Delay in diagnosis is the most common allegation made against physicians in the course of medical malpractice litigation. In this video presentation, Dr. Cotton discusses common ways in which a delay in diagnosis can arise and offers practical strategies for minimizing the risk of this occurrence.
In this video, Dr. Cotton discusses the common causes of medication-related malpractice and offers practical guidance on how to avoid them. He also critiques the prevailing approaches to this problem and demonstrates why most of them are unlikely to be successful.
In this video module, Dr. Cotton reviews the basic medical principles of pain management and then presents a series of actual cases in which physicians encountered legal problems because they did not adhere to these principles.
Each module consists of a 50 minute audio presentation, in which Victor Cotton, MD, JD discusses common medical-legal dilemmas. Each module qualifies for 2 hours of AMA PRA Category 1 Credit. For learners who prefer to read, six of the modules (Dr-Pt Relationship, Better Documentation, HIPAA, Informed Consent, Proper Prescribing and Standard of Care) also have a reference article authored by Dr. Cotton, which covers the same material.
Avoiding a medical malpractice lawsuit is the central goal of risk management education. However, many of the ideas as to how we should accomplish this are not scientifically sound or clinically practical. This presentation approaches lawsuits from a scientific perspective and examines the variables which much come together to create a lawsuit. Using a series of brief case studies, the presentation simultaneously evaluates the methods by which we can avoid a lawsuit.
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.
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
In this audio lecture, Dr. Cotton discusses documentation by starting with the clinical situations that are most frequently targeted by plaintiff attorneys. He then offers guidance as to how we can handle these situations in a way that allows the medical record to be used for us rather than against us.
In this audio module, Dr. Cotton discusses a series of common documentation dilemmas and offers practical guidance as to how they can be managed. The scenarios include curbside consults, telephone calls, radiology reports, and procedures that are compromised by complications.
In this audio presentation, Dr. Cotton discusses the legal risks of medical marijuana. Although it has been legalized in more than half of the 50 states, the medical use of marijuana still creates a number of legal risks for both physicians and patients. In that most physicians will eventually be seeing patients who are using medical marijuana, understanding these risks is essential.
In this audio lecture, Dr. Cotton discusses the medical-legal aspects of patients who record the doctor-patient encounter and demonstrates the difficulty in using these recordings in a courtroom. He also examines the complex and burdensome telemedicine regulations that have recently be adopted and demonstrates their numerous legal shortcomings.
In this audio presentation, Dr. Cotton offers practical strategies for reducing the legal risks associated with an online presence. The topics discussed include a medical practice’s website, blogging, social networking, the use text messaging and mobile devices, and managing the impact of physician rating websites
This module presents a series of actual medical malpractice cases, which Dr. Cotton then analyses and discusses. Although the cases come from various areas of medicine, the teaching points are applicable to everyone who sees a patient.
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
This module continues the series of lectures in which Dr. Cotton critiques actual malpractice cases. This module focuses on identifying those patients who are at highest risk of suing us and outlines common mistakes that we make in managing them. It also discusses the various strategies that plaintiff attorneys use and reviews ways that we can minimize their effectiveness.
In this audio presentation, Dr. Cotton reviews published studies that are foundational to understanding medical malpractice and demonstrates that most of what we have been taught about lawsuits is incorrect.
In this audio presentation, Dr. Cotton walks through a medical malpractice lawsuit and discusses the various ways in which the process can confuse, burden and discourage physicians. Unlike many presentations of this nature, Dr. Cotton does not delve into legal technicalities and does not use scare tactics. Instead, he discusses what physicians need to know to make it through a lawsuit and achieve the best possible result with the least amount of pain.
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.
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 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.
Each module consists of a series of 8-10 case studies in written format. All of the modules were written by Victor R. Cotton, MD, JD. Each module qualifies for one (1) hour of AMA PRA Category 1 Credit.
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.
Is a clinician required to arrive at the correct diagnosis the first time he sees the patient?
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.
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.
If a patient’s complaint cannot be adequately addressed by the third visit, further evaluation and/or consultation is in order.
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 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.
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.
If the diagnosis could have been made in a more timely manner, does the failure to make the diagnosis constitute a delay?
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.
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.
The delay in diagnosis here is due to shortcomings in the science of medicine, and it is therefore not legally actionable.
This module discusses the operation of The National Practitioner Data Bank and analyses the situations in which a medical malpractice lawsuit is reported to the Data Bank. It also evaluates several ways in which a Data Bank entry can be sidestepped.
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.
At what point in the course of a medical malpractice lawsuit does an entry appear against the physician in the Data Bank?
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.
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.
The Data Bank is not notified and no entry is generated until money changes hands.
Each module consists of a 45 minute recorded live webinar presentation, in which Victor Cotton, MD, JD discusses relevant medical-legal topics. Each module qualifies for 1 hour of AMA PRA Category 1 Credit.