as directed” when the dosing regimen might be too lengthy or require too many changes, such as tapering a dose of prednisone.
The need for written instructions also applies when giving medication samples to patients. Often samples do not come with patient instructions, and even if they do, the instructions may be separated from the sample provided. It may be difficult for the patient to find dosing information in a lengthy and dense product information guide, which may or may not be included in the sample package. This presents another situation in which great care is needed to prevent potential drug errors.
In addition to providing written instructions, the health care provider may use other precautions to prevent patients from misunderstanding or completely forgetting instructions. Examples include asking the patient to repeat the instructions before leaving the examining room, and using the opportunity to clarify any misunderstandings; or having the medical assistant recheck to be sure the patient does not have any questions about medications or other instructions before leaving the office. So many times I have had an assistant advise me that the patient is confused about instructions but did not want to “bother” me or take up my time with questions. And yet, this same patient was willing to tell the assistant that questions remained. The more opportunities that exist to clarify instructions, the better. —JP
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
An Alabama woman with chronic asthma went to a pharmacy to pick up a refill of 10-mg warfarin tablets, prescribed by the defendant physician. She began to take the medication as prescribed, one tablet bid. Eleven days later, she was hospitalized with shortness of breath. A blood test revealed elevated warfarin levels.
The plaintiff alleged negligence on the part of the pharmacy, the physician, and the family practice with which the physician was associated. The plaintiff claimed that warfarin toxicity had exacerbated her asthma and that she should not have been taking more than one tablet per day. The plaintiff claimed that the prescription was inappropriate and that the pharmacy should have had some system in place to catch excessive prescription dosing.
The pharmacy was dismissed from the action.
The defendant physician claimed that the plaintiff had been given oral instructions regarding dosage, as the dosage had been modified based on blood testing, and the label on the prescription bottle did not reflect the dosage instructions given to the plaintiff. The defendant claimed that the prescription had been written to reduce the required number of trips to the pharmacy, to accommodate the plaintiff’s difficulty in arranging for transportation. The defendant also maintained that the episode had not impacted the plaintiff’s asthma.
OUTCOME
According to a published report, a defense verdict was returned.
COMMENT
Here is a case in which doing a favor nearly turned into a malpractice judgment. Only the defense verdict saved this physician. Warfarin is a dangerous drug, as even a small change in dosing can cause a dramatic and deadly adverse effect. Warfarin level monitoring and subsequent dose modification present an especially rich opportunity for error.
In support of the need to provide clinical summaries of office visits to patients, the Health Resources and Services Administration cites research stating that 40% to 80% of medical information provided by practitioners “is forgotten immediately after a clinic visit.” Of the information that is remembered, almost one-half is remembered incorrectly. (See www.hrsa.gov/healthit/toolbox/HealthITAdoption toolbox/MeaningfulUse/howdoiprovideclinicalsummaries.html). It is important to remember that an office visit may be a stressful event for a patient, and visual or auditory deficits may come into play as well. These deficits may not always be obvious to the provider.
At the very least, this means that a clearly written documentation of the correct dosage of the medication must be provided to the patient. This is especially true when there is an absence of written instructions on the medication bottle or if the instructions are eliminated from the prescription for any reason. The written instruction provided at the office may also act as a safety check for the patient that will confirm the accuracy of the prescription provided at the pharmacy.
How many times have health care providers written a script for a dose different from the dose that the patient was orally instructed to take? This may occur for many reasons, including (as happened in this case) saving the patient difficult trips to a pharmacy. Another reason might be to help a patient to save on copays when a greater number of doses of a medication fall within standard practice parameters. I have often seen prescriptions written with instructions “take as directed” when the dosing regimen might be too lengthy or require too many changes, such as tapering a dose of prednisone.
The need for written instructions also applies when giving medication samples to patients. Often samples do not come with patient instructions, and even if they do, the instructions may be separated from the sample provided. It may be difficult for the patient to find dosing information in a lengthy and dense product information guide, which may or may not be included in the sample package. This presents another situation in which great care is needed to prevent potential drug errors.
In addition to providing written instructions, the health care provider may use other precautions to prevent patients from misunderstanding or completely forgetting instructions. Examples include asking the patient to repeat the instructions before leaving the examining room, and using the opportunity to clarify any misunderstandings; or having the medical assistant recheck to be sure the patient does not have any questions about medications or other instructions before leaving the office. So many times I have had an assistant advise me that the patient is confused about instructions but did not want to “bother” me or take up my time with questions. And yet, this same patient was willing to tell the assistant that questions remained. The more opportunities that exist to clarify instructions, the better. —JP
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
An Alabama woman with chronic asthma went to a pharmacy to pick up a refill of 10-mg warfarin tablets, prescribed by the defendant physician. She began to take the medication as prescribed, one tablet bid. Eleven days later, she was hospitalized with shortness of breath. A blood test revealed elevated warfarin levels.
The plaintiff alleged negligence on the part of the pharmacy, the physician, and the family practice with which the physician was associated. The plaintiff claimed that warfarin toxicity had exacerbated her asthma and that she should not have been taking more than one tablet per day. The plaintiff claimed that the prescription was inappropriate and that the pharmacy should have had some system in place to catch excessive prescription dosing.
The pharmacy was dismissed from the action.
The defendant physician claimed that the plaintiff had been given oral instructions regarding dosage, as the dosage had been modified based on blood testing, and the label on the prescription bottle did not reflect the dosage instructions given to the plaintiff. The defendant claimed that the prescription had been written to reduce the required number of trips to the pharmacy, to accommodate the plaintiff’s difficulty in arranging for transportation. The defendant also maintained that the episode had not impacted the plaintiff’s asthma.
OUTCOME
According to a published report, a defense verdict was returned.
COMMENT
Here is a case in which doing a favor nearly turned into a malpractice judgment. Only the defense verdict saved this physician. Warfarin is a dangerous drug, as even a small change in dosing can cause a dramatic and deadly adverse effect. Warfarin level monitoring and subsequent dose modification present an especially rich opportunity for error.
In support of the need to provide clinical summaries of office visits to patients, the Health Resources and Services Administration cites research stating that 40% to 80% of medical information provided by practitioners “is forgotten immediately after a clinic visit.” Of the information that is remembered, almost one-half is remembered incorrectly. (See www.hrsa.gov/healthit/toolbox/HealthITAdoption toolbox/MeaningfulUse/howdoiprovideclinicalsummaries.html). It is important to remember that an office visit may be a stressful event for a patient, and visual or auditory deficits may come into play as well. These deficits may not always be obvious to the provider.
At the very least, this means that a clearly written documentation of the correct dosage of the medication must be provided to the patient. This is especially true when there is an absence of written instructions on the medication bottle or if the instructions are eliminated from the prescription for any reason. The written instruction provided at the office may also act as a safety check for the patient that will confirm the accuracy of the prescription provided at the pharmacy.
How many times have health care providers written a script for a dose different from the dose that the patient was orally instructed to take? This may occur for many reasons, including (as happened in this case) saving the patient difficult trips to a pharmacy. Another reason might be to help a patient to save on copays when a greater number of doses of a medication fall within standard practice parameters. I have often seen prescriptions written with instructions “take as directed” when the dosing regimen might be too lengthy or require too many changes, such as tapering a dose of prednisone.
The need for written instructions also applies when giving medication samples to patients. Often samples do not come with patient instructions, and even if they do, the instructions may be separated from the sample provided. It may be difficult for the patient to find dosing information in a lengthy and dense product information guide, which may or may not be included in the sample package. This presents another situation in which great care is needed to prevent potential drug errors.
In addition to providing written instructions, the health care provider may use other precautions to prevent patients from misunderstanding or completely forgetting instructions. Examples include asking the patient to repeat the instructions before leaving the examining room, and using the opportunity to clarify any misunderstandings; or having the medical assistant recheck to be sure the patient does not have any questions about medications or other instructions before leaving the office. So many times I have had an assistant advise me that the patient is confused about instructions but did not want to “bother” me or take up my time with questions. And yet, this same patient was willing to tell the assistant that questions remained. The more opportunities that exist to clarify instructions, the better. —JP
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
iPad Rollout at UC-Irvine Medical Center Prompts Security Measures
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
The University of California’s Irvine Medical Center has been issuing iPads to its incoming class of 100 medical students and to all 18 resident physicians in its department of emergency medicine.1 The entire medical curriculum is on the iPad and employs document sharing via the SharePoint collaborative software platform, says Adam Gold, the medical center’s director of emerging technologies.
But the use of these new technologies and subsequent clamoring by students, professors, physicians, and other staff to connect their own mobile devices to the network have led to the establishment of security and management guidelines for monitoring technology use, now spelled out in the new “Bring Your Own Device” policy, Gold explains.
Reference
Premature Infant Erroneously Deemed Nonviable
Premature Infant Erroneously Deemed Nonviable
The plaintiff mother was six months pregnant with her first child when she miscarried at her home in Massachusetts, and an ambulance was called. The EMTs helped the woman to a stretcher, then went to retrieve the fetus from the bathroom floor. The infant was seen moving its head, and the EMTs summoned ALS to the scene. The infant was placed in a small box. The ALS personnel visually assessed the infant and determined that it was “nonviable.” No fetal heart check was conducted in the field.
The mother and fetus arrived at the hospital 17 minutes after the ambulance was called. At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The infant was taken to the special care nursery and placed under a warmer, where resuscitation efforts began. The infant was later transported to another hospital’s neonatal ICU for further care and treatment but at six weeks of age died of brain damage due to oxygen deprivation.
The plaintiff claimed that the EMTs should have provided evaluation and treatment for the infant and that they lacked proper training to determine the viability of a newborn. The plaintiff also claimed that placing the infant inside a plastic bag inside a box with a lid further deprived it of oxygen.
OUTCOME
A settlement of $1 million was reached.
COMMENT
This case illustrates the perils of allowing prehospital personnel excessive latitude in determining when resuscitation efforts should terminate. Unless death is obvious, vigorous resuscitation and expeditious transport must be undertaken.
In most jurisdictions, “obvious” death requires clear evidence of death (eg, rigor mortis) or a clearly nonsurvivable injury (eg, decapitation, fully transected trunk). In cases where death is not evident under regional Emergency Medical Services guidelines, resuscitation efforts must be full and robust, continuing until medical control orders them to cease.
Medical control refers to medical direction given to responding prehospital personnel; it may be “online” or “offline.” Online control refers to direct clinician-to–prehospital provider direction via radio or telecommunication means, whereas offline control refers to indirect guidance via preestablished protocols and guidelines. In cases in which responding personnel are uncertain whether the indicators of death are met under existing offline protocols, resuscitation efforts should begin and proceed until online medical control orders those efforts terminated.
Jurors will expect an ambulance to move swiftly to the scene, with EMS personnel providing prompt stabilization and rapid transport to the hospital. Jurors will view premature decisions to “count a patient out” harshly.
To be fair, transporting a patient with little chance for survival presents a burden to the immediate community. While transporting such a patient (and for some time immediately following arrival at the hospital), the ambulance is out of service and unavailable to other patients requiring transport who stand a better chance of survival. However, jurors will expect a patient with even a slim chance for survival to be given that chance.
Those who are incontrovertibly deceased should not be transported via ambulance. —DML
Aortic Dissection Misdiagnosed as Abdominal Pain and Hypertension
A 35-year-old Illinois man experienced sudden-onset severe abdominal pain at work. An ambulance was called. His co-workers described him as crying and writhing on the floor, with difficulty breathing and profuse sweating. The ambulance report described abdominal pain and cold, pale, diaphoretic skin but normal vital signs.
At the hospital emergency department (ED), the triage nurse noted mid-abdominal pain that felt like cramping, normal vital signs, and skin that was pink, warm, and dry. The defendant emergency physician, Dr. M., noted that the patient described moderate abdominal pain in the epigastric area. Dr. M.’s initial impression was gastritis or pancreatitis, but he ordered a cardiac work-up to rule out acute coronary syndrome. Cardiac enzyme levels were normal, but ECG results were abnormal and consistent with cardiac ischemia or hypertension. A chest x-ray showed an enlarged heart, which was consistent with the patient’s known history of hypertension.
The man’s co-workers, who visited him in a hallway in the ED, stated that the department was very busy. They stated that the patient was complaining of chest pain and spitting up blood, and that hospital personnel were paying him little attention.
The patient was given a “GI cocktail,” after which he vomited and reported feeling better. Dr. M. reevaluated him, noted that the patient reported no more abdominal pain, and discharged him with a diagnosis of abdominal pain and hypertension.
At discharge, the patient was instructed to follow up with a health care provider the following day for his hypertension and enlarged heart. According to a nurse’s note, the patient ambulated without difficulty at the time of discharge. The friend who picked him up, however, claimed that he was still in significant pain and had trouble walking to her car.
Six days later, the man was found dead at home. An autopsy revealed aortic dissection as the cause of death.
Plaintiff for the decedent claimed that Dr. M. failed to perform a proper history and physical examination, which would have revealed the signs and symptoms described by the decedent’s co-workers. It was undisputed that the co-workers’ description of the decedent’s condition at work was suggestive of aortic dissection. The plaintiff claimed that CT should have been ordered, with results indicating surgery; this would likely have prevented the man’s death. The plaintiff also claimed that the decedent’s abnormal ECG results should have prompted hospital admission and an inpatient cardiac work-up.
The defendant claimed that the decedent never reported the severe and dramatic symptoms described by his co-workers, to the paramedics, the triage nurse, or the emergency physician. Dr. M. further maintained that a proper history and physical examination were performed, that proper studies were conducted and appropriate medications provided, and that the decedent was properly discharged in an improved condition.
OUTCOME
The defendant hospital settled for $75,000 before trial. According to a published account, a defense verdict was returned, although an earlier trial in the case had ended in a $3.7 million verdict.
COMMENT
A history of abdominal pain and hypertension makes aortic dissection a diagnostic possibility, but it is unclear whether aortic dissection was considered as part of the differential diagnosis. The sudden onset and severe nature of the pain were clues, but controversy arose over whether this presentation was conveyed to the prehospital responders, the triage nurse, and/or the emergency physician.
This case was apparently retried following a substantial $3.7 million verdict, with the second result being quite different: a $75,000 settlement from the hospital and a defense verdict. It is unclear why the case was retried.
There are a few noteworthy points in this case. First, there was a disconnect between the description of the patient’s presentation given by his co-workers and the content of the EMS, nursing, and physician notes. The co-workers described sudden onset of severe pain, resulting in the patient crying and writhing on the floor; the triage nurse characterized the pain as abdominal “cramping” in quality, with the physician noting the patient’s description as “moderate” in intensity—a substantial difference. Whenever possible, attempt to elicit history from different sources and document each source of the information. In this case, more than likely the patient’s original presentation was not clearly communicated by the patient or by his co-workers to any of the treatment providers—the EMTs, the triage nurses and other hospital personnel, and the emergency physician.
Second, use of a “GI cocktail” as a diagnostic test to distinguish between gastrointestinal (GI) and non-GI causes of abdominal or chest pain can be problematic. The composition of the GI cocktail is generally antacid, viscous lidocaine, and an anticholinergic agent. Here, after consuming the GI cocktail, the patient said he felt better—perhaps falsely suggesting a gastrointestinal source of pain. While the use of a GI cocktail may provide symptomatic relief in certain circumstances, there is inadequate evidence to support making diagnostic decisions based on a patient’s response to it. So don’t.
Third, EDs are often overcrowded and chaotically busy. Such conditions can result in an overburdened staff, with clinicians feeling they did the best they could in an extremely difficult environment. Some clinicians have remarked they would like the jury to see “how the ED was that day”—to explain the pressure, the pace, and the other dire and pressing patient needs. But the malpractice plaintiff wants the jury to see “how the ED was that day,” too—to support the conclusion that the patient was not given the proper time, attention, and care that his or her condition warranted. Here, the plaintiff’s co-workers were willing to testify that the patient was “kept in the hallway,” that the department was “very busy,” and the personnel did not “pay much attention” to the patient—all to support the conclusion that the care was substandard.
While I can’t offer any breakthrough suggestions to cure the problem of ED overcrowding, I can recommend that clinicians do their best to make sure patients roomed in unconventional locations (such as the hallway) receive full attention and requisite concern so that they do not feel (or are not perceived as) neglected. A patient who has been placed in the hallway is still a patient in the hospital under your care. It goes without saying that a clinician should never form diagnostic or treatment impressions by virtue of where a patient is being examined: When a patient in the hallway is discovered to be acutely ill, immediate steps must be taken to re-room that patient. —DML
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Premature Infant Erroneously Deemed Nonviable
The plaintiff mother was six months pregnant with her first child when she miscarried at her home in Massachusetts, and an ambulance was called. The EMTs helped the woman to a stretcher, then went to retrieve the fetus from the bathroom floor. The infant was seen moving its head, and the EMTs summoned ALS to the scene. The infant was placed in a small box. The ALS personnel visually assessed the infant and determined that it was “nonviable.” No fetal heart check was conducted in the field.
The mother and fetus arrived at the hospital 17 minutes after the ambulance was called. At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The infant was taken to the special care nursery and placed under a warmer, where resuscitation efforts began. The infant was later transported to another hospital’s neonatal ICU for further care and treatment but at six weeks of age died of brain damage due to oxygen deprivation.
The plaintiff claimed that the EMTs should have provided evaluation and treatment for the infant and that they lacked proper training to determine the viability of a newborn. The plaintiff also claimed that placing the infant inside a plastic bag inside a box with a lid further deprived it of oxygen.
OUTCOME
A settlement of $1 million was reached.
COMMENT
This case illustrates the perils of allowing prehospital personnel excessive latitude in determining when resuscitation efforts should terminate. Unless death is obvious, vigorous resuscitation and expeditious transport must be undertaken.
In most jurisdictions, “obvious” death requires clear evidence of death (eg, rigor mortis) or a clearly nonsurvivable injury (eg, decapitation, fully transected trunk). In cases where death is not evident under regional Emergency Medical Services guidelines, resuscitation efforts must be full and robust, continuing until medical control orders them to cease.
Medical control refers to medical direction given to responding prehospital personnel; it may be “online” or “offline.” Online control refers to direct clinician-to–prehospital provider direction via radio or telecommunication means, whereas offline control refers to indirect guidance via preestablished protocols and guidelines. In cases in which responding personnel are uncertain whether the indicators of death are met under existing offline protocols, resuscitation efforts should begin and proceed until online medical control orders those efforts terminated.
Jurors will expect an ambulance to move swiftly to the scene, with EMS personnel providing prompt stabilization and rapid transport to the hospital. Jurors will view premature decisions to “count a patient out” harshly.
To be fair, transporting a patient with little chance for survival presents a burden to the immediate community. While transporting such a patient (and for some time immediately following arrival at the hospital), the ambulance is out of service and unavailable to other patients requiring transport who stand a better chance of survival. However, jurors will expect a patient with even a slim chance for survival to be given that chance.
Those who are incontrovertibly deceased should not be transported via ambulance. —DML
Aortic Dissection Misdiagnosed as Abdominal Pain and Hypertension
A 35-year-old Illinois man experienced sudden-onset severe abdominal pain at work. An ambulance was called. His co-workers described him as crying and writhing on the floor, with difficulty breathing and profuse sweating. The ambulance report described abdominal pain and cold, pale, diaphoretic skin but normal vital signs.
At the hospital emergency department (ED), the triage nurse noted mid-abdominal pain that felt like cramping, normal vital signs, and skin that was pink, warm, and dry. The defendant emergency physician, Dr. M., noted that the patient described moderate abdominal pain in the epigastric area. Dr. M.’s initial impression was gastritis or pancreatitis, but he ordered a cardiac work-up to rule out acute coronary syndrome. Cardiac enzyme levels were normal, but ECG results were abnormal and consistent with cardiac ischemia or hypertension. A chest x-ray showed an enlarged heart, which was consistent with the patient’s known history of hypertension.
The man’s co-workers, who visited him in a hallway in the ED, stated that the department was very busy. They stated that the patient was complaining of chest pain and spitting up blood, and that hospital personnel were paying him little attention.
The patient was given a “GI cocktail,” after which he vomited and reported feeling better. Dr. M. reevaluated him, noted that the patient reported no more abdominal pain, and discharged him with a diagnosis of abdominal pain and hypertension.
At discharge, the patient was instructed to follow up with a health care provider the following day for his hypertension and enlarged heart. According to a nurse’s note, the patient ambulated without difficulty at the time of discharge. The friend who picked him up, however, claimed that he was still in significant pain and had trouble walking to her car.
Six days later, the man was found dead at home. An autopsy revealed aortic dissection as the cause of death.
Plaintiff for the decedent claimed that Dr. M. failed to perform a proper history and physical examination, which would have revealed the signs and symptoms described by the decedent’s co-workers. It was undisputed that the co-workers’ description of the decedent’s condition at work was suggestive of aortic dissection. The plaintiff claimed that CT should have been ordered, with results indicating surgery; this would likely have prevented the man’s death. The plaintiff also claimed that the decedent’s abnormal ECG results should have prompted hospital admission and an inpatient cardiac work-up.
The defendant claimed that the decedent never reported the severe and dramatic symptoms described by his co-workers, to the paramedics, the triage nurse, or the emergency physician. Dr. M. further maintained that a proper history and physical examination were performed, that proper studies were conducted and appropriate medications provided, and that the decedent was properly discharged in an improved condition.
OUTCOME
The defendant hospital settled for $75,000 before trial. According to a published account, a defense verdict was returned, although an earlier trial in the case had ended in a $3.7 million verdict.
COMMENT
A history of abdominal pain and hypertension makes aortic dissection a diagnostic possibility, but it is unclear whether aortic dissection was considered as part of the differential diagnosis. The sudden onset and severe nature of the pain were clues, but controversy arose over whether this presentation was conveyed to the prehospital responders, the triage nurse, and/or the emergency physician.
This case was apparently retried following a substantial $3.7 million verdict, with the second result being quite different: a $75,000 settlement from the hospital and a defense verdict. It is unclear why the case was retried.
There are a few noteworthy points in this case. First, there was a disconnect between the description of the patient’s presentation given by his co-workers and the content of the EMS, nursing, and physician notes. The co-workers described sudden onset of severe pain, resulting in the patient crying and writhing on the floor; the triage nurse characterized the pain as abdominal “cramping” in quality, with the physician noting the patient’s description as “moderate” in intensity—a substantial difference. Whenever possible, attempt to elicit history from different sources and document each source of the information. In this case, more than likely the patient’s original presentation was not clearly communicated by the patient or by his co-workers to any of the treatment providers—the EMTs, the triage nurses and other hospital personnel, and the emergency physician.
Second, use of a “GI cocktail” as a diagnostic test to distinguish between gastrointestinal (GI) and non-GI causes of abdominal or chest pain can be problematic. The composition of the GI cocktail is generally antacid, viscous lidocaine, and an anticholinergic agent. Here, after consuming the GI cocktail, the patient said he felt better—perhaps falsely suggesting a gastrointestinal source of pain. While the use of a GI cocktail may provide symptomatic relief in certain circumstances, there is inadequate evidence to support making diagnostic decisions based on a patient’s response to it. So don’t.
Third, EDs are often overcrowded and chaotically busy. Such conditions can result in an overburdened staff, with clinicians feeling they did the best they could in an extremely difficult environment. Some clinicians have remarked they would like the jury to see “how the ED was that day”—to explain the pressure, the pace, and the other dire and pressing patient needs. But the malpractice plaintiff wants the jury to see “how the ED was that day,” too—to support the conclusion that the patient was not given the proper time, attention, and care that his or her condition warranted. Here, the plaintiff’s co-workers were willing to testify that the patient was “kept in the hallway,” that the department was “very busy,” and the personnel did not “pay much attention” to the patient—all to support the conclusion that the care was substandard.
While I can’t offer any breakthrough suggestions to cure the problem of ED overcrowding, I can recommend that clinicians do their best to make sure patients roomed in unconventional locations (such as the hallway) receive full attention and requisite concern so that they do not feel (or are not perceived as) neglected. A patient who has been placed in the hallway is still a patient in the hospital under your care. It goes without saying that a clinician should never form diagnostic or treatment impressions by virtue of where a patient is being examined: When a patient in the hallway is discovered to be acutely ill, immediate steps must be taken to re-room that patient. —DML
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Premature Infant Erroneously Deemed Nonviable
The plaintiff mother was six months pregnant with her first child when she miscarried at her home in Massachusetts, and an ambulance was called. The EMTs helped the woman to a stretcher, then went to retrieve the fetus from the bathroom floor. The infant was seen moving its head, and the EMTs summoned ALS to the scene. The infant was placed in a small box. The ALS personnel visually assessed the infant and determined that it was “nonviable.” No fetal heart check was conducted in the field.
The mother and fetus arrived at the hospital 17 minutes after the ambulance was called. At the hospital, a nurse noticed that the fetus was warm and had a heartbeat. The infant was taken to the special care nursery and placed under a warmer, where resuscitation efforts began. The infant was later transported to another hospital’s neonatal ICU for further care and treatment but at six weeks of age died of brain damage due to oxygen deprivation.
The plaintiff claimed that the EMTs should have provided evaluation and treatment for the infant and that they lacked proper training to determine the viability of a newborn. The plaintiff also claimed that placing the infant inside a plastic bag inside a box with a lid further deprived it of oxygen.
OUTCOME
A settlement of $1 million was reached.
COMMENT
This case illustrates the perils of allowing prehospital personnel excessive latitude in determining when resuscitation efforts should terminate. Unless death is obvious, vigorous resuscitation and expeditious transport must be undertaken.
In most jurisdictions, “obvious” death requires clear evidence of death (eg, rigor mortis) or a clearly nonsurvivable injury (eg, decapitation, fully transected trunk). In cases where death is not evident under regional Emergency Medical Services guidelines, resuscitation efforts must be full and robust, continuing until medical control orders them to cease.
Medical control refers to medical direction given to responding prehospital personnel; it may be “online” or “offline.” Online control refers to direct clinician-to–prehospital provider direction via radio or telecommunication means, whereas offline control refers to indirect guidance via preestablished protocols and guidelines. In cases in which responding personnel are uncertain whether the indicators of death are met under existing offline protocols, resuscitation efforts should begin and proceed until online medical control orders those efforts terminated.
Jurors will expect an ambulance to move swiftly to the scene, with EMS personnel providing prompt stabilization and rapid transport to the hospital. Jurors will view premature decisions to “count a patient out” harshly.
To be fair, transporting a patient with little chance for survival presents a burden to the immediate community. While transporting such a patient (and for some time immediately following arrival at the hospital), the ambulance is out of service and unavailable to other patients requiring transport who stand a better chance of survival. However, jurors will expect a patient with even a slim chance for survival to be given that chance.
Those who are incontrovertibly deceased should not be transported via ambulance. —DML
Aortic Dissection Misdiagnosed as Abdominal Pain and Hypertension
A 35-year-old Illinois man experienced sudden-onset severe abdominal pain at work. An ambulance was called. His co-workers described him as crying and writhing on the floor, with difficulty breathing and profuse sweating. The ambulance report described abdominal pain and cold, pale, diaphoretic skin but normal vital signs.
At the hospital emergency department (ED), the triage nurse noted mid-abdominal pain that felt like cramping, normal vital signs, and skin that was pink, warm, and dry. The defendant emergency physician, Dr. M., noted that the patient described moderate abdominal pain in the epigastric area. Dr. M.’s initial impression was gastritis or pancreatitis, but he ordered a cardiac work-up to rule out acute coronary syndrome. Cardiac enzyme levels were normal, but ECG results were abnormal and consistent with cardiac ischemia or hypertension. A chest x-ray showed an enlarged heart, which was consistent with the patient’s known history of hypertension.
The man’s co-workers, who visited him in a hallway in the ED, stated that the department was very busy. They stated that the patient was complaining of chest pain and spitting up blood, and that hospital personnel were paying him little attention.
The patient was given a “GI cocktail,” after which he vomited and reported feeling better. Dr. M. reevaluated him, noted that the patient reported no more abdominal pain, and discharged him with a diagnosis of abdominal pain and hypertension.
At discharge, the patient was instructed to follow up with a health care provider the following day for his hypertension and enlarged heart. According to a nurse’s note, the patient ambulated without difficulty at the time of discharge. The friend who picked him up, however, claimed that he was still in significant pain and had trouble walking to her car.
Six days later, the man was found dead at home. An autopsy revealed aortic dissection as the cause of death.
Plaintiff for the decedent claimed that Dr. M. failed to perform a proper history and physical examination, which would have revealed the signs and symptoms described by the decedent’s co-workers. It was undisputed that the co-workers’ description of the decedent’s condition at work was suggestive of aortic dissection. The plaintiff claimed that CT should have been ordered, with results indicating surgery; this would likely have prevented the man’s death. The plaintiff also claimed that the decedent’s abnormal ECG results should have prompted hospital admission and an inpatient cardiac work-up.
The defendant claimed that the decedent never reported the severe and dramatic symptoms described by his co-workers, to the paramedics, the triage nurse, or the emergency physician. Dr. M. further maintained that a proper history and physical examination were performed, that proper studies were conducted and appropriate medications provided, and that the decedent was properly discharged in an improved condition.
OUTCOME
The defendant hospital settled for $75,000 before trial. According to a published account, a defense verdict was returned, although an earlier trial in the case had ended in a $3.7 million verdict.
COMMENT
A history of abdominal pain and hypertension makes aortic dissection a diagnostic possibility, but it is unclear whether aortic dissection was considered as part of the differential diagnosis. The sudden onset and severe nature of the pain were clues, but controversy arose over whether this presentation was conveyed to the prehospital responders, the triage nurse, and/or the emergency physician.
This case was apparently retried following a substantial $3.7 million verdict, with the second result being quite different: a $75,000 settlement from the hospital and a defense verdict. It is unclear why the case was retried.
There are a few noteworthy points in this case. First, there was a disconnect between the description of the patient’s presentation given by his co-workers and the content of the EMS, nursing, and physician notes. The co-workers described sudden onset of severe pain, resulting in the patient crying and writhing on the floor; the triage nurse characterized the pain as abdominal “cramping” in quality, with the physician noting the patient’s description as “moderate” in intensity—a substantial difference. Whenever possible, attempt to elicit history from different sources and document each source of the information. In this case, more than likely the patient’s original presentation was not clearly communicated by the patient or by his co-workers to any of the treatment providers—the EMTs, the triage nurses and other hospital personnel, and the emergency physician.
Second, use of a “GI cocktail” as a diagnostic test to distinguish between gastrointestinal (GI) and non-GI causes of abdominal or chest pain can be problematic. The composition of the GI cocktail is generally antacid, viscous lidocaine, and an anticholinergic agent. Here, after consuming the GI cocktail, the patient said he felt better—perhaps falsely suggesting a gastrointestinal source of pain. While the use of a GI cocktail may provide symptomatic relief in certain circumstances, there is inadequate evidence to support making diagnostic decisions based on a patient’s response to it. So don’t.
Third, EDs are often overcrowded and chaotically busy. Such conditions can result in an overburdened staff, with clinicians feeling they did the best they could in an extremely difficult environment. Some clinicians have remarked they would like the jury to see “how the ED was that day”—to explain the pressure, the pace, and the other dire and pressing patient needs. But the malpractice plaintiff wants the jury to see “how the ED was that day,” too—to support the conclusion that the patient was not given the proper time, attention, and care that his or her condition warranted. Here, the plaintiff’s co-workers were willing to testify that the patient was “kept in the hallway,” that the department was “very busy,” and the personnel did not “pay much attention” to the patient—all to support the conclusion that the care was substandard.
While I can’t offer any breakthrough suggestions to cure the problem of ED overcrowding, I can recommend that clinicians do their best to make sure patients roomed in unconventional locations (such as the hallway) receive full attention and requisite concern so that they do not feel (or are not perceived as) neglected. A patient who has been placed in the hallway is still a patient in the hospital under your care. It goes without saying that a clinician should never form diagnostic or treatment impressions by virtue of where a patient is being examined: When a patient in the hallway is discovered to be acutely ill, immediate steps must be taken to re-room that patient. —DML
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
National initiative cuts incidence of birth hypoxia by 25%
Although it’s not a new trend, ObGyns are changing how they practice medicine as a direct result of the high cost or availability of liability insurance. From 2009 through 2011 about 18% of practicing obstetricians decreased the number of high-risk patients they were treating, 15% increased the number of cesarean deliveries they performed, 13.5% stopped offering vaginal birth after cesarean, and 5% stopped practicing obstetrics altogether, according to the American Congress of Obstetrics and Gynecology.1 Liability exposure, in part, also has resulted in fewer hospitals across the United States offering birthing services.2
The Premier Perinatal Safety Initiative (PPSI) is a national endeavor, involving 14 hospitals, designed to 1) lower the incidence of preventable adverse birth events, such as birth asphyxia and neonatal neurologic disability, 2) better define preventable perinatal harm, 3) identify measures to improve outcomes, and 4) evaluate the effect of harm reductions on liability claims and pay-outs.2
Reduced adverse events
In 2 years, PPSI hospitals reduced, on average2:
- birth hypoxia and asphyxia by 25%
- neonatal birth trauma by 22%
- complications from administering anesthesia during labor and delivery by 15%
- postpartum hemorrhage by 5.4%.
The adverse outcome index rate, which measures the number of patients with one or more of the identified adverse events as a proportion of total deliveries, was reduced by 7.5%, or 144 fewer adverse events from 2008 to 2010. All hospitals scored below the 2008 Agency for Healthcare Research and Quality (AHRQ) Provider Rate, a national comparative rate measuring perinatal harm.2
Reduced liability claims
In addition, liability claims and payouts decreased by 39% from 2006 to 2010, versus 10% at nonparticipating hospitals. All PPSI hospitals averaged 18 liability claims per year at baseline, but that number dropped to 10 in 2009 and is trending to 8 in 2010 (final claims losses are not yet available because it typically takes 2 years or longer for a claim to be filed).2
Strategies to achieve best outcomes
The best outcomes were achieved with two factors: An increased adherence to evidence-based care bundles in participating hospitals, and enhanced communication and teamwork among hospital staff.2
Increased adherence to evidence-based care bundles. Grouping essential processes together in care bundles helped clinical staff remember to take all of the necessary steps to provide optimal care. For a care bundle to be considered adhered to, staff were scored as “all or none,” meaning that all elements of the care bundle must have been observed for credit to have been given. For instance, the augmenting care bundle included four essential steps. If fetal weight was not calculated before oxytocin was administered, no credit was given for the care provided.2
PPSI hospitals significantly improved compliance with care bundles from 2008 to 2010. On average2:
- Elective induction bundle compliance increased from 58% to 88%.
- Augmentation bundle compliance increased from 33% to 72%.
- Vacuum bundle compliance increased from 9% to 51%.
High-reliability teams. PPSI hospitals implemented proven strategies for certain high-risk protocols known to enhance communication and teamwork, including2:
- TeamSTEPPS®. Developed by AHRQ, TeamSTEPPS produces highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.
- Situation Background Assessment Recommendation (SBAR). An effective situational briefing strategy used by the US Navy helps people communicate relevant case facts in a respectful, focused, and effective manner.
- Simulation drills. Practice exercises feature actresses and mannequins reacting as real patients during the birthing process.
Data regarding outcomes for these communication and teamwork strategies in the PPSI hospitals continues to be evaluated, and will be available in fall 2013.
Study information
Baseline data was completed in a retrospective study of harm outcome data from 2006 and 2007. During Phase 1, health-care teams implemented interventions and worked on improving performance and perinatal safety improvement across approximately 145,000 births. Phase 2 began in January 2011 and will be completed in December 2012.2
The 14 participating hospitals include 4 with small birth volume (1,000 to 2,499 births per year), 8 with medium birth volume (2,500 to 5,000 births per year), and 2 with large birth volume (5,000 or more births per year) in 10 states: Illinois, Kentucky, Massachusetts, Minnesota, New Mexico, Ohio, Tennessee, Texas, Washington, and Wisconsin. Six of 14 hospitals have academic teaching status.2
We want to hear from you! Tell us what you think.
1. 2012 ACOG survey on professional liability results. The American Congress of Obstetricians and Gynecologists Web site. http://www.acog.org/About_ACOG/ACOG_Departments/Professional_Liability/2012_Survey_Results. Accessed December 11, 2012.
2. Reducing preventable birth injuries and liability claims through evidence-based care, enhanced teamwork. Premier Perinatal Safety Initiative Phase 1 Summary, 2008–2010. PPSI_member_white_paper_Nov2012_FINAL.pdf. Published December 2010. Accessed December 11, 2012.
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Although it’s not a new trend, ObGyns are changing how they practice medicine as a direct result of the high cost or availability of liability insurance. From 2009 through 2011 about 18% of practicing obstetricians decreased the number of high-risk patients they were treating, 15% increased the number of cesarean deliveries they performed, 13.5% stopped offering vaginal birth after cesarean, and 5% stopped practicing obstetrics altogether, according to the American Congress of Obstetrics and Gynecology.1 Liability exposure, in part, also has resulted in fewer hospitals across the United States offering birthing services.2
The Premier Perinatal Safety Initiative (PPSI) is a national endeavor, involving 14 hospitals, designed to 1) lower the incidence of preventable adverse birth events, such as birth asphyxia and neonatal neurologic disability, 2) better define preventable perinatal harm, 3) identify measures to improve outcomes, and 4) evaluate the effect of harm reductions on liability claims and pay-outs.2
Reduced adverse events
In 2 years, PPSI hospitals reduced, on average2:
- birth hypoxia and asphyxia by 25%
- neonatal birth trauma by 22%
- complications from administering anesthesia during labor and delivery by 15%
- postpartum hemorrhage by 5.4%.
The adverse outcome index rate, which measures the number of patients with one or more of the identified adverse events as a proportion of total deliveries, was reduced by 7.5%, or 144 fewer adverse events from 2008 to 2010. All hospitals scored below the 2008 Agency for Healthcare Research and Quality (AHRQ) Provider Rate, a national comparative rate measuring perinatal harm.2
Reduced liability claims
In addition, liability claims and payouts decreased by 39% from 2006 to 2010, versus 10% at nonparticipating hospitals. All PPSI hospitals averaged 18 liability claims per year at baseline, but that number dropped to 10 in 2009 and is trending to 8 in 2010 (final claims losses are not yet available because it typically takes 2 years or longer for a claim to be filed).2
Strategies to achieve best outcomes
The best outcomes were achieved with two factors: An increased adherence to evidence-based care bundles in participating hospitals, and enhanced communication and teamwork among hospital staff.2
Increased adherence to evidence-based care bundles. Grouping essential processes together in care bundles helped clinical staff remember to take all of the necessary steps to provide optimal care. For a care bundle to be considered adhered to, staff were scored as “all or none,” meaning that all elements of the care bundle must have been observed for credit to have been given. For instance, the augmenting care bundle included four essential steps. If fetal weight was not calculated before oxytocin was administered, no credit was given for the care provided.2
PPSI hospitals significantly improved compliance with care bundles from 2008 to 2010. On average2:
- Elective induction bundle compliance increased from 58% to 88%.
- Augmentation bundle compliance increased from 33% to 72%.
- Vacuum bundle compliance increased from 9% to 51%.
High-reliability teams. PPSI hospitals implemented proven strategies for certain high-risk protocols known to enhance communication and teamwork, including2:
- TeamSTEPPS®. Developed by AHRQ, TeamSTEPPS produces highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.
- Situation Background Assessment Recommendation (SBAR). An effective situational briefing strategy used by the US Navy helps people communicate relevant case facts in a respectful, focused, and effective manner.
- Simulation drills. Practice exercises feature actresses and mannequins reacting as real patients during the birthing process.
Data regarding outcomes for these communication and teamwork strategies in the PPSI hospitals continues to be evaluated, and will be available in fall 2013.
Study information
Baseline data was completed in a retrospective study of harm outcome data from 2006 and 2007. During Phase 1, health-care teams implemented interventions and worked on improving performance and perinatal safety improvement across approximately 145,000 births. Phase 2 began in January 2011 and will be completed in December 2012.2
The 14 participating hospitals include 4 with small birth volume (1,000 to 2,499 births per year), 8 with medium birth volume (2,500 to 5,000 births per year), and 2 with large birth volume (5,000 or more births per year) in 10 states: Illinois, Kentucky, Massachusetts, Minnesota, New Mexico, Ohio, Tennessee, Texas, Washington, and Wisconsin. Six of 14 hospitals have academic teaching status.2
We want to hear from you! Tell us what you think.
Although it’s not a new trend, ObGyns are changing how they practice medicine as a direct result of the high cost or availability of liability insurance. From 2009 through 2011 about 18% of practicing obstetricians decreased the number of high-risk patients they were treating, 15% increased the number of cesarean deliveries they performed, 13.5% stopped offering vaginal birth after cesarean, and 5% stopped practicing obstetrics altogether, according to the American Congress of Obstetrics and Gynecology.1 Liability exposure, in part, also has resulted in fewer hospitals across the United States offering birthing services.2
The Premier Perinatal Safety Initiative (PPSI) is a national endeavor, involving 14 hospitals, designed to 1) lower the incidence of preventable adverse birth events, such as birth asphyxia and neonatal neurologic disability, 2) better define preventable perinatal harm, 3) identify measures to improve outcomes, and 4) evaluate the effect of harm reductions on liability claims and pay-outs.2
Reduced adverse events
In 2 years, PPSI hospitals reduced, on average2:
- birth hypoxia and asphyxia by 25%
- neonatal birth trauma by 22%
- complications from administering anesthesia during labor and delivery by 15%
- postpartum hemorrhage by 5.4%.
The adverse outcome index rate, which measures the number of patients with one or more of the identified adverse events as a proportion of total deliveries, was reduced by 7.5%, or 144 fewer adverse events from 2008 to 2010. All hospitals scored below the 2008 Agency for Healthcare Research and Quality (AHRQ) Provider Rate, a national comparative rate measuring perinatal harm.2
Reduced liability claims
In addition, liability claims and payouts decreased by 39% from 2006 to 2010, versus 10% at nonparticipating hospitals. All PPSI hospitals averaged 18 liability claims per year at baseline, but that number dropped to 10 in 2009 and is trending to 8 in 2010 (final claims losses are not yet available because it typically takes 2 years or longer for a claim to be filed).2
Strategies to achieve best outcomes
The best outcomes were achieved with two factors: An increased adherence to evidence-based care bundles in participating hospitals, and enhanced communication and teamwork among hospital staff.2
Increased adherence to evidence-based care bundles. Grouping essential processes together in care bundles helped clinical staff remember to take all of the necessary steps to provide optimal care. For a care bundle to be considered adhered to, staff were scored as “all or none,” meaning that all elements of the care bundle must have been observed for credit to have been given. For instance, the augmenting care bundle included four essential steps. If fetal weight was not calculated before oxytocin was administered, no credit was given for the care provided.2
PPSI hospitals significantly improved compliance with care bundles from 2008 to 2010. On average2:
- Elective induction bundle compliance increased from 58% to 88%.
- Augmentation bundle compliance increased from 33% to 72%.
- Vacuum bundle compliance increased from 9% to 51%.
High-reliability teams. PPSI hospitals implemented proven strategies for certain high-risk protocols known to enhance communication and teamwork, including2:
- TeamSTEPPS®. Developed by AHRQ, TeamSTEPPS produces highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.
- Situation Background Assessment Recommendation (SBAR). An effective situational briefing strategy used by the US Navy helps people communicate relevant case facts in a respectful, focused, and effective manner.
- Simulation drills. Practice exercises feature actresses and mannequins reacting as real patients during the birthing process.
Data regarding outcomes for these communication and teamwork strategies in the PPSI hospitals continues to be evaluated, and will be available in fall 2013.
Study information
Baseline data was completed in a retrospective study of harm outcome data from 2006 and 2007. During Phase 1, health-care teams implemented interventions and worked on improving performance and perinatal safety improvement across approximately 145,000 births. Phase 2 began in January 2011 and will be completed in December 2012.2
The 14 participating hospitals include 4 with small birth volume (1,000 to 2,499 births per year), 8 with medium birth volume (2,500 to 5,000 births per year), and 2 with large birth volume (5,000 or more births per year) in 10 states: Illinois, Kentucky, Massachusetts, Minnesota, New Mexico, Ohio, Tennessee, Texas, Washington, and Wisconsin. Six of 14 hospitals have academic teaching status.2
We want to hear from you! Tell us what you think.
1. 2012 ACOG survey on professional liability results. The American Congress of Obstetricians and Gynecologists Web site. http://www.acog.org/About_ACOG/ACOG_Departments/Professional_Liability/2012_Survey_Results. Accessed December 11, 2012.
2. Reducing preventable birth injuries and liability claims through evidence-based care, enhanced teamwork. Premier Perinatal Safety Initiative Phase 1 Summary, 2008–2010. PPSI_member_white_paper_Nov2012_FINAL.pdf. Published December 2010. Accessed December 11, 2012.
More NEWS FOR YOUR PRACTICE…
<list type="bullet"> <item><para>Antidepressants linked to pregnancy risks in infertility treatment</para></item> <item><para>Highlights from 41st Annual AAGL Meeting in Las Vegas</para></item> <item><para>In a study of compliance, a new contraceptive patch tops the pill</para></item> <item><para>Breast cancer genome analysis highlights 4 subtypes, link to ovarian cancer</para></item> <item><para>ObGyns’ status of Maintenance of Certification now public</para></item> <item><para>VTE risk varies by hormone therapy formulation</para></item> </list>
1. 2012 ACOG survey on professional liability results. The American Congress of Obstetricians and Gynecologists Web site. http://www.acog.org/About_ACOG/ACOG_Departments/Professional_Liability/2012_Survey_Results. Accessed December 11, 2012.
2. Reducing preventable birth injuries and liability claims through evidence-based care, enhanced teamwork. Premier Perinatal Safety Initiative Phase 1 Summary, 2008–2010. PPSI_member_white_paper_Nov2012_FINAL.pdf. Published December 2010. Accessed December 11, 2012.
More NEWS FOR YOUR PRACTICE…
<list type="bullet"> <item><para>Antidepressants linked to pregnancy risks in infertility treatment</para></item> <item><para>Highlights from 41st Annual AAGL Meeting in Las Vegas</para></item> <item><para>In a study of compliance, a new contraceptive patch tops the pill</para></item> <item><para>Breast cancer genome analysis highlights 4 subtypes, link to ovarian cancer</para></item> <item><para>ObGyns’ status of Maintenance of Certification now public</para></item> <item><para>VTE risk varies by hormone therapy formulation</para></item> </list>
When your patients disclose ‘insider information’
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
My patient is an officer in a large corporation. During therapy, he sometimes talks about how the company is doing. Would I risk malpractice liability if I used this information in managing my retirement investments?
Submitted by “Dr. B”
As most physicians find out within a short time of finishing medical school, doctors learn all kinds of useful things from their patients, including information that can help them manage personal matters outside their practices. But are you allowed to use nonpublic business information to make investment decisions?
As this article explains, legal rules and case law suggest that if psychiatrists or therapists act on potentially profitable business information incidentally mentioned by a patient during treatment, they may be subject to serious legal problems. To explain why, we’ll begin with a brief overview of business terms, including “securities” and “insider trading.” Then, to answer Dr. B’s question, we’ll look at what kind of legal consequences may result if mental health professionals are found guilty of “misappropriating” confidential business information.
Securities and security rules
Approximately one-half to two-thirds of Americans have money invested in the stock market—either through their retirement plans, by owning mutual funds, or by holding stocks of individual companies.1 Stocks are a type of financial instrument, or security, that companies issue to raise capital. Companies also raise money by issuing debt, typically in the form of bonds that pay interest to the holder, who in buying the bond has in effect loaned money to the company. Derivatives refer to securities that have prices that move up or down depending on the value of some underlying asset, such as stock prices.2
Stock prices fluctuate in reaction to general economic developments—changes in the unemployment rate, in the cost of basic materials (eg, oil or metals used in manufacturing), or in government policies that influence consumers’ purchasing decisions. But the key factor in determining the price of a company’s stock is investors’ beliefs about the company’s future earnings.3 Because investors usually have to make educated guesses about a company’s future, actually knowing something about a company before the general public finds out would give an investor a huge—but possibly unfair—advantage over other investors.
Making markets fair for all investors is the key purpose of U.S. laws on trading securities. In the 1930s, Congress created the Securities and Exchange Commission (SEC), a federal agency charged with ensuring that companies report the truth about their financial situation and that potential investors receive full, fair disclosure of available public information.4 Among the many ways that the SEC does this is by enforcing regulations concerning “insider trading.”
‘Insider trading’
Corporate “insiders” (eg, directors or employees) often know a lot about how their businesses are doing, and they buy or sell stock in their own companies. Such trading is legal if the insiders follow federal regulations about the timing of their investments and report them publicly.
Insider trading is illegal, however, if an individual acquires material, nonpublic information about a corporation through a relationship that involves trust and confidence and then uses that information when buying or selling a security. The SEC has prosecuted corporate employees who traded securities after learning of confidential developments in their companies, friends and family members of corporate officers who bought or sold securities after getting such information, and employees of law firms who misused information they received while providing services to corporations whose securities they traded.5
To be guilty of insider trading, a person must:
- buy or sell a security based on information that the person realizes is material and nonpublic,6 and
- have received the confidential information under circumstances that create a duty of trust or confidence.7
If both of these conditions are met, the person has wrongfully used confidential information with which he was entrusted, or “misappropriated” that information for personal gain.8
Physicians sometimes gain information that, if used for investment decisions, might lead to accusations of insider trading. Stock prices of pharmaceutical companies rise before public announcements of clinical drug trials, which suggests that information about those results leaks out in advance.9 Recently, physicians have gotten into well-publicized legal trouble by making investment decisions based on information they obtained while participating on an institution’s board10 and from learning early results of clinical drug trials.11
But would it be wrong for a psychiatrist to make a potentially profitable investment based on information obtained incidentally during a treatment encounter? After all, it’s not as though the psychiatrist would be a corporate insider or would have acquired the information improperly. Yet courts have ruled that a psychiatrist’s trading on such information might constitute malpractice and could be grounds for even more serious legal consequences.
Potential malpractice issues
The federal court ruling in United States v Willis12 describes how a psychiatrist learned during treatment that a patient’s husband was seeking to become CEO of a large bank. Realizing that this development might make the bank more valuable, the psychiatrist told his broker what he had learned and purchased 13,000 shares of the bank’s stock for himself and his children. When the husband’s efforts were announced publicly a few weeks later, the psychiatrist sold the shares at a big profit.
Quoting the vow of confidentiality contained in the Hippocratic Oath (Box),13 the court held that the psychiatrist had an obligation to the patient not to disclose information learned during her treatment without her permission. The court said the patient “had an economic interest in preserving the confidentiality of the information disclosed,” and the psychiatrist’s actions “might have jeopardized her husband’s advancement” and financial benefits the wife would have gained. Also, the psychiatrist’s “disclosures jeopardized the psychiatrist-patient relationship,” which might negate the wife’s financial investment in her care, require her to find a new psychiatrist, or require additional treatment to deal with how the psychiatrist’s behavior had affected her.12
And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings—things that should not ever be blurted out outside—I will remain silent, holding such things to be unutterable.
Source: Reference 13
More legal consequences
Dr. Willis had legal problems more serious than just a malpractice lawsuit. He faced criminal prosecution for insider trading and mail fraud, and the court refused to dismiss these charges. The court reasoned that the psychiatrist received the information while in a position of trust and confidence, and breached that trust when he used that confidential information for his personal benefit—behavior that meets the legal definition of “misappropriation.” Because the psychiatrist received stock trade confirmations through the U.S. mail, he also could face federal charges of mail fraud. Ultimately, Dr. Willis pled guilty and paid $137,000 in fines and penalties. Although Dr. Willis retained his New Jersey medical license and avoided a prison sentence, the district court sentenced him to 5 years of probation and required that he perform 3,000 hours of community service.14,15
In a second case,16 a licensed clinical social worker made investments through a broker based on information learned during a therapy session about upcoming business developments (the 1994 Lockheed-Martin Marietta merger). The social worker pled guilty to insider trading, forfeited the illegal gains, and paid a large fine.
Related Resources
- Insider trading versus medical professionalism. Lancet. 2005;366(9488):781.
- Nijm LM. The online message board controversy. Physicians hit with claims of libel and insider trading by their employers. J Leg Med. 2000;21(2):223-239.
Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Jacobe D. In U.S., 54% have stock market investments, lowest since 1999. Gallup Economy. http://www.gallup.com/poll/147206/stock-market-investments-lowest-1999.aspx. Published April 20, 2011. Accessed October 9, 2012.
2. Roman S. Introduction to the mathematics of finance: from risk management to options pricing. New York NY: Springer-Verlag; 2004.
3. Elton EJ, Gruber MJ, Brown SJ, et al. Modern portfolio theory and investment analysis. Hoboken, NJ: John Wiley & Sons; 2010.
4. Keller E, Gehlmann GA. Introductory comment: a historical introduction to the Securities Act of 1933 and the Securities Exchange Act of 1934. Ohio State Law Journal. 1988;49:329-352.
5. U.S. Securities and Exchange Commission. Insider trading. http://www.sec.gov/answers/insider.htm. Published April 19, 2001. Accessed October 9, 2012.
6. 17 CFR 240. 10b5-1.
7. 17 CFR 240. 10b5-2.
8. United States v O’Hagan, 521 U.S. 642 (1997).
9. Rothenstein JM, Tomlinson G, Tannock IF, et al. Company stock prices before and after public announcements related to oncology drugs. J Natl Cancer Inst. 2011;103(20):1507-1512.
10. U.S. Securities and Exchange Commission. SEC charges five physicians with insider trading in stock of medical professional liability insurer. http://www.sec.gov/news/press/2012/2012-132.htm. Published July 10, 2012. Accessed October 9, 2012.
11. Two more are sentenced in insider trading cases. New York Times. December 21 2011:B9. http://www.nytimes.com/2011/12/22/business/in-crackdown-on-insider-trading-two-more-are-sentenced.html?_r=0. Accessed October 9, 2012.
12. United States v Willis, 737 F Supp 269 (SD NY 1990).
13. von Staden H. “In a pure and holy way”: personal and professional conduct in the Hippocratic Oath? J Hist Med Allied Sci. 1996;51(4):404-437.
14. 24 Sec Reg & L Rep (BNA) 7 (1992).
15. Psychiatrist is sentenced. New York Times. January 8 1992. http://www.nytimes.com/1992/01/08/business/credit-markets-psychiatrist-is-sentenced.html. Accessed November 5, 2012.
16. SEC v Cooper, Litigation Rel. No. 14754, 60 S.E.C. Docket 2430 (1995).
Douglas Mossman, MD
Dr. Mossman is Professor and Program Director, University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Douglas Mossman, MD
Dr. Mossman is Professor and Program Director, University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Douglas Mossman, MD
Dr. Mossman is Professor and Program Director, University of Cincinnati Forensic Psychiatry Fellowship, Cincinnati, OH
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
My patient is an officer in a large corporation. During therapy, he sometimes talks about how the company is doing. Would I risk malpractice liability if I used this information in managing my retirement investments?
Submitted by “Dr. B”
As most physicians find out within a short time of finishing medical school, doctors learn all kinds of useful things from their patients, including information that can help them manage personal matters outside their practices. But are you allowed to use nonpublic business information to make investment decisions?
As this article explains, legal rules and case law suggest that if psychiatrists or therapists act on potentially profitable business information incidentally mentioned by a patient during treatment, they may be subject to serious legal problems. To explain why, we’ll begin with a brief overview of business terms, including “securities” and “insider trading.” Then, to answer Dr. B’s question, we’ll look at what kind of legal consequences may result if mental health professionals are found guilty of “misappropriating” confidential business information.
Securities and security rules
Approximately one-half to two-thirds of Americans have money invested in the stock market—either through their retirement plans, by owning mutual funds, or by holding stocks of individual companies.1 Stocks are a type of financial instrument, or security, that companies issue to raise capital. Companies also raise money by issuing debt, typically in the form of bonds that pay interest to the holder, who in buying the bond has in effect loaned money to the company. Derivatives refer to securities that have prices that move up or down depending on the value of some underlying asset, such as stock prices.2
Stock prices fluctuate in reaction to general economic developments—changes in the unemployment rate, in the cost of basic materials (eg, oil or metals used in manufacturing), or in government policies that influence consumers’ purchasing decisions. But the key factor in determining the price of a company’s stock is investors’ beliefs about the company’s future earnings.3 Because investors usually have to make educated guesses about a company’s future, actually knowing something about a company before the general public finds out would give an investor a huge—but possibly unfair—advantage over other investors.
Making markets fair for all investors is the key purpose of U.S. laws on trading securities. In the 1930s, Congress created the Securities and Exchange Commission (SEC), a federal agency charged with ensuring that companies report the truth about their financial situation and that potential investors receive full, fair disclosure of available public information.4 Among the many ways that the SEC does this is by enforcing regulations concerning “insider trading.”
‘Insider trading’
Corporate “insiders” (eg, directors or employees) often know a lot about how their businesses are doing, and they buy or sell stock in their own companies. Such trading is legal if the insiders follow federal regulations about the timing of their investments and report them publicly.
Insider trading is illegal, however, if an individual acquires material, nonpublic information about a corporation through a relationship that involves trust and confidence and then uses that information when buying or selling a security. The SEC has prosecuted corporate employees who traded securities after learning of confidential developments in their companies, friends and family members of corporate officers who bought or sold securities after getting such information, and employees of law firms who misused information they received while providing services to corporations whose securities they traded.5
To be guilty of insider trading, a person must:
- buy or sell a security based on information that the person realizes is material and nonpublic,6 and
- have received the confidential information under circumstances that create a duty of trust or confidence.7
If both of these conditions are met, the person has wrongfully used confidential information with which he was entrusted, or “misappropriated” that information for personal gain.8
Physicians sometimes gain information that, if used for investment decisions, might lead to accusations of insider trading. Stock prices of pharmaceutical companies rise before public announcements of clinical drug trials, which suggests that information about those results leaks out in advance.9 Recently, physicians have gotten into well-publicized legal trouble by making investment decisions based on information they obtained while participating on an institution’s board10 and from learning early results of clinical drug trials.11
But would it be wrong for a psychiatrist to make a potentially profitable investment based on information obtained incidentally during a treatment encounter? After all, it’s not as though the psychiatrist would be a corporate insider or would have acquired the information improperly. Yet courts have ruled that a psychiatrist’s trading on such information might constitute malpractice and could be grounds for even more serious legal consequences.
Potential malpractice issues
The federal court ruling in United States v Willis12 describes how a psychiatrist learned during treatment that a patient’s husband was seeking to become CEO of a large bank. Realizing that this development might make the bank more valuable, the psychiatrist told his broker what he had learned and purchased 13,000 shares of the bank’s stock for himself and his children. When the husband’s efforts were announced publicly a few weeks later, the psychiatrist sold the shares at a big profit.
Quoting the vow of confidentiality contained in the Hippocratic Oath (Box),13 the court held that the psychiatrist had an obligation to the patient not to disclose information learned during her treatment without her permission. The court said the patient “had an economic interest in preserving the confidentiality of the information disclosed,” and the psychiatrist’s actions “might have jeopardized her husband’s advancement” and financial benefits the wife would have gained. Also, the psychiatrist’s “disclosures jeopardized the psychiatrist-patient relationship,” which might negate the wife’s financial investment in her care, require her to find a new psychiatrist, or require additional treatment to deal with how the psychiatrist’s behavior had affected her.12
And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings—things that should not ever be blurted out outside—I will remain silent, holding such things to be unutterable.
Source: Reference 13
More legal consequences
Dr. Willis had legal problems more serious than just a malpractice lawsuit. He faced criminal prosecution for insider trading and mail fraud, and the court refused to dismiss these charges. The court reasoned that the psychiatrist received the information while in a position of trust and confidence, and breached that trust when he used that confidential information for his personal benefit—behavior that meets the legal definition of “misappropriation.” Because the psychiatrist received stock trade confirmations through the U.S. mail, he also could face federal charges of mail fraud. Ultimately, Dr. Willis pled guilty and paid $137,000 in fines and penalties. Although Dr. Willis retained his New Jersey medical license and avoided a prison sentence, the district court sentenced him to 5 years of probation and required that he perform 3,000 hours of community service.14,15
In a second case,16 a licensed clinical social worker made investments through a broker based on information learned during a therapy session about upcoming business developments (the 1994 Lockheed-Martin Marietta merger). The social worker pled guilty to insider trading, forfeited the illegal gains, and paid a large fine.
Related Resources
- Insider trading versus medical professionalism. Lancet. 2005;366(9488):781.
- Nijm LM. The online message board controversy. Physicians hit with claims of libel and insider trading by their employers. J Leg Med. 2000;21(2):223-239.
Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Discuss this article at www.facebook.com/CurrentPsychiatry
Dear Dr. Mossman:
My patient is an officer in a large corporation. During therapy, he sometimes talks about how the company is doing. Would I risk malpractice liability if I used this information in managing my retirement investments?
Submitted by “Dr. B”
As most physicians find out within a short time of finishing medical school, doctors learn all kinds of useful things from their patients, including information that can help them manage personal matters outside their practices. But are you allowed to use nonpublic business information to make investment decisions?
As this article explains, legal rules and case law suggest that if psychiatrists or therapists act on potentially profitable business information incidentally mentioned by a patient during treatment, they may be subject to serious legal problems. To explain why, we’ll begin with a brief overview of business terms, including “securities” and “insider trading.” Then, to answer Dr. B’s question, we’ll look at what kind of legal consequences may result if mental health professionals are found guilty of “misappropriating” confidential business information.
Securities and security rules
Approximately one-half to two-thirds of Americans have money invested in the stock market—either through their retirement plans, by owning mutual funds, or by holding stocks of individual companies.1 Stocks are a type of financial instrument, or security, that companies issue to raise capital. Companies also raise money by issuing debt, typically in the form of bonds that pay interest to the holder, who in buying the bond has in effect loaned money to the company. Derivatives refer to securities that have prices that move up or down depending on the value of some underlying asset, such as stock prices.2
Stock prices fluctuate in reaction to general economic developments—changes in the unemployment rate, in the cost of basic materials (eg, oil or metals used in manufacturing), or in government policies that influence consumers’ purchasing decisions. But the key factor in determining the price of a company’s stock is investors’ beliefs about the company’s future earnings.3 Because investors usually have to make educated guesses about a company’s future, actually knowing something about a company before the general public finds out would give an investor a huge—but possibly unfair—advantage over other investors.
Making markets fair for all investors is the key purpose of U.S. laws on trading securities. In the 1930s, Congress created the Securities and Exchange Commission (SEC), a federal agency charged with ensuring that companies report the truth about their financial situation and that potential investors receive full, fair disclosure of available public information.4 Among the many ways that the SEC does this is by enforcing regulations concerning “insider trading.”
‘Insider trading’
Corporate “insiders” (eg, directors or employees) often know a lot about how their businesses are doing, and they buy or sell stock in their own companies. Such trading is legal if the insiders follow federal regulations about the timing of their investments and report them publicly.
Insider trading is illegal, however, if an individual acquires material, nonpublic information about a corporation through a relationship that involves trust and confidence and then uses that information when buying or selling a security. The SEC has prosecuted corporate employees who traded securities after learning of confidential developments in their companies, friends and family members of corporate officers who bought or sold securities after getting such information, and employees of law firms who misused information they received while providing services to corporations whose securities they traded.5
To be guilty of insider trading, a person must:
- buy or sell a security based on information that the person realizes is material and nonpublic,6 and
- have received the confidential information under circumstances that create a duty of trust or confidence.7
If both of these conditions are met, the person has wrongfully used confidential information with which he was entrusted, or “misappropriated” that information for personal gain.8
Physicians sometimes gain information that, if used for investment decisions, might lead to accusations of insider trading. Stock prices of pharmaceutical companies rise before public announcements of clinical drug trials, which suggests that information about those results leaks out in advance.9 Recently, physicians have gotten into well-publicized legal trouble by making investment decisions based on information they obtained while participating on an institution’s board10 and from learning early results of clinical drug trials.11
But would it be wrong for a psychiatrist to make a potentially profitable investment based on information obtained incidentally during a treatment encounter? After all, it’s not as though the psychiatrist would be a corporate insider or would have acquired the information improperly. Yet courts have ruled that a psychiatrist’s trading on such information might constitute malpractice and could be grounds for even more serious legal consequences.
Potential malpractice issues
The federal court ruling in United States v Willis12 describes how a psychiatrist learned during treatment that a patient’s husband was seeking to become CEO of a large bank. Realizing that this development might make the bank more valuable, the psychiatrist told his broker what he had learned and purchased 13,000 shares of the bank’s stock for himself and his children. When the husband’s efforts were announced publicly a few weeks later, the psychiatrist sold the shares at a big profit.
Quoting the vow of confidentiality contained in the Hippocratic Oath (Box),13 the court held that the psychiatrist had an obligation to the patient not to disclose information learned during her treatment without her permission. The court said the patient “had an economic interest in preserving the confidentiality of the information disclosed,” and the psychiatrist’s actions “might have jeopardized her husband’s advancement” and financial benefits the wife would have gained. Also, the psychiatrist’s “disclosures jeopardized the psychiatrist-patient relationship,” which might negate the wife’s financial investment in her care, require her to find a new psychiatrist, or require additional treatment to deal with how the psychiatrist’s behavior had affected her.12
And about whatever I may see or hear in treatment, or even without treatment, in the life of human beings—things that should not ever be blurted out outside—I will remain silent, holding such things to be unutterable.
Source: Reference 13
More legal consequences
Dr. Willis had legal problems more serious than just a malpractice lawsuit. He faced criminal prosecution for insider trading and mail fraud, and the court refused to dismiss these charges. The court reasoned that the psychiatrist received the information while in a position of trust and confidence, and breached that trust when he used that confidential information for his personal benefit—behavior that meets the legal definition of “misappropriation.” Because the psychiatrist received stock trade confirmations through the U.S. mail, he also could face federal charges of mail fraud. Ultimately, Dr. Willis pled guilty and paid $137,000 in fines and penalties. Although Dr. Willis retained his New Jersey medical license and avoided a prison sentence, the district court sentenced him to 5 years of probation and required that he perform 3,000 hours of community service.14,15
In a second case,16 a licensed clinical social worker made investments through a broker based on information learned during a therapy session about upcoming business developments (the 1994 Lockheed-Martin Marietta merger). The social worker pled guilty to insider trading, forfeited the illegal gains, and paid a large fine.
Related Resources
- Insider trading versus medical professionalism. Lancet. 2005;366(9488):781.
- Nijm LM. The online message board controversy. Physicians hit with claims of libel and insider trading by their employers. J Leg Med. 2000;21(2):223-239.
Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. Jacobe D. In U.S., 54% have stock market investments, lowest since 1999. Gallup Economy. http://www.gallup.com/poll/147206/stock-market-investments-lowest-1999.aspx. Published April 20, 2011. Accessed October 9, 2012.
2. Roman S. Introduction to the mathematics of finance: from risk management to options pricing. New York NY: Springer-Verlag; 2004.
3. Elton EJ, Gruber MJ, Brown SJ, et al. Modern portfolio theory and investment analysis. Hoboken, NJ: John Wiley & Sons; 2010.
4. Keller E, Gehlmann GA. Introductory comment: a historical introduction to the Securities Act of 1933 and the Securities Exchange Act of 1934. Ohio State Law Journal. 1988;49:329-352.
5. U.S. Securities and Exchange Commission. Insider trading. http://www.sec.gov/answers/insider.htm. Published April 19, 2001. Accessed October 9, 2012.
6. 17 CFR 240. 10b5-1.
7. 17 CFR 240. 10b5-2.
8. United States v O’Hagan, 521 U.S. 642 (1997).
9. Rothenstein JM, Tomlinson G, Tannock IF, et al. Company stock prices before and after public announcements related to oncology drugs. J Natl Cancer Inst. 2011;103(20):1507-1512.
10. U.S. Securities and Exchange Commission. SEC charges five physicians with insider trading in stock of medical professional liability insurer. http://www.sec.gov/news/press/2012/2012-132.htm. Published July 10, 2012. Accessed October 9, 2012.
11. Two more are sentenced in insider trading cases. New York Times. December 21 2011:B9. http://www.nytimes.com/2011/12/22/business/in-crackdown-on-insider-trading-two-more-are-sentenced.html?_r=0. Accessed October 9, 2012.
12. United States v Willis, 737 F Supp 269 (SD NY 1990).
13. von Staden H. “In a pure and holy way”: personal and professional conduct in the Hippocratic Oath? J Hist Med Allied Sci. 1996;51(4):404-437.
14. 24 Sec Reg & L Rep (BNA) 7 (1992).
15. Psychiatrist is sentenced. New York Times. January 8 1992. http://www.nytimes.com/1992/01/08/business/credit-markets-psychiatrist-is-sentenced.html. Accessed November 5, 2012.
16. SEC v Cooper, Litigation Rel. No. 14754, 60 S.E.C. Docket 2430 (1995).
1. Jacobe D. In U.S., 54% have stock market investments, lowest since 1999. Gallup Economy. http://www.gallup.com/poll/147206/stock-market-investments-lowest-1999.aspx. Published April 20, 2011. Accessed October 9, 2012.
2. Roman S. Introduction to the mathematics of finance: from risk management to options pricing. New York NY: Springer-Verlag; 2004.
3. Elton EJ, Gruber MJ, Brown SJ, et al. Modern portfolio theory and investment analysis. Hoboken, NJ: John Wiley & Sons; 2010.
4. Keller E, Gehlmann GA. Introductory comment: a historical introduction to the Securities Act of 1933 and the Securities Exchange Act of 1934. Ohio State Law Journal. 1988;49:329-352.
5. U.S. Securities and Exchange Commission. Insider trading. http://www.sec.gov/answers/insider.htm. Published April 19, 2001. Accessed October 9, 2012.
6. 17 CFR 240. 10b5-1.
7. 17 CFR 240. 10b5-2.
8. United States v O’Hagan, 521 U.S. 642 (1997).
9. Rothenstein JM, Tomlinson G, Tannock IF, et al. Company stock prices before and after public announcements related to oncology drugs. J Natl Cancer Inst. 2011;103(20):1507-1512.
10. U.S. Securities and Exchange Commission. SEC charges five physicians with insider trading in stock of medical professional liability insurer. http://www.sec.gov/news/press/2012/2012-132.htm. Published July 10, 2012. Accessed October 9, 2012.
11. Two more are sentenced in insider trading cases. New York Times. December 21 2011:B9. http://www.nytimes.com/2011/12/22/business/in-crackdown-on-insider-trading-two-more-are-sentenced.html?_r=0. Accessed October 9, 2012.
12. United States v Willis, 737 F Supp 269 (SD NY 1990).
13. von Staden H. “In a pure and holy way”: personal and professional conduct in the Hippocratic Oath? J Hist Med Allied Sci. 1996;51(4):404-437.
14. 24 Sec Reg & L Rep (BNA) 7 (1992).
15. Psychiatrist is sentenced. New York Times. January 8 1992. http://www.nytimes.com/1992/01/08/business/credit-markets-psychiatrist-is-sentenced.html. Accessed November 5, 2012.
16. SEC v Cooper, Litigation Rel. No. 14754, 60 S.E.C. Docket 2430 (1995).