The doctor-patient relationship forms the basis for all malpractice related liability. It is thus critically important to know how it is formed and how it can be ended. This presentation looks at a number of different doctor-patient interactions: direct, indirect, in person, by phone, primary care, consultant, after hours, in the emergency room, and in social settings, in order to demonstrate the circumstances which combine to create a doctor-patient relationship.

In addition, the presentation covers the ways in which a doctor-patient relationship can end, including fully evaluating the do's and don'ts of unilateral termination by the physician.

At the conclusion of this module, the learner should be able to:

--Understand the various ways in which a doctor-patient relationship can come into existence

--Explain the ways in which a doctor-patient relationship can be properly and improperly terminated

--Describe the unique effects that an emergency room situation has on the analysis of a doctor-patient relationship

The standard of care is not just a figure of speech, it is the central legal obligation that every clinician owes to every patient, in every situation. Thus, the ability to define the standard of care is the key to the entire malpractice system. This presentation starts with the legal definition and molds it into clinical terms which are then applied to a series of case studies representing common clinical challenges.

For example, how does the standard of care differ for an expert versus a non-expert, how does the community affect the standard of care, does the standard demand perfection or does it allow mistakes, how does denial of coverage by an insurer affect the standard of care, how does patient non-compliance factor in, what if there is more than one viable treatment option or, even worse, no proven approach, how soon does new technology become the standard of care? This presentation puts the listener in a position of being able to address confidently any standard of care dilemma that they may encounter.

At the conclusion of this module, the learner should be able to:

--Define the standard of care in medical-legal and clinical terms

--Recognize how the standard of care varies with the situation in which the care is delivered

--Evaluate practice guidelines, conflicting literature, and ill-defined clinical situations from a standard of care perspective

Prescription drug related lawsuits are the fastest growing area of medical liability. This presentation examines the lines of responsibility as they are drawn between manufacturer, physician, pharmacist and patient.

For example, where does the responsibility for an idiosyncratic drug reaction fall, how much must the patient be told about the potential complications of treatment, what if the patient misuses the drug, what are the risks of prescribing off-label and how should they be handled, how should product safety issues such as black box warnings be managed, what if the patient's insurer will not pay for the medication, how should physicians manage alternative medication use, how should the risks associated with product recalls be handled. This presentation is a must for any person who writes a prescription.

At the conclusion of this module, the learner should be able to:

--Understand how risk and benefit are incorporated into the use of every prescription medication

--Describe the portions of the package insert which are clinically and legally important

--Explain the physician's responsibility when it comes to products liability and drug recalls

Although it is clear that a patient must consent to treatment and also has the right to refuse treatment, many clinicians are not sure what role that they should play in informing, persuading and advising the patient as to the various options, risks and benefits. This presentation uses a series of case studies to develop these concepts.

For example, when is informed consent required, how inclusive and how specific must the physician be in outlining the various risks, benefits and alternatives, what if the physician fails to mention a risk which the patient then experiences, what if the patient does not understand, what if the patient denies being told of the risk, must informed consent be obtained by the treating physician or can someone else do it, when does an "informed refusal" apply, which patients are permitted to refuse treatment and what types of treatment can they refuse, when is a physician permitted to ignore the patient's wishes in terms of consent or refusal.

At the conclusion of this module, the learner should be able to:

--Recognize the clinical situations in which informed consent applies

--Describe the nature of the discussion which must take place as part of informed consent

--Explain the steps which must occur in order for a physician to be held responsible for violating a patient's right to informed consent

More is not necessarily better. In our desire to be medical-legally sound, many physicians now spend more time with the chart than with the patient. Unfortunately, the adage "document, document, document" probably creates as many legal problems as it solves.

This presentation looks at ways of improving documentation rather than just adding documentation. The case studies evaluate the documentation options when faced with unexpectedly bad clinical outcomes, medical errors, differences of opinion with other providers, threats of being sued, lost charts, patient non-compliance, errors in charting, and late entries. It also evaluates some common documentation "myths" and examines the legal consequences of font size, ink color and choice of punctuation.

At the conclusion of this module, the learner should be able to:

--Describe the five elements which are a necessary part of every medical record entry

--Explain why many commonly held beliefs about documentation are both incorrect and unhelpful

--Recognize the proper way to address mistakes in the medical record

The most frustrating thing about HIPAA is that it has never been explained properly. HIPAA actually improved patient related communication by placing everyone under the same set of simple federal rules. Despite all that has been said, HIPAA is surprisingly conducive to the practice of medicine and difficult to violate with anything short of unprofessional conduct.

This presentation evaluates the common HIPAA dilemmas - talking with family members, leaving messages on answering machines, communicating confidentially in a busy emergency room, overheard conversations, pharmaceutical representatives in the office, announcing patient names in a waiting room, the use of patient sign-in sheets, a patient's right to access and alter his/her record, and handling insurance company pre-authorizations. In the end, HIPAA does not require anything more than that which we have always regarded as "proper, professional conduct."

At the conclusion of this module, the learner should be able to:

--Describe some of the common HIPAA misconceptions that can unnecessarily compromise patient care

--Recognize the difference between and incidental disclosure and a HIPAA violation

--Understand the types of information that can be shared with the patient, his family, and other treating clinicians

This module examines actual malpractice cases and critiques the events that resulted in litigation.

At the conclusion of this module, the learner should be able to:

--Resolve medical-legal dilemmas in a manner that is clinically and legally sound

--Avoid common errors in communication which increase the risk of litigation

--Recognize those patients and conditions which pose the greatest medical-legal risk and manage them effectively

Delay in diagnosis is one of the three most common allegations in medical malpractice lawsuits. Delays in diagnosis are created by a number of factors, many of which are not within the control of the physician. This module develops the concept of delay in diagnosis starting with the basics of diagnostic expectation and the limits of medical science, and then incorporates the effect of external factors, including patient non-compliance and managed care restrictions.

At the conclusion of this module, the learner should be able to:

--Understand the types of delays in diagnosis which are acceptable and discern them from those which are unacceptable

--Define the role that causation plays in a delay in diagnosis

--Incorporate external factors such as managed care and patient non-compliance into the analysis of a delay in diagnosis

This module provides the insight necessary for physicians to adequately manage patients' pain without becoming a target of the "War on Drugs." The cases help physicians find a balance between the competing legal concerns of a "failure to adequately treat pain" and an encounter with the Drug Enforcement Agency.

At the conclusion of this module, the learner should be able to:

--Manage chronic pain in a medical-legally sound manner

--Minimize the risk of scrutiny from the Drug Enforcement Agency

--Understand the effect of "Pain Treatment" legislation on the practice of medicine

This module describes the manner in which potentially problematic new patients can be avoided and existing problematic patients can be dismissed. In addition, the cases examine other medical-legal issues sometimes incurred with opioid use, including Driving Under the Influence laws, death due to respiratory depression, liability for causing chemical dependence, and the OxyContin debacle.

At the conclusion of this module, the learner should be able to:

--Properly screen new patients and dismiss problematic pain patients from a medical practice

--Manage opioid dependence, addiction and previous addiction from a medical-legal perspective

--Understand how opioid prescribing and use can trigger a number of legal issues

It goes without saying that no doctor wants to provide, and no patient wants to receive, medical care which is futile. The problem is ascertaining when a medical intervention becomes futile, and then knowing what a clinician can/should do at that juncture. This module examines the manner in which the legal system has struggled with the issue of futility.

At the conclusion of this module, the learner should be able to:

--Define the concept of futile medical care in practical terms

--Understand how the legal system has dealt with the concept of futility

--Recognize the limited value of the "Futile Medical Care Laws" that have been passed in a number of states

This module outlines the difficulties presented by the managed care pre-authorization process, denials of coverage and formularies, and defines the physician's options and obligations in each of these situations.

At the conclusion of this module, the learner should be able to:

--Understand the extent of his obligation to a patient whose care must be delivered within the confines of a managed care environment

--Avoid common misstates that can follow a managed care decision that restricts patient care

--Deliver the standard of care regardless of the patient's healthcare coverage

This module examines the liability associated with a denial of coverage by a managed care company and addresses the various laws and court cases which have influenced this area. In addition, various strategies for effectively negotiating with managed care companies are evaluated.

At the conclusion of this module, the learner should be able to:

--Evaluate the legal options for a patient who experiences a denial of coverage from a managed care plan

--Understand the types of legislation that are needed to change the current situation

--Effectively interface and negotiate with a managed care company without violating the law

Because every malpractice lawsuit originates with an unsatisfactory medical outcome, it is often proposed that we can reduce our legal risk by improving the manner in which we manage "bad outcomes." The idea is logical, but the methodology that will help us achieve this result is completely unstudied and unknown. This module examines the phenomenal manner in which physicians presently handle bad outcomes and evaluates whether our conduct is consistent with applicable ethical and legal principles.

At the conclusion of this module, the learner should be able to:

--Discuss the effectiveness of our current approach to medical errors in terms of avoiding malpractice lawsuits

--Describe the roles of empathy, equanimity and honesty in patient care

--Understand the roles that determining fault and assigning blame play in the interaction between doctor and patient

The receipt, review and communication of test results are integral parts of the practice of medicine, while misplaced and miscommunicated test results are a common cause of medical malpractice litigation. This module analyzes the dilemmas caused by lost reports, inaccurate interpretations, and "Dictated, but not read" reports, and offers practical strategies which minimize the opportunity for error.

At the conclusion of this module, the learner should be able to:

--Implement a simple system that virtually eliminates the liability associated with misplacing a lab report

--Understand a clinician's obligation when a test result is reported incorrectly

--Recognize the legal shortcomings and impracticality of patient "tracking" systems

This module provides a practical approach to the issue of competency by presenting a number of scenarios in which a patient refuses care, and then evaluates how each situation should be handled.
At the conclusion of this module, the learner should be able to:

--Understand when a person is permitted to refuse medical care

--Reliably determine whether a patient is competent to make his own healthcare decisions

--Manage situations in which a patient's refusal of care presents a danger to himself or others

This module evaluates more complex issues in medical decision making than Module 1.0, including a patient's refusal of care based on religious reasons, a parent's right to refuse care for a child, and the healthcare conflict that can arise between mother and fetus.

At the conclusion of this module, the learner should be able to:

--Manage patients who refuse medical care based on religious reasons

--Understand parental rights and obligations as they relate to the medical care of minor children

--Properly assess the legal issues surrounding the health and well-being of unborn children

This module examines the ways in which healthcare decisions should be made for incompetent persons. The cases evaluate living wills, durable powers of attorney, the role of the patient's family, situations where there is no guidance, and situations where the available guidance is contradictory.

At the conclusion of this module, the learner should be able to:

--Understand the role of Living Wills and Durable Powers of Attorney in the delivery of patient care

--Properly manage incompetent patients who do not have any Advanced Healthcare Directive

--Appreciate the importance of decision-making harmony among physician, patient and family

Because most medical-legal education focuses on the physician's obligations and legal duties, one could easily conclude that the patient has no responsibility. Fortunately, this is not correct. This module examines the legal concept of personal responsibility and demonstrates that it is, in fact, still the backbone of our legal system.

At the conclusion of this module, the learner will be able to:

--Understand how to establish clear lines of responsibility between doctor and patient

--Avoid the compromises in patient care that can occur when responsibilities become unclear

--Recognize the role that common sense plays in our medical-legal system

This module examines liability as it relates to product defects, shortcomings and recalls. The cases distinguish the manufacturer's obligations from those of the physician, and provide guidance for caring for patients in the wake of a product recall.

At the conclusion of this module, the learner should be able to:

--Understand manufacturer liability and physician liability for product recalls

--Properly manage patients who are affected by a product recall

--Recognize the role of class action litigation in products liability

This module discusses the medical-legal aspects of "Dear Doctor" letters and demonstrates how they should be managed. It also addresses the management of Black Box Warnings, the role of Informed Consent, and the risks of "off-label" use as they relate to product recalls and Products Liability.

At the conclusion of this module, the learner should be able to:

--Address "Dear Doctor" letters in a medical-legally sound manner

--Understand the implication of using products which receive boxed warnings

--Properly manage communication with the patient in the wake of a product recall

This module examines the respective roles and responsibilities of referring and consulting physicians. The cases address the importance of defining our roles, common mistakes in co-management, the issue of liability for one another's errors, handling disagreements, and curbside consults.

At the conclusion of this module, the learner will be able to:

--Define the respective responsibilities of referring and consulting physicians

--Avoid mistakes that are commonly made when patients are co-managed

--Effectively manage differences of opinion and minimize the risks of miscommunication

A tremendous amount of heathcare communication takes place over the telephone. Some of these calls are directly between doctor and patient, while others involve office staff acting on our behalf. This module examines the medical-legal aspects of scheduling appointments, triaging patients, after-hours calls, calls from other clinicians, and the difficulty of documenting phone calls.

At the conclusion of this module, the learner should be able to:

--Understand the physician's legal responsibility for those who work on his behalf

--Recognize when a phone call from another clinician represents the potential for liability

--Determine when and how a phone call from a patient should be documented in the medical record

This module examines some of the newer medical-legal issues which can arise in the course of electronic and telephonic communication with patients. The cases address internet communications, telemedicine laws, phone calls from attorneys, and the recurrent problems created as a result of our over-interpretation of HIPAA.

At the conclusion of this module, the learner should be able to:

--Recognize that HIPAA did not change the manner in which we should communicate with patients

--Avoid liability when communicating via the internet

--Understand when a telemedicine law may be applicable and communicate with our patients accordingly

This module examines the type of patients who choose to sue us and what is known about why they do so. It also examines the increasingly popular risk management theory of full disclosure and apology for errors, and demonstrates that it is unlikely to reduce our risk of being sued.

At the conclusion of this module, the learner should be able to:

--Describe which patients sue us for medical malpractice

--Discuss why patients sue us for medical malpractice

--Determine the viability of full disclosure and apology for medical errors as a risk management strategy