Medical Malpractice Cases Involving Medical Students.

PURPOSE: This study uses a large national legal database to analyze characteristics of malpractice claims involving U.S. medical students. METHOD: The Westlaw database was searched in September 2023 for malpractice cases involving medical students from January 1, 1900, through September 1, 2023. Each case was independently reviewed by 2 authors, abstracting each variable. Categorical data were summarized as frequency of occurrence (i.e., number and percentage), and continuous data were summarized with means, medians, and ranges. All authors independently reviewed the dataset to identify potential themes and codes. RESULTS: There were 65 cases that met the inclusion criteria. Reported patient outcomes were death (19, 29%), pain (25, 38%), and disability (36, 55%). The most common specialties involved were emergency medicine (16, 25%), general surgery (14, 22%), and obstetrics and gynecology (13, 20%). The most common primary alleged errors attributed to students related to medical decision-making (30, 46%), procedural complication (24, 37%), and poor communication (11, 17%). Among 23 (35%) cases reporting year of training, 1 (4%) included a second-year student, 13 (57%) included third-year students, and 9 (39%) included fourth-year students. Of the 65 lawsuits, 28 (43%) resulted in a settlement or verdict against the medical student. The total amount paid in these cases was $78,192,612, with a mean (median) of $3,007,408 ($1,050,000) per case. Of these 28 cases, 14 (50%) cited minimal or no physician supervision. CONCLUSIONS: Medical malpractice claims involving medical students are rare but commonly relate to medical decision-making, procedural complication, and poor communication, with a lack of supervision being frequently cited. These results can be used to guide students and supervising physicians on how to avoid scenarios that may increase vulnerability to medical malpractice lawsuits.

Adult Congenital Heart Disease in the Emergency Department.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

A review of medical malpractice cases involving trainees in the emergency department.

Background: This study characterizes medical malpractice lawsuits involving trainees providing care in the emergency department (ED), affording insight into the types of patients involved, clinical scenarios, and legal outcomes of these cases. Methods: Cases were identified using the legal database, Westlaw. Per chart review methods, relevant information was abstracted by 2 trained reviewers onto a standardized data abstraction form, with a senior author arbitrating disagreements. Results: We identified 60 cases reported between 1982 and 2017 in which a trainee was named in a lawsuit related to patient care provided in the ED. The most common alleged errors included diagnostic (n = 37, 61%), treatment (n = 13, 21%), and procedural errors (n = 19, 16%). In 21 cases (35%), it was alleged that no attending physician was directly involved in the care at any time. The attending was noted to have seen the patient in person at any point in only 11 total cases (18%). Of the 50 cases with known outcomes, 15 (30%) decided in favor of the patient, 21 (42%) were resolved in the physician's favor, and 14 (28%) were settled. Conclusion: This study underscores that trainees are vulnerable to malpractice cases and that lack of direct supervision is a prominent theme in these cases. This information suggests areas for further work and may help training programs, trainees, and supervising physicians design their practice patterns in ways that mitigate these risks in the future.

Return Rates for Opioid versus Nonopioid Management of Patients with Abdominal Pain in the Emergency Department.

BACKGROUND: Research suggests that opioid treatment for abdominal pain, which comprises a large proportion of patients presenting to the emergency department (ED), may contribute to long-term opioid use without significant benefits with regard to symptom management. OBJECTIVES: This study seeks to assess the association between opioid use for management of abdominal pain in the ED and return ED visits for abdominal pain within 30 days for patients discharged from the ED at initial presentation. METHODS: We conducted a retrospective, multicenter observational study of adult patients presenting to and discharged from 21 EDs with a chief concern of abdominal pain between November 2018 and April 2020. The proportion of 30-day return visits to the ED for patients who received opioid analgesics was compared with a reference group of patients who only received acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or both. RESULTS: Of the 4745 patients, 1304 (27.5%) received opioids and 1101 (23.2%) only received either acetaminophen, NSAIDs, or both. Among those given opioids, 287 (22.0%) returned to the ED for abdominal pain within 30 days, compared with 162 (14.7%) of those in the reference group (odds ratio 1.57, 95% confidence interval 1.27-1.95, p-value < 0.001). CONCLUSION: Patients given opioids for abdominal pain in the ED had 57% increased odds of a return ED visit within 30 days compared with those given only acetaminophen or NSAIDs. This warrants further research on the use of nonopioid analgesics in the ED, especially in patients with anticipated discharge.

Stercoral Colitis in the Emergency Department: A Retrospective Review of Presentation, Management, and Outcomes.

STUDY OBJECTIVE: Stercoral colitis is inflammation of the bowel wall caused by fecal impaction. Despite reported high morbidity and risk of perforation, little research assessing outcomes is available. This study characterizes the presentation, management, and outcomes of emergency department patients with stercoral colitis. METHODS: We performed a retrospective chart review of ED patients with stercoral colitis identified on computed tomography (CT) scan. Of 814, 522 visits to multiple EDs across the US, 269 met the inclusion criteria. Variables regarding patient presentation, management, and outcomes were extracted from electronic medical records. Results were analyzed with percentages and 95% confidence intervals (CIs). RESULTS: Of 269 patients, the median age was 76 years. The most common chief concern was abdominal pain/distension (33.8%). However, abdominal pain was documented as absent in 62.1% of cases. The most common CT findings included fecal impaction (96.7%), bowel wall inflammation (72.9%), and fat stranding (48.3%). Eighty-four (31.2%) patients were discharged home from the ED, and over half of these (45/84, 53.6%) received no enema, laxatives, or disimpaction. Overall, 9 patients (3.3%, 95% CI 1.6% to 6.5%) required surgical management of a related complication within 3 months, 27 (10.0%, 95% CI 6.8% to 14.4%) returned to the ED within 72 hours, and 9 (3.3%, 95% CI 1.6% to 6.5%) died from a cause related to stercoral colitis within 3 months. CONCLUSION: Patients with stercoral colitis often present in a nonspecific manner, and short-term mortality is substantial. In this study, most discharged patients did not receive recommended treatment. This represents the largest ED study of stercoral colitis and provides further evidence linking this diagnosis with adverse outcomes.

Gender differences in academic productivity, educational positions, and leadership appointments of physicians in the U.S.

BACKGROUND: Promotions in academic medicine are frequently based on number of publications and leadership positions held. While prior study has established women publish less than men, many evaluations are limited to individual specialties and do not evaluate involvement with educational activities. OBJECTIVE: To compare gender differences in academic output, intramural leadership positions, and educational leadership positions of academic physicians. METHODS: The curriculum vitae and de-identified demographic data of all permanent physicians employed at a multi-site academic medical center were reviewed from April to May 2020. Multivariable logistic and Poisson regressions evaluated leadership positions and number of publications. RESULTS: Of 3,359 physicians in the demographic database, 32.3% (n = 1,087) were women and 72.5% were white (n = 2,510). Of the 3,015 physicians in the curriculum vitae database, 32% (n = 962) were women. Women were more likely (p < 0.001) to be assistant professor (54% vs. 42.7%) and less likely to be associate (18.1% vs. 20.3%) or full professor (14.6% vs. 29.1%). Women assistant professors published 22% fewer articles (ratio estimate = 0.78, p < 0.001), associate professors 18% less (coefficient = 0.82, p < 0.001), and full professors 23% less (coefficient = 0.77, p < 0.001). Fewer women were program directors for residencies (1.6% vs. 2.9%, p = 0.02) or fellowships (5.4% vs. 7.4%, p = 0.04), and held fewer division or department leadership positions (OR 0.8, 95% CI as [0.6, 1.0], p = 0.03). CONCLUSION: Women physicians do not outperform men across any education, leadership, or publication category. A cultural shift is needed to redefine traditional metrics for leadership appointments if academic medicine hopes to achieve equity.

Review of Cardiac Malpractice Cases Involving a Trainee.

Lawsuits involving medical trainees are underappreciated and poorly documented, including within cardiology-related fields. The purpose of this review was to characterize clinical characteristics and legal outcomes of cardiology- and cardiac surgery-related lawsuits involving trainees. Westlaw, an online legal research database containing legal records from around the United States, was retrospectively reviewed for malpractice cases involving medical students, residents, or fellows through November 2020. Cases included both cardiac and cardiac surgery cases. A total of 28 cases were identified, with 16 involving female patients (57%). In the 17 cases in which patient age was included, the median age was 51 years. A total of 22 (79%) cases resulted in death or permanent disability. The most common alleged errors included procedural issues (n = 14, 50%) and failure to diagnose (n = 7, 25%). A total of 14 cases (50%) ended in favor of the physicians, 9 (32%) ended in a settlement or verdict against the physician, and 5 cases had an unknown outcome. Of the 8 cases in which the settlement or verdict amount was reported, the median payment was $1,291,992 with a range of $220,507-$30,000,000. This review of cardiac and cardiac surgery malpractice cases involving a trainee suggests trainee involvement in procedures and diagnosis may confer relatively high liability risks for both trainees and their supervisors.

Medical Malpractice Lawsuits Involving Trainees in Obstetrics and Gynecology in the USA.

BACKGROUND: While the liability risks for obstetrics and gynecology (ob/gyn) physicians are widely recognized, little is known about how trainees have been involved in ob/gyn lawsuits. OBJECTIVES: To characterize involvement of trainees in malpractice lawsuits related to ob/gyn. METHODS: The legal database Westlaw was utilized to collect ob/gyn-related malpractice lawsuits involving trainees reported from 1986 to 2020 in the USA. OUTCOME: Forty-six malpractice cases involving ob/gyn trainees were identified, including 34 cases related to obstetrics and 12 to gynecology. There were 11 cases alleging lack of informed consent, including 7 cases alleging lack of consent for trainee involvement. Of the 34 obstetrics cases, 27 related to procedural complications, 17 to treatment, 13 to diagnosis, and 4 to informed consent. Of these, 17 were decided in favor of the physician, 6 resulted in findings of negligence, 9 had unknown outcomes, and 3 ended in settlement. For the 6 cases ending in a finding of negligence, the mean award was $2,174,472 compared to $685,000 for those that were settled. Of the 12 gynecology cases, 8 related to procedural complications, 7 to informed consent, 3 to diagnosis, and 2 to treatment. Of these, 6 were decided in favor of the physician, 3 resulted in findings of negligence, and 3 had unknown outcomes. For the cases ending in a finding of negligence, the mean award was $465,000. CONCLUSIONS AND OUTLOOK: This review of malpractice cases highlights types of situations in which trainees are sued and reveals the importance of designing curriculum around faculty training and supervision regarding trainee involvement in patient care.

Charting Practices to Protect Against Malpractice: Case Reviews and Learning Points.

INTRODUCTION: Medical documentation issues play a role in 10-20% of medical malpractice lawsuits. Inaccurate, incomplete, or generic records undermine a physician's defense and make a plaintiff's lawyer more likely to take on a case. Despite the frequency of documentation errors in malpractice suits, physicians receive very little education or feedback on their documentation. Our objective in this case series was to evaluate malpractice cases related to documentation to help improve physicians' documentation and minimize their liability risks. METHODS: We used Thomson Reuters Westlaw legal database to identify malpractice cases related to documentation. Common issues related to documentation and themes in the cases were identified and highlighted. RESULTS: We classified cases into the following categories: incomplete documentation; inaccurate text; transcription errors; judgmental language; and alteration of documentation. By evaluating real cases, physicians can better understand common errors of other practitioners and avoid these in their own practice. CONCLUSION: Emergency physicians can reduce their liability risks by relying less on forms and templates and making a habit of documenting discussions with the patients, recording others' involvement in patient care (chaperones, consultants, trainees, etc.), addressing others' notes (triage staff, nurses, residents, etc.), paying attention to accuracy of transcribed or dictated information, avoiding judgmental language, and refraining from altering patient charts.

Let's Be Honest: These Medical Malpractice Cases Were a Pain in the Back.

INTRODUCTION: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated. CASE REPORT: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making. CONCLUSION: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments.

Group Practice Size Consolidation in Emergency Medicine.

STUDY OBJECTIVE: Practice consolidation is common and has been shown to affect the quality and cost of care across multiple health care delivery settings, including hospitals, nursing homes, and physician practices. Despite a long history of large practice management group formation in emergency medicine and intensifying media attention paid to this topic, little is known about the recent practice consolidation trends within the specialty. METHODS: All data were obtained from the Centers for Medicare and Medicaid Services Physician Compare database, which contains physician and group practice data from 2012 to 2020. We assessed practice size changes for both individual emergency physicians and groups. RESULTS: From 2012 to 2020, the proportion of emergency physicians in groups sized less than 25 has decreased substantially from 40.2% to 22.7%. Physicians practicing in groups of more than or equal to 500 physicians increased from 15.5% to 24%. CONCLUSION: Since 2012, we observed a steady trend toward increased consolidation of emergency department practice with nearly 1 in 4 emergency physicians nationally working in groups with more than 500 physicians in 2020 compared with 1 in 7 in 2012. Although the relationship between consolidation is likely to draw the most attention from policymakers or payers seeking to negotiate prices in the near term and advance payment models in the long term, greater attention is required to understand the effects of practice consolidation on emergency care.

State Variability in Peer Review Protections Heightens Liability Risks.

OBJECTIVE: To highlight various state-specific gaps in legal protections involving the peer review process with the goal of helping participants better identify and address potential hazards so they may continue to confidently engage in peer review activities. METHODS: State laws regarding peer review protections involving privilege and confidentiality were searched through Westlaw (a legal research database) and state government websites and categorized. RESULTS: Gaps in protection were identified in 17 states and the District of Columbia. In the 18 jurisdictions in which potential legal gaps were identified, the most common exceptions involved peer review activities that were initiated without a legally required number of participants, were not formally mandated by the institution or other external body, or that were voluntarily discussed outside of the peer review context by participants in the process. CONCLUSION: The widespread variability in state-based peer review protections showcases the complexity of deciphering peer review law and emphasizes the need to not just read the relevant state and federal laws but to obtain the professional guidance of a lawyer experienced in peer review law before engaging in peer review activities. These measures will improve providers' engagement in peer review and strengthen an important tool for quality improvement.

Relationship Between Pain Management Modality and Return Rates for Lower Back Pain in the Emergency Department.

BACKGROUND: Emerging evidence suggests that opioid use for patients with acute low back pain does not improve functional outcomes and contributes to long-term opioid use. Little is known about the impact of opioid administration in the emergency department (ED) for patients with low back pain. OBJECTIVES: This study compares 30-day return rates after administration of various pain management modalities for emergency department (ED) patients with low back pain. METHODS: We conducted a retrospective multicenter observational study of patients in the ED who were diagnosed with low back pain and discharged home in 21 EDs between November 2018 and April 2020. Patients were categorized based on the pain management they received in the ED and compared with the reference group of patients receiving only nonsteroidal anti-inflammatory drugs, acetaminophen, or a combination of the two. The proportions of ED return visits within 30 d for each medication category was calculated and associations between analgesia categories and proportions of return visits were assessed using logistic regression models to obtain odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Patients with low back pain who received any opioid, intravenous opioid, or intramuscular opioid had significantly increased proportions of a return visit within 30 d (32% [OR 1.78 {95% CI 1.21-2.64}]; 33% [OR 1.83 {95% CI 1.18-2.86}]; and 39% [OR 2.38 {95% CI 1.35-4.12}], respectively) when compared with patients who received nonsteroidal anti-inflammatory drugs (19%), acetaminophen (20%), or a combination of the two (8%). CONCLUSIONS: Patients receiving opioids were more likely to return to the ED within 30 d than those receiving received nonsteroidal anti-inflammatory drugs or acetaminophen. This suggests that the use of opioids for low back pain in the ED may not be an effective strategy, and there may be an opportunity to appropriately treat more of these patients with nonopioid medications.

Descriptive Analysis of Components of Emergency Medicine Residency Program Websites.

INTRODUCTION: Most emergency medicine (EM) applicants use the internet as a source of information when evaluating residency programs. Previous studies have analyzed the components of residency program websites; however, there is a paucity of information regarding EM program websites. The purpose of our study was to analyze information on EM residency program websites. METHODS: In April-May 2020, we evaluated 249 United States EM residency program websites for presence or absence of 38 items relevant to EM applicants. Descriptive statistics were performed, including means and standard deviations. RESULTS: Of the 249 EM websites evaluated, the websites contained a mean of 20 of 38 items (53%). Only 16 programs (6%) contained at least three-quarters of the items of interest, and no programs contained all 38 items. The general categories with the least amount of items were social media use (9%), research (46%), and lifestyle (49%), compared to the other general categories such as application process (58%), resident information (63%), general program information (67%), and facility information (69%). The items provided by programs most often included program description (98%), blocks and rotations (91%), and faculty listing (88%). The items provided least often included housing/neighborhood information (17%) and social media links (19%). CONCLUSION: Our comprehensive review of EM residency websites in the US revealed the absence of many variables on most programs' websites. Use of this information to enhance accessibility of desired information stands to benefit both applicants and programs in the increasingly competitive specialty of EM.

Medicare Reimbursement to Physicians Decreased for Common Emergency Medicine Services From 2000 to 2020.

STUDY OBJECTIVE: The change in reimbursement rates for emergency physician services has yet to be quantified. We attempted to fill this knowledge gap by evaluating the monetary trends in Medicare reimbursement rates over the last 20 years for the most common emergency medicine services. METHODS: We obtained commonly used Current Procedural Terminology (CPT) codes in emergency medicine from the American College of Emergency Physicians website. We queried the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services for each of the included CPT codes, and we extracted reimbursement data. We adjusted all monetary data for inflation to 2020 US dollars by using changes to the United States consumer price index. Both the average annual and the total percentage change in reimbursement were calculated on the basis of these adjusted trends for all included services. RESULTS: Reimbursement by Medicare for the services decreased by an average of 29.13% from 2000 to 2020 after adjusting for inflation. There was a stable decline in adjusted reimbursement rates throughout the study period, with an average decrease of 1.61% each year. The largest decrease was seen for laceration repairs up to 7.5 cm, with reimbursement rates for all 4 relevant CPT codes decreasing by more than 60%. CONCLUSION: When adjusted for inflation, Medicare reimbursement declined by an average of 29% over the last 20 years for the 20 most common emergency medicine services. Knowledge of these trends is essential to address current controversies in emergency medicine billing adequately and advocate for sustainable payment system reform.

Patient Length of Stay Under the Two-Midnight Rule: Assessing the Accuracy of Providers' Predictions.

EXECUTIVE SUMMARY: We sought to determine emergency medicine physicians' accuracy in designating patients' disposition status as "inpatient" or "observation" at the time of hospital admission in the context of Medicare's Two-Midnight rule and to identify characteristics that may improve the providers' predictions. We conducted a 90-day observational study of emergency department (ED) admissions involving adults aged 65 years and older and assessed the accuracy of physicians' disposition decisions. Logistic regression models were fit to explore associations and predictors of disposition. A total of 2,257 patients 65 and older were admitted through the ED. The overall error rate in physician designation of observation or inpatient was 36%. Diagnoses most strongly associated with stays lasting less than two midnights included diverticulitis, syncope, and nonspecific chest pain. Diagnoses most strongly associated with stays lasting two or more midnights included orthopedic fractures, biliary tract disease, and back pain. ED physicians inaccurately predicted patient length of stay in more than one third of all patients. Under the Two-Midnight rule, these inaccurate predictions place hospitals at risk of underpayment and patients at risk of significant financial liability. Further work is needed to increase providers' awareness of the financial repercussions of their admission designations and to identify interventions that can improve prediction accuracy.

Anaphylaxis-related Malpractice Lawsuits.

INTRODUCTION: Anaphylaxis continues to cause significant morbidity and mortality. Healthcare providers struggle to promptly recognize and appropriately treat anaphylaxis patients. The goal of this study was to characterize anaphylaxis-related malpractice lawsuits. METHODS: We collected jury verdicts, settlements, and court opinions regarding alleged medical malpractice involving anaphylaxis from May 2011 through May 2016 from an online legal database (Thomson Reuters Westlaw). Data were abstracted onto a standardized data form. RESULTS: We identified 30 anaphylaxis-related malpractice lawsuits. In 80% of cases, the trigger was iatrogenic (40% intravenous [IV] contrast, 33% medications, 7% latex). Sixteen (53%) cases resulted in death, 7 (23%) in permanent cardiac and/or neurologic damage, and 7 (23%) in less severe outcomes. Fourteen (47%) of the lawsuits were related to exposure to a known trigger. Delayed recognition or treatment was cited in 12 (40%) cases and inappropriate IV epinephrine dosing was reported in 5 (17%) cases. Defendants were most commonly physicians (n=15, 50%) and nurses (n=5, 17%). The most common physician specialties named were radiology and primary care (n=3, 10% each), followed by emergency medicine, anesthesiology, and cardiology (n=2, 7% each). Among the 30 cases, 14 (47%) favored the defendant, 8 (37%) resulted in findings of negligence, 3 (10%) cases settled, and 5 (17%) had an unknown legal outcome. CONCLUSION: Additional anaphylaxis education, provision of epinephrine autoinjectors or other alternatives to reduce dosing errors, and stronger safeguards to prevent administration of known allergens would all likely reduce anaphylaxis-related patient morbidity and mortality and providers' legal vulnerability to anaphylaxis-related lawsuits.