Managing Your Practice

The author reports no financial relationships relevant to this article.

“Immediately after the event I was a wreck. I vaguely remember talking to the family; I don’t know if I was much use to them.… That night I got drunk. It was the only way I could sleep. A sensitive colleague came and sat with me.”¹

As an ObGyn, it is almost certain that you will be sued sometime during your career. Specific actions that I’ll describe in this article can help you deal with the stress associated with the adverse event that precipitates the lawsuit and the lawsuit itself. To begin, remember:

• Anticipation is the best defense
• Knowledge is power
• Action counters passivity
• A supportive environment is essential.

How can you anticipate litigation?

What is the risk? No nationwide reporting system tracks the incidence of medical malpractice claims. A recent survey by the American College of Obstetricians and Gynecologists, however, found that 89% of practicing ObGyns had been sued at least once in their career, with an average of 2.62 claims for every ObGyn.² Because a claim usually takes years to resolve, a substantial number of ObGyns are involved in litigation at any one time.

You can successfully anticipate litigation by maintaining familiarity with your state’s statute of limitations—usually, this period is 2 to 3 years after discovery of the incident, with exceptions for children, the disabled, and designated special circumstances. If a plaintiff’s case is not filed within this time, a disputed outcome can never be the subject of a malpractice claim.

ObGyns are keenly aware of the exception that extends the time period during which a case may be filed on behalf of a child after discovery of the alleged injury. Many states set 8 years as the cutoff for filing a claim; others, such as Illinois, extend the period for as long as 2 years after a child’s 18th birthday. This long tail of vulnerability creates unpredictability for insurers, who must estimate the relationship between current premiums and potential payouts (often in the distant future), resulting in high premiums for ObGyns’ insurance. More importantly, it creates an undercurrent of anxiety and uncertainty for those ObGyns who must contemplate defending themselves in court for incidents that occurred in the distant past.

Listen to your feelings whenever you suspect that a patient is dissatisfied or that a bad outcome may lead to a claim, and take appropriate action. Reexamine your risk management procedures and discuss your concerns with your risk manager. Because it may take years for a case to be filed and many more for it to be adjudicated, possibly by trial, your best defense is clear, accurate, comprehensive, and contemporaneous documentation of the situation. Any later review of the case will be based on records that, if clearly kept, will be easily and unambiguously interpreted despite the passage of time.

Responding to an adverse event

The severity of the outcome, the nature of your relationship with the patient, and the degree of your responsibility for an adverse event contribute to the intensity of your initial emotional response. If a mistake caused the event, your reaction may be even more severe.^3-6 Whatever the specifics of the event, you may ruminate about your role and degree of responsibility (TABLE 1).

TABLE 1

Questions that might nag you after a “bad” outcome

Is this my fault?
Could I have prevented this from happening?
Did I make a mistake in this patient’s diagnosis or treatment?
Did I make a mistake in judgment?
Could I have done something else (such as perform a cesarean section or decide not to perform a VBAC)?
Did I harbor unconscious transference feelings (such as feelings of dislike, mistrust, or anger) toward this patient?
Did I miss some signs I should have seen?
Would this have happened no matter what I had done?
Are others to blame?

TABLE 2

The 3 “must-do” actions after an adverse event

Medical steps Take necessary actions to limit further injury or disability Obtain appropriate consultations Review the medical record; anticipate the patient’s follow-up needs and make recommendations for further treatment
Notifications Follow the health-care system’s and insurer’s guidelines for notifying the patient and family Inform the institution’s risk manager and your professional liability carrier as soon as possible Write a description of the event for the record and a narrative for your personal file (and your lawyer’s) in case a suit is filed later Do not talk with the media
Disclosures Acknowledge your ethical obligation to be truthful Follow your institution’s and insurer’s guidelines on disclosure Expect to feel intimidated and uneasy in discussing your role in the event Expect the patient and family to be angry and disappointed with you Convey an interest in the patient’s and family’s emotional state; express sorrow for their loss Tell the patient and family what you know for sure; don’t speculate about what is unknown and don’t make false promises or false reassurances Don’t hurry; give the patient and family time to ask questions Expect to feel somewhat better after a truthful exchange

 

Expect that your view of the circumstances will generate a complex array of feelings: shock, anxiety, depression, shame, guilt, self-blame, disbelief, self-doubt and inadequacy, anger, and, even, relief from not having to work with a difficult patient anymore.

Most physicians feel a personal sense of failure and inadequacy when they are unable to prevent a patient’s death or serious injury. Although serious events evoke greater distress, any event that may eventually be judged an error or become the subject of a lawsuit can give rise to anxiety, decreased confidence, sleep disturbances, and decreased job satisfaction.⁶ In the midst of such feelings, you must:

• deal with the event’s medical complications, relevant notifications, and disclosures (TABLE 2)
• address the emotional pain of the injured patient or family
• participate in mandated reviews
• recognize and manage the emotional disruption to you (TABLE 3).

Self-evaluation. To cope with distress when a patient dies, you could attend the funeral. You also might:

• make changes in your practice that alert you to problem patients
• introduce a more structured approach to patients with particular clinical conditions, using practice guidelines as a resource⁷
• become more alert to patients who may benefit from consultation or referral.

Balance the time you devote to work and personal life. Schedule regular time for recreation and active sports, which can help you prepare for the prolonged stress that follows being sued. Engage a personal physician to monitor your physical and emotional health and to recommend appropriate referrals, when indicated.

TABLE 3

Get a grip on your emotions, before and during litigation

Anticipate having repeated thoughts and preoccupations about the event; work toward a realistic view of it
Recognize your feelings and work to understand their source
Talk with a trusted confidant (spouse, colleague) about your feelings
Monitor your emotional and physical status; if indicated, seek appropriate consultation
Avoid situations that generate anxiety and increase stress
Monitor and address changes in your relationships with family, patients, colleagues, and staff
Be understanding of yourself and others; develop a realistic view of yourself as a “good doctor”
Engage in active sports and take regular vacations unrelated to professional activities
Control what can be controlled

Knowledge is power

What can I expect? A lawsuit generates a mixture of common emotions and exacerbates those felt at the time of the bad outcome: shock, outrage, anxiety, anguish, dread, depression, helplessness, hopelessness, feelings of being misunderstood, and the anger and vulnerability associated with a narcissistic injury. Ordinarily we possess a healthy narcissism—that is, good feelings of self-esteem and a set of ideals that motivate and gratify us. When we suffer a tragic outcome or are sued, our self-esteem and ideals are directly challenged, resulting in feelings of failure, criticism, and public humiliation. These feelings can damage our sense of self and generate further feelings of shame, depression, and rage—all signs of a so-called narcissistic injury. As one ObGyn stated, learning that a lawsuit was filed “just prolonged my misery.”⁸

Each of us reacts in our own way to a lawsuit—and differently to each lawsuit if we are sued more than once—because of:

• our personality traits and personal circumstances
• the specifics of a case
• our relationship with the patient
• the public nature of a lawsuit
• a range of other variables that makes each case unique.

Suddenly, you who perceive yourself as caring, beneficent, well-meaning, and devoted to your patients are publicly accused of being careless and incompetent, of harming the patient by failing to meet your minimal obligations. Psychiatrists Ferrell and Price⁹ capture the impact of these allegations:

Here are the sense of assault and violation, the feelings of outrage and fear. Most painfully, here is the narcissistic injury, the astonishing wound to our understanding of ourselves as admirable, well-meaning people.

Litigation is a lengthy process with defined stages (TABLE 4). You have little control over a slow-paced process that involves an array of participants (lawyers, judges, jury, experts) whose behavior is unpredictable. This can make you feel dependent, vulnerable, and impotent.

TABLE 4

Pocket guide to what happens in court

STAGE OF ACTION	WHAT IT MEANS FOR DEFENDANT AND PLAINTIFF
Summons	Notification that a suit has been filed
Complaint	The nature of the allegation in legal terms
Pleadings	The attorney begins to communicate with the court by filing motions; a request that the court do something
Discovery	A process designed to obtain information about the case: Interrogatories (written questions) Depositions (oral questions and answers under oath) Inspection of documents Expert witnesses (persons used to establish the relationship between the event and the standard of care)
Summary judgment	A motion asking the court, after the facts have been established by discovery, to decide the validity of the case; if granted, the case is resolved without a trial by jury
Settlement	An agreement between parties that resolves their legal dispute
Trial	Case is presented to the judge or a judge and jury to determine culpability
Verdict	Decision reached by the deciding body
Posttrial	If the defendant receives an unfavorable verdict, motions may be offered to the court to void or appeal the verdict

 

Be active, not passive

What you can do. Contact your insurer and risk manager immediately. Inquire about the average length of litigation in your jurisdiction (it might be 1 to 5, or more, years, depending on locality, type of case, and severity of injury). Ask your attorney to describe the steps in the process and your role as the case proceeds.

Take whatever steps are necessary to cover your clinical duties. If your initial emotional reaction is disruptive, obtain coverage or rearrange your schedule. Expect to change or limit your schedule before depositions and during trial to allow adequate time for preparation.

Accept the fact that you must play by rules far different from those of medical care. Litigation is time-consuming and frustrating. Delays and so-called continuances are common in legal proceedings, so expect them. Consider adapting to your situation the strategies that other sued physicians have found useful in regaining control over their life and work (TABLE 5).

TABLE 5

Regain control and manage your practice during litigation

Learn as much as you can about the legal process
Introduce good risk-management strategies, such as efficient record-keeping, into your practice
Clarify the responsibilities of office personnel and coverage responsibilities with associates
Rearrange office schedules during periods of increased stress
Reevaluate your time commitments to work and family
Participate in relevant continuing education
Make sure your financial and estate planning is current
Cooperate with legal counsel
Devote sufficient time to deposition preparation and other demands of the case
Carefully evaluate the advice of legal and insurance counsel regarding a settlement
Don’t try to “fit patients in” while on trial; a trial is a full-time job

Get needed support

Talking about the case. Sharing, with responsible confidants, your emotional reactions to being sued is healthy for you and others affected. Lawyers, however, may caution you not to “talk to anybody” about the case. They don’t want you to say anything that would suggest liability or jeopardize their defense of the case.

This may be good legal advice, but it is not good psychological advice. The support of others is a natural help during major life events that cause enormous stress and disruption.¹⁰ You can resolve this dilemma by accepting the discipline of talking about your feelings regarding the case without discussing the specifics of the case.

In addition to lawyers and claims representatives, you may talk with your spouse or another trusted person or colleague about your feelings. When you choose to talk with a psychiatrist or other mental health professional about your litigation experiences, you are protected by the confidentiality inherent in the doctor–patient relationship.

Trust issues. At the core of all medical work lies trust. As a well-trained and competent professional, you do not expect to be sued by patients with whom you have trusting and often long-term relationships. Most physicians acknowledge that after being sued their relationships with patients change.^11,12 You may find it difficult to reestablish trusting and comfortable relationships with other patients, especially those who have conditions similar, often high-risk, to that of the suing patient.

A charge of negligence exposes our vulnerabilities and leaves us feeling hurt and betrayed, feelings that are not easily overcome. As one psychiatrist ruefully observed: “I lost my innocence.”⁸

Conflicted feelings may emerge. The distress associated with a lawsuit often exacerbates the many outside stressors associated with practice. Many solo practitioners find themselves already overextended, working longer hours, covering more hospitals, and rarely taking vacations. Younger physicians who prize “time off” and lifestyle above other incentives remain stressed by the unpredictable schedules associated with ObGyn practice. Women physicians increasingly constitute a greater percentage of the ObGyn specialty. Although some work part-time or, at least, fewer hours than their male counterparts, they must nonetheless keep current and continually hone their skills.

The stress associated with all of these conditions can increase an ObGyn’s vulnerability to the occurrence of an adverse event and, eventually, to a lawsuit. It is also known that physicians involved in a claim-producing event are twice as likely as their non–claim-producing counterparts to have another such event within the ensuing 12 months.¹³

When you are sued, you may feel overwhelmed and out of control. Because physicians’ ability to control their schedule and work hours is a known major predictor of their overall health (as evidenced by a balance between their work and personal life),¹⁴ regaining control over those aspects of your life that are “controllable” (TABLE 5) is an essential strategy in dealing with a lawsuit.

As a result of your lawsuit, you may contemplate changing practice circumstances or retiring early. Feelings that you must change the way you practice and chronic anxiety about your work are barriers to good practice. Personal therapy may help if you remain uneasy or cannot resolve life choices that overshadow your work with patients.

 

Seek medical or psychiatric care?

Be alert to the point at which you or others involved in litigation need a referral for medical or psychiatric consultation. Sued physicians, their families, and colleagues often experience psychiatric conditions or other problems, such as:

• major depression
• adjustment disorder
• posttraumatic stress disorder
• worsening of a previously diagnosed psychiatric illness
• physical symptoms that require diagnosis and treatment
• alcohol and drug misuse or abuse
• anxiety and distress that interfere with work
• self-medication, especially for insomnia
• disturbances and dysfunctional behaviors that affect marital and family life.^15,16

Take stock—then, it’s “steady as you go”

Most of us have stable and supportive relationships and are, for the most part, psychologically healthy and professionally competent. It is normal, however, to experience distress in response to the trauma of a bad outcome (whatever its origin) and the lawsuit that may follow. Most physicians are resilient—that is, able to manage the stress without developing major symptoms—but some benefit from professional support.

Whatever your reaction to being sued, become familiar with the climate of litigation in the jurisdiction where the case was filed, including the incidence and outcome of cases. For example, does a similar case to yours usually result in settlement or—if it goes to trial—does it take 2 to 5, or more, years to resolve?

Last, it’s a comfort to know that approximately 70% of complaints filed result in no payment (no settlement) for the plaintiff. When a case does go to trial, physicians win 80% of the time.

The challenge, then, for you when you are sued? Take an active role in managing your distress in ways that contribute to your vindication and to the continuity of care for your patients.

The author reports no financial relationships relevant to this article.

“Immediately after the event I was a wreck. I vaguely remember talking to the family; I don’t know if I was much use to them.… That night I got drunk. It was the only way I could sleep. A sensitive colleague came and sat with me.”¹

As an ObGyn, it is almost certain that you will be sued sometime during your career. Specific actions that I’ll describe in this article can help you deal with the stress associated with the adverse event that precipitates the lawsuit and the lawsuit itself. To begin, remember:

• Anticipation is the best defense
• Knowledge is power
• Action counters passivity
• A supportive environment is essential.

How can you anticipate litigation?

What is the risk? No nationwide reporting system tracks the incidence of medical malpractice claims. A recent survey by the American College of Obstetricians and Gynecologists, however, found that 89% of practicing ObGyns had been sued at least once in their career, with an average of 2.62 claims for every ObGyn.² Because a claim usually takes years to resolve, a substantial number of ObGyns are involved in litigation at any one time.

You can successfully anticipate litigation by maintaining familiarity with your state’s statute of limitations—usually, this period is 2 to 3 years after discovery of the incident, with exceptions for children, the disabled, and designated special circumstances. If a plaintiff’s case is not filed within this time, a disputed outcome can never be the subject of a malpractice claim.

ObGyns are keenly aware of the exception that extends the time period during which a case may be filed on behalf of a child after discovery of the alleged injury. Many states set 8 years as the cutoff for filing a claim; others, such as Illinois, extend the period for as long as 2 years after a child’s 18th birthday. This long tail of vulnerability creates unpredictability for insurers, who must estimate the relationship between current premiums and potential payouts (often in the distant future), resulting in high premiums for ObGyns’ insurance. More importantly, it creates an undercurrent of anxiety and uncertainty for those ObGyns who must contemplate defending themselves in court for incidents that occurred in the distant past.

Listen to your feelings whenever you suspect that a patient is dissatisfied or that a bad outcome may lead to a claim, and take appropriate action. Reexamine your risk management procedures and discuss your concerns with your risk manager. Because it may take years for a case to be filed and many more for it to be adjudicated, possibly by trial, your best defense is clear, accurate, comprehensive, and contemporaneous documentation of the situation. Any later review of the case will be based on records that, if clearly kept, will be easily and unambiguously interpreted despite the passage of time.

Responding to an adverse event

The severity of the outcome, the nature of your relationship with the patient, and the degree of your responsibility for an adverse event contribute to the intensity of your initial emotional response. If a mistake caused the event, your reaction may be even more severe.^3-6 Whatever the specifics of the event, you may ruminate about your role and degree of responsibility (TABLE 1).

TABLE 1

Questions that might nag you after a “bad” outcome

Is this my fault?
Could I have prevented this from happening?
Did I make a mistake in this patient’s diagnosis or treatment?
Did I make a mistake in judgment?
Could I have done something else (such as perform a cesarean section or decide not to perform a VBAC)?
Did I harbor unconscious transference feelings (such as feelings of dislike, mistrust, or anger) toward this patient?
Did I miss some signs I should have seen?
Would this have happened no matter what I had done?
Are others to blame?

TABLE 2

The 3 “must-do” actions after an adverse event

Medical steps Take necessary actions to limit further injury or disability Obtain appropriate consultations Review the medical record; anticipate the patient’s follow-up needs and make recommendations for further treatment
Notifications Follow the health-care system’s and insurer’s guidelines for notifying the patient and family Inform the institution’s risk manager and your professional liability carrier as soon as possible Write a description of the event for the record and a narrative for your personal file (and your lawyer’s) in case a suit is filed later Do not talk with the media
Disclosures Acknowledge your ethical obligation to be truthful Follow your institution’s and insurer’s guidelines on disclosure Expect to feel intimidated and uneasy in discussing your role in the event Expect the patient and family to be angry and disappointed with you Convey an interest in the patient’s and family’s emotional state; express sorrow for their loss Tell the patient and family what you know for sure; don’t speculate about what is unknown and don’t make false promises or false reassurances Don’t hurry; give the patient and family time to ask questions Expect to feel somewhat better after a truthful exchange

 

Expect that your view of the circumstances will generate a complex array of feelings: shock, anxiety, depression, shame, guilt, self-blame, disbelief, self-doubt and inadequacy, anger, and, even, relief from not having to work with a difficult patient anymore.

Most physicians feel a personal sense of failure and inadequacy when they are unable to prevent a patient’s death or serious injury. Although serious events evoke greater distress, any event that may eventually be judged an error or become the subject of a lawsuit can give rise to anxiety, decreased confidence, sleep disturbances, and decreased job satisfaction.⁶ In the midst of such feelings, you must:

• deal with the event’s medical complications, relevant notifications, and disclosures (TABLE 2)
• address the emotional pain of the injured patient or family
• participate in mandated reviews
• recognize and manage the emotional disruption to you (TABLE 3).

Self-evaluation. To cope with distress when a patient dies, you could attend the funeral. You also might:

• make changes in your practice that alert you to problem patients
• introduce a more structured approach to patients with particular clinical conditions, using practice guidelines as a resource⁷
• become more alert to patients who may benefit from consultation or referral.

Balance the time you devote to work and personal life. Schedule regular time for recreation and active sports, which can help you prepare for the prolonged stress that follows being sued. Engage a personal physician to monitor your physical and emotional health and to recommend appropriate referrals, when indicated.

TABLE 3

Get a grip on your emotions, before and during litigation

Anticipate having repeated thoughts and preoccupations about the event; work toward a realistic view of it
Recognize your feelings and work to understand their source
Talk with a trusted confidant (spouse, colleague) about your feelings
Monitor your emotional and physical status; if indicated, seek appropriate consultation
Avoid situations that generate anxiety and increase stress
Monitor and address changes in your relationships with family, patients, colleagues, and staff
Be understanding of yourself and others; develop a realistic view of yourself as a “good doctor”
Engage in active sports and take regular vacations unrelated to professional activities
Control what can be controlled

Knowledge is power

What can I expect? A lawsuit generates a mixture of common emotions and exacerbates those felt at the time of the bad outcome: shock, outrage, anxiety, anguish, dread, depression, helplessness, hopelessness, feelings of being misunderstood, and the anger and vulnerability associated with a narcissistic injury. Ordinarily we possess a healthy narcissism—that is, good feelings of self-esteem and a set of ideals that motivate and gratify us. When we suffer a tragic outcome or are sued, our self-esteem and ideals are directly challenged, resulting in feelings of failure, criticism, and public humiliation. These feelings can damage our sense of self and generate further feelings of shame, depression, and rage—all signs of a so-called narcissistic injury. As one ObGyn stated, learning that a lawsuit was filed “just prolonged my misery.”⁸

Each of us reacts in our own way to a lawsuit—and differently to each lawsuit if we are sued more than once—because of:

• our personality traits and personal circumstances
• the specifics of a case
• our relationship with the patient
• the public nature of a lawsuit
• a range of other variables that makes each case unique.

Suddenly, you who perceive yourself as caring, beneficent, well-meaning, and devoted to your patients are publicly accused of being careless and incompetent, of harming the patient by failing to meet your minimal obligations. Psychiatrists Ferrell and Price⁹ capture the impact of these allegations:

Here are the sense of assault and violation, the feelings of outrage and fear. Most painfully, here is the narcissistic injury, the astonishing wound to our understanding of ourselves as admirable, well-meaning people.

Litigation is a lengthy process with defined stages (TABLE 4). You have little control over a slow-paced process that involves an array of participants (lawyers, judges, jury, experts) whose behavior is unpredictable. This can make you feel dependent, vulnerable, and impotent.

TABLE 4

Pocket guide to what happens in court

STAGE OF ACTION	WHAT IT MEANS FOR DEFENDANT AND PLAINTIFF
Summons	Notification that a suit has been filed
Complaint	The nature of the allegation in legal terms
Pleadings	The attorney begins to communicate with the court by filing motions; a request that the court do something
Discovery	A process designed to obtain information about the case: Interrogatories (written questions) Depositions (oral questions and answers under oath) Inspection of documents Expert witnesses (persons used to establish the relationship between the event and the standard of care)
Summary judgment	A motion asking the court, after the facts have been established by discovery, to decide the validity of the case; if granted, the case is resolved without a trial by jury
Settlement	An agreement between parties that resolves their legal dispute
Trial	Case is presented to the judge or a judge and jury to determine culpability
Verdict	Decision reached by the deciding body
Posttrial	If the defendant receives an unfavorable verdict, motions may be offered to the court to void or appeal the verdict

 

Be active, not passive

What you can do. Contact your insurer and risk manager immediately. Inquire about the average length of litigation in your jurisdiction (it might be 1 to 5, or more, years, depending on locality, type of case, and severity of injury). Ask your attorney to describe the steps in the process and your role as the case proceeds.

Take whatever steps are necessary to cover your clinical duties. If your initial emotional reaction is disruptive, obtain coverage or rearrange your schedule. Expect to change or limit your schedule before depositions and during trial to allow adequate time for preparation.

Accept the fact that you must play by rules far different from those of medical care. Litigation is time-consuming and frustrating. Delays and so-called continuances are common in legal proceedings, so expect them. Consider adapting to your situation the strategies that other sued physicians have found useful in regaining control over their life and work (TABLE 5).

TABLE 5

Regain control and manage your practice during litigation

Learn as much as you can about the legal process
Introduce good risk-management strategies, such as efficient record-keeping, into your practice
Clarify the responsibilities of office personnel and coverage responsibilities with associates
Rearrange office schedules during periods of increased stress
Reevaluate your time commitments to work and family
Participate in relevant continuing education
Make sure your financial and estate planning is current
Cooperate with legal counsel
Devote sufficient time to deposition preparation and other demands of the case
Carefully evaluate the advice of legal and insurance counsel regarding a settlement
Don’t try to “fit patients in” while on trial; a trial is a full-time job

Get needed support

Talking about the case. Sharing, with responsible confidants, your emotional reactions to being sued is healthy for you and others affected. Lawyers, however, may caution you not to “talk to anybody” about the case. They don’t want you to say anything that would suggest liability or jeopardize their defense of the case.

This may be good legal advice, but it is not good psychological advice. The support of others is a natural help during major life events that cause enormous stress and disruption.¹⁰ You can resolve this dilemma by accepting the discipline of talking about your feelings regarding the case without discussing the specifics of the case.

In addition to lawyers and claims representatives, you may talk with your spouse or another trusted person or colleague about your feelings. When you choose to talk with a psychiatrist or other mental health professional about your litigation experiences, you are protected by the confidentiality inherent in the doctor–patient relationship.

Trust issues. At the core of all medical work lies trust. As a well-trained and competent professional, you do not expect to be sued by patients with whom you have trusting and often long-term relationships. Most physicians acknowledge that after being sued their relationships with patients change.^11,12 You may find it difficult to reestablish trusting and comfortable relationships with other patients, especially those who have conditions similar, often high-risk, to that of the suing patient.

A charge of negligence exposes our vulnerabilities and leaves us feeling hurt and betrayed, feelings that are not easily overcome. As one psychiatrist ruefully observed: “I lost my innocence.”⁸

Conflicted feelings may emerge. The distress associated with a lawsuit often exacerbates the many outside stressors associated with practice. Many solo practitioners find themselves already overextended, working longer hours, covering more hospitals, and rarely taking vacations. Younger physicians who prize “time off” and lifestyle above other incentives remain stressed by the unpredictable schedules associated with ObGyn practice. Women physicians increasingly constitute a greater percentage of the ObGyn specialty. Although some work part-time or, at least, fewer hours than their male counterparts, they must nonetheless keep current and continually hone their skills.

The stress associated with all of these conditions can increase an ObGyn’s vulnerability to the occurrence of an adverse event and, eventually, to a lawsuit. It is also known that physicians involved in a claim-producing event are twice as likely as their non–claim-producing counterparts to have another such event within the ensuing 12 months.¹³

When you are sued, you may feel overwhelmed and out of control. Because physicians’ ability to control their schedule and work hours is a known major predictor of their overall health (as evidenced by a balance between their work and personal life),¹⁴ regaining control over those aspects of your life that are “controllable” (TABLE 5) is an essential strategy in dealing with a lawsuit.

As a result of your lawsuit, you may contemplate changing practice circumstances or retiring early. Feelings that you must change the way you practice and chronic anxiety about your work are barriers to good practice. Personal therapy may help if you remain uneasy or cannot resolve life choices that overshadow your work with patients.

 

Seek medical or psychiatric care?

Be alert to the point at which you or others involved in litigation need a referral for medical or psychiatric consultation. Sued physicians, their families, and colleagues often experience psychiatric conditions or other problems, such as:

• major depression
• adjustment disorder
• posttraumatic stress disorder
• worsening of a previously diagnosed psychiatric illness
• physical symptoms that require diagnosis and treatment
• alcohol and drug misuse or abuse
• anxiety and distress that interfere with work
• self-medication, especially for insomnia
• disturbances and dysfunctional behaviors that affect marital and family life.^15,16

Take stock—then, it’s “steady as you go”

Most of us have stable and supportive relationships and are, for the most part, psychologically healthy and professionally competent. It is normal, however, to experience distress in response to the trauma of a bad outcome (whatever its origin) and the lawsuit that may follow. Most physicians are resilient—that is, able to manage the stress without developing major symptoms—but some benefit from professional support.

Whatever your reaction to being sued, become familiar with the climate of litigation in the jurisdiction where the case was filed, including the incidence and outcome of cases. For example, does a similar case to yours usually result in settlement or—if it goes to trial—does it take 2 to 5, or more, years to resolve?

Last, it’s a comfort to know that approximately 70% of complaints filed result in no payment (no settlement) for the plaintiff. When a case does go to trial, physicians win 80% of the time.

The challenge, then, for you when you are sued? Take an active role in managing your distress in ways that contribute to your vindication and to the continuity of care for your patients.

The author reports no financial relationships relevant to this article.

“Immediately after the event I was a wreck. I vaguely remember talking to the family; I don’t know if I was much use to them.… That night I got drunk. It was the only way I could sleep. A sensitive colleague came and sat with me.”¹

As an ObGyn, it is almost certain that you will be sued sometime during your career. Specific actions that I’ll describe in this article can help you deal with the stress associated with the adverse event that precipitates the lawsuit and the lawsuit itself. To begin, remember:

• Anticipation is the best defense
• Knowledge is power
• Action counters passivity
• A supportive environment is essential.

How can you anticipate litigation?

What is the risk? No nationwide reporting system tracks the incidence of medical malpractice claims. A recent survey by the American College of Obstetricians and Gynecologists, however, found that 89% of practicing ObGyns had been sued at least once in their career, with an average of 2.62 claims for every ObGyn.² Because a claim usually takes years to resolve, a substantial number of ObGyns are involved in litigation at any one time.

You can successfully anticipate litigation by maintaining familiarity with your state’s statute of limitations—usually, this period is 2 to 3 years after discovery of the incident, with exceptions for children, the disabled, and designated special circumstances. If a plaintiff’s case is not filed within this time, a disputed outcome can never be the subject of a malpractice claim.

ObGyns are keenly aware of the exception that extends the time period during which a case may be filed on behalf of a child after discovery of the alleged injury. Many states set 8 years as the cutoff for filing a claim; others, such as Illinois, extend the period for as long as 2 years after a child’s 18th birthday. This long tail of vulnerability creates unpredictability for insurers, who must estimate the relationship between current premiums and potential payouts (often in the distant future), resulting in high premiums for ObGyns’ insurance. More importantly, it creates an undercurrent of anxiety and uncertainty for those ObGyns who must contemplate defending themselves in court for incidents that occurred in the distant past.

Listen to your feelings whenever you suspect that a patient is dissatisfied or that a bad outcome may lead to a claim, and take appropriate action. Reexamine your risk management procedures and discuss your concerns with your risk manager. Because it may take years for a case to be filed and many more for it to be adjudicated, possibly by trial, your best defense is clear, accurate, comprehensive, and contemporaneous documentation of the situation. Any later review of the case will be based on records that, if clearly kept, will be easily and unambiguously interpreted despite the passage of time.

Responding to an adverse event

The severity of the outcome, the nature of your relationship with the patient, and the degree of your responsibility for an adverse event contribute to the intensity of your initial emotional response. If a mistake caused the event, your reaction may be even more severe.^3-6 Whatever the specifics of the event, you may ruminate about your role and degree of responsibility (TABLE 1).

TABLE 1

Questions that might nag you after a “bad” outcome

Is this my fault?
Could I have prevented this from happening?
Did I make a mistake in this patient’s diagnosis or treatment?
Did I make a mistake in judgment?
Could I have done something else (such as perform a cesarean section or decide not to perform a VBAC)?
Did I harbor unconscious transference feelings (such as feelings of dislike, mistrust, or anger) toward this patient?
Did I miss some signs I should have seen?
Would this have happened no matter what I had done?
Are others to blame?

TABLE 2

The 3 “must-do” actions after an adverse event

Medical steps Take necessary actions to limit further injury or disability Obtain appropriate consultations Review the medical record; anticipate the patient’s follow-up needs and make recommendations for further treatment
Notifications Follow the health-care system’s and insurer’s guidelines for notifying the patient and family Inform the institution’s risk manager and your professional liability carrier as soon as possible Write a description of the event for the record and a narrative for your personal file (and your lawyer’s) in case a suit is filed later Do not talk with the media
Disclosures Acknowledge your ethical obligation to be truthful Follow your institution’s and insurer’s guidelines on disclosure Expect to feel intimidated and uneasy in discussing your role in the event Expect the patient and family to be angry and disappointed with you Convey an interest in the patient’s and family’s emotional state; express sorrow for their loss Tell the patient and family what you know for sure; don’t speculate about what is unknown and don’t make false promises or false reassurances Don’t hurry; give the patient and family time to ask questions Expect to feel somewhat better after a truthful exchange

 

Expect that your view of the circumstances will generate a complex array of feelings: shock, anxiety, depression, shame, guilt, self-blame, disbelief, self-doubt and inadequacy, anger, and, even, relief from not having to work with a difficult patient anymore.

Most physicians feel a personal sense of failure and inadequacy when they are unable to prevent a patient’s death or serious injury. Although serious events evoke greater distress, any event that may eventually be judged an error or become the subject of a lawsuit can give rise to anxiety, decreased confidence, sleep disturbances, and decreased job satisfaction.⁶ In the midst of such feelings, you must:

• deal with the event’s medical complications, relevant notifications, and disclosures (TABLE 2)
• address the emotional pain of the injured patient or family
• participate in mandated reviews
• recognize and manage the emotional disruption to you (TABLE 3).

Self-evaluation. To cope with distress when a patient dies, you could attend the funeral. You also might:

• make changes in your practice that alert you to problem patients
• introduce a more structured approach to patients with particular clinical conditions, using practice guidelines as a resource⁷
• become more alert to patients who may benefit from consultation or referral.

Balance the time you devote to work and personal life. Schedule regular time for recreation and active sports, which can help you prepare for the prolonged stress that follows being sued. Engage a personal physician to monitor your physical and emotional health and to recommend appropriate referrals, when indicated.

TABLE 3

Get a grip on your emotions, before and during litigation

Anticipate having repeated thoughts and preoccupations about the event; work toward a realistic view of it
Recognize your feelings and work to understand their source
Talk with a trusted confidant (spouse, colleague) about your feelings
Monitor your emotional and physical status; if indicated, seek appropriate consultation
Avoid situations that generate anxiety and increase stress
Monitor and address changes in your relationships with family, patients, colleagues, and staff
Be understanding of yourself and others; develop a realistic view of yourself as a “good doctor”
Engage in active sports and take regular vacations unrelated to professional activities
Control what can be controlled

Knowledge is power

What can I expect? A lawsuit generates a mixture of common emotions and exacerbates those felt at the time of the bad outcome: shock, outrage, anxiety, anguish, dread, depression, helplessness, hopelessness, feelings of being misunderstood, and the anger and vulnerability associated with a narcissistic injury. Ordinarily we possess a healthy narcissism—that is, good feelings of self-esteem and a set of ideals that motivate and gratify us. When we suffer a tragic outcome or are sued, our self-esteem and ideals are directly challenged, resulting in feelings of failure, criticism, and public humiliation. These feelings can damage our sense of self and generate further feelings of shame, depression, and rage—all signs of a so-called narcissistic injury. As one ObGyn stated, learning that a lawsuit was filed “just prolonged my misery.”⁸

Each of us reacts in our own way to a lawsuit—and differently to each lawsuit if we are sued more than once—because of:

• our personality traits and personal circumstances
• the specifics of a case
• our relationship with the patient
• the public nature of a lawsuit
• a range of other variables that makes each case unique.

Suddenly, you who perceive yourself as caring, beneficent, well-meaning, and devoted to your patients are publicly accused of being careless and incompetent, of harming the patient by failing to meet your minimal obligations. Psychiatrists Ferrell and Price⁹ capture the impact of these allegations:

Here are the sense of assault and violation, the feelings of outrage and fear. Most painfully, here is the narcissistic injury, the astonishing wound to our understanding of ourselves as admirable, well-meaning people.

Litigation is a lengthy process with defined stages (TABLE 4). You have little control over a slow-paced process that involves an array of participants (lawyers, judges, jury, experts) whose behavior is unpredictable. This can make you feel dependent, vulnerable, and impotent.

TABLE 4

Pocket guide to what happens in court

STAGE OF ACTION	WHAT IT MEANS FOR DEFENDANT AND PLAINTIFF
Summons	Notification that a suit has been filed
Complaint	The nature of the allegation in legal terms
Pleadings	The attorney begins to communicate with the court by filing motions; a request that the court do something
Discovery	A process designed to obtain information about the case: Interrogatories (written questions) Depositions (oral questions and answers under oath) Inspection of documents Expert witnesses (persons used to establish the relationship between the event and the standard of care)
Summary judgment	A motion asking the court, after the facts have been established by discovery, to decide the validity of the case; if granted, the case is resolved without a trial by jury
Settlement	An agreement between parties that resolves their legal dispute
Trial	Case is presented to the judge or a judge and jury to determine culpability
Verdict	Decision reached by the deciding body
Posttrial	If the defendant receives an unfavorable verdict, motions may be offered to the court to void or appeal the verdict

 

Be active, not passive

What you can do. Contact your insurer and risk manager immediately. Inquire about the average length of litigation in your jurisdiction (it might be 1 to 5, or more, years, depending on locality, type of case, and severity of injury). Ask your attorney to describe the steps in the process and your role as the case proceeds.

Take whatever steps are necessary to cover your clinical duties. If your initial emotional reaction is disruptive, obtain coverage or rearrange your schedule. Expect to change or limit your schedule before depositions and during trial to allow adequate time for preparation.

Accept the fact that you must play by rules far different from those of medical care. Litigation is time-consuming and frustrating. Delays and so-called continuances are common in legal proceedings, so expect them. Consider adapting to your situation the strategies that other sued physicians have found useful in regaining control over their life and work (TABLE 5).

TABLE 5

Regain control and manage your practice during litigation

Learn as much as you can about the legal process
Introduce good risk-management strategies, such as efficient record-keeping, into your practice
Clarify the responsibilities of office personnel and coverage responsibilities with associates
Rearrange office schedules during periods of increased stress
Reevaluate your time commitments to work and family
Participate in relevant continuing education
Make sure your financial and estate planning is current
Cooperate with legal counsel
Devote sufficient time to deposition preparation and other demands of the case
Carefully evaluate the advice of legal and insurance counsel regarding a settlement
Don’t try to “fit patients in” while on trial; a trial is a full-time job

Get needed support

Talking about the case. Sharing, with responsible confidants, your emotional reactions to being sued is healthy for you and others affected. Lawyers, however, may caution you not to “talk to anybody” about the case. They don’t want you to say anything that would suggest liability or jeopardize their defense of the case.

This may be good legal advice, but it is not good psychological advice. The support of others is a natural help during major life events that cause enormous stress and disruption.¹⁰ You can resolve this dilemma by accepting the discipline of talking about your feelings regarding the case without discussing the specifics of the case.

In addition to lawyers and claims representatives, you may talk with your spouse or another trusted person or colleague about your feelings. When you choose to talk with a psychiatrist or other mental health professional about your litigation experiences, you are protected by the confidentiality inherent in the doctor–patient relationship.

Trust issues. At the core of all medical work lies trust. As a well-trained and competent professional, you do not expect to be sued by patients with whom you have trusting and often long-term relationships. Most physicians acknowledge that after being sued their relationships with patients change.^11,12 You may find it difficult to reestablish trusting and comfortable relationships with other patients, especially those who have conditions similar, often high-risk, to that of the suing patient.

A charge of negligence exposes our vulnerabilities and leaves us feeling hurt and betrayed, feelings that are not easily overcome. As one psychiatrist ruefully observed: “I lost my innocence.”⁸

Conflicted feelings may emerge. The distress associated with a lawsuit often exacerbates the many outside stressors associated with practice. Many solo practitioners find themselves already overextended, working longer hours, covering more hospitals, and rarely taking vacations. Younger physicians who prize “time off” and lifestyle above other incentives remain stressed by the unpredictable schedules associated with ObGyn practice. Women physicians increasingly constitute a greater percentage of the ObGyn specialty. Although some work part-time or, at least, fewer hours than their male counterparts, they must nonetheless keep current and continually hone their skills.

The stress associated with all of these conditions can increase an ObGyn’s vulnerability to the occurrence of an adverse event and, eventually, to a lawsuit. It is also known that physicians involved in a claim-producing event are twice as likely as their non–claim-producing counterparts to have another such event within the ensuing 12 months.¹³

When you are sued, you may feel overwhelmed and out of control. Because physicians’ ability to control their schedule and work hours is a known major predictor of their overall health (as evidenced by a balance between their work and personal life),¹⁴ regaining control over those aspects of your life that are “controllable” (TABLE 5) is an essential strategy in dealing with a lawsuit.

As a result of your lawsuit, you may contemplate changing practice circumstances or retiring early. Feelings that you must change the way you practice and chronic anxiety about your work are barriers to good practice. Personal therapy may help if you remain uneasy or cannot resolve life choices that overshadow your work with patients.

 

Seek medical or psychiatric care?

Be alert to the point at which you or others involved in litigation need a referral for medical or psychiatric consultation. Sued physicians, their families, and colleagues often experience psychiatric conditions or other problems, such as:

• major depression
• adjustment disorder
• posttraumatic stress disorder
• worsening of a previously diagnosed psychiatric illness
• physical symptoms that require diagnosis and treatment
• alcohol and drug misuse or abuse
• anxiety and distress that interfere with work
• self-medication, especially for insomnia
• disturbances and dysfunctional behaviors that affect marital and family life.^15,16

Take stock—then, it’s “steady as you go”

Most of us have stable and supportive relationships and are, for the most part, psychologically healthy and professionally competent. It is normal, however, to experience distress in response to the trauma of a bad outcome (whatever its origin) and the lawsuit that may follow. Most physicians are resilient—that is, able to manage the stress without developing major symptoms—but some benefit from professional support.

Whatever your reaction to being sued, become familiar with the climate of litigation in the jurisdiction where the case was filed, including the incidence and outcome of cases. For example, does a similar case to yours usually result in settlement or—if it goes to trial—does it take 2 to 5, or more, years to resolve?

Last, it’s a comfort to know that approximately 70% of complaints filed result in no payment (no settlement) for the plaintiff. When a case does go to trial, physicians win 80% of the time.

The challenge, then, for you when you are sued? Take an active role in managing your distress in ways that contribute to your vindication and to the continuity of care for your patients.

It goes without saying that physicians need to keep their knowledge and skills current, but too many private practitioners overlook the similar needs of their employees. Continuing education is as important for your staff as it is for you.

Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

There are a lot of good reasons to invest in ongoing staff training. The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. The better their skills and the greater their confidence, the less supervision they need from you and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees' competence makes them feel valued and appreciated. This leads to reduced turnover, which, alone, often pays for the training.

You already do the yearly OSHA training because the law requires it, and you have everyone recertified periodically in basic or advanced CPR (or you should). I'm talking about going beyond the basic stuff that satisfies legal requirements but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses so they are always current on the latest third-party changes. Others include keyboarding and computer courses for staff members who work with computers, and Excel and QuickBooks classes for your bookkeeper.

Continuing education does not have to be costly, and in some cases it can be free. Pharmaceutical representatives will be happy to thoroughly brief your staff on a new medication or medical instrument, or to refresh their memories on an established one. Just make sure the presentation is as impartial as possible, given the obvious conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators/Managers (www.ada-m.org

Many other venues are available for employee education, both online and in conventional classrooms.

Courses are offered in a wide variety of relevant subjects, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far, the most common question I receive on this issue is this: “What if I pay for all that training and the employees leave?”

My answer, invariably, is this: “What if you don't, and they stay?”

Well-trained employees are vastly preferable to untrained ones, even with the small risk of the occasional staffer who accepts training and then moves on. By and large, well-trained employees will stay. Education fosters loyalty.

Employees who know that you care enough about them to advance their skills will sense that they have a stake in the practice and will be less likely to want to leave.

In any case, everyone will benefit from a well-trained staff: you, your employees, your practice, and most importantly, your patients.

It goes without saying that physicians need to keep their knowledge and skills current, but too many private practitioners overlook the similar needs of their employees. Continuing education is as important for your staff as it is for you.

Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

There are a lot of good reasons to invest in ongoing staff training. The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. The better their skills and the greater their confidence, the less supervision they need from you and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees' competence makes them feel valued and appreciated. This leads to reduced turnover, which, alone, often pays for the training.

You already do the yearly OSHA training because the law requires it, and you have everyone recertified periodically in basic or advanced CPR (or you should). I'm talking about going beyond the basic stuff that satisfies legal requirements but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses so they are always current on the latest third-party changes. Others include keyboarding and computer courses for staff members who work with computers, and Excel and QuickBooks classes for your bookkeeper.

Continuing education does not have to be costly, and in some cases it can be free. Pharmaceutical representatives will be happy to thoroughly brief your staff on a new medication or medical instrument, or to refresh their memories on an established one. Just make sure the presentation is as impartial as possible, given the obvious conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators/Managers (www.ada-m.org

Many other venues are available for employee education, both online and in conventional classrooms.

Courses are offered in a wide variety of relevant subjects, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far, the most common question I receive on this issue is this: “What if I pay for all that training and the employees leave?”

My answer, invariably, is this: “What if you don't, and they stay?”

Well-trained employees are vastly preferable to untrained ones, even with the small risk of the occasional staffer who accepts training and then moves on. By and large, well-trained employees will stay. Education fosters loyalty.

Employees who know that you care enough about them to advance their skills will sense that they have a stake in the practice and will be less likely to want to leave.

In any case, everyone will benefit from a well-trained staff: you, your employees, your practice, and most importantly, your patients.

It goes without saying that physicians need to keep their knowledge and skills current, but too many private practitioners overlook the similar needs of their employees. Continuing education is as important for your staff as it is for you.

Like you, staff members provide better care to patients when they know the latest findings and techniques. They also provide better information: When patients ask questions of your staff, either in the office or over the phone (which happens more often than you probably think), you certainly want their answers to be accurate and up to date.

There are a lot of good reasons to invest in ongoing staff training. The more your employees know, the more productive they will be. Not only will they complete everyday duties more efficiently, they will be stimulated to learn new tasks and accept more responsibility.

Staffers who have learned new skills are more willing to take on new challenges. The better their skills and the greater their confidence, the less supervision they need from you and the more they become involved in their work.

They will also be happier in their jobs. Investing in your employees' competence makes them feel valued and appreciated. This leads to reduced turnover, which, alone, often pays for the training.

You already do the yearly OSHA training because the law requires it, and you have everyone recertified periodically in basic or advanced CPR (or you should). I'm talking about going beyond the basic stuff that satisfies legal requirements but does not motivate your people to loftier goals.

An obvious example is sending your insurance people annually to coding and insurance processing courses so they are always current on the latest third-party changes. Others include keyboarding and computer courses for staff members who work with computers, and Excel and QuickBooks classes for your bookkeeper.

Continuing education does not have to be costly, and in some cases it can be free. Pharmaceutical representatives will be happy to thoroughly brief your staff on a new medication or medical instrument, or to refresh their memories on an established one. Just make sure the presentation is as impartial as possible, given the obvious conflict of interest involved.

Your office manager should join the Association of Dermatology Administrators/Managers (www.ada-m.org

Many other venues are available for employee education, both online and in conventional classrooms.

Courses are offered in a wide variety of relevant subjects, including medical terminology, record keeping and accounting, laboratory skills, diagnostic tests and procedures, pharmacology and medication administration, patient relations, medical law and ethics, and many others.

By far, the most common question I receive on this issue is this: “What if I pay for all that training and the employees leave?”

My answer, invariably, is this: “What if you don't, and they stay?”

Well-trained employees are vastly preferable to untrained ones, even with the small risk of the occasional staffer who accepts training and then moves on. By and large, well-trained employees will stay. Education fosters loyalty.

Employees who know that you care enough about them to advance their skills will sense that they have a stake in the practice and will be less likely to want to leave.

In any case, everyone will benefit from a well-trained staff: you, your employees, your practice, and most importantly, your patients.

Did maternal pelvic structure cause injury?

The plaintiff infant, whose birth was complicated by shoulder dystocia, was delivered using low forceps. Following birth, the child was found to have a brachial plexus injury and unusual bruising on the chest, back, and arm. She has mild residual loss of strength.

Patient’s claim Excessive traction was applied during delivery.

Doctor’s defense The shoulder dystocia, which was mild, was relieved with the McRoberts maneuver, and traction was never applied. The mother’s pelvic structure and positioning of the fetus caused the child’s injuries.

Verdict Illinois defense verdict.

Parents refuse, but oxytocin is given

The plaintiff child was delivered at 42 weeks’ gestation by emergency cesarean section and was diagnosed with dystonic cerebral palsy. Despite the parents’ objection, the obstetrician had the nurse administer oxytocin during labor. According to hospital rules, the oxytocin should have been discontinued when the mother’s contractions became hyperstimulated, but it was not.

Patient’s claim The mother’s contractions did not require administration of oxytocin under the hospital’s rules, and its dosage continued to be increased even when adequate labor was reached. Also, the obstetrician did not see the mother until it was time to perform the cesarean section.

Doctor’s defense There was no negligence. The sudden bradycardia in the fetal heart rate could not have been anticipated.

Verdict $30.8 million Florida verdict.

Woman with fibroids dies of uterine cancer

A 41-year-old woman visited Dr. A because of abnormal uterine bleeding and infertility. After he diagnosed uterine fibroids, she chose to undergo a myomectomy instead of a hysterectomy. The abnormal bleeding continued and she was diagnosed the following month with a postoperative infection. The infection resolved after treatment with antibiotics. Six months after the surgery, the abnormal bleeding returned with increased volume and a bad odor. The next month, Dr. B performed surgery and diagnosed uterine cancer. The patient was treated for 3 years and then died.

Patient’s claim The diagnosis of cancer was delayed. More testing, including a biopsy, should have been done after the myomectomy.

Doctor’s defense The patient was treated properly for a postsurgery infection, which is not uncommon, and had healed a month following the surgery. Her condition improved until she developed an aggressive cancer, which was not foreseen.

Verdict New York defense verdict.

Did maternal pelvic structure cause injury?

The plaintiff infant, whose birth was complicated by shoulder dystocia, was delivered using low forceps. Following birth, the child was found to have a brachial plexus injury and unusual bruising on the chest, back, and arm. She has mild residual loss of strength.

Patient’s claim Excessive traction was applied during delivery.

Doctor’s defense The shoulder dystocia, which was mild, was relieved with the McRoberts maneuver, and traction was never applied. The mother’s pelvic structure and positioning of the fetus caused the child’s injuries.

Verdict Illinois defense verdict.

Parents refuse, but oxytocin is given

The plaintiff child was delivered at 42 weeks’ gestation by emergency cesarean section and was diagnosed with dystonic cerebral palsy. Despite the parents’ objection, the obstetrician had the nurse administer oxytocin during labor. According to hospital rules, the oxytocin should have been discontinued when the mother’s contractions became hyperstimulated, but it was not.

Patient’s claim The mother’s contractions did not require administration of oxytocin under the hospital’s rules, and its dosage continued to be increased even when adequate labor was reached. Also, the obstetrician did not see the mother until it was time to perform the cesarean section.

Doctor’s defense There was no negligence. The sudden bradycardia in the fetal heart rate could not have been anticipated.

Verdict $30.8 million Florida verdict.

Woman with fibroids dies of uterine cancer

A 41-year-old woman visited Dr. A because of abnormal uterine bleeding and infertility. After he diagnosed uterine fibroids, she chose to undergo a myomectomy instead of a hysterectomy. The abnormal bleeding continued and she was diagnosed the following month with a postoperative infection. The infection resolved after treatment with antibiotics. Six months after the surgery, the abnormal bleeding returned with increased volume and a bad odor. The next month, Dr. B performed surgery and diagnosed uterine cancer. The patient was treated for 3 years and then died.

Patient’s claim The diagnosis of cancer was delayed. More testing, including a biopsy, should have been done after the myomectomy.

Doctor’s defense The patient was treated properly for a postsurgery infection, which is not uncommon, and had healed a month following the surgery. Her condition improved until she developed an aggressive cancer, which was not foreseen.

Verdict New York defense verdict.

Did maternal pelvic structure cause injury?

The plaintiff infant, whose birth was complicated by shoulder dystocia, was delivered using low forceps. Following birth, the child was found to have a brachial plexus injury and unusual bruising on the chest, back, and arm. She has mild residual loss of strength.

Patient’s claim Excessive traction was applied during delivery.

Doctor’s defense The shoulder dystocia, which was mild, was relieved with the McRoberts maneuver, and traction was never applied. The mother’s pelvic structure and positioning of the fetus caused the child’s injuries.

Verdict Illinois defense verdict.

Parents refuse, but oxytocin is given

The plaintiff child was delivered at 42 weeks’ gestation by emergency cesarean section and was diagnosed with dystonic cerebral palsy. Despite the parents’ objection, the obstetrician had the nurse administer oxytocin during labor. According to hospital rules, the oxytocin should have been discontinued when the mother’s contractions became hyperstimulated, but it was not.

Patient’s claim The mother’s contractions did not require administration of oxytocin under the hospital’s rules, and its dosage continued to be increased even when adequate labor was reached. Also, the obstetrician did not see the mother until it was time to perform the cesarean section.

Doctor’s defense There was no negligence. The sudden bradycardia in the fetal heart rate could not have been anticipated.

Verdict $30.8 million Florida verdict.

Woman with fibroids dies of uterine cancer

A 41-year-old woman visited Dr. A because of abnormal uterine bleeding and infertility. After he diagnosed uterine fibroids, she chose to undergo a myomectomy instead of a hysterectomy. The abnormal bleeding continued and she was diagnosed the following month with a postoperative infection. The infection resolved after treatment with antibiotics. Six months after the surgery, the abnormal bleeding returned with increased volume and a bad odor. The next month, Dr. B performed surgery and diagnosed uterine cancer. The patient was treated for 3 years and then died.

Patient’s claim The diagnosis of cancer was delayed. More testing, including a biopsy, should have been done after the myomectomy.

Doctor’s defense The patient was treated properly for a postsurgery infection, which is not uncommon, and had healed a month following the surgery. Her condition improved until she developed an aggressive cancer, which was not foreseen.

Verdict New York defense verdict.

www.IdealMedicalHome.org

The next time you find breathing room to attempt something new in the interest of improving care, try this: Ask every patient who walks through your door the following four questions:

▸ Do you suffer from chronic pain?

▸ Is your emotional health stable?

▸ Do you have adequate financial resources?

▸ Do you have the confidence you need to manage your conditions?

These four questions represent a distillation of several decades of research aimed at identifying approaches to care that get patients to step up to the plate and manage their conditions more effectively. They also elegantly address fundamental attributes that can apply to an entire patient base, rather than to a select few.

Many of us have become very good at the delivery of care for patients with big ticket diagnoses, such as diabetes or asthma. Although I applaud those improvements in care, the reality is that many practices have exhausted their resources on managing this handful of patients, with little or no improvement energy left over for all the rest of the patients in the practice.

Just as we would miss patients with hypertension if we did not measure blood pressure, so would we miss a lot of information about our patients' emotional health if we relied solely on our perceptions and gut instincts. Good evidence shows that people with chronic pain or emotional problems don't do as well and end up hospitalized more often.

Using these four questions as a vital sign can help identify individuals who are headed in a bad direction, and can help allocate practice resources. The patient with diabetes who is confident, has no financial or emotional issues, and is not in chronic pain isn't going to require a lot of practice effort. Alternatively, years of research have shown us that the patient with chronic pain and emotional instability will require a lot more attention.

Similarly, we can help patients overcome a lack of confidence. Much of the time, this common problem stems from a patient's history of biting off more than he or she can chew. Losing 25 pounds or running 3 miles a day are laudable goals, but the failure to achieve them results in some patients feeling helpless and giving up. Studies show us the benefit of helping patients make small, achievable changes. Start by asking what he or she can do next Tuesday, and then follow up.

Of course, asking questions will require that you have a plan in place if a problem is uncovered. If you are lucky enough to practice in a region with pain specialists or mental health care providers, have referral information handy. If not, there are terrific guidelines available to help you weigh in on those issues. Although there isn't much a physician can do to address a patient's finances, we can be more sensitive about the costs of the drugs we prescribe.

Finally, I want to acknowledge that asking these questions in everyday practice is a matter of sweat equity. We practice in an environment that pays for volume, not quality of care. Until we figure out a way to finance quality care and not just volume, it is out of pure professionalism that my primary care colleagues would try this simple screen. And yet, an incredible amount of research demonstrates that delivering better primary care would help lower the costs of health care in the United States. Enabling primary care physicians to ask four simple questions—and paying them to follow up on any problems uncovered—would allow us to finally do the job we need to be doing.

www.IdealMedicalHome.org

The next time you find breathing room to attempt something new in the interest of improving care, try this: Ask every patient who walks through your door the following four questions:

▸ Do you suffer from chronic pain?

▸ Is your emotional health stable?

▸ Do you have adequate financial resources?

▸ Do you have the confidence you need to manage your conditions?

These four questions represent a distillation of several decades of research aimed at identifying approaches to care that get patients to step up to the plate and manage their conditions more effectively. They also elegantly address fundamental attributes that can apply to an entire patient base, rather than to a select few.

Many of us have become very good at the delivery of care for patients with big ticket diagnoses, such as diabetes or asthma. Although I applaud those improvements in care, the reality is that many practices have exhausted their resources on managing this handful of patients, with little or no improvement energy left over for all the rest of the patients in the practice.

Just as we would miss patients with hypertension if we did not measure blood pressure, so would we miss a lot of information about our patients' emotional health if we relied solely on our perceptions and gut instincts. Good evidence shows that people with chronic pain or emotional problems don't do as well and end up hospitalized more often.

Using these four questions as a vital sign can help identify individuals who are headed in a bad direction, and can help allocate practice resources. The patient with diabetes who is confident, has no financial or emotional issues, and is not in chronic pain isn't going to require a lot of practice effort. Alternatively, years of research have shown us that the patient with chronic pain and emotional instability will require a lot more attention.

Similarly, we can help patients overcome a lack of confidence. Much of the time, this common problem stems from a patient's history of biting off more than he or she can chew. Losing 25 pounds or running 3 miles a day are laudable goals, but the failure to achieve them results in some patients feeling helpless and giving up. Studies show us the benefit of helping patients make small, achievable changes. Start by asking what he or she can do next Tuesday, and then follow up.

Of course, asking questions will require that you have a plan in place if a problem is uncovered. If you are lucky enough to practice in a region with pain specialists or mental health care providers, have referral information handy. If not, there are terrific guidelines available to help you weigh in on those issues. Although there isn't much a physician can do to address a patient's finances, we can be more sensitive about the costs of the drugs we prescribe.

Finally, I want to acknowledge that asking these questions in everyday practice is a matter of sweat equity. We practice in an environment that pays for volume, not quality of care. Until we figure out a way to finance quality care and not just volume, it is out of pure professionalism that my primary care colleagues would try this simple screen. And yet, an incredible amount of research demonstrates that delivering better primary care would help lower the costs of health care in the United States. Enabling primary care physicians to ask four simple questions—and paying them to follow up on any problems uncovered—would allow us to finally do the job we need to be doing.

www.IdealMedicalHome.org

The next time you find breathing room to attempt something new in the interest of improving care, try this: Ask every patient who walks through your door the following four questions:

▸ Do you suffer from chronic pain?

▸ Is your emotional health stable?

▸ Do you have adequate financial resources?

▸ Do you have the confidence you need to manage your conditions?

These four questions represent a distillation of several decades of research aimed at identifying approaches to care that get patients to step up to the plate and manage their conditions more effectively. They also elegantly address fundamental attributes that can apply to an entire patient base, rather than to a select few.

Many of us have become very good at the delivery of care for patients with big ticket diagnoses, such as diabetes or asthma. Although I applaud those improvements in care, the reality is that many practices have exhausted their resources on managing this handful of patients, with little or no improvement energy left over for all the rest of the patients in the practice.

Just as we would miss patients with hypertension if we did not measure blood pressure, so would we miss a lot of information about our patients' emotional health if we relied solely on our perceptions and gut instincts. Good evidence shows that people with chronic pain or emotional problems don't do as well and end up hospitalized more often.

Using these four questions as a vital sign can help identify individuals who are headed in a bad direction, and can help allocate practice resources. The patient with diabetes who is confident, has no financial or emotional issues, and is not in chronic pain isn't going to require a lot of practice effort. Alternatively, years of research have shown us that the patient with chronic pain and emotional instability will require a lot more attention.

Similarly, we can help patients overcome a lack of confidence. Much of the time, this common problem stems from a patient's history of biting off more than he or she can chew. Losing 25 pounds or running 3 miles a day are laudable goals, but the failure to achieve them results in some patients feeling helpless and giving up. Studies show us the benefit of helping patients make small, achievable changes. Start by asking what he or she can do next Tuesday, and then follow up.

Of course, asking questions will require that you have a plan in place if a problem is uncovered. If you are lucky enough to practice in a region with pain specialists or mental health care providers, have referral information handy. If not, there are terrific guidelines available to help you weigh in on those issues. Although there isn't much a physician can do to address a patient's finances, we can be more sensitive about the costs of the drugs we prescribe.

Finally, I want to acknowledge that asking these questions in everyday practice is a matter of sweat equity. We practice in an environment that pays for volume, not quality of care. Until we figure out a way to finance quality care and not just volume, it is out of pure professionalism that my primary care colleagues would try this simple screen. And yet, an incredible amount of research demonstrates that delivering better primary care would help lower the costs of health care in the United States. Enabling primary care physicians to ask four simple questions—and paying them to follow up on any problems uncovered—would allow us to finally do the job we need to be doing.

Ah, the start of a new year—the traditional time for resolutions, for turning over new leaves, for promising (yet again) to break all those annoying bad habits once and for all.

As long as you're pledging to break bad habits at home, why not set your mind to breaking some bad habits at the office as well?

I can't presume to know what your professional bad habits are, but I do know the ones I get asked about most often, so I can offer a top 10 list that might provide inspiration for your personal list of resolutions:

Start on Time

Many physicians complain about running behind. Guess what? Your patients complain about it, too. Waiting is the most common patient complaint, and you can't hope to run on time if you don't start on time. No single change will improve office efficiency more than this.

Spend Less Time on the Web

Okay, I confess that this one is on my own list this year. Fear not, RxDerm-L and DermChat members. I'll still be there, but you will notice from now on that my posts will be time stamped early in the morning or late at night and not during office hours. It is just too easy to start clicking that mouse and to continue until you're half an hour behind. We all have plenty of other short tasks that we could be completing during those brief office lulls.

Permit Fewer Interruptions

Phone calls and pharmaceutical representatives seem to be the big interrupters in most offices. Make some rules, and stick to them. I'll stop to take an emergency call or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps are instructed to make appointments, like everybody else, and I generally limit rep appointments to one a day, scheduled a few minutes before I start my afternoon hours.

Organize Samples

We strip all of the space-wasting packaging off of our samples and store them, alphabetically, in cardboard parts bins that can be purchased from many industrial catalogs. Besides always knowing what you have on hand, you'll always know what you're out of and your staff will waste far less time searching for the samples that you want. Also, a bin system makes logging samples in and out much easier, should that become a requirement (as the Food and Drug Administration keeps promising).

Clear Your Horizontal File Cabinet

That would be the mess on your desk—all the paperwork you never seem to get to. (Probably because you're answering e-mail.) Set aside an hour or two and get it all done. You'll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don't start a new mess. There's an entire column on this subject in the Archive Collection.

Keep a Closer Eye on the Office's Financial Situation

Most physicians delegate the bookkeeping, and that's fine, but ignoring the financial side completely creates an atmosphere that can facilitate embezzlement. Set aside a couple of hours each month to review the books personally. And make sure that your employees know you're doing it.

Make Sure Your Long-Range Financial Planning Is on Track

This is another aspect physicians tend to set and forget, but economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well diversified and that all other aspects of your finances—budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts—are in the best shape possible.

Pay Down Your Debt

Debt can destroy the best-laid retirement plans. If you carry significant debt, make sure that you set up a plan to pay it off as soon as you can.

Take More Vacations

Remember Eastern's First Law: Your last words will not be, “I wish I had spent more time in the office.” If you have been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you're busy making other plans.”

Look at Yourself

A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. That being the case, it behooves you to take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing, ask your spouse. I'm sure he or she will be happy to outline them for you … in great detail.

Ah, the start of a new year—the traditional time for resolutions, for turning over new leaves, for promising (yet again) to break all those annoying bad habits once and for all.

As long as you're pledging to break bad habits at home, why not set your mind to breaking some bad habits at the office as well?

I can't presume to know what your professional bad habits are, but I do know the ones I get asked about most often, so I can offer a top 10 list that might provide inspiration for your personal list of resolutions:

Start on Time

Many physicians complain about running behind. Guess what? Your patients complain about it, too. Waiting is the most common patient complaint, and you can't hope to run on time if you don't start on time. No single change will improve office efficiency more than this.

Spend Less Time on the Web

Okay, I confess that this one is on my own list this year. Fear not, RxDerm-L and DermChat members. I'll still be there, but you will notice from now on that my posts will be time stamped early in the morning or late at night and not during office hours. It is just too easy to start clicking that mouse and to continue until you're half an hour behind. We all have plenty of other short tasks that we could be completing during those brief office lulls.

Permit Fewer Interruptions

Phone calls and pharmaceutical representatives seem to be the big interrupters in most offices. Make some rules, and stick to them. I'll stop to take an emergency call or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps are instructed to make appointments, like everybody else, and I generally limit rep appointments to one a day, scheduled a few minutes before I start my afternoon hours.

Organize Samples

We strip all of the space-wasting packaging off of our samples and store them, alphabetically, in cardboard parts bins that can be purchased from many industrial catalogs. Besides always knowing what you have on hand, you'll always know what you're out of and your staff will waste far less time searching for the samples that you want. Also, a bin system makes logging samples in and out much easier, should that become a requirement (as the Food and Drug Administration keeps promising).

Clear Your Horizontal File Cabinet

That would be the mess on your desk—all the paperwork you never seem to get to. (Probably because you're answering e-mail.) Set aside an hour or two and get it all done. You'll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don't start a new mess. There's an entire column on this subject in the Archive Collection.

Keep a Closer Eye on the Office's Financial Situation

Most physicians delegate the bookkeeping, and that's fine, but ignoring the financial side completely creates an atmosphere that can facilitate embezzlement. Set aside a couple of hours each month to review the books personally. And make sure that your employees know you're doing it.

Make Sure Your Long-Range Financial Planning Is on Track

This is another aspect physicians tend to set and forget, but economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well diversified and that all other aspects of your finances—budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts—are in the best shape possible.

Pay Down Your Debt

Debt can destroy the best-laid retirement plans. If you carry significant debt, make sure that you set up a plan to pay it off as soon as you can.

Take More Vacations

Remember Eastern's First Law: Your last words will not be, “I wish I had spent more time in the office.” If you have been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you're busy making other plans.”

Look at Yourself

A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. That being the case, it behooves you to take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing, ask your spouse. I'm sure he or she will be happy to outline them for you … in great detail.

Ah, the start of a new year—the traditional time for resolutions, for turning over new leaves, for promising (yet again) to break all those annoying bad habits once and for all.

As long as you're pledging to break bad habits at home, why not set your mind to breaking some bad habits at the office as well?

I can't presume to know what your professional bad habits are, but I do know the ones I get asked about most often, so I can offer a top 10 list that might provide inspiration for your personal list of resolutions:

Start on Time

Many physicians complain about running behind. Guess what? Your patients complain about it, too. Waiting is the most common patient complaint, and you can't hope to run on time if you don't start on time. No single change will improve office efficiency more than this.

Spend Less Time on the Web

Okay, I confess that this one is on my own list this year. Fear not, RxDerm-L and DermChat members. I'll still be there, but you will notice from now on that my posts will be time stamped early in the morning or late at night and not during office hours. It is just too easy to start clicking that mouse and to continue until you're half an hour behind. We all have plenty of other short tasks that we could be completing during those brief office lulls.

Permit Fewer Interruptions

Phone calls and pharmaceutical representatives seem to be the big interrupters in most offices. Make some rules, and stick to them. I'll stop to take an emergency call or one from an immediate family member; all others get routed to the nurses or are returned at lunch or after hours. Reps are instructed to make appointments, like everybody else, and I generally limit rep appointments to one a day, scheduled a few minutes before I start my afternoon hours.

Organize Samples

We strip all of the space-wasting packaging off of our samples and store them, alphabetically, in cardboard parts bins that can be purchased from many industrial catalogs. Besides always knowing what you have on hand, you'll always know what you're out of and your staff will waste far less time searching for the samples that you want. Also, a bin system makes logging samples in and out much easier, should that become a requirement (as the Food and Drug Administration keeps promising).

Clear Your Horizontal File Cabinet

That would be the mess on your desk—all the paperwork you never seem to get to. (Probably because you're answering e-mail.) Set aside an hour or two and get it all done. You'll find some interesting stuff in there. Then, for every piece of paper that arrives on your desk from now on, follow the DDD Rule: Do it, Delegate it, or Destroy it. Don't start a new mess. There's an entire column on this subject in the Archive Collection.

Keep a Closer Eye on the Office's Financial Situation

Most physicians delegate the bookkeeping, and that's fine, but ignoring the financial side completely creates an atmosphere that can facilitate embezzlement. Set aside a couple of hours each month to review the books personally. And make sure that your employees know you're doing it.

Make Sure Your Long-Range Financial Planning Is on Track

This is another aspect physicians tend to set and forget, but economic conditions change all the time. Once a year, you should sit down with your accountant and lawyer and make sure your investments are well diversified and that all other aspects of your finances—budgets, credit ratings, insurance coverage, tax situations, college savings, estate plans, retirement accounts—are in the best shape possible.

Pay Down Your Debt

Debt can destroy the best-laid retirement plans. If you carry significant debt, make sure that you set up a plan to pay it off as soon as you can.

Take More Vacations

Remember Eastern's First Law: Your last words will not be, “I wish I had spent more time in the office.” If you have been working too much, this is the year to start spending more time enjoying your life, your friends and family, and the world. As John Lennon said, “Life is what happens to you while you're busy making other plans.”

Look at Yourself

A private practice lives or dies on the personalities of its physicians, and your staff copies your personality and style. That being the case, it behooves you to take a hard, honest look at yourself. Identify your negative personality traits and work to eliminate them. If you have any difficulty finding the things that need changing, ask your spouse. I'm sure he or she will be happy to outline them for you … in great detail.

Diabetic smoker blames others for CP

A woman had her final visit with her ObGyn 1 week before her scheduled cesarean section. When she arrived at the hospital at 36 weeks’ gestation for the procedure, the attending ObGyn delivered the child, who was born with severe acidosis and hypoxia and was diagnosed with cerebral palsy. The mother was diabetic and a smoker.

Patient’s claim Signs of a compromised infant were evident at her last visit to the ObGyn, and the child should have been delivered that day. Also, on the day of the actual delivery, the physician should have performed the delivery more expeditiously.

Doctor’s defense The infant was harmed before 34 weeks’ gestation. This was a high-risk pregnancy: the mother did not comply with diabetes management, and she continued to smoke although warned not to.

Verdict Massachusetts defense verdict.

Brain damage occurred despite “timely” birth

An active-duty Marine pregnant with her first child was examined twice at the labor and delivery unit and sent home. Five days before her due date—and 1 day following the previous visit—she returned with ruptured membranes and was admitted by a family practice resident. Four hours later, oxytocin was started because of decreased variability in the fetal monitoring with some late decelerations. A drop in the fetal heart rate followed the start of an epidural. A fetal scalp electrode was inserted, and within 15 minutes the mother was moved to the operating room. The attending family practice physician and the attending OB were called, and delivery by cesarean section was performed within another 15 minutes.

At birth, the infant was severely distressed. Intubation was attempted by a first-year intern, but after 25 minutes, the tube was found to be in the right mainstream bronchus with complete collapse of the left lung. For 10 minutes there was no heartbeat, but the staff reported a 5-minute Apgar score of 5. The infant was transferred to a second hospital, where a feeding gastrostomy and tracheotomy were placed. Two months later, the infant was transferred to a third hospital and, finally, 3 months after that, transferred home. The child suffered severe brain damage and developmental delay.

Patient’s claim The physicians failed to recognize the nonreassuring fetal monitoring strips and deliver early.

Doctor’s defense The delivery was timely.

Verdict $5.3 million California settlement.

Was ureteral injury caused by negligence?

A 49-year-old woman presented at the hospital for removal of an ovarian mass 10 cm × 12 cm in diameter. At the first incision, the two surgeons discovered severe pelvic adhesive disease, the result of a previous hysterectomy. The mass was not visible, but they finally located it—lower in the pelvic cavity than normal and near the ureter—and removed it.

Although the patient complained of pain in the back and left flank, several days passed before physicians discovered that the ureter had been cut and urine was backing up into the left kidney. The patient demanded transfer to another hospital.

Five days after the original surgery, a nephrostomy tube was inserted to drain the left kidney, but the patient’s abdomen was too inflamed to immediately repair the injury. She was discharged 3 days later. She was readmitted for treatment of severe infection due to the nephrostomy tube and then underwent more procedures to change the tube. Finally, 6 months after the initial surgery, she underwent left distal ureteral reimplantation and placement of an indwelling left ureteral stent.

Patient’s claim The physicians were negligent for failing (1) to identify the ureter prior to cutting out the ovarian mass and (2) to check the course of the ureter after the mass had been removed.

Doctor’s defense (1) The cystic mass was difficult to dissect, and a general surgeon was called to confirm that no injury had occurred. (2) Following abdominal ultrasonography and CT, cystoscopy by a urologist confirmed a ureteral injury. The need for a nephrostomy was discussed, but the patient demanded a transfer and thus left the care of the defendants. (3) The patient’s outcome was ultimately good.

Verdict Texas defense verdict.

Placental abruption—and baby is stillborn

A woman in her 23rd week of pregnancy arrived at the hospital with ruptured membranes and bleeding. She was diagnosed with placental abruption, and the fetus was alive as confirmed by ultrasonography. Two hours after her arrival, a cesarean section was performed, but the baby was stillborn.

Patient’s claim The infant should have been delivered within 30 minutes of the decision to perform a cesarean section.

Doctor’s defense Both preparation of the mother for surgery and performance of the cesarean section were timely. Also, the child had only a 10% chance of survival because of his early gestational age.

 

Verdict Illinois defense verdict. Prior to the verdict, the hospital entered a confidential high/low agreement with the plaintiff.

Did surgeon fail to identify the ureter?

A breast cancer survivor in her 40s tested positive for the familial gene BRCA1, which increased her chance of developing ovarian cancer by up to 70%. To reduce that chance, she chose to have an oophorectomy, which was performed by an ObGyn. Two days after her discharge from the hospital, she complained of flank pain and inability to void. She met the ObGyn in the emergency room, where diagnostic tests confirmed an obstructed ureter. Following five stenting procedures, the patient underwent ureteral reimplantation surgery, which alleviated but did not completely cure her symptoms.

Patient’s claim The ObGyn failed to identify the ureter so as to protect it from injury and also failed to inspect for ureteral injury following surgery. When he could not find the ureter, he should have consulted with another physician to help find the ureter or convert from laparoscopic to open surgery.

Doctor’s defense The injury would have occurred even if the ureter had been identified.

Verdict $500,000 Maryland verdict.

Diabetic smoker blames others for CP

A woman had her final visit with her ObGyn 1 week before her scheduled cesarean section. When she arrived at the hospital at 36 weeks’ gestation for the procedure, the attending ObGyn delivered the child, who was born with severe acidosis and hypoxia and was diagnosed with cerebral palsy. The mother was diabetic and a smoker.

Patient’s claim Signs of a compromised infant were evident at her last visit to the ObGyn, and the child should have been delivered that day. Also, on the day of the actual delivery, the physician should have performed the delivery more expeditiously.

Doctor’s defense The infant was harmed before 34 weeks’ gestation. This was a high-risk pregnancy: the mother did not comply with diabetes management, and she continued to smoke although warned not to.

Verdict Massachusetts defense verdict.

Brain damage occurred despite “timely” birth

An active-duty Marine pregnant with her first child was examined twice at the labor and delivery unit and sent home. Five days before her due date—and 1 day following the previous visit—she returned with ruptured membranes and was admitted by a family practice resident. Four hours later, oxytocin was started because of decreased variability in the fetal monitoring with some late decelerations. A drop in the fetal heart rate followed the start of an epidural. A fetal scalp electrode was inserted, and within 15 minutes the mother was moved to the operating room. The attending family practice physician and the attending OB were called, and delivery by cesarean section was performed within another 15 minutes.

At birth, the infant was severely distressed. Intubation was attempted by a first-year intern, but after 25 minutes, the tube was found to be in the right mainstream bronchus with complete collapse of the left lung. For 10 minutes there was no heartbeat, but the staff reported a 5-minute Apgar score of 5. The infant was transferred to a second hospital, where a feeding gastrostomy and tracheotomy were placed. Two months later, the infant was transferred to a third hospital and, finally, 3 months after that, transferred home. The child suffered severe brain damage and developmental delay.

Patient’s claim The physicians failed to recognize the nonreassuring fetal monitoring strips and deliver early.

Doctor’s defense The delivery was timely.

Verdict $5.3 million California settlement.

Was ureteral injury caused by negligence?

A 49-year-old woman presented at the hospital for removal of an ovarian mass 10 cm × 12 cm in diameter. At the first incision, the two surgeons discovered severe pelvic adhesive disease, the result of a previous hysterectomy. The mass was not visible, but they finally located it—lower in the pelvic cavity than normal and near the ureter—and removed it.

Although the patient complained of pain in the back and left flank, several days passed before physicians discovered that the ureter had been cut and urine was backing up into the left kidney. The patient demanded transfer to another hospital.

Five days after the original surgery, a nephrostomy tube was inserted to drain the left kidney, but the patient’s abdomen was too inflamed to immediately repair the injury. She was discharged 3 days later. She was readmitted for treatment of severe infection due to the nephrostomy tube and then underwent more procedures to change the tube. Finally, 6 months after the initial surgery, she underwent left distal ureteral reimplantation and placement of an indwelling left ureteral stent.

Patient’s claim The physicians were negligent for failing (1) to identify the ureter prior to cutting out the ovarian mass and (2) to check the course of the ureter after the mass had been removed.

Doctor’s defense (1) The cystic mass was difficult to dissect, and a general surgeon was called to confirm that no injury had occurred. (2) Following abdominal ultrasonography and CT, cystoscopy by a urologist confirmed a ureteral injury. The need for a nephrostomy was discussed, but the patient demanded a transfer and thus left the care of the defendants. (3) The patient’s outcome was ultimately good.

Verdict Texas defense verdict.

Placental abruption—and baby is stillborn

A woman in her 23rd week of pregnancy arrived at the hospital with ruptured membranes and bleeding. She was diagnosed with placental abruption, and the fetus was alive as confirmed by ultrasonography. Two hours after her arrival, a cesarean section was performed, but the baby was stillborn.

Patient’s claim The infant should have been delivered within 30 minutes of the decision to perform a cesarean section.

Doctor’s defense Both preparation of the mother for surgery and performance of the cesarean section were timely. Also, the child had only a 10% chance of survival because of his early gestational age.

 

Verdict Illinois defense verdict. Prior to the verdict, the hospital entered a confidential high/low agreement with the plaintiff.

Did surgeon fail to identify the ureter?

A breast cancer survivor in her 40s tested positive for the familial gene BRCA1, which increased her chance of developing ovarian cancer by up to 70%. To reduce that chance, she chose to have an oophorectomy, which was performed by an ObGyn. Two days after her discharge from the hospital, she complained of flank pain and inability to void. She met the ObGyn in the emergency room, where diagnostic tests confirmed an obstructed ureter. Following five stenting procedures, the patient underwent ureteral reimplantation surgery, which alleviated but did not completely cure her symptoms.

Patient’s claim The ObGyn failed to identify the ureter so as to protect it from injury and also failed to inspect for ureteral injury following surgery. When he could not find the ureter, he should have consulted with another physician to help find the ureter or convert from laparoscopic to open surgery.

Doctor’s defense The injury would have occurred even if the ureter had been identified.

Verdict $500,000 Maryland verdict.

Diabetic smoker blames others for CP

A woman had her final visit with her ObGyn 1 week before her scheduled cesarean section. When she arrived at the hospital at 36 weeks’ gestation for the procedure, the attending ObGyn delivered the child, who was born with severe acidosis and hypoxia and was diagnosed with cerebral palsy. The mother was diabetic and a smoker.

Patient’s claim Signs of a compromised infant were evident at her last visit to the ObGyn, and the child should have been delivered that day. Also, on the day of the actual delivery, the physician should have performed the delivery more expeditiously.

Doctor’s defense The infant was harmed before 34 weeks’ gestation. This was a high-risk pregnancy: the mother did not comply with diabetes management, and she continued to smoke although warned not to.

Verdict Massachusetts defense verdict.

Brain damage occurred despite “timely” birth

An active-duty Marine pregnant with her first child was examined twice at the labor and delivery unit and sent home. Five days before her due date—and 1 day following the previous visit—she returned with ruptured membranes and was admitted by a family practice resident. Four hours later, oxytocin was started because of decreased variability in the fetal monitoring with some late decelerations. A drop in the fetal heart rate followed the start of an epidural. A fetal scalp electrode was inserted, and within 15 minutes the mother was moved to the operating room. The attending family practice physician and the attending OB were called, and delivery by cesarean section was performed within another 15 minutes.

At birth, the infant was severely distressed. Intubation was attempted by a first-year intern, but after 25 minutes, the tube was found to be in the right mainstream bronchus with complete collapse of the left lung. For 10 minutes there was no heartbeat, but the staff reported a 5-minute Apgar score of 5. The infant was transferred to a second hospital, where a feeding gastrostomy and tracheotomy were placed. Two months later, the infant was transferred to a third hospital and, finally, 3 months after that, transferred home. The child suffered severe brain damage and developmental delay.

Patient’s claim The physicians failed to recognize the nonreassuring fetal monitoring strips and deliver early.

Doctor’s defense The delivery was timely.

Verdict $5.3 million California settlement.

Was ureteral injury caused by negligence?

A 49-year-old woman presented at the hospital for removal of an ovarian mass 10 cm × 12 cm in diameter. At the first incision, the two surgeons discovered severe pelvic adhesive disease, the result of a previous hysterectomy. The mass was not visible, but they finally located it—lower in the pelvic cavity than normal and near the ureter—and removed it.

Although the patient complained of pain in the back and left flank, several days passed before physicians discovered that the ureter had been cut and urine was backing up into the left kidney. The patient demanded transfer to another hospital.

Five days after the original surgery, a nephrostomy tube was inserted to drain the left kidney, but the patient’s abdomen was too inflamed to immediately repair the injury. She was discharged 3 days later. She was readmitted for treatment of severe infection due to the nephrostomy tube and then underwent more procedures to change the tube. Finally, 6 months after the initial surgery, she underwent left distal ureteral reimplantation and placement of an indwelling left ureteral stent.

Patient’s claim The physicians were negligent for failing (1) to identify the ureter prior to cutting out the ovarian mass and (2) to check the course of the ureter after the mass had been removed.

Doctor’s defense (1) The cystic mass was difficult to dissect, and a general surgeon was called to confirm that no injury had occurred. (2) Following abdominal ultrasonography and CT, cystoscopy by a urologist confirmed a ureteral injury. The need for a nephrostomy was discussed, but the patient demanded a transfer and thus left the care of the defendants. (3) The patient’s outcome was ultimately good.

Verdict Texas defense verdict.

Placental abruption—and baby is stillborn

A woman in her 23rd week of pregnancy arrived at the hospital with ruptured membranes and bleeding. She was diagnosed with placental abruption, and the fetus was alive as confirmed by ultrasonography. Two hours after her arrival, a cesarean section was performed, but the baby was stillborn.

Patient’s claim The infant should have been delivered within 30 minutes of the decision to perform a cesarean section.

Doctor’s defense Both preparation of the mother for surgery and performance of the cesarean section were timely. Also, the child had only a 10% chance of survival because of his early gestational age.

 

Verdict Illinois defense verdict. Prior to the verdict, the hospital entered a confidential high/low agreement with the plaintiff.

Did surgeon fail to identify the ureter?

A breast cancer survivor in her 40s tested positive for the familial gene BRCA1, which increased her chance of developing ovarian cancer by up to 70%. To reduce that chance, she chose to have an oophorectomy, which was performed by an ObGyn. Two days after her discharge from the hospital, she complained of flank pain and inability to void. She met the ObGyn in the emergency room, where diagnostic tests confirmed an obstructed ureter. Following five stenting procedures, the patient underwent ureteral reimplantation surgery, which alleviated but did not completely cure her symptoms.

Patient’s claim The ObGyn failed to identify the ureter so as to protect it from injury and also failed to inspect for ureteral injury following surgery. When he could not find the ureter, he should have consulted with another physician to help find the ureter or convert from laparoscopic to open surgery.

Doctor’s defense The injury would have occurred even if the ureter had been identified.

Verdict $500,000 Maryland verdict.