What I thought I would do is I have a talk here on staying out of medical legal trouble and I'm the perfect person to talk about it because I've gotten myself in trouble more than once. But I will go through this relatively quickly for a couple of reasons. One the slides are going to be in your materials and secondly this probably is still hopefully a bit abstract to all of you and until you really get to that point it may not mean quite as much to you. But let me make just a few remarks and then maybe address one or two questions and then we'll move on in quick time here. I'm also not a lawyer. I'll make three points. The first point is it's actually not uncommon at all for gastroenterologists to be sued. In this classical study from about 10 years ago Amitabh Chandra's group from Harvard looked at various specialties and as you can see the rate of getting sued in GI was above 10% at that point in time and I suspect that hasn't changed much as an annual rate. Secondly if you then plot this out over the lifetime of your career and you would consider yourself in what Chandra tiered as the high risk group which included interventional endoscopists then you're approaching 100% of a likelihood of potentially having at least one malpractice lawsuit. So this is something that may very well happen to us. There are a number of analyses looking at what are the most common reasons for GI providers to get sued. I just picked one 20 year study here and as you can see cognitive errors, you know, the young woman coming in with lower abdominal pain and there's a missed abscess in a newly diagnosed Crohn's patient which is one of the two malpractice suits that I was involved in. Missed colon cancers as Jason and all of us will tell you is a very high risk area as are any procedure related complications. I will skip over some of the technical stuff here again this becomes more interest unfortunately when you're in the midst of it and I just want to briefly focus on the orange tips here without going into too much detail. First of all and there's just 10 arbitrary issues that I want to bring up with you. A question that often comes up is the ASG puts out guidelines, you know, what if I do something different for whatever reason on my patient. It is very useful to be aware of those guidelines and if you do divert from them then document it because this is something attorneys will bring up and at least try to argue in lawsuits. Secondly and this I'm sure comes up in all of your training programs when you're doing high risk procedures such as ERCPs in potentially young, potentially female patients with borderline indications and think about what are the alternative options. Don't only think about it but discuss it and document the discussion with the patient. Thirdly in our, you haven't experienced the pre-electronic medical record age that some of us have but now with EMRs it's very easy for attorneys to go into those, look at time stamps and look at your documentation. So document in a timely fashion. Don't ever change documentation after the fact, you know, there's something happening, you start getting worried about is there some medical legal implication going back and falsifying or changing records is the last thing, the very last thing you want to do. Don't put Mergener in my email to Colleen, oh you can't believe Colleen what I just did, this is what happened to me. These emails are discoverable in a lawsuit so don't put anything in there you don't want on the front paper of a newspaper. Vicarious liability is becoming more and more an issue as we're using more and more helpers in our clinics, advanced practice providers as an example but also any other office staff working with you, you are ultimately liable for the actions or inactions of those providers whether or not you were directly involved. And it goes so far as if there's an established duty with a patient and that patient called the office with an urgent matter and the office assistant may not have forwarded that email or that phone call, that message to you. You never heard about it, you're still potentially liable for anything that happens as a result of this. So that goes to of course the quality of how medical groups, academic and non-academic are being set up, what kind of safety net do you establish, what training do you do with the various provider and helper groups. And then documenting for example for advanced practice providers if you onboard them to your practice, many practices have defined training programs where we put them through a few weeks of course, give them some money for annual or biannual update courses and then document precisely the training we did for those APPs, document that in our files that can help in turn when the discussion gets to or they were clueless, didn't know what they were doing, how were you even preparing them for their jobs. I'm going to skip over sedation, that's obviously an area where we all sometimes in our everyday clinical practice run into issues and therefore they can become important liabilities. Obviously if patients are frail, we're going to want to involve whatever support we need. Self-consent is a huge issue in terms of medical legal risk, ultimately the physician, you are responsible. It's very appropriate and possible for your APP to start the discussion with a patient. I've worked as a GI hospitalist for many years in a community hospital where we had a team of APPs and the GI hospitalists seeing new consults in the hospital and the APP would see the consult, determine is an EGD needed and talk to the patient about risks, benefits and so on and so forth, document that but ultimately you need to close the loop at the very latest before you do the actual procedure that day, double check with the patient, make sure there's no additional questions and document that. What needs to be disclosed is what has been termed what a reasonable patient would want to know. So you can see already there's no hard and fast rules which is why there's lawsuits and there's attorneys and there's juries but the mindset here, the legal mindset is what would a reasonable patient put in the same situation have wanted to know from you about the risks of this procedure and so what Andrew Felt for example who did a lot of writing on medical legal issues in GI has suggested is to consider three elements, the nature of the risk, the magnitude and the probability. Questions come up all the time as to you know do you have to for example disclose the very worst thing that can possibly happen in EGD i.e. death. You talk about death with every patient in your endoscopy unit. I don't do that. Different providers take different approaches, I'll poll the faculty here, anyone routinely talk about death for essentially every procedure? No. Some do. I know of colleagues who bring that up all the time and they believe they're specifically thorough but those are sort of the rough elements to consider and you ultimately have to make your own judgment. Just one quick comment because it comes up all the time about patients withdrawing consent. You're in the middle of a colonoscopy, you've used conscious sedation, the patient is ouching, you can't scope your way out of the sigmoid, you say stop, stop, can't take it anymore, can they withdraw consent? As you see mentioned here on the slide theoretically and in general yes. The answer is yes and the reason you want to be extra careful in that situation is that there have been arguments made that if you then continue and the patient repeatedly tells you not to, that can be considered battery and in certain circumstances that's a criminal not a civil matter which gets you in a whole different set of problems. In that particular situation be extra careful, all of that said there's of course an argument to be made, can that patient really, is that patient with it enough in the moment to, would they make that same argument had they not gotten the fentanyl and the Verset? You will still have to make your own judgment but if it was me I'm erring on the safe side in these situations so if I can't control their discomfort in that particular example with maybe a little bit more sedation relatively quickly or a different technique or what have you then I err on the side of not pushing the scope any further. And then last not least complications of course are a risk area and how many of you have been directly involved with an endoscopy where a complication has happened that was, you call it significant? So those I don't know about you all but those can be very emotionally uncomfortable situations where especially if you put a big hole in someone's colon or stomach or esophagus it not only is it of course a significant medical issue but there's sort of a subconscious tendency to withdraw from that situation as much as possible right to when the family is outside to tell them briefly to sugar coat potentially things to not see them in follow up but someone else might see them and so on and so forth. Instead of leaning backwards lean in in those situations so make sure you engage patients and family and of course ideally with the benefit of hindsight before you start doing the procedure the more they know you and you know them the least likely you are to get sued even if something really bad happens but when it does happen no matter how you did pre-procedure then don't withdraw and not only of course do the usual thing consult the surgeons document everything but don't pull out of embarrassment or fear. And this goes a bit to patient communication I just want to mention one classical study here that gets cited quite a bit you're not surprised to know that in other studies you know physicians that take a lot of time with patients are less likely to get sued. What might be a bit surprising in this study here they took Harvard undergraduates knew nothing about medicine scrambled the content of a conversation so all the undergrads could hear is the tone of the physician and they were able to predict with pretty good accuracy who the physicians were that were more likely to have had lawsuits against them. So it just goes to what I know we all know but sometimes in the heat of the moment maybe not remember which is again the patient physician interaction taking the time being considerate being compassionate and going back frequently is very important number of course good books. And then my last point here is simply that if I think back at the last 20-25 years of doing this there's a lot of things we can learn you during fellowship and afterwards about safe endoscopic techniques, safe polypectomy techniques all of that is extremely important where I have gotten in trouble more than with technical issues is on busy days. So we're all being squeezed more and more you're going to be asked to do more no matter whether you go into academia or private practice and it might continue year over year you feel like you have to run a little bit faster every day it's the days where you pretty much in hindsight you knew this was going to be not so good day or halfway through the day you're running two hours late already right so now you're trying to catch up. If you can at least figure out a way to hit the pause button long enough to say to yourself got to be extra careful today let's not rush even more but go the other way take a little bit more time figure out a way to explain to your spouse that you're going to be an hour late for dinner right figure out a way to apologize to the kids that you're missing a ball game but just be extra careful with those kinds of situations that you know in hindsight often times we can see coming because those are the days where just out of rushing something bad is going to happen. If you do and as I said at the beginning there's at least a chance you might find yourself in a lawsuit as a defendant you'll be very surprised of the environment which is extremely artificial. First of all it takes a long time and it can take years and it goes through depositions and this that and the other. Secondly it's really theater and we as physicians you're so into learning and teaching that when you're sitting in these conversations and the lawyer from the other party starts asking you questions and they're relatively short and they're relatively general they're essentially trying to lay a trap for you. So don't be sitting there first of all and answering any more than you absolutely have to. Don't start trying to teach them. They're not wanting to be taught they're wanting to extract sentences from you that they will turn around and use against you. So be short, be precise, don't mistake this as some general conversation it really is theater and hopefully your attorney before you go into these deposition situations will prep you for it and they usually do but still remember that this is they do this all the time. They have great practice in it and they love nothing more than the physician guy who's sitting there rambling away about the gallbladder and oh yeah let me just tell you this that and the other and oh no that's not how it works. So that's not what that's all about. It's about getting you on the hook essentially and that's all they care about and that's the unfortunate truth but that's the way the system works. So minimize the risk with all those issues that I mentioned. It's possible you get sued. When that happens it's also again nice going back to your network to have someone who you can informally talk to about this, someone who's not involved because it's an extremely stressful situation and the goal of the other side is to paint you as the last crook that walked the earth. That is the goal. That's how they succeed and that's how they will try to make you feel. So when that happens it's nice to have people around you who say take a deep breath. So I'll stop here. We'll see if there's a question or two. We can take that and otherwise we'll go on to our next talk. Yes? I have a question about liability with APPs and I wanted to ask especially something that I struggled with over the past couple of years is that how much autonomy and oversight do you think is appropriate to give APPs in GI? So say that one more time. How much oversight or autonomy to give APPs? In GI, yes. Yeah, so it varies from APP to APP. So I had in my last practice a group of at the end 9 APPs. Some of them were very new and they acted like interns and they weren't given any oversight, any independent oversight. And then I had a couple of APPs who'd been with us for 20 years. They were better than I am and half of my partners and they were essentially working totally independently and all I did was co-sign notes and briefly see the patient and check in with them. So it really, I don't have a good answer for you also from a legal perspective. It's totally appropriate if you have someone like that to let them run as long as you take care of the important legal steps. Let me check with the faculty what you guys do and how you work with APPs. How much autonomy do they have in your environments? I think most of you, if not all of you, have APPs. Colleen, any thoughts there? I agree with your observations. Some of them have long experience, work well under pressure in high velocity situations and others require a lot more time, a lot more backup, education and oversight. There also will be some state regulations that vary a bit with regard to scope of practice and required oversight necessities. So, for example, in the state of Tennessee we're required to sign off on 10% of the APP's chart. I sign off on 100% because that's just me. But I think the important observation is to know their skill and your comfort level with that. So if it's okay, maybe Jason, a quick last comment and then I would like to reserve if there are more questions. We have an hour at the end of the course, at the end of the day for final panel discussions. We'll put some of those questions in there. I think this is a real conundrum. We use APPs a lot in the VA. There is no formal training program for certification as a GI, nurse practitioner, or PA. So it's really homegrown. But I know Joe Vacari had a role in some courses for APPs that the ASG, I think, partnered with. All the comments I agree with. It's very APP dependent. I think the important part that Jason is talking about is onboarding. I think you need a process within your practice to onboard. We have a course now that onboards in some of the non-clinical activities, but we also have a clinical part of the course. So you have to educate them. You just can't turn them loose. I think that's a really big mistake. So we worked hard with our APPs building an in-house project and then we have some ASU help. And then you find out who can fly on their own. I think if you do that, we invested in time and effort. And our APPs in the clinic, they work autonomously. They're on their own. In the hospital, we work together. But you need to take the time and effort to educate them. And if, God forbid, you get into legal trouble, those kinds of things help you, as I was saying earlier. If you have a program, formalized program, you standardize it, you use it the same way for every APP that's being onboarded, and you document that onboarding process, that can certainly be brought up in these discussions.

medical-legal trouble

gastroenterologist

lawsuits

cognitive errors

missed diagnoses

procedure-related complications