Avoiding Delays in Diagnosis

Use the video player to view an excerpt from this module.

Avoiding Medication-Related Malpractice

Use the video player to view an excerpt from this module.

Legal Aspects of Pain Management

Use the video player to view an excerpt from this module.

Avoiding Malpractice Lawsuits

Use the audio player to hear an excerpt from this module.

Avoiding Malpractice Lawsuits

Below are what other physicians have said about this module.

• Very interesting presentation with lots of good examples. - H. Brings
• Our practice took this course last year. It was a good (i.e.valuable) experience then and remains so. - R. Quinn
• Very good, easy to understand lecture. - T. Utran
• Excellent job Dr. Cotton. Practicing 30 years now and this is the most succinct, practical medical-legal advice I have ever received. - R. Poppin
• Excellent - G. Ardoin
• Great module - C. Oliver
• I have taken many of these courses over the years and it was nice to hear someone finally tell it like it is. - C. Walsh
• Excellent educational activity. - S. Leonard
• Great job Dr. Cotton - J. Collier
• Very real - D. Knapp
• Excellent again! - A. Williams

Better Documentation

Use the audio player to hear an excerpt from this module.

Better Documentation

Below are what other physicians have said about this module.

• Thank you, Dr. Cotton for dispelling the myths of documentation. – R. Quinn
• I want to thank Dr. Cotton for his way to approach the reality of the medico-legal dilemmas we face daily. –A. Torres
• Great presentation! – M. Follmer
• One of the best features of these modules is that they were helpful in allaying fear of law suits based on documentary, operational, and technical matters. Practicing consistently good medicine requires enough attention in itself. The suggestions put forth in these modules were easy to understand and simple to implement allowing me to focus my attention on taking care of the patients. Thanks – M. Clinton
• This has been the best series presented to us. This should be given to all practitioners in the US and all the medical schools and residencies – P. Battle
• Extremely relevant, excellent content – L. Wolfe
• All the modules I have completed have been clear, concise, pertinent and easy to listen to. They have been helpful reminders, increased awareness of issues and presented some new information. I would not hesitate to recommend this series to other health providers. – G. Slate
• I would enjoy having more lectures from Dr. Cotton. This is such a stressful subject for any physician that even talking about it creates unease. He addresses the issues in a very practical, nonthreatening way. – J. Zimbelman
• Excellent, once again! – D. Ferrante
• Overall these series of lectures are excellent and should be heard by all physicians. – R. Evans
• Well done. - W. McKee
• I really enjoy the precision of the information and the folksy but expert approach Dr. Cotton takes to delivering this presentation. - L. Boyajian-O'Neill
• Great module; insightful,clear about rules that apply to documentation - W. Lawrence
• excellent, simplifies my life - M. Suenram
• I love emphasis on patient, not the chart. Thank you for validating what I knew was right. It seems all we hear is,"document, document...." - J. Welsh

Documentation Dilemmas

Use the audio player to hear an excerpt from this module.

Documentation Dilemmas

Below are what other physicians have said about this module.

• Good presentation. Short concise clear and relevant. - W. Reynolds
• excellent - A. Lang
• GOOD LEARNING EXPERIENCE - L. Benson
• Great lesson. - J. Oro
• You have a nice way of teaching. - J. Hoche
• I thought this lecture was very valuable to my practice and I am glad I listened to it. Furthermore, the presentor did an excellent job. The info was concise and well presented. - J. Gover
• Very well done - learned a lot about the leagalities of curbside consults - D. Maxfield
• As always, easy listening, very informative, to the point, and reassuring - McClinton
• Dr. Cotton as always provides a good perspective to medical providers as to why we do what we do - J. Hougaard
• A very nice lecture. Glad you covered operative complications. - H. Klepacz
• Good, common sense approach to documentation - K. Hogan

Malpractice Case Discussions

Use the audio player to hear an excerpt from this module.

Malpractice Case Discussions

Below are what other physicians have said about this module.

• Excellent case reviews! - J. Mallory
• Good module - C. Oliver
• Good examples - A. Nemechek
• Very interesting and helpful module. - S. Leonard
• Very interesting selection of cases . . . - J. Collier
• Very enjoyable and informative. - S. Allos
• Excellent discussion. - W. Reynolds
• Great module, very informative! - A. Sanchez
• I think it was great. Make it longer - D. Pollizi
• This is a very clear, concise and practical course. I wish all required continuing ed or refresher courses were like this one. - N. Inhofe
• Was clear, to the point and well articulated. Enjoyed the entire presentation, and re-calibrated my thoughts. The statement to take care of the patient is often lost amongst the multiple demands made on the physician. Thanks for reminding to take care of the patient. - F. Ramji
• great tool for learning - G. Khan
• Very clear speaker and repeats the important points in varying ways to make sure they are heard. - W. Marilyn
• enjoyable speaking style - D. Kem
• This was a highly informative module. - M. Canulty
• Excellent program, no additional comments - S. Vinekar
• Concise. Relevant. - A. Weedn
• I really like his pacing and tone. This was a very good module and his excellent speaking voice made this easier. Thanks - D. Donahue

Malpractice Case Discussions II

Use the audio player to hear an excerpt from this module.

Malpractice Case Discussions II

Below are what other physicians have said about this module.

• VERY GOOD COURSE - H. Dao
• Excellent course. - J. Vandoorninck
• Great job! - C. Reinhardt
• Good discussion on mistakes vs malpractice - T. Monahan
• Once again, this was very instructive and helpful - D. Philgreen

Malpractice Case Discussions III

Use the audio player to hear an excerpt from this module.

Malpractice Case Discussions III

Below are what other physicians have said about this module.

• Excellent module. Thank you. - J. Vandoorninck
• Great presentation information a good reminder of risk in practice - J. Lee
• Great presentation information a good reminder of risk in practice
• would you consider giving talk to medical societies? ground rounds? - S. Razmzman
• really enjoy his presentations. Alot of things he discusses make sense. - S. Allos
• as always, your modules are excellent and thought provoking - F. Webster

Managing Refusals of Care

Use the audio player to hear an excerpt from this module.

Managing Refusals of Care

Below are what other physicians have said about this module.

• GOOD MODULE - L. Benson
• Once again, well done and excellent presentation. - J. Gover
• I am a pediatric oncologist. Having heard the presentation, I feel more emboldened to challenge parents who refuse standards of care - J. Vandoorninck
• Very informative course - C. Mendez
• Informative and valuable in confirming this issue. - M. Mayor
• good discussion of a difficult topic. - F. Webster
• I really enjoy Dr. Cotton--very logical and straightforward. - L. Boyajian-O'Neill

Navigating the Legal Process

Use the audio player to hear an excerpt from this module.

Navigating the Legal Process

Below are what other physicians have said about this module.

• Important information to put things into perspective - T. Edwards-Lee
• THANKS - S. Bentacor
• Excellent - J. Thomas
• I need to do this again and probably need reinforcement next year. - J. Sisk
• Very helpful information - S. Leondard
• good to know the process, should we have to go through. - F. Akharahmad
• Very clear and helpful lecture - M. Gharavi
• Good information very well delivered by the speaker - J. Lee
• As expected very good and informative. Knows how to make the topic easier to swollow. - S. Allos
• I think that these are some of the most coherent and well done lectures to which I have listened. - F. Webster
• please let us know when in St Louis or KC area again so I can thank him personally! - Alfa

The Doctor-Patient Relationship

Use the audio player to hear an excerpt from this module.

The Doctor-Patient Relationship

Below are what other physicians have said about this module.

• Best malpractice lecture I've ever received. – R. Laxton
• Dr. Cotton: These Modules are simply wonderful. Very educational, but also very entertaining. After nearly 50 years in practice I thought I had considered everything, but each of your Modules brings new light on the subject. Thank you so much for your time and talents. – J. Metcalf
• Absolutely brilliant! – M. Young
• Excellent. –W. Rosenfeldt
• Very practical, thanks – R. Valet
• Very comprehensive presentation – K. McCoy
• Speaker was great. – R. Henry
• A very clear and precise presentation. – R. Dematteis
• This section gave me some relief from worry about my obligation to patients awaiting appointments. Thanks – M. Clinton
• Really well done. Thanks. – K. Kusek
• An excellent lecture. He spoke clearly and gave good examples. – H. Klepacz
• I have noticed before this course, front desk personnel giving out medical advice and triaging patients..... and now with this information about this putting me into a doctor-patient relationship there are some changes that will need to happen. – D. Thompson
• Very clearly presented. I appreciated the real-life scenarios. – S. Leonard

The Standard of Care

Use the audio player to hear an excerpt from this module.

The Standard of Care

Below are what other physicians have said about this module.

• I feel empowered by learning this and other modules. – C. So
• The examples are extremely helpful in cementing the information and making it real to life situations. – C. Kohrs
• Very well done! – G. Dildy
• Well done. – J. Shaw
• Excellent examples, made the info very clear. – H. Klepacz
• excellent information very useful – R. Botnick
• Very valuable insights provided, thank you ! – A. Heimer
• Excellent course - J. Barros
• Very useful seminar - J. Agdeepsingh
• Excellent! - C. Reinhardt
• Very informative lecture, defines a key point in medical malpractice defense that is often just "tossed" about - M. Madden
• This program was very informative and interesting. - K. Dollar
• OVERALL GOOD....REALLY LIKED THE "STYLE" OF YOUR PRESENTATION - D.L.
• Great speaker, very good at summarizing complicated legal concepts to non lawyers! - Alfa
• Excellent, very clear - L. Rodgers
• Makes me more aware of my responsibility to the patients and encourages me to keep up with the current standard of care - G. Goliath

Actual Malpractice Cases

Below is a sample Case Study from this module.

Make the Diagnosis Already

Fact Pattern

A 36 year old woman’s family sued her internist for medical malpractice after the patient died of a pulmonary embolism. The patient first presented with recent onset of cough and shortness of breath. Her chest was noted as clear to auscultation. She had no fever and was otherwise well. A chest X-ray was normal. She was diagnosed with probable bronchitis and treated with an antibiotic.

She called several days later and stated that the cough had improved but that she was still short of breath. She was advised to finish the antibiotic. One week later, she returned to the office. She had finished the antibiotic. She reported occasional cough, continued shortness of breath and occasional dizzy spells. She had a history of panic attacks and migraine headaches. She lived alone and reported increased stress at work.

Her pulse was 96, but her examination was otherwise normal. She was diagnosed with “anxiety disorder” and her SSRI dose was increased. Two days later, she collapsed at work. An ambulance was called, but she could not be resuscitated. Autopsy revealed multiple pulmonary emboli of varying ages and pulmonary infarctions.

One week prior to her first visit, she had flown home to Philadelphia from Europe. She was also taking oral contraceptives. The lawsuit alleged a failure to make a timely diagnosis of pulmonary emboli, which resulted in her death.

Issue

Is a clinician required to arrive at the correct diagnosis the first time he sees the patient?

Rule

We are not always required to make the correct diagnosis at the time of the first encounter, but the overall care of the patient must progress in the direction of diagnosis.

Analysis

Pulmonary embolism can be a difficult diagnosis to make. And, the mere fact that the diagnosis was missed is not necessarily medical malpractice. The problem here is that this patient presented three times with unexplained shortness of breath and the diagnosis was not even considered. On the first visit, a diagnosis of bronchitis was made. Although a possibility, bronchitis is generally not associated with shortness of breath. The patient then called and again complained of dyspnea. After the second office visit for shortness of breath, a diagnosis of anxiety was made. Although anxiety can cause feelings of breathlessness, this did not adequately explain the patient’s elevated pulse.

Because many complaints are never adequately explained and resolve without any consequences, a lengthy work-up is not required every time a patient mentions something. On the other hand, this patient complained of shortness of breath on multiple occasions. And, none of the working diagnoses explained her entire clinical picture.

Most patients, family members and jurors understand that medicine is not perfect and that clinicians sometimes miss things. But, three misses in a row is difficult to explain or defend. Here, just about any test could have changed the outcome. A repeat chest film, pulse oximetry, or EKG could have given clues to the fact that this was not an anxiety disorder. Unfortunately, none of these were ever done.

Conclusion

If a patient’s complaint cannot be adequately addressed by the third visit, further evaluation and/or consultation is in order.

Actual Malpractice Cases

Below are what other physicians have said about this module.

• These modules put into perspective a lot of medico-legal issues that we experience everyday and drives home the issue that we must always diligently strive to practice prudent, conscientious medicine. – G. Duremdes
• Excellently put together – M. Wilson
• Thoughtful - C. Wood
• The examples are excellent. Very helpful module. - S. Leonard
• Very helpful to read about actual situations and see alternatives to what happened.  - J. Clark
• Good information. - Krakes-Stephen
• Good information well presented. - B. Garner
• Excellent the way it is now presented - P. Boylan
• Good review - D. Knapp
• You have a great business model. - B. Bernstein
• Good case studies. - W. Reynolds
• It is always nice to get to know the result of the litigation. - Peralta

Delay in Diagnosis

Below is a sample Case Study from this module.

Scientific Limitations and Delays in Diagnosis

Fact Pattern

Mr. X is a 42 year old man who presents to the emergency room with chest pain. Dr. A evaluates his condition in accordance with the latest algorithm from the American College of Cardiology. Based on Mr. X’s history, EKG and blood enzymes, the algorithm states that his risk of myocardial ischemia is one in 10,000, and recommends that he be discharged with instructions to see his physician within the next week. Dr. A discusses the situation with Mr. X and discharges him from the emergency room. Two days later, Mr. X suffers a myocardial infarction and dies.

Issue

If the diagnosis could have been made in a more timely manner, does the failure to make the diagnosis constitute a delay?

Rule

The legal issue with respect to delay in diagnosis is not whether the diagnosis could have been made sooner, but whether it should have been made sooner.

Analysis

In this case, if Mr. X had been admitted to the hospital, observed, and undergone cardiac catheterization, it is likely that the diagnosis of coronary ischemia could have been made and his life saved. However, that is irrelevant. The legal issue is not whether a sooner diagnosis of cardiac ischemia was theoretically possible; it is whether a physician who was proceeding in a scholarly, attentive manner would have made the diagnosis in the emergency room and/or admitted the patient. And, if that person would have, then Dr. A should have. If that is the case, then Dr. A’s care of Mr. X would constitute a legally actionable “delay in diagnosis.”

From what we are told, Dr. A treated Mr. X in accordance with the latest recommendation from the American College of Cardiology – the experts in the field. In doing so, he delivered a scholarly, attentive approach to the situation, and thus delivered the standard of care. Unfortunately, the imperfect nature of the science of medicine led him to the wrong diagnosis. This delayed making the proper diagnosis, and Mr. X died. Although the diagnosis could have been made sooner, there is no reasonable basis for saying that it should have been made sooner.

Conclusion

The delay in diagnosis here is due to shortcomings in the science of medicine, and it is therefore not legally actionable.

Delay in Diagnosis

Below are what other physicians have said about this module.

• Helpful - K. Stephens
• informative - J. Iddings
• Good information, well-presented. - B. Garner
• Excellent - clarifies these issues well - C. White
• It was nice to know that causation is still required - R. Wheeler
• well done cases - A. Katiny

The National Practitioner Data Bank - Module 1.0

Below is a sample Case Study from this module.

Being Sued

Fact Pattern

Dr. A is sued for medical malpractice in a case involving post-operative complications. His malpractice insurance company hires an attorney and they begin defending the case. Unfortunately, within a few weeks, some of the details of the case appear in the local newspapers and become widely known in the community.

Issue

At what point in the course of a medical malpractice lawsuit does an entry appear against the physician in the Data Bank?

Rule

A medical malpractice lawsuit is not reported to the Data Bank until a payment (if any) is made on behalf of a physician or other practitioner. If a payment is not made, the Data Bank is never notified and no entry is ever generated.

Analysis

Although Dr. A has been sued, allegations have been made, and the details made known in the lay press, these events are not reportable to the Data Bank. If one were to query the Data Bank at this juncture, no entry would be found with respect to this matter. 

Similarly, if the case is dropped, dismissed, or Dr. A wins the case at trial, no entry is made in the Data Bank. The Data Bank does not track mere allegations or cases in which the defendant physician prevails, for these situations have little association with substandard physician performance.

Conclusion

The Data Bank is not notified and no entry is generated until money changes hands.

The National Practitioner Data Bank - Module 1.0

Below are what other physicians have said about this module.

• Very interesting-a secret society like the Star Chamber in English history - D. Knapp
• Informative - M. Watterson
• A good learning module. - K. Razzag

The National Practitioner Data Bank - Module 2.0

Below are what other physicians have said about this module.

• Excellent review - M. Watterson

The National Practitioner Data Bank - Module 3.0

Below are what other physicians have said about this module.

• Informative - M. Watterson