Managing Your Practice

Did young woman need hysterectomy?

A few months after giving birth, a 22-year-old woman presented to her ObGyn with lower abdominal pain and vaginal bleeding. Although she wanted more children, she consented to a total hysterectomy to avoid developing a very dangerous condition. However, she was not clear on what that condition was.

Patient’s claim The hysterectomy was unnecessary, because she had a normal post-childbirth problem that could have been treated with Depo-Provera or oral contraceptives. She did not give informed consent, because her condition was not explained to her, and the hospital chart and physician’s office chart differed significantly. Finally, the hospital was negligent for credentialing the physician, who had a high rate of hysterectomies in women under 30 and had several lawsuits filed against him.

Doctor’s defense The ObGyn offered the patient alternatives to a hysterectomy, but she insisted on a hysterectomy. The hospital claimed it followed its credentialing procedures.

Verdict $1.75 million Washington verdict. The physician was found to be 90% at fault, and the hospital 10% at fault. Post-trial motions were pending.

Woman hears “cancer” and has hysterectomy

A 24-year-old woman underwent a hysterectomy because she believed the doctor told her she had cancer.

Patient’s claim She was told the surgery was necessary because of cancer, but she did not have cancer—thus the hysterectomy was unnecessary. Also, she did not give informed consent.

Doctor’s defense As the patient did not want the frequent follow-up needed with other options to treat her precancerous growth, a hysterectomy was a legitimate treatment choice. She was fully informed of all options, and the surgery was performed properly.

Verdict Illinois defense verdict.

Did young woman need hysterectomy?

A few months after giving birth, a 22-year-old woman presented to her ObGyn with lower abdominal pain and vaginal bleeding. Although she wanted more children, she consented to a total hysterectomy to avoid developing a very dangerous condition. However, she was not clear on what that condition was.

Patient’s claim The hysterectomy was unnecessary, because she had a normal post-childbirth problem that could have been treated with Depo-Provera or oral contraceptives. She did not give informed consent, because her condition was not explained to her, and the hospital chart and physician’s office chart differed significantly. Finally, the hospital was negligent for credentialing the physician, who had a high rate of hysterectomies in women under 30 and had several lawsuits filed against him.

Doctor’s defense The ObGyn offered the patient alternatives to a hysterectomy, but she insisted on a hysterectomy. The hospital claimed it followed its credentialing procedures.

Verdict $1.75 million Washington verdict. The physician was found to be 90% at fault, and the hospital 10% at fault. Post-trial motions were pending.

Woman hears “cancer” and has hysterectomy

A 24-year-old woman underwent a hysterectomy because she believed the doctor told her she had cancer.

Patient’s claim She was told the surgery was necessary because of cancer, but she did not have cancer—thus the hysterectomy was unnecessary. Also, she did not give informed consent.

Doctor’s defense As the patient did not want the frequent follow-up needed with other options to treat her precancerous growth, a hysterectomy was a legitimate treatment choice. She was fully informed of all options, and the surgery was performed properly.

Verdict Illinois defense verdict.

Did young woman need hysterectomy?

A few months after giving birth, a 22-year-old woman presented to her ObGyn with lower abdominal pain and vaginal bleeding. Although she wanted more children, she consented to a total hysterectomy to avoid developing a very dangerous condition. However, she was not clear on what that condition was.

Patient’s claim The hysterectomy was unnecessary, because she had a normal post-childbirth problem that could have been treated with Depo-Provera or oral contraceptives. She did not give informed consent, because her condition was not explained to her, and the hospital chart and physician’s office chart differed significantly. Finally, the hospital was negligent for credentialing the physician, who had a high rate of hysterectomies in women under 30 and had several lawsuits filed against him.

Doctor’s defense The ObGyn offered the patient alternatives to a hysterectomy, but she insisted on a hysterectomy. The hospital claimed it followed its credentialing procedures.

Verdict $1.75 million Washington verdict. The physician was found to be 90% at fault, and the hospital 10% at fault. Post-trial motions were pending.

Woman hears “cancer” and has hysterectomy

A 24-year-old woman underwent a hysterectomy because she believed the doctor told her she had cancer.

Patient’s claim She was told the surgery was necessary because of cancer, but she did not have cancer—thus the hysterectomy was unnecessary. Also, she did not give informed consent.

Doctor’s defense As the patient did not want the frequent follow-up needed with other options to treat her precancerous growth, a hysterectomy was a legitimate treatment choice. She was fully informed of all options, and the surgery was performed properly.

Verdict Illinois defense verdict.

Erb’s palsy occurs after “turtle sign”

During delivery, the infant plaintiff crowned at one point and then withdrew back into the birth canal in a “turtle sign.” The physician performed a McRoberts maneuver, one nurse allegedly applied fundal pressure, and a second nurse applied suprapubic pressure. At birth, the child had an Apgar of 2 and was soon diagnosed with Erb’s palsy because of right brachial plexus injury.

Patient’s claim The physician pulled too long on the fetus before suprapubic pressure was applied; excessive fundal pressure was used; an episiotomy should have been done; and the physician should have rotated the fetus.

Doctor’s defense He responded properly to the turtle sign. Also, the injury can occur in the absence of negligence.

Verdict Tennessee defense verdict. Post-trial motions were pending.

Was anesthesiologist late for emergency?

A pregnant 34-year-old woman presented with ruptured membranes at the hospital 5 days before her due date. She had felt good fetal movement earlier that morning, but could not detect movement by the afternoon. An electronic fetal monitor was connected and oxytocin ordered. When the nurse noted decreased long-term variability, the attending physician responded and evaluated the fetus and tracings. At about midnight of the following day, the resident physician was called, and oxytocin was increased. When the mother began pushing, the fetal heart rate dropped and remained below baseline. It was decided to do an emergency cesarean section, which was performed without the anesthesiologist when he failed to respond to a page within 20 minutes. The anesthesiologist—who was asleep in the call room and unable to hear the pages with the air conditioner on—responded immediately when he awoke, and topped off the epidural. The child was born limp, apneic, and cyanotic and was diagnosed with hypoxic–ischemic encephalopathy, severe metabolic acidosis, and respiratory depression. She cannot walk, talk, or hold her head upright, is fed through a G tube, and takes medication for a seizure disorder.

Patient’s claim Delivery should have been expedited when the resident physician was called on the second day because of signs of fetal hypoxia, and oxytocin should not have been increased.

Doctor’s defense According to the nurse, attending physician, and resident, fetal hypoxia was not evident, and the problems were caused by the anesthesiologist. The latter said there was no delay and disputed the claims of when he was paged and when he arrived.

Verdict $4 million Massachusetts settlement.

Woman refuses C-section—repeatedly

A 37-year-old pregnant woman who had previously delivered a healthy boy by cesarean section was advised to have a vaginal delivery for this pregnancy. When she was 2 weeks past her due date, she was admitted to the hospital for induction of labor and vaginal birth. The baby was at +2 to +3 station after 4 hours in the second stage of labor. The physician recommended a cesarean section, and the woman declined. A vacuum-assisted delivery with fundal pressure was unsuccessful. Again the physician recommended a cesarean section, and the woman declined. The physician then tried using forceps, but gave up when he couldn’t position the forceps properly. For a third time, he recommended a cesarean section, and she declined. When the physician ordered fundal pressure—and the nurses refused—the husband applied it. Within minutes the woman agreed to a cesarean section. The child was born with cerebral palsy, right-sided paralysis, cognitive deficits, and learning disabilities, as well as facial bruises, a large cephalohematoma, and swelling of the scalp. Three hours later the child began to have seizure motions.

Patient’s claim The physician was negligent for failing to provide enough information about cesarean sections during labor. He was also negligent for using vacuum, forceps, and fundal pressure.

Doctor’s defense The mother was sufficiently informed about cesarean sections, and he handled the attempted vaginal delivery appropriately. Also, the infarction was due to placental thrombophilia that occurred before labor.

Verdict California defense verdict.

Did she agree to the tubal ligation?

A 35-year-old woman who had previously delivered 2 children by cesarean section wanted to attempt a vaginal delivery with her third child. When labor progressed slowly, the ObGyn decided to perform a cesarean section and recommended also a tubal ligation.

Patient’s claim The tubal ligation was done without her consent and against her wishes. She refused the procedure initially and again after the cesarean section.

Doctor’s defense The patient did refuse the tubal ligation initially, but gave verbal consent in the operating room.

Verdict $435,00 North Carolina settlement, including $100,000 from the hospital and $335,000 from the physician.

Despite report, ovary was not removed

A 38-year-old woman, who had a history of sarcoidosis and hysterectomy with removal of the right ovary, presented at the hospital with lower-left-quadrant pain. A mass on the left ovary was discovered, and she underwent laparoscopic surgery 5 days later to remove the mass, and also the ovary and fallopian tube. In the operative report, the physician noted he had removed the ovary. The patient complained of postoperative pain. Several months later, a CT scan showed the presence of the left ovary and fallopian tube. Eleven months following the initial procedure, further surgery indicated extensive intra-abdominal adhesions and an ovarian mass that required laparoscopic lysis of adhesions, as well as removal of the ovary and fallopian tube. The pathology report mentioned the presence of the tube and the ovary, which had multiple cystic follicles and a focal area of fibrosis, and a hemorrhagic area. After the surgery, the patient suffered from back pain, and 5 months later was diagnosed with hydronephrosis due to a stricture of the left distal ureter.

Patient’s claim The initial surgery was not done properly, so further procedures were required. Surgical clips used in the second surgery caused the stricture of the ureter, which required more surgery to insert a stent. However, because the stricture could not be opened, ureteral reimplantation was necessary.

Doctor’s defense Not reported.

Verdict $925,000 New York settlement after opening statements.

Erb’s palsy occurs after “turtle sign”

During delivery, the infant plaintiff crowned at one point and then withdrew back into the birth canal in a “turtle sign.” The physician performed a McRoberts maneuver, one nurse allegedly applied fundal pressure, and a second nurse applied suprapubic pressure. At birth, the child had an Apgar of 2 and was soon diagnosed with Erb’s palsy because of right brachial plexus injury.

Patient’s claim The physician pulled too long on the fetus before suprapubic pressure was applied; excessive fundal pressure was used; an episiotomy should have been done; and the physician should have rotated the fetus.

Doctor’s defense He responded properly to the turtle sign. Also, the injury can occur in the absence of negligence.

Verdict Tennessee defense verdict. Post-trial motions were pending.

Was anesthesiologist late for emergency?

A pregnant 34-year-old woman presented with ruptured membranes at the hospital 5 days before her due date. She had felt good fetal movement earlier that morning, but could not detect movement by the afternoon. An electronic fetal monitor was connected and oxytocin ordered. When the nurse noted decreased long-term variability, the attending physician responded and evaluated the fetus and tracings. At about midnight of the following day, the resident physician was called, and oxytocin was increased. When the mother began pushing, the fetal heart rate dropped and remained below baseline. It was decided to do an emergency cesarean section, which was performed without the anesthesiologist when he failed to respond to a page within 20 minutes. The anesthesiologist—who was asleep in the call room and unable to hear the pages with the air conditioner on—responded immediately when he awoke, and topped off the epidural. The child was born limp, apneic, and cyanotic and was diagnosed with hypoxic–ischemic encephalopathy, severe metabolic acidosis, and respiratory depression. She cannot walk, talk, or hold her head upright, is fed through a G tube, and takes medication for a seizure disorder.

Patient’s claim Delivery should have been expedited when the resident physician was called on the second day because of signs of fetal hypoxia, and oxytocin should not have been increased.

Doctor’s defense According to the nurse, attending physician, and resident, fetal hypoxia was not evident, and the problems were caused by the anesthesiologist. The latter said there was no delay and disputed the claims of when he was paged and when he arrived.

Verdict $4 million Massachusetts settlement.

Woman refuses C-section—repeatedly

A 37-year-old pregnant woman who had previously delivered a healthy boy by cesarean section was advised to have a vaginal delivery for this pregnancy. When she was 2 weeks past her due date, she was admitted to the hospital for induction of labor and vaginal birth. The baby was at +2 to +3 station after 4 hours in the second stage of labor. The physician recommended a cesarean section, and the woman declined. A vacuum-assisted delivery with fundal pressure was unsuccessful. Again the physician recommended a cesarean section, and the woman declined. The physician then tried using forceps, but gave up when he couldn’t position the forceps properly. For a third time, he recommended a cesarean section, and she declined. When the physician ordered fundal pressure—and the nurses refused—the husband applied it. Within minutes the woman agreed to a cesarean section. The child was born with cerebral palsy, right-sided paralysis, cognitive deficits, and learning disabilities, as well as facial bruises, a large cephalohematoma, and swelling of the scalp. Three hours later the child began to have seizure motions.

Patient’s claim The physician was negligent for failing to provide enough information about cesarean sections during labor. He was also negligent for using vacuum, forceps, and fundal pressure.

Doctor’s defense The mother was sufficiently informed about cesarean sections, and he handled the attempted vaginal delivery appropriately. Also, the infarction was due to placental thrombophilia that occurred before labor.

Verdict California defense verdict.

Did she agree to the tubal ligation?

A 35-year-old woman who had previously delivered 2 children by cesarean section wanted to attempt a vaginal delivery with her third child. When labor progressed slowly, the ObGyn decided to perform a cesarean section and recommended also a tubal ligation.

Patient’s claim The tubal ligation was done without her consent and against her wishes. She refused the procedure initially and again after the cesarean section.

Doctor’s defense The patient did refuse the tubal ligation initially, but gave verbal consent in the operating room.

Verdict $435,00 North Carolina settlement, including $100,000 from the hospital and $335,000 from the physician.

Despite report, ovary was not removed

A 38-year-old woman, who had a history of sarcoidosis and hysterectomy with removal of the right ovary, presented at the hospital with lower-left-quadrant pain. A mass on the left ovary was discovered, and she underwent laparoscopic surgery 5 days later to remove the mass, and also the ovary and fallopian tube. In the operative report, the physician noted he had removed the ovary. The patient complained of postoperative pain. Several months later, a CT scan showed the presence of the left ovary and fallopian tube. Eleven months following the initial procedure, further surgery indicated extensive intra-abdominal adhesions and an ovarian mass that required laparoscopic lysis of adhesions, as well as removal of the ovary and fallopian tube. The pathology report mentioned the presence of the tube and the ovary, which had multiple cystic follicles and a focal area of fibrosis, and a hemorrhagic area. After the surgery, the patient suffered from back pain, and 5 months later was diagnosed with hydronephrosis due to a stricture of the left distal ureter.

Patient’s claim The initial surgery was not done properly, so further procedures were required. Surgical clips used in the second surgery caused the stricture of the ureter, which required more surgery to insert a stent. However, because the stricture could not be opened, ureteral reimplantation was necessary.

Doctor’s defense Not reported.

Verdict $925,000 New York settlement after opening statements.

Erb’s palsy occurs after “turtle sign”

During delivery, the infant plaintiff crowned at one point and then withdrew back into the birth canal in a “turtle sign.” The physician performed a McRoberts maneuver, one nurse allegedly applied fundal pressure, and a second nurse applied suprapubic pressure. At birth, the child had an Apgar of 2 and was soon diagnosed with Erb’s palsy because of right brachial plexus injury.

Patient’s claim The physician pulled too long on the fetus before suprapubic pressure was applied; excessive fundal pressure was used; an episiotomy should have been done; and the physician should have rotated the fetus.

Doctor’s defense He responded properly to the turtle sign. Also, the injury can occur in the absence of negligence.

Verdict Tennessee defense verdict. Post-trial motions were pending.

Was anesthesiologist late for emergency?

A pregnant 34-year-old woman presented with ruptured membranes at the hospital 5 days before her due date. She had felt good fetal movement earlier that morning, but could not detect movement by the afternoon. An electronic fetal monitor was connected and oxytocin ordered. When the nurse noted decreased long-term variability, the attending physician responded and evaluated the fetus and tracings. At about midnight of the following day, the resident physician was called, and oxytocin was increased. When the mother began pushing, the fetal heart rate dropped and remained below baseline. It was decided to do an emergency cesarean section, which was performed without the anesthesiologist when he failed to respond to a page within 20 minutes. The anesthesiologist—who was asleep in the call room and unable to hear the pages with the air conditioner on—responded immediately when he awoke, and topped off the epidural. The child was born limp, apneic, and cyanotic and was diagnosed with hypoxic–ischemic encephalopathy, severe metabolic acidosis, and respiratory depression. She cannot walk, talk, or hold her head upright, is fed through a G tube, and takes medication for a seizure disorder.

Patient’s claim Delivery should have been expedited when the resident physician was called on the second day because of signs of fetal hypoxia, and oxytocin should not have been increased.

Doctor’s defense According to the nurse, attending physician, and resident, fetal hypoxia was not evident, and the problems were caused by the anesthesiologist. The latter said there was no delay and disputed the claims of when he was paged and when he arrived.

Verdict $4 million Massachusetts settlement.

Woman refuses C-section—repeatedly

A 37-year-old pregnant woman who had previously delivered a healthy boy by cesarean section was advised to have a vaginal delivery for this pregnancy. When she was 2 weeks past her due date, she was admitted to the hospital for induction of labor and vaginal birth. The baby was at +2 to +3 station after 4 hours in the second stage of labor. The physician recommended a cesarean section, and the woman declined. A vacuum-assisted delivery with fundal pressure was unsuccessful. Again the physician recommended a cesarean section, and the woman declined. The physician then tried using forceps, but gave up when he couldn’t position the forceps properly. For a third time, he recommended a cesarean section, and she declined. When the physician ordered fundal pressure—and the nurses refused—the husband applied it. Within minutes the woman agreed to a cesarean section. The child was born with cerebral palsy, right-sided paralysis, cognitive deficits, and learning disabilities, as well as facial bruises, a large cephalohematoma, and swelling of the scalp. Three hours later the child began to have seizure motions.

Patient’s claim The physician was negligent for failing to provide enough information about cesarean sections during labor. He was also negligent for using vacuum, forceps, and fundal pressure.

Doctor’s defense The mother was sufficiently informed about cesarean sections, and he handled the attempted vaginal delivery appropriately. Also, the infarction was due to placental thrombophilia that occurred before labor.

Verdict California defense verdict.

Did she agree to the tubal ligation?

A 35-year-old woman who had previously delivered 2 children by cesarean section wanted to attempt a vaginal delivery with her third child. When labor progressed slowly, the ObGyn decided to perform a cesarean section and recommended also a tubal ligation.

Patient’s claim The tubal ligation was done without her consent and against her wishes. She refused the procedure initially and again after the cesarean section.

Doctor’s defense The patient did refuse the tubal ligation initially, but gave verbal consent in the operating room.

Verdict $435,00 North Carolina settlement, including $100,000 from the hospital and $335,000 from the physician.

Despite report, ovary was not removed

A 38-year-old woman, who had a history of sarcoidosis and hysterectomy with removal of the right ovary, presented at the hospital with lower-left-quadrant pain. A mass on the left ovary was discovered, and she underwent laparoscopic surgery 5 days later to remove the mass, and also the ovary and fallopian tube. In the operative report, the physician noted he had removed the ovary. The patient complained of postoperative pain. Several months later, a CT scan showed the presence of the left ovary and fallopian tube. Eleven months following the initial procedure, further surgery indicated extensive intra-abdominal adhesions and an ovarian mass that required laparoscopic lysis of adhesions, as well as removal of the ovary and fallopian tube. The pathology report mentioned the presence of the tube and the ovary, which had multiple cystic follicles and a focal area of fibrosis, and a hemorrhagic area. After the surgery, the patient suffered from back pain, and 5 months later was diagnosed with hydronephrosis due to a stricture of the left distal ureter.

Patient’s claim The initial surgery was not done properly, so further procedures were required. Surgical clips used in the second surgery caused the stricture of the ureter, which required more surgery to insert a stent. However, because the stricture could not be opened, ureteral reimplantation was necessary.

Doctor’s defense Not reported.

Verdict $925,000 New York settlement after opening statements.

DR. SARADARIAN is a family physician with a Branchville, N.J.-based solo practice.

The next time you manage to fill an hour responding to patients' e-mails, completing camp forms, or researching referrals, consider this: Some family physicians are starting to bill their patients for all that extra time. In this month's column, Dr. Kathleen A. Saradarian explains how she sets her fee policy for patients.

Some insurance plans have indicated that as long as the patient is aware of these charges ahead of time, the charges are fair game. Others have sent warnings that the patient can be charged only copays, deductibles, and coinsurance, thus ignoring those “noncovered” items that are frequently not specified in contracts. So earlier this year, I began having patients sign a policy letter that they take home after the signed document is scanned into our electronic health record (EHR) system. For the most part, patients have accepted these fees. I think their acceptance is based on the fact that only those individuals utilizing the extra services are paying for the services.

I think it's powerful to spell out for patients the drawbacks of accepting payment from insurance companies. My letter explains that I participate in health insurance plans for the convenience of my patients. I cannot control what an insurance company will and will not cover. Nor can I control the amount of money that an insurance company sets as the allowable fee for my services.

I explain the bottom line: While the expense of running a practice has continued to increase from year to year, I have been unable to increase the amount of money the insurance companies pay me for my services; any increases that have occurred have not kept up with inflation and increasing costs. I therefore can no longer afford to provide uncompensated services free of charge.

In addition to charging a fee for e-mail and telephone consultations, we now charge nominal fees to patients the first time they request that a document be mailed, or if we are asked to write a letter or complete a school or camp medical history form at a time other than an office visit made specifically for that purpose.

By New Jersey state law, we are permitted to charge a fee for copying medical records. We therefore charge a $1 per page fee to copy a paper medical chart. And if the patient's history and records are stored electronically, there is a flat $10 fee for the summary. It costs time and money to provide such files, and recovering those costs is perfectly legal. However, state laws vary.

We also charge for medication refill requests that are not accompanied by an office visit. Although I do my best at each visit to make sure that patients have enough medication to last until their next visit, I often spend 2–3 hours every evening processing refill requests or requests for new medication for an old problem. Usually this is because people are overdue for their office visit. In the event that a patient is not overdue for a visit, a fee is not assessed.

Finally, the policy letter explains that a procedural code was created for offering office hours beyond the usual business hours. This extra fee ($30) is submitted first to the patient's insurance company. However, should the insurance company refuse to pay but allow the patient to be charged (“noncovered and billable”), the policy letter explains that the patient is then responsible for the fee.

For the most part, patients are accepting these fees as a fair charge for the extra work done on their behalf. Although a few individuals have balked, most patients understand, especially those who look at their explanation of benefit statements and see what we get paid versus what we charge. It is unfortunate that things have come to this. Many patients are already paying more and more for their health care out of pocket, and health insurance costs keep climbing. Unfortunately, much of that heath insurance money is not going toward their health care, but to insurance administrative overhead.

It's too early to tell if this will be successful or make much of a difference in the bottom line, but at least it already has patients thinking ahead about refills and planning to avoid those extra fees. This gets me home earlier at night, which is really the purpose.

DR. SARADARIAN is a family physician with a Branchville, N.J.-based solo practice.

The next time you manage to fill an hour responding to patients' e-mails, completing camp forms, or researching referrals, consider this: Some family physicians are starting to bill their patients for all that extra time. In this month's column, Dr. Kathleen A. Saradarian explains how she sets her fee policy for patients.

Some insurance plans have indicated that as long as the patient is aware of these charges ahead of time, the charges are fair game. Others have sent warnings that the patient can be charged only copays, deductibles, and coinsurance, thus ignoring those “noncovered” items that are frequently not specified in contracts. So earlier this year, I began having patients sign a policy letter that they take home after the signed document is scanned into our electronic health record (EHR) system. For the most part, patients have accepted these fees. I think their acceptance is based on the fact that only those individuals utilizing the extra services are paying for the services.

I think it's powerful to spell out for patients the drawbacks of accepting payment from insurance companies. My letter explains that I participate in health insurance plans for the convenience of my patients. I cannot control what an insurance company will and will not cover. Nor can I control the amount of money that an insurance company sets as the allowable fee for my services.

I explain the bottom line: While the expense of running a practice has continued to increase from year to year, I have been unable to increase the amount of money the insurance companies pay me for my services; any increases that have occurred have not kept up with inflation and increasing costs. I therefore can no longer afford to provide uncompensated services free of charge.

In addition to charging a fee for e-mail and telephone consultations, we now charge nominal fees to patients the first time they request that a document be mailed, or if we are asked to write a letter or complete a school or camp medical history form at a time other than an office visit made specifically for that purpose.

By New Jersey state law, we are permitted to charge a fee for copying medical records. We therefore charge a $1 per page fee to copy a paper medical chart. And if the patient's history and records are stored electronically, there is a flat $10 fee for the summary. It costs time and money to provide such files, and recovering those costs is perfectly legal. However, state laws vary.

We also charge for medication refill requests that are not accompanied by an office visit. Although I do my best at each visit to make sure that patients have enough medication to last until their next visit, I often spend 2–3 hours every evening processing refill requests or requests for new medication for an old problem. Usually this is because people are overdue for their office visit. In the event that a patient is not overdue for a visit, a fee is not assessed.

Finally, the policy letter explains that a procedural code was created for offering office hours beyond the usual business hours. This extra fee ($30) is submitted first to the patient's insurance company. However, should the insurance company refuse to pay but allow the patient to be charged (“noncovered and billable”), the policy letter explains that the patient is then responsible for the fee.

For the most part, patients are accepting these fees as a fair charge for the extra work done on their behalf. Although a few individuals have balked, most patients understand, especially those who look at their explanation of benefit statements and see what we get paid versus what we charge. It is unfortunate that things have come to this. Many patients are already paying more and more for their health care out of pocket, and health insurance costs keep climbing. Unfortunately, much of that heath insurance money is not going toward their health care, but to insurance administrative overhead.

It's too early to tell if this will be successful or make much of a difference in the bottom line, but at least it already has patients thinking ahead about refills and planning to avoid those extra fees. This gets me home earlier at night, which is really the purpose.

DR. SARADARIAN is a family physician with a Branchville, N.J.-based solo practice.

The next time you manage to fill an hour responding to patients' e-mails, completing camp forms, or researching referrals, consider this: Some family physicians are starting to bill their patients for all that extra time. In this month's column, Dr. Kathleen A. Saradarian explains how she sets her fee policy for patients.

Some insurance plans have indicated that as long as the patient is aware of these charges ahead of time, the charges are fair game. Others have sent warnings that the patient can be charged only copays, deductibles, and coinsurance, thus ignoring those “noncovered” items that are frequently not specified in contracts. So earlier this year, I began having patients sign a policy letter that they take home after the signed document is scanned into our electronic health record (EHR) system. For the most part, patients have accepted these fees. I think their acceptance is based on the fact that only those individuals utilizing the extra services are paying for the services.

I think it's powerful to spell out for patients the drawbacks of accepting payment from insurance companies. My letter explains that I participate in health insurance plans for the convenience of my patients. I cannot control what an insurance company will and will not cover. Nor can I control the amount of money that an insurance company sets as the allowable fee for my services.

I explain the bottom line: While the expense of running a practice has continued to increase from year to year, I have been unable to increase the amount of money the insurance companies pay me for my services; any increases that have occurred have not kept up with inflation and increasing costs. I therefore can no longer afford to provide uncompensated services free of charge.

In addition to charging a fee for e-mail and telephone consultations, we now charge nominal fees to patients the first time they request that a document be mailed, or if we are asked to write a letter or complete a school or camp medical history form at a time other than an office visit made specifically for that purpose.

By New Jersey state law, we are permitted to charge a fee for copying medical records. We therefore charge a $1 per page fee to copy a paper medical chart. And if the patient's history and records are stored electronically, there is a flat $10 fee for the summary. It costs time and money to provide such files, and recovering those costs is perfectly legal. However, state laws vary.

We also charge for medication refill requests that are not accompanied by an office visit. Although I do my best at each visit to make sure that patients have enough medication to last until their next visit, I often spend 2–3 hours every evening processing refill requests or requests for new medication for an old problem. Usually this is because people are overdue for their office visit. In the event that a patient is not overdue for a visit, a fee is not assessed.

Finally, the policy letter explains that a procedural code was created for offering office hours beyond the usual business hours. This extra fee ($30) is submitted first to the patient's insurance company. However, should the insurance company refuse to pay but allow the patient to be charged (“noncovered and billable”), the policy letter explains that the patient is then responsible for the fee.

For the most part, patients are accepting these fees as a fair charge for the extra work done on their behalf. Although a few individuals have balked, most patients understand, especially those who look at their explanation of benefit statements and see what we get paid versus what we charge. It is unfortunate that things have come to this. Many patients are already paying more and more for their health care out of pocket, and health insurance costs keep climbing. Unfortunately, much of that heath insurance money is not going toward their health care, but to insurance administrative overhead.

It's too early to tell if this will be successful or make much of a difference in the bottom line, but at least it already has patients thinking ahead about refills and planning to avoid those extra fees. This gets me home earlier at night, which is really the purpose.

Every medical office, even the smallest, should have a time clock, but a surprisingly large percentage of them do not. Although it is hardly a new innovation—the first commercial time clocks were built in the early 20th century by the company that later became IBM—the medical profession has been slow to adapt to this basic business practice.

There are two very good reasons why you should have a time clock. The first is obvious: to punch your employees' time cards. This is essential even if all your employees are paid weekly or semiweekly rather than by the hour.

The other (and possibly more important) reason, which we will come back to, is to punch in your patients.

In most states, any employee who works more than 40 hours in a given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they worked hundreds of hours of unpaid overtime.

This may be completely untrue, but labor boards almost invariably side with employees in such disputes, unless the employer can produce time records that disprove the claim. A time clock is cheap insurance against a large, unexpected, and possibly unjustified payment to a former employee.

For part-time, hourly-wage employees, time records are even more important, as you obviously want to pay them only for the hours they work. If you are paying your part-timers for the number of hours they should be working without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time, or to stay the entire length of their shifts, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can't count on being paid for the extra time.

Time clocks also work to the advantage of your employees: Since they will be paid only for the time they work, they will be paid for all the time they work. If any employees object to your installing a clock, point out that they will be assured of payment for fractional time worked past their usual hours—time which might have gone unpaid before.

As for your patients, a time clock is a great tool in the endless struggle to run on time, as I mentioned in a column addressing that subject 3 years ago. (If you missed “How to Run on Time,” go to www.skinandallergynews.com

As each patient arrives, have your receptionist time stamp the encounter form that goes to the back with the patient's chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are—and you'll have an answer for the curmudgeon who insists he's been sitting there for 21/2 hours.

Time/attendance systems range from relatively simple to relatively complex.

My office has had an old-fashioned stamp-type time clock for 26 years, but nowadays you can get something far more sophisticated than that if you wish.

Many of the newer clocks will automatically calculate time between punches and add up total work time, and they can be configured for weekly, biweekly, semimonthly, or monthly pay periods. At least one will automatically deduct break time from the totals.

If you have a problem with “buddy punching” (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic software systems, both Web based and in house, that can be deployed across a local computer network. They will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third-party payroll services. (As always, I have no financial interest in any product or service discussed in this column.)

If you go the electronic route, make sure the software incorporates security measures to prevent time alterations by unauthorized employees. You can never be too careful.

Every medical office, even the smallest, should have a time clock, but a surprisingly large percentage of them do not. Although it is hardly a new innovation—the first commercial time clocks were built in the early 20th century by the company that later became IBM—the medical profession has been slow to adapt to this basic business practice.

There are two very good reasons why you should have a time clock. The first is obvious: to punch your employees' time cards. This is essential even if all your employees are paid weekly or semiweekly rather than by the hour.

The other (and possibly more important) reason, which we will come back to, is to punch in your patients.

In most states, any employee who works more than 40 hours in a given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they worked hundreds of hours of unpaid overtime.

This may be completely untrue, but labor boards almost invariably side with employees in such disputes, unless the employer can produce time records that disprove the claim. A time clock is cheap insurance against a large, unexpected, and possibly unjustified payment to a former employee.

For part-time, hourly-wage employees, time records are even more important, as you obviously want to pay them only for the hours they work. If you are paying your part-timers for the number of hours they should be working without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time, or to stay the entire length of their shifts, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can't count on being paid for the extra time.

Time clocks also work to the advantage of your employees: Since they will be paid only for the time they work, they will be paid for all the time they work. If any employees object to your installing a clock, point out that they will be assured of payment for fractional time worked past their usual hours—time which might have gone unpaid before.

As for your patients, a time clock is a great tool in the endless struggle to run on time, as I mentioned in a column addressing that subject 3 years ago. (If you missed “How to Run on Time,” go to www.skinandallergynews.com

As each patient arrives, have your receptionist time stamp the encounter form that goes to the back with the patient's chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are—and you'll have an answer for the curmudgeon who insists he's been sitting there for 21/2 hours.

Time/attendance systems range from relatively simple to relatively complex.

My office has had an old-fashioned stamp-type time clock for 26 years, but nowadays you can get something far more sophisticated than that if you wish.

Many of the newer clocks will automatically calculate time between punches and add up total work time, and they can be configured for weekly, biweekly, semimonthly, or monthly pay periods. At least one will automatically deduct break time from the totals.

If you have a problem with “buddy punching” (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic software systems, both Web based and in house, that can be deployed across a local computer network. They will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third-party payroll services. (As always, I have no financial interest in any product or service discussed in this column.)

If you go the electronic route, make sure the software incorporates security measures to prevent time alterations by unauthorized employees. You can never be too careful.

Every medical office, even the smallest, should have a time clock, but a surprisingly large percentage of them do not. Although it is hardly a new innovation—the first commercial time clocks were built in the early 20th century by the company that later became IBM—the medical profession has been slow to adapt to this basic business practice.

There are two very good reasons why you should have a time clock. The first is obvious: to punch your employees' time cards. This is essential even if all your employees are paid weekly or semiweekly rather than by the hour.

The other (and possibly more important) reason, which we will come back to, is to punch in your patients.

In most states, any employee who works more than 40 hours in a given week must be paid overtime wages. Employees know this, and disgruntled ones have been known to file complaints stating that they worked hundreds of hours of unpaid overtime.

This may be completely untrue, but labor boards almost invariably side with employees in such disputes, unless the employer can produce time records that disprove the claim. A time clock is cheap insurance against a large, unexpected, and possibly unjustified payment to a former employee.

For part-time, hourly-wage employees, time records are even more important, as you obviously want to pay them only for the hours they work. If you are paying your part-timers for the number of hours they should be working without documenting how many hours they actually work, you could be paying for a lot of nonwork. Employees have little incentive to arrive on time, or to stay the entire length of their shifts, if they know they are being paid for a set number of hours anyway. And they certainly will balk at staying late if they can't count on being paid for the extra time.

Time clocks also work to the advantage of your employees: Since they will be paid only for the time they work, they will be paid for all the time they work. If any employees object to your installing a clock, point out that they will be assured of payment for fractional time worked past their usual hours—time which might have gone unpaid before.

As for your patients, a time clock is a great tool in the endless struggle to run on time, as I mentioned in a column addressing that subject 3 years ago. (If you missed “How to Run on Time,” go to www.skinandallergynews.com

As each patient arrives, have your receptionist time stamp the encounter form that goes to the back with the patient's chart. As you take each chart off the door and enter the room, one glance at the time stamp will tell you exactly how long that patient has been waiting.

Now you no longer have to guess how far behind you are—and you'll have an answer for the curmudgeon who insists he's been sitting there for 21/2 hours.

Time/attendance systems range from relatively simple to relatively complex.

My office has had an old-fashioned stamp-type time clock for 26 years, but nowadays you can get something far more sophisticated than that if you wish.

Many of the newer clocks will automatically calculate time between punches and add up total work time, and they can be configured for weekly, biweekly, semimonthly, or monthly pay periods. At least one will automatically deduct break time from the totals.

If you have a problem with “buddy punching” (employees punching in or out for each other), some clocks are equipped to recognize fingerprints or hand contours.

There are also electronic software systems, both Web based and in house, that can be deployed across a local computer network. They will print time sheets with employee hours and earnings calculated, and some will even interface with financial software such as QuickBooks and other third-party payroll services. (As always, I have no financial interest in any product or service discussed in this column.)

If you go the electronic route, make sure the software incorporates security measures to prevent time alterations by unauthorized employees. You can never be too careful.

Should patient have to ask for testing?

A man was tested by Dr. A and found to be a thalassemia carrier, but his wife was not tested. When she became pregnant and blood work at 6 weeks indicated anemia, no testing for thalassemia was performed by Dr. B. The child was born with thalassemia, a condition that affects the body’s ability to produce hemoglobin, and will need blood transfusions throughout his life.

Patient’s claim The mother would have had an abortion if she had known the baby would have thalassemia.

Doctor’s defense Because the parents knew the father was a carrier, the defendants relied on the mother to be tested if she became pregnant. Also, the parents would not have chosen an abortion.

Verdict $14 million New Jersey verdict against Dr. B only.

Advice to deaf patient is disputed

The parents of a baby girl born with spina bifida were profoundly deaf. The mother’s deafness since birth was due to the genetic disorder Waardenburg syndrome.

Patient’s claim The physician failed to communicate the importance of 1) taking folic acid to prevent birth defects and 2) maternal serum α-fetoprotein (MSAFP) testing to determine if spina bifida was present. The physician also failed to determine what caused the mother’s deafness so she could be referred for genetic counseling. They would have aborted the fetus if they had known of the spina bifida.

Doctor’s defense When the defendant asked about genetic disorders in the family, she was told there were none. She discussed folic acid with the mother, who refused MSAFP testing when it was suggested. The couple also never brought a sign language interpreter with them. The defendant added that there was no scientific evidence that folic acid affects neural tube defects associated with a genetic syndrome such as Waardenburg.

Verdict Kansas defense verdict.

Deaths due to untreated thrombocytopenia?

A 34-year-old woman who was 27½ weeks pregnant presented at the hospital with burning in the chest, diarrhea, nausea, vomiting, and headache. She had protein in her urine, and an OB diagnosed a urinary tract infection and sent her home. In less than 24 hours, she returned by ambulance to the hospital, where she remained for observation. The defendant OBs did not come and no lab tests were ordered.

The following morning, lab results indicated HELLP syndrome or thrombotic thrombocytopenic purpura (TTP). Treatment for HELLP syndrome (delivery of the fetus—a problem because of its prematurity) and TTP (plasma exchange) could not be done at the defendant hospital, but the mother was not transferred to another hospital and consultations were not sought. A day later, an internal medicine physician was consulted, and he urged that a physician specializing in TTP also be consulted, but that was not done. Later, ultrasonography indicated the fetus had died. Fifteen hours after the stillborn baby was delivered, the mother suffered cardiovascular collapse and died.

Patient’s claim The defendants were negligent in treating the woman’s thrombocytopenia and not transferring her to another hospital in a timely manner.

Doctor’s defense Not reported.

Verdict A North Carolina settlement, which included $1,325,000 from the OB defendants and $750,000 from the hospital defendants.

Doctor ignores lump, and patient delays

A patient reported a pea-sized lump in her right breast to her gynecologist after several weeks. When he examined her at a later date, she again reported the lump, but he did not order a sonogram, mammogram, or biopsy. Over a year later, the patient was examined by a family practice physician, who examined the lump and ordered a mammogram. Seven months later, a biopsy showed the presence of cancer. As the cancer had spread to her lymph nodes, she required extensive treatment.

Patient’s claim The gynecologist was negligent for not diagnosing the cancer earlier.

Doctor’s defense Not reported.

Verdict $1,275,647.61 gross verdict in Florida. The woman was found 34% at fault, and the ObGyn, 66% at fault.

Ureteral stricture follows oophorectomy

The cystic ovaries of a 59-year-old woman were removed by an ObGyn in a procedure that was uneventful despite the presence of scarring and adhesions from previous surgeries, including a hysterectomy years earlier. The operative report did not mention that the ureters were visualized, although other structures were noted. The day after surgery, the patient was discharged in satisfactory condition. Two weeks later she returned to her physician with severe left flank pain. She was hospitalized, and a radiologist and urologist were consulted. She was diagnosed with a left ureteral stricture. The urologist placed a nephroureteral stent, and the patient wore a urostomy bag for 1 month until an indwelling stent was placed. Over the next year, she underwent frequent stent changes under general anesthesia.

Patient’s claim The physician failed to visualize the ureter during the surgery and was negligent in placing a staple in it, thus causing the injury.

Doctor’s defense He had visualized the ureter and properly placed the staples. The stricture was due to scar tissue.

Verdict Three Virginia trials resulted in a hung jury, a mistrial, and finally a defense verdict.

Bladder injury during tubal ligation

A 25-year-old woman pregnant with her first child made plans with a family physician to undergo a tubal ligation the day after delivery. During the procedure, performed under general anesthesia, the woman’s bladder was lacerated and a sudden gush of fluid contaminated the surgical site. A urologist was called immediately and repaired the damage successfully. After 2 days, the patient was discharged, but she returned 5 hours later with intense abdominal pain, the result of a ruptured bladder. Another repair was followed by further complications and more hospital visits.

Patient’s claim Because of a lack of bladder control, she requires ongoing treatment, including the use of catheters to drain her bladder.

Doctor’s defense A lacerated bladder is a known complication of tubal ligation. Because the patient did not urinate before the surgery as he instructed her, the bladder was distended and discharged an unexpected gush of fluid when it was lacerated. Her ongoing problems, however, are not a result of the laceration or repair.

Verdict Indiana defense verdict.

Sex impossible after too much surgery?

A 52-year-old woman underwent a hysterectomy, bladder neck suspension to repair a cystocele, and implantation of a synthetic suburethral sling, all performed by an ObGyn. Following surgery, the patient suffered erosion of the sling into the vagina, causing a chronic infection with discharge and pain. After undergoing further procedures, including debridement and resection of the vagina, she has vaginal scar tissue, muscle myalgia, chronic vaginal pain or irritation and discharge, and the loss of her vagina due to scarring and foreshortening. She and her husband can no longer have sexual intercourse.

Patient’s claim The sling procedure was unnecessary. Also the physician mishandled the postoperative complications resulting from the sling, and he did not refer her to a specialist in a timely manner.

Doctor’s defense The patient had complained of stress urinary incontinence, and the sling procedure was indicated because of a hypermobile urethra. Also the complications were handled properly.

Verdict $5 million Illinois verdict, including $1 million for the woman’s husband for loss of consortium.

IUD in place while pregnant with twins

A month after giving birth to her first child, a 19-year-old woman underwent a Pap smear and had an IUD inserted for birth control. After reviewing the Pap results, the physician asked the patient to return for a cervical biopsy. During the colposcopy, the physician removed the IUD because it was partially expelled from her cervix. A week later he inserted a new IUD, but neither he nor the patient knew she was 2 weeks pregnant. When she suffered severe bleeding and cramping 2 months later, a pregnancy test indicated she was pregnant, and a sonogram revealed twins with the IUD in place. The string was not visible, so the IUD could not be removed. The patient was put on bed rest to avoid a threatened miscarriage. At a second facility, it was confirmed that the IUD could not be removed. The patient was diagnosed with an incompetent cervix and, following placement of a cervical cerclage, was told to remain on rest. Within a month, she miscarried.

Patient’s claim The physician was negligent for inserting an IUD without determining if she was pregnant, and the IUD caused the miscarriage.

Doctor’s defense A pregnancy test prior to insertion of an IUD is not the standard of care, especially when the patient reports regular periods. Also, the miscarriage was not related to the IUD.

Verdict Missouri defense verdict.

Was mother’s brain damage avoidable?

A 27-year-old pregnant woman at full term presented at the hospital for labor augmentation. Her OB was Dr. A. Dr. B, the anesthesiologist, was called a few hours later to place an epidural. Later, the patient began vomiting and experiencing seizures and became unresponsive. Neither Dr. A nor Dr. B was present. Fetal bradycardia was diagnosed and an emergency cesarean section was performed. During the delivery, the mother experienced cardiac arrest, uterine atony, and disseminated intravascular coagulation. She was resuscitated, but suffered severe brain damage. She must use a wheelchair because of cognitive and neurological impairments.

Patient’s claim Three things should have been done: earlier cesarean section, suctioning after the vomiting, and intubation.

Doctor’s defense The patient had an unpredictable and untreatable amniotic fluid embolism.

Verdict New York defense verdict, but posttrial motions were pending.

Depo-Provera is given to pregnant woman

When a 28-year-old woman with a history of alcohol and drug abuse requested contraceptive medication, she was prescribed 3 injections of Depo-Provera over 6 months. At each exam, she reported a weight gain, breast tenderness, and swelling of her breasts. The ObGyn said those were side effects of the medication. When she went to another physician 7 months after the first injection, it was determined that she was late in her seventh month of pregnancy. Unable to terminate the pregnancy, she delivered a child with significant, permanent disabilities. To care for the child, she quit her job and moved in with her parents.

Patient’s claim The physician failed to rule out pregnancy before the first injection.

Doctor’s defense The plaintiff had no damages.

Verdict $400,000 Massachusetts settlement.

Video supports claims of negligence

Shoulder dystocia occurred during delivery of the plaintiff’s child. Because of brachial plexus damage, the child suffers from Erb’s palsy and has undergone surgery to try to restore function to her arm, hand, and fingers.

Patient’s claim The defendants did not tell her to stop pushing when shoulder dystocia was discovered, and were negligent for using the McRoberts maneuver, suprapubic pressure, and excessive traction. The plaintiff provided video documentation of the delivery.

Doctor’s defense Negligence was denied.

Verdict $1 million Maryland verdict.

Should patient have to ask for testing?

A man was tested by Dr. A and found to be a thalassemia carrier, but his wife was not tested. When she became pregnant and blood work at 6 weeks indicated anemia, no testing for thalassemia was performed by Dr. B. The child was born with thalassemia, a condition that affects the body’s ability to produce hemoglobin, and will need blood transfusions throughout his life.

Patient’s claim The mother would have had an abortion if she had known the baby would have thalassemia.

Doctor’s defense Because the parents knew the father was a carrier, the defendants relied on the mother to be tested if she became pregnant. Also, the parents would not have chosen an abortion.

Verdict $14 million New Jersey verdict against Dr. B only.

Advice to deaf patient is disputed

The parents of a baby girl born with spina bifida were profoundly deaf. The mother’s deafness since birth was due to the genetic disorder Waardenburg syndrome.

Patient’s claim The physician failed to communicate the importance of 1) taking folic acid to prevent birth defects and 2) maternal serum α-fetoprotein (MSAFP) testing to determine if spina bifida was present. The physician also failed to determine what caused the mother’s deafness so she could be referred for genetic counseling. They would have aborted the fetus if they had known of the spina bifida.

Doctor’s defense When the defendant asked about genetic disorders in the family, she was told there were none. She discussed folic acid with the mother, who refused MSAFP testing when it was suggested. The couple also never brought a sign language interpreter with them. The defendant added that there was no scientific evidence that folic acid affects neural tube defects associated with a genetic syndrome such as Waardenburg.

Verdict Kansas defense verdict.

Deaths due to untreated thrombocytopenia?

A 34-year-old woman who was 27½ weeks pregnant presented at the hospital with burning in the chest, diarrhea, nausea, vomiting, and headache. She had protein in her urine, and an OB diagnosed a urinary tract infection and sent her home. In less than 24 hours, she returned by ambulance to the hospital, where she remained for observation. The defendant OBs did not come and no lab tests were ordered.

The following morning, lab results indicated HELLP syndrome or thrombotic thrombocytopenic purpura (TTP). Treatment for HELLP syndrome (delivery of the fetus—a problem because of its prematurity) and TTP (plasma exchange) could not be done at the defendant hospital, but the mother was not transferred to another hospital and consultations were not sought. A day later, an internal medicine physician was consulted, and he urged that a physician specializing in TTP also be consulted, but that was not done. Later, ultrasonography indicated the fetus had died. Fifteen hours after the stillborn baby was delivered, the mother suffered cardiovascular collapse and died.

Patient’s claim The defendants were negligent in treating the woman’s thrombocytopenia and not transferring her to another hospital in a timely manner.

Doctor’s defense Not reported.

Verdict A North Carolina settlement, which included $1,325,000 from the OB defendants and $750,000 from the hospital defendants.

Doctor ignores lump, and patient delays

A patient reported a pea-sized lump in her right breast to her gynecologist after several weeks. When he examined her at a later date, she again reported the lump, but he did not order a sonogram, mammogram, or biopsy. Over a year later, the patient was examined by a family practice physician, who examined the lump and ordered a mammogram. Seven months later, a biopsy showed the presence of cancer. As the cancer had spread to her lymph nodes, she required extensive treatment.

Patient’s claim The gynecologist was negligent for not diagnosing the cancer earlier.

Doctor’s defense Not reported.

Verdict $1,275,647.61 gross verdict in Florida. The woman was found 34% at fault, and the ObGyn, 66% at fault.

Ureteral stricture follows oophorectomy

The cystic ovaries of a 59-year-old woman were removed by an ObGyn in a procedure that was uneventful despite the presence of scarring and adhesions from previous surgeries, including a hysterectomy years earlier. The operative report did not mention that the ureters were visualized, although other structures were noted. The day after surgery, the patient was discharged in satisfactory condition. Two weeks later she returned to her physician with severe left flank pain. She was hospitalized, and a radiologist and urologist were consulted. She was diagnosed with a left ureteral stricture. The urologist placed a nephroureteral stent, and the patient wore a urostomy bag for 1 month until an indwelling stent was placed. Over the next year, she underwent frequent stent changes under general anesthesia.

Patient’s claim The physician failed to visualize the ureter during the surgery and was negligent in placing a staple in it, thus causing the injury.

Doctor’s defense He had visualized the ureter and properly placed the staples. The stricture was due to scar tissue.

Verdict Three Virginia trials resulted in a hung jury, a mistrial, and finally a defense verdict.

Bladder injury during tubal ligation

A 25-year-old woman pregnant with her first child made plans with a family physician to undergo a tubal ligation the day after delivery. During the procedure, performed under general anesthesia, the woman’s bladder was lacerated and a sudden gush of fluid contaminated the surgical site. A urologist was called immediately and repaired the damage successfully. After 2 days, the patient was discharged, but she returned 5 hours later with intense abdominal pain, the result of a ruptured bladder. Another repair was followed by further complications and more hospital visits.

Patient’s claim Because of a lack of bladder control, she requires ongoing treatment, including the use of catheters to drain her bladder.

Doctor’s defense A lacerated bladder is a known complication of tubal ligation. Because the patient did not urinate before the surgery as he instructed her, the bladder was distended and discharged an unexpected gush of fluid when it was lacerated. Her ongoing problems, however, are not a result of the laceration or repair.

Verdict Indiana defense verdict.

Sex impossible after too much surgery?

A 52-year-old woman underwent a hysterectomy, bladder neck suspension to repair a cystocele, and implantation of a synthetic suburethral sling, all performed by an ObGyn. Following surgery, the patient suffered erosion of the sling into the vagina, causing a chronic infection with discharge and pain. After undergoing further procedures, including debridement and resection of the vagina, she has vaginal scar tissue, muscle myalgia, chronic vaginal pain or irritation and discharge, and the loss of her vagina due to scarring and foreshortening. She and her husband can no longer have sexual intercourse.

Patient’s claim The sling procedure was unnecessary. Also the physician mishandled the postoperative complications resulting from the sling, and he did not refer her to a specialist in a timely manner.

Doctor’s defense The patient had complained of stress urinary incontinence, and the sling procedure was indicated because of a hypermobile urethra. Also the complications were handled properly.

Verdict $5 million Illinois verdict, including $1 million for the woman’s husband for loss of consortium.

IUD in place while pregnant with twins

A month after giving birth to her first child, a 19-year-old woman underwent a Pap smear and had an IUD inserted for birth control. After reviewing the Pap results, the physician asked the patient to return for a cervical biopsy. During the colposcopy, the physician removed the IUD because it was partially expelled from her cervix. A week later he inserted a new IUD, but neither he nor the patient knew she was 2 weeks pregnant. When she suffered severe bleeding and cramping 2 months later, a pregnancy test indicated she was pregnant, and a sonogram revealed twins with the IUD in place. The string was not visible, so the IUD could not be removed. The patient was put on bed rest to avoid a threatened miscarriage. At a second facility, it was confirmed that the IUD could not be removed. The patient was diagnosed with an incompetent cervix and, following placement of a cervical cerclage, was told to remain on rest. Within a month, she miscarried.

Patient’s claim The physician was negligent for inserting an IUD without determining if she was pregnant, and the IUD caused the miscarriage.

Doctor’s defense A pregnancy test prior to insertion of an IUD is not the standard of care, especially when the patient reports regular periods. Also, the miscarriage was not related to the IUD.

Verdict Missouri defense verdict.

Was mother’s brain damage avoidable?

A 27-year-old pregnant woman at full term presented at the hospital for labor augmentation. Her OB was Dr. A. Dr. B, the anesthesiologist, was called a few hours later to place an epidural. Later, the patient began vomiting and experiencing seizures and became unresponsive. Neither Dr. A nor Dr. B was present. Fetal bradycardia was diagnosed and an emergency cesarean section was performed. During the delivery, the mother experienced cardiac arrest, uterine atony, and disseminated intravascular coagulation. She was resuscitated, but suffered severe brain damage. She must use a wheelchair because of cognitive and neurological impairments.

Patient’s claim Three things should have been done: earlier cesarean section, suctioning after the vomiting, and intubation.

Doctor’s defense The patient had an unpredictable and untreatable amniotic fluid embolism.

Verdict New York defense verdict, but posttrial motions were pending.

Depo-Provera is given to pregnant woman

When a 28-year-old woman with a history of alcohol and drug abuse requested contraceptive medication, she was prescribed 3 injections of Depo-Provera over 6 months. At each exam, she reported a weight gain, breast tenderness, and swelling of her breasts. The ObGyn said those were side effects of the medication. When she went to another physician 7 months after the first injection, it was determined that she was late in her seventh month of pregnancy. Unable to terminate the pregnancy, she delivered a child with significant, permanent disabilities. To care for the child, she quit her job and moved in with her parents.

Patient’s claim The physician failed to rule out pregnancy before the first injection.

Doctor’s defense The plaintiff had no damages.

Verdict $400,000 Massachusetts settlement.

Video supports claims of negligence

Shoulder dystocia occurred during delivery of the plaintiff’s child. Because of brachial plexus damage, the child suffers from Erb’s palsy and has undergone surgery to try to restore function to her arm, hand, and fingers.

Patient’s claim The defendants did not tell her to stop pushing when shoulder dystocia was discovered, and were negligent for using the McRoberts maneuver, suprapubic pressure, and excessive traction. The plaintiff provided video documentation of the delivery.

Doctor’s defense Negligence was denied.

Verdict $1 million Maryland verdict.

Should patient have to ask for testing?

A man was tested by Dr. A and found to be a thalassemia carrier, but his wife was not tested. When she became pregnant and blood work at 6 weeks indicated anemia, no testing for thalassemia was performed by Dr. B. The child was born with thalassemia, a condition that affects the body’s ability to produce hemoglobin, and will need blood transfusions throughout his life.

Patient’s claim The mother would have had an abortion if she had known the baby would have thalassemia.

Doctor’s defense Because the parents knew the father was a carrier, the defendants relied on the mother to be tested if she became pregnant. Also, the parents would not have chosen an abortion.

Verdict $14 million New Jersey verdict against Dr. B only.

Advice to deaf patient is disputed

The parents of a baby girl born with spina bifida were profoundly deaf. The mother’s deafness since birth was due to the genetic disorder Waardenburg syndrome.

Patient’s claim The physician failed to communicate the importance of 1) taking folic acid to prevent birth defects and 2) maternal serum α-fetoprotein (MSAFP) testing to determine if spina bifida was present. The physician also failed to determine what caused the mother’s deafness so she could be referred for genetic counseling. They would have aborted the fetus if they had known of the spina bifida.

Doctor’s defense When the defendant asked about genetic disorders in the family, she was told there were none. She discussed folic acid with the mother, who refused MSAFP testing when it was suggested. The couple also never brought a sign language interpreter with them. The defendant added that there was no scientific evidence that folic acid affects neural tube defects associated with a genetic syndrome such as Waardenburg.

Verdict Kansas defense verdict.

Deaths due to untreated thrombocytopenia?

A 34-year-old woman who was 27½ weeks pregnant presented at the hospital with burning in the chest, diarrhea, nausea, vomiting, and headache. She had protein in her urine, and an OB diagnosed a urinary tract infection and sent her home. In less than 24 hours, she returned by ambulance to the hospital, where she remained for observation. The defendant OBs did not come and no lab tests were ordered.

The following morning, lab results indicated HELLP syndrome or thrombotic thrombocytopenic purpura (TTP). Treatment for HELLP syndrome (delivery of the fetus—a problem because of its prematurity) and TTP (plasma exchange) could not be done at the defendant hospital, but the mother was not transferred to another hospital and consultations were not sought. A day later, an internal medicine physician was consulted, and he urged that a physician specializing in TTP also be consulted, but that was not done. Later, ultrasonography indicated the fetus had died. Fifteen hours after the stillborn baby was delivered, the mother suffered cardiovascular collapse and died.

Patient’s claim The defendants were negligent in treating the woman’s thrombocytopenia and not transferring her to another hospital in a timely manner.

Doctor’s defense Not reported.

Verdict A North Carolina settlement, which included $1,325,000 from the OB defendants and $750,000 from the hospital defendants.

Doctor ignores lump, and patient delays

A patient reported a pea-sized lump in her right breast to her gynecologist after several weeks. When he examined her at a later date, she again reported the lump, but he did not order a sonogram, mammogram, or biopsy. Over a year later, the patient was examined by a family practice physician, who examined the lump and ordered a mammogram. Seven months later, a biopsy showed the presence of cancer. As the cancer had spread to her lymph nodes, she required extensive treatment.

Patient’s claim The gynecologist was negligent for not diagnosing the cancer earlier.

Doctor’s defense Not reported.

Verdict $1,275,647.61 gross verdict in Florida. The woman was found 34% at fault, and the ObGyn, 66% at fault.

Ureteral stricture follows oophorectomy

The cystic ovaries of a 59-year-old woman were removed by an ObGyn in a procedure that was uneventful despite the presence of scarring and adhesions from previous surgeries, including a hysterectomy years earlier. The operative report did not mention that the ureters were visualized, although other structures were noted. The day after surgery, the patient was discharged in satisfactory condition. Two weeks later she returned to her physician with severe left flank pain. She was hospitalized, and a radiologist and urologist were consulted. She was diagnosed with a left ureteral stricture. The urologist placed a nephroureteral stent, and the patient wore a urostomy bag for 1 month until an indwelling stent was placed. Over the next year, she underwent frequent stent changes under general anesthesia.

Patient’s claim The physician failed to visualize the ureter during the surgery and was negligent in placing a staple in it, thus causing the injury.

Doctor’s defense He had visualized the ureter and properly placed the staples. The stricture was due to scar tissue.

Verdict Three Virginia trials resulted in a hung jury, a mistrial, and finally a defense verdict.

Bladder injury during tubal ligation

A 25-year-old woman pregnant with her first child made plans with a family physician to undergo a tubal ligation the day after delivery. During the procedure, performed under general anesthesia, the woman’s bladder was lacerated and a sudden gush of fluid contaminated the surgical site. A urologist was called immediately and repaired the damage successfully. After 2 days, the patient was discharged, but she returned 5 hours later with intense abdominal pain, the result of a ruptured bladder. Another repair was followed by further complications and more hospital visits.

Patient’s claim Because of a lack of bladder control, she requires ongoing treatment, including the use of catheters to drain her bladder.

Doctor’s defense A lacerated bladder is a known complication of tubal ligation. Because the patient did not urinate before the surgery as he instructed her, the bladder was distended and discharged an unexpected gush of fluid when it was lacerated. Her ongoing problems, however, are not a result of the laceration or repair.

Verdict Indiana defense verdict.

Sex impossible after too much surgery?

A 52-year-old woman underwent a hysterectomy, bladder neck suspension to repair a cystocele, and implantation of a synthetic suburethral sling, all performed by an ObGyn. Following surgery, the patient suffered erosion of the sling into the vagina, causing a chronic infection with discharge and pain. After undergoing further procedures, including debridement and resection of the vagina, she has vaginal scar tissue, muscle myalgia, chronic vaginal pain or irritation and discharge, and the loss of her vagina due to scarring and foreshortening. She and her husband can no longer have sexual intercourse.

Patient’s claim The sling procedure was unnecessary. Also the physician mishandled the postoperative complications resulting from the sling, and he did not refer her to a specialist in a timely manner.

Doctor’s defense The patient had complained of stress urinary incontinence, and the sling procedure was indicated because of a hypermobile urethra. Also the complications were handled properly.

Verdict $5 million Illinois verdict, including $1 million for the woman’s husband for loss of consortium.

IUD in place while pregnant with twins

A month after giving birth to her first child, a 19-year-old woman underwent a Pap smear and had an IUD inserted for birth control. After reviewing the Pap results, the physician asked the patient to return for a cervical biopsy. During the colposcopy, the physician removed the IUD because it was partially expelled from her cervix. A week later he inserted a new IUD, but neither he nor the patient knew she was 2 weeks pregnant. When she suffered severe bleeding and cramping 2 months later, a pregnancy test indicated she was pregnant, and a sonogram revealed twins with the IUD in place. The string was not visible, so the IUD could not be removed. The patient was put on bed rest to avoid a threatened miscarriage. At a second facility, it was confirmed that the IUD could not be removed. The patient was diagnosed with an incompetent cervix and, following placement of a cervical cerclage, was told to remain on rest. Within a month, she miscarried.

Patient’s claim The physician was negligent for inserting an IUD without determining if she was pregnant, and the IUD caused the miscarriage.

Doctor’s defense A pregnancy test prior to insertion of an IUD is not the standard of care, especially when the patient reports regular periods. Also, the miscarriage was not related to the IUD.

Verdict Missouri defense verdict.

Was mother’s brain damage avoidable?

A 27-year-old pregnant woman at full term presented at the hospital for labor augmentation. Her OB was Dr. A. Dr. B, the anesthesiologist, was called a few hours later to place an epidural. Later, the patient began vomiting and experiencing seizures and became unresponsive. Neither Dr. A nor Dr. B was present. Fetal bradycardia was diagnosed and an emergency cesarean section was performed. During the delivery, the mother experienced cardiac arrest, uterine atony, and disseminated intravascular coagulation. She was resuscitated, but suffered severe brain damage. She must use a wheelchair because of cognitive and neurological impairments.

Patient’s claim Three things should have been done: earlier cesarean section, suctioning after the vomiting, and intubation.

Doctor’s defense The patient had an unpredictable and untreatable amniotic fluid embolism.

Verdict New York defense verdict, but posttrial motions were pending.

Depo-Provera is given to pregnant woman

When a 28-year-old woman with a history of alcohol and drug abuse requested contraceptive medication, she was prescribed 3 injections of Depo-Provera over 6 months. At each exam, she reported a weight gain, breast tenderness, and swelling of her breasts. The ObGyn said those were side effects of the medication. When she went to another physician 7 months after the first injection, it was determined that she was late in her seventh month of pregnancy. Unable to terminate the pregnancy, she delivered a child with significant, permanent disabilities. To care for the child, she quit her job and moved in with her parents.

Patient’s claim The physician failed to rule out pregnancy before the first injection.

Doctor’s defense The plaintiff had no damages.

Verdict $400,000 Massachusetts settlement.

Video supports claims of negligence

Shoulder dystocia occurred during delivery of the plaintiff’s child. Because of brachial plexus damage, the child suffers from Erb’s palsy and has undergone surgery to try to restore function to her arm, hand, and fingers.

Patient’s claim The defendants did not tell her to stop pushing when shoulder dystocia was discovered, and were negligent for using the McRoberts maneuver, suprapubic pressure, and excessive traction. The plaintiff provided video documentation of the delivery.

Doctor’s defense Negligence was denied.

Verdict $1 million Maryland verdict.

After 15 years of managing a full-time-equivalent panel of 2,000 patients for the University of California, San Diego Medical Group, Dr. Martin C. Schulman was burned out and frustrated at not being able to fully address the needs of his patients. In 2005, he transitioned to a new model of care, one he describes as a hybrid between a micropractice and concierge care. In this month's column, Dr. Schulman provides some pointers for those who are thinking of taking the plunge into an alternative model of care

There are many alternative models of care, but two of the most common—concierge and micropractice care—provide patient-centered care by limiting the number of patients per practice. Concierge practices do so by charging an annual fee, typically at least $1,500; micropractices tend to limit patient panel size by keeping staff and other overhead costs as low as possible.

I tried to meld the two models. For one person, I charge a $600 annual fee, which doesn't cover visits but provides 24/7 access to me via cell phone or e-mail, and same-day, hourlong appointments scheduled in one-hour increments so they occur on time and are unhurried.

My overhead costs are relatively low. I have one staff member who is a combination medical assistant and receptionist. My medical records are electronic, so there's no file clerk, and I have a cash-only (“insurance-free”) practice, so there's no billing person. Accepting only cash means that my collection rate is near 100%, and my accounts receivable are near $0. Patients leave with a statement of their CPT and ICD-9 codes for their visits so they can file their own insurance claims. I only need to charge 125% of Medicare rates for E&M (evaluation and management) services and less than that for procedures.

Credit card information is collected to bill the annual fee in quarterly installments. To attract families, annual fees are adjusted based on the number of family members.

Base the model on the population you're serving. If you're in an area where people have quick and easy access to their physicians, a concierge model of care will not bring added value. But if you're in a heavily managed care area, there's a good chance that concierge care will do well. Is the community likely to support an annual fee? Do many of them have health savings accounts? For relatively healthy individuals, a micropractice with a low or no annual fee is more appealing. Patients with chronic conditions will perhaps benefit most from a concierge model practice.

There are a number of concierge practice advisors and management companies. Several of them are members of the Society for Innovative Medical Practice Design (www.simpd.com

Dr. Gordon Moore started the ideal micropractice (IMP) concept (www.idealmicropractice.orghttp://health.groups.yahoo.com/group/Practiceimprovement1

Keep an open mind to ways to stay solvent. I supplement my practice income by subleasing space to specialists and doing travel consultations and immunizations for nonmembers. I supplement my personal income with a part-time, nonclinical family medicine position with the Physician Assessment and Clinical Education program at the University of California, San Diego.

My goal is to grow to a steady patient panel of around 500 patients. Only a third of my current patients came from my former medical practice, so most of my patients are new. Networking opportunities can be a springboard for patient recruitment (I belong to a meets-weekly community business group and the local chamber of commerce). I also provide brochures to my patients and local specialists. Finally, have a practice Web site to promote your practice and explain your philosophy. Mine is www.martyschulmanmd.com

After 15 years of managing a full-time-equivalent panel of 2,000 patients for the University of California, San Diego Medical Group, Dr. Martin C. Schulman was burned out and frustrated at not being able to fully address the needs of his patients. In 2005, he transitioned to a new model of care, one he describes as a hybrid between a micropractice and concierge care. In this month's column, Dr. Schulman provides some pointers for those who are thinking of taking the plunge into an alternative model of care

There are many alternative models of care, but two of the most common—concierge and micropractice care—provide patient-centered care by limiting the number of patients per practice. Concierge practices do so by charging an annual fee, typically at least $1,500; micropractices tend to limit patient panel size by keeping staff and other overhead costs as low as possible.

I tried to meld the two models. For one person, I charge a $600 annual fee, which doesn't cover visits but provides 24/7 access to me via cell phone or e-mail, and same-day, hourlong appointments scheduled in one-hour increments so they occur on time and are unhurried.

My overhead costs are relatively low. I have one staff member who is a combination medical assistant and receptionist. My medical records are electronic, so there's no file clerk, and I have a cash-only (“insurance-free”) practice, so there's no billing person. Accepting only cash means that my collection rate is near 100%, and my accounts receivable are near $0. Patients leave with a statement of their CPT and ICD-9 codes for their visits so they can file their own insurance claims. I only need to charge 125% of Medicare rates for E&M (evaluation and management) services and less than that for procedures.

Credit card information is collected to bill the annual fee in quarterly installments. To attract families, annual fees are adjusted based on the number of family members.

Base the model on the population you're serving. If you're in an area where people have quick and easy access to their physicians, a concierge model of care will not bring added value. But if you're in a heavily managed care area, there's a good chance that concierge care will do well. Is the community likely to support an annual fee? Do many of them have health savings accounts? For relatively healthy individuals, a micropractice with a low or no annual fee is more appealing. Patients with chronic conditions will perhaps benefit most from a concierge model practice.

There are a number of concierge practice advisors and management companies. Several of them are members of the Society for Innovative Medical Practice Design (www.simpd.com

Dr. Gordon Moore started the ideal micropractice (IMP) concept (www.idealmicropractice.orghttp://health.groups.yahoo.com/group/Practiceimprovement1

Keep an open mind to ways to stay solvent. I supplement my practice income by subleasing space to specialists and doing travel consultations and immunizations for nonmembers. I supplement my personal income with a part-time, nonclinical family medicine position with the Physician Assessment and Clinical Education program at the University of California, San Diego.

My goal is to grow to a steady patient panel of around 500 patients. Only a third of my current patients came from my former medical practice, so most of my patients are new. Networking opportunities can be a springboard for patient recruitment (I belong to a meets-weekly community business group and the local chamber of commerce). I also provide brochures to my patients and local specialists. Finally, have a practice Web site to promote your practice and explain your philosophy. Mine is www.martyschulmanmd.com

After 15 years of managing a full-time-equivalent panel of 2,000 patients for the University of California, San Diego Medical Group, Dr. Martin C. Schulman was burned out and frustrated at not being able to fully address the needs of his patients. In 2005, he transitioned to a new model of care, one he describes as a hybrid between a micropractice and concierge care. In this month's column, Dr. Schulman provides some pointers for those who are thinking of taking the plunge into an alternative model of care

There are many alternative models of care, but two of the most common—concierge and micropractice care—provide patient-centered care by limiting the number of patients per practice. Concierge practices do so by charging an annual fee, typically at least $1,500; micropractices tend to limit patient panel size by keeping staff and other overhead costs as low as possible.

I tried to meld the two models. For one person, I charge a $600 annual fee, which doesn't cover visits but provides 24/7 access to me via cell phone or e-mail, and same-day, hourlong appointments scheduled in one-hour increments so they occur on time and are unhurried.

My overhead costs are relatively low. I have one staff member who is a combination medical assistant and receptionist. My medical records are electronic, so there's no file clerk, and I have a cash-only (“insurance-free”) practice, so there's no billing person. Accepting only cash means that my collection rate is near 100%, and my accounts receivable are near $0. Patients leave with a statement of their CPT and ICD-9 codes for their visits so they can file their own insurance claims. I only need to charge 125% of Medicare rates for E&M (evaluation and management) services and less than that for procedures.

Credit card information is collected to bill the annual fee in quarterly installments. To attract families, annual fees are adjusted based on the number of family members.

Base the model on the population you're serving. If you're in an area where people have quick and easy access to their physicians, a concierge model of care will not bring added value. But if you're in a heavily managed care area, there's a good chance that concierge care will do well. Is the community likely to support an annual fee? Do many of them have health savings accounts? For relatively healthy individuals, a micropractice with a low or no annual fee is more appealing. Patients with chronic conditions will perhaps benefit most from a concierge model practice.

There are a number of concierge practice advisors and management companies. Several of them are members of the Society for Innovative Medical Practice Design (www.simpd.com

Dr. Gordon Moore started the ideal micropractice (IMP) concept (www.idealmicropractice.orghttp://health.groups.yahoo.com/group/Practiceimprovement1

Keep an open mind to ways to stay solvent. I supplement my practice income by subleasing space to specialists and doing travel consultations and immunizations for nonmembers. I supplement my personal income with a part-time, nonclinical family medicine position with the Physician Assessment and Clinical Education program at the University of California, San Diego.

My goal is to grow to a steady patient panel of around 500 patients. Only a third of my current patients came from my former medical practice, so most of my patients are new. Networking opportunities can be a springboard for patient recruitment (I belong to a meets-weekly community business group and the local chamber of commerce). I also provide brochures to my patients and local specialists. Finally, have a practice Web site to promote your practice and explain your philosophy. Mine is www.martyschulmanmd.com