Index 279

INDEX

279

A

Abdominal painemergency room, 109–110

Abdominoplastygenerating malpractice claims, 192

Accelerated compensation events(ACEs), 273

proposals, 267Access to health care, 218–222

evaluating, 219MICRA, 221, 222

Accident compensation systemsno-fault, 266–267

ACEPtemporary holding orders, 106

ACEs, 273proposals, 267

Actuarial science, 5–6ADH, 161–162Administrability

vs accountability, 267Administrative compensation

schemes, 241Admissible expert testimony, 28ADR, 266–268Adversarial system

governing malpractice disputes,260

Adversarial witnesses, 27Adverse events

limited disclosure of, 271Affirmative duty, 182Affordability, 219

vs fairness, 267Aftercare instructions

emergency medicine, 105Agency for Healthcare Research

and Qualityeffective tort reforms, 219–220

ALAE, 206

ALH, 162Allegations

family physician risk manage-ment, 91–92

Allocated loss adjustment expense(ALAE), 206

Alternative dispute resolution(ADR), 266–268

Ambiguous questions, 55–56American Academy of Actuaries

effective medical malpracticereforms, 215

American College of EmergencyPhysicians (ACEP)

temporary holding orders, 106Anesthesiologists

malpractice suits, 135–137Anesthesiology, 115–137

disasters, 126–132documentation, 120–121injury prevention, 122–125

dental, 122–125literature search, 136malpractice claims, 116–120newly identified risks, 132–135records, 120risk management, 120–122

Angerplastic and reconstructive sur-

gery medical liability,196–197

Annual pap smearimportance, 170–171

Answersphysician witness, 61

Antibiotic-resistant infections, 95Anticipation

physician witness, 61Antishock trousers, 147Aortic aneurysm

dissecting, 94

280 Index

Appellate attorneys, 13Appellate practice, 13Appendicitis

emergency room, 109–110Arbitration, 239tArtificial blood vessels, 220Art of Cross-Examination, 46ASC-US, 168, 173–174Assets

insurance companies, 7Assimilation

pause for, 68Attendant costs, 202Attention

feigning, 66Attorney–client relationship, 25–26,

46–48physician witnesses, 46–48

Attorneys, 25–26appellate, 13biographical information about,

26butterfly plaintiff, 59client solicitation, 203doctors and, 249educating about case, 38–39fee limits, 239tfreight train plaintiff, 58–59ignoramus, 59litigation, 25–26meeting with immediately, 31–

33pal plaintiff, 58plaintiff

contingency fees, 18–19at deposition, 58–59perspective on risk reduction,

35–40sliding contingency fee scale,

18provided by liability insurance

company, 25–26time bomb, 59

Atypical angina pectoris, 94

Atypical duct hyperplasia (ADH),161–162

Atypical lobular hyperplasia(ALH), 162

Atypical squamous cells of undeter-mined significance (ASC-US), 168

Authenticationonline communications, 83

Authoritative informationonline communications, 84–85

Authoritative sources, 56Authoritative textbooks, 56Authority

physicianserosion of, x

physician witness subject to, 42Autonomy

doctrine of, 141medical profession, xii–xiii

Autopsydead fetus, 144

Avoidability standard, 240Avoidable injuries, 255–256Awards

caps on, 237size of, 237

B

Baby deliveriescessation of, 220

Bad doctor fallacy, ix, 209–211Bad faith malpractice claims, 217Bedpan mutuals, 231Binding arbitration, 239tBirth injury compensation funds

no-fault, 266–267Blepharoplasty

generating malpractice claims,191–192

Body dysmorphic disorderplastic and reconstructive sur-

gery medical liability,197–198

Index 281

Body language, 69–70, 141Bowel injuries

during surgery, 149Breach, 16–17Breast augmentation

generating malpractice claims,191

Breast biopsy, 160–163malpractice claims, 161–163

diagnostic errors, 162Breast cancer

delayed diagnosis of, 143microscopic diagnosis of, 160–

163Breast cancer litigation, 153–165

clinical context, 153–160Breast cancer malpractice claims

age, 159f, 159–160diagnosis delay, 157–158lymph node status, 159mammography, 156–157mass discovery, 155overall outcomes, 155physician specialties, 155–156,

156fpresenting symptoms, 155tumor size, 158–159

Breast fine needle aspirationfalse-negative, 160–161malpractice claims, 160–163triple test strategy, 161

Breast reductiongenerating malpractice claims,

191But for causation, 16Butterfly plaintiff attorneys, 59

C

Californiahealth care system, 221–222MICRA, 201

attorneys’ contingency feeslimit, 214

caps, 213–217collateral source rule, 214

effect on health care costs,221

noneconomic damage limit,213–217

periodic payments, 214provisions of, 213tsavings from, 215f

reforms, 214Cancer

delayed diagnosis of, 143Canons of statutory interpretation,

23CAP, 168Caps, 259Carefulness

physician witness, 45Cauda equina syndrome

emergency room, 111Causation, 16–17, 140

legal, 16Centers for Medicare and Medicaid

Services (CMS), 273Cephalosporin prophylaxis

for hysterectomies, 142–143Cervical cancer

delayed diagnosis of, 143Cervical spine

emergency room, 110Cesarean sections (C-sections)

rates of, 217–218Change-of-shift

emergency medicine, 106Charges

fee-based online consultationeRisk guidelines, 86

Chartinganesthesiology, 120–121

Chest painemergency room, 109

Childhood vaccinescost affected by tort tax, 202

Choiceinformation, 269–272

Citing textbooks or journalsphysician witness, 43–44

282 Index

Claims. see Malpractice claimsCLIA 88, 168Client solicitation

by attorneys, 203Clinical Laboratory Improvement

Act of 1988 (CLIA 88), 168Clinical trials

withdrawal from, 220CMS, 273COBRA, 107Coca-Cola, 203Collateral source offsets, 237–238,

239tCollateral source rule

reform, 19–20College of American Pathologists

(CAP), 168Colorado

MICRA reforms, 214Combined ratio, 7Commercial information

online communications, 85Common Good, 203Common law rules, 22Communication

emergency medicine, 102–103failure to, 140nurse–physician

problems of, 70–71online eRisk Guidelines, 83–85online patient–physician, 86patient–physician

e-mail, 80–81patient safety, 65–74plastic and reconstructive sur-

gery medical liability, 196Community clinics

volunteer physicians, 221Compensable injuries, 16–17Compensation

poor, 258–260Complications

failure to document, 140Composed

physician witness, 61

Compound questions, 56Comprehensive liability reform

approaches to, 263–272Comprehensive malpractice reform

guiding principles, 263Compromised

caused by litigation systemhealth care, 220–221

Compromised health carecaused by litigation system

examples of, 220–221Confidence

patient, 234Confidentiality

online communications, 83Congressional Budget Office

MICRA-based reforms, 216Conning & Co., 207Consent. See Informed consentConstitutions

state, 23Consultants

jury, 26standard of care, 141

Consumersdecision making, 270

Contemporary medical malpracticelitigation, ix

Contemporary medical practiceexacerbating medical malprac-

tice liability, 204Contingency fees, 237

plaintiff attorneys, 18–19Contingency fee scale

slidingplaintiff attorneys, 18

Contributory negligence, 23–24Conventional tort reform, 237tCooperativeness

physician witness, 45Cost-based reimbursement, 253Costs

future, 4Court

limiting access to, 236

Index 283

Courteousnessphysician witness, 42

Court-made rules, 22Courtroom

defendant familiarizing one’sself with, 60

Courtsspecialized medical, 265

CPTfor telephone-based care, 79

Credibility impeacheddefendants, 55–58

Crier, Catherine, 203Criminal penalties

faced by physicians, xC-sections, 147

rates of, 217–218vaginal birth after, 148

Cultural variationemergency medicine, 103

Current malpractice crisispolicy issues, 234–235

Current Procedural Technology(CPT)

for telephone-based care, 79

D

Damagescap, 239teconomic, 259noneconomic, 17caps on, 216, 237recoverable noneconomic

limitations on, 18–19scheduling, 267

Danzon, Patricia, 270DCIS, 161–162

misdiagnosis, 162Dead fetus

autopsy, 144malpractice, 143–144

Defendantsbreaching standard of care, 16causing injury to plaintiff, 16credibility impeached, 55–58

duty to plaintiff, 16plaintiff’s knowledge of strate-

gies and information, 54–55

testimonyplaintiff summarizing, 56–57

Defensive medicine, 217–218, 256–257

cost of, 218medical community, 234negative, 257

Delay, 257–258Delayed lab or x-ray reports

emergency medicine, 105–106Delivery

anesthesia disasters, 127–128regional anesthesia, 150

Demeanorphysician witness, 44

Dental injuriesanesthesiology, 124–125

Deposition, 39–40, 53–61objections raised during, 59oral, 29–30

Diagnosisonline vs fee-based online con-

sultation eRisk guidelines,86

Diagnostic errorsbreast biopsy malpractice claims,

162Digital divide, 81Dignity

patient, 92Disclosure

plastic and reconstructive sur-gery medical liability,182–183

requirements, 235Discovery, 54–58

planimportance of, 31–33

procedural rules of, 17process

time, 29–30

284 Index

Dissatisfactionwith medical profession, xii–xiii

Dissecting aortic aneurysm, 94Distractions, 66–67, 67Doctors. See Physician(s)Doctors Company (TDC)

breast cancer claims, 154–163pap smear litigation, 167–179

Doctrine of autonomy, 141Doctrine of vicarious liability, 90–91Documentation, 97

anesthesiology, 120–121emergency medicine, 103–104nursing notes, 104–105patient explanations, 38plastic and reconstructive sur-

gery medical liability,185–186

template charts, 104Double-dipping, 237–238Double-negatives, 56Dress

physician witness, 47, 60Drug addicts

emergency room, 112Ductal carcinoma in situ (DCIS)

low-grade, 161–162misdiagnosis, 162

Duty, 16–17

E

Early offers, 273program, 240, 241reforms, 266–268

Economic damages, 259Economic loss, 16Economy

downturn in, 234Edema of preeclampsia, 149–150Electronic fetal heart rate monitor-

ing, 144E-mail, 87

patient–physician communica-tion, 80–81

E-medicinephysician’s office, 75–87

Emergency Medical Treatment andActive Labor Act(EMTALA), 106–107

Emergency medicine, 101–113communication, 102–103documentation, 103–104lack of English, 103

Emergency subject matteronline communications, 84

Emotion-laden words, 67Employee Retirement Income Secu-

rity Act (ERISA), 204, 268Employer-sponsored health care

workers compensation analogy,274

EMTALA, 106–107Endotracheal intubation

emergency room, 111–112End-tidal carbon dioxide monitors,

116English

lack ofemergency medicine, 103

Enhance expertise, 265Enoxaparin (Lovenox)

epidural hematomas with, 130Enterprise liability, 241, 268, 273

hospital-based, 269Epidural abscess

emergency room, 111Epidural blocks, 130Epidural hematoma

after epidural block, 129–130ERISA, 204, 268ERisk guidelines, 82–85

fee-based online consultation,85–86

ERisk Working Group, 82Errors

diagnosticbreast biopsy malpractice

claims, 162disclosure mandates

Pennsylvania, 271interpretation

Index 285

pap smears, 173–174medical, 269, 270

IOM report, 235limited disclosure of, 271public awareness of, 234Texas case, 251–252

prescriptionfamily physician risk manage-

ment, 99public skepticism about, 234sampling

pap smears, 171screening

pap smears, 171–172Esophageal intubation

anesthesia disasters, 126–127Ethics

physician witness, 51Evidence

scientificrelevant and reliable, 28

substantial, 26Evidentiary rules, 17Exclusivity, 267Expectations

failure to clearly define, 140patient

Internet-based care, 80–81plastic and reconstructive

surgery medical liability,188

Experience ratingof physicians, 229

Expertise-based arguments, 265Expertise-related reforms, 264Expert resolution, 264–266Experts accountable to nonexperts,

264Expert testimony

admissible, 28Expert witnesses, 26–29, 230

necessity of, 50–51Explanations

patientdocumentation, 38

F

Faceliftgenerating malpractice claims,

191–192Facts

interpretation, 14–15Factual causation test, 16Failure to communicate, 140False-negative breast fine needle

aspiration, 160–161False-negative pap smears, 168Families

communication with in emer-gency room, 102–103

Family physician risk management,89–100

allegations, 91–92clinical issues, 93–95differential diagnosis, 93issues, 96–97language barrier, 100most common claims against,

93–94physician extenders, 93procedures, 99–100rules, 92–93standards of care, 91telephone, 98unforeseen legal pitfalls, 90–91

Federal anti-kickback statute, 268Federal government

Medicare spending reduction, xFederal health programs

liability issues, 249Federally funded state demonstra-

tion projects, 272–273Federal patient protection act, 250Fee-based online consultation eRisk

guidelines, 85–86Feedback

pause for, 68Fees

contingency, 237disclosure

286 Index

fee-based online consultationeRisk guidelines, 85

limits, 239tsliding contingency scale

plaintiff attorneys, 18usual and customary, 253

Feigning attention, 66Fetal heart rate (FHR) monitoring

electronic, 144Fetus

deadautopsy, 144malpractice, 143–144

FHRelectronic monitoring, 144

Financial markets, 5–6Fine needle aspiration (FNA)

breastfalse-negative, 160–161malpractice claims, 160–163triple test strategy, 161

Firesoperating room, 131–132oropharyngeal airway, 132pediatric airway, 132

First do no harm, 92Flat caps on noneconomic or total

damages, 259Florida

access to care, 219commission on malpractice

crisis, 207Governor’s Select Task Force,

207, 216, 219pilot project endorsement,

241malpractice insurers decline, 212

Florid adenosismisdiagnosis, 162

FNA. See Fine needle aspiration(FNA)

For-profit corporate medicine, xiFostering Rapid Advances in

Health Care: Learning FromSystem Demonstration, 272

Freight train plaintiff attorneys, 58–59

Frequency, 205–206reduction of, 236by specialty, 205–206, 206f

Frequently asked questions, 87Future costs, 4Future losses

estimating, 5

G

Game players, 14–15GAO. See General Accounting

Office (GAO)General Accounting Office (GAO)

malpractice insurance cost report(2003), 208

premium rate adjustments (2000to 2002), 209

tort reform, 220Generosity, 267Government structure, 249Governor’s Select Task Force on

Healthcare Professional Li-ability Insurance in Florida.See Florida, Governor’s Se-lect Task Force

Groomingphysician witness, 47

Gynecology and obstetricsmalpractice, 139–150

H

Harvard Medical Practice Study,210, 232, 255–256

Headachesemergency room, 110postsubdural puncture, 130–131

Health careaccess to, 218–222

evaluating, 219MICRA, 221, 222

employer-sponsoredworkers compensation anal-

ogy, 274

Index 287

Health care systemCalifornia, 221–222

Health Insurance Portability andAccountability Act (HIPAA),79, 82, 90

Health policy reviewmedical malpractice, 227–241

Health system changeTexas case, 251–252

Heart valves, 220Hemabate

for obstetric hemorrhage, 146Hemorrhage

obstetrics, 147subarachnoid

emergency room, 110Heparin

epidural hematomas with, 130HIE, 145High-grade squamous intraepithelial

lesion (HSIL), 168High-risk specialties, 234HIPAA, 79, 82, 90Hospital-based enterprise liability, 269Hospitals

sole locus of legal responsibility,240

House Resolution 4600, 216Howard, Philip, 203HSIL, 168Huber, Peter, 202Humility

physician witness, 41Hypertension

pregnancy, 148Hypothetical questions, 56Hypoxic-ischemic encephalopathy

(HIE), 145Hysterectomy

patient selection, 149

I

Iatrogenic injuriesdeterrence

reducing rates, 254

Identity disclosurefee-based online consultation

eRisk guidelines, 86Ignoramus attorneys, 59Income

insurers, 7Incurred loss, 6–7Industrial base, 261–262Industrial litigation

liability and health systemchange, 252–253

Informationand choice, 269–272fee-based online consultation

eRisk guidelines, 86online communications

authoritative, 84–85commercial, 85

Informed consent, xii, 96–97, 140, 230anesthesiology, 120–122, 123f–

124felements of, 185fee-based online consultation

eRisk guidelines, 85online communications, 83–84plastic and reconstructive sur-

gery medical liability, 183regional blocks, 130

Informed refusal, 96–97Injuries

avoidable, 255–256bowel

during surgery, 149compensable, 16–17dental

anesthesiology, 124–125iatrogenic

deterrence, 254negligent, 233

Institute of Medicine (IOM), 272,273

patient safety, 255–256pilot project endorsement, 2412000 Report on medical error,

235

288 Index

Institutional liability, 268–269Institutional self-insurance arrange-

ments, 231Insurance. See also Medical mal-

practice insurance; Medicalpractice insurance

liability, 260–262byproduct of, 262professional, 4

pricingaccording to legal risks, 261

pricing according to legal risks, 261professional liability, 4

Insurance companies. See alsoMedical malpractice insur-ance companies

assets, 7expenses, 4liability

providing attorneys, 25–26mutual, 4ownership, 4publicly traded commercial, 4reciprocal, 4

Insurance cycle, 231Insurance premiums

burden equitably apportioned, 5impacts on, 238

Insurance ratesinterest rates, 6

Insurersincome, 7

Integrated delivery systemssole locus of legal responsibility,

240Internet-based care, 79–87

appropriateness, 81–82patient expectation, 80–81physician perspective, 80practical, technical, financial

considerations, 87privacy, 82–86security, 82–86standards of care, 82–83value, 81–82

Interpersonal relationshipswith patients, 37–38

Interpretation, 14–15Interpretation errors

pap smears, 173–174Interpreters

emergency medicine, 103Interruptions, 57–58Invasive ductal carcinoma

misdiagnosis, 162Invasive lobular carcinoma

failure to recognize, 162Investments

income, 6fall in, 209

premium, 5–6IOM. See Institute of Medicine

(IOM)Ischemic optic neuropathy, 133–134

J

Joint-and-several liabilityeliminating, 236

Joint underwriting associations, 230Journals

citing by physician witness, 43–44

Judge-made rules, 22Judges, 26–27

physician witness actions to-ward, 45

Judicial nullificationof tort reforms, 209

Judicial process, 53–61Jurors

prospectivevoir dire, 26

Jury, 26Jury consultants, 26

K

Kindnessphysician witness, 42

Knee injuryemergency room, 110–111

Index 289

L

Labor and deliveryanesthesia disasters, 127–128regional anesthesia, 150

Labor epidurals and spinalsanesthesia disasters, 127–128

Labor inductioncomplications, 144

Lab reportsdelayed

emergency medicine, 105–106

Lack of Englishemergency medicine, 103

Languagetailoring, 69–70

Language barrierfamily physician risk manage-

ment, 100Language variations

emergency medicine, 103Laparotomy sponge

losing during delivery, 148Laryngeal mask airways (LMA),

116Laws

impact on medical practice, xi–xii

Lawsuitsper physician, 12

Lawyers. See AttorneysLCIS, 161–162

misdiagnosis, 162Legal causation, 16Legal defense

estimating costs, 5as insurance company expenses,

4Legal doctrine

impact of changes in, 230Legal process, 257–260Legal reform

case for, 201–223medical context of, 204value of, 213–214

Legal standards of carereplacing medical standards of

care, xiiLiability

comprehensive reformapproaches to, 263–272

doctrine of vicarious, 90–91enterprise, 241, 268, 273and health system change, 251–

254cost containment, 253industrial litigation, 252–253medical progress, 251–252

hospital-based enterprise, 269institutional, 268–269insurance companies, 7joint-and-several

eliminating, 236medical

economic analysis of, 270expansion of, 203

medical malpracticeexacerbated by managed care,

204organizational, 268pap smear

limiting, 170–171professional

refusal to offer, 209rising costs for skilled nursing

facilities, 260vicarious

doctrine of, 90–91Liability crisis

professionalstates facing, 215

Liability insurance, 260–262byproduct of, 262professional, 4

Liability insurance companyproviding attorneys, 25–26

Liability lawexpansion of, 202

Liability reformand patient safety, 255

290 Index

Liability rule of negligencesubstantive, 15–17

MICRA, 18Liability rules

modification of, 236Libby Zion case, 271Licensing jurisdiction

online communications, 84Limitations period, 18–19Limiting access to court, 236Listening, 66–68, 140

bad habits, 66–67for facts only, 67skills, 67–68

Literature searchanesthesiology, 136

Litigation. See also Malpracticelitigation

emotionally burdened physi-cians, 218

nonmeritorious, 206Litigation cells, 172Litigation game

players importance in, 24–25Litigation rules, 14–15

importance, 15–22Li v. Yellow Cab Co. , 24LMA, 116Lobular carcinoma in situ (LCIS),

161–162misdiagnosis, 162

Locality rule, xii, 230Locum tenens, 79Losses

estimating future, 5incurred, 6–7as insurance company expenses,

4Loss reserves, 6–7Lovenox

epidural hematomas with, 130Low-grade ductal carcinoma in situ,

161–162Low-grade squamous intraepithelial

lesion (LSIL), 171

LSIL, 171Lump sum judgment rule, 20–22

M

MAC, 116Malpractice, 248

expert driven cases, 28gynecology and obstetrics, 139–

150Malpractice claims. See also Breast

cancer malpractice claimsabdominoplasty, 192analysis

Milliman USA, 216anesthesiology, 116–120

brain damage, 119fcardiovascular injuries, 118death, 119fdental injuries, 119findemnity payments, 118–

119, 119fby injury, 117, 117fneurologic injuries, 117–118,

120patient death, 117surgical complications, 118unanticipated awareness, 118

bad faith, 217blepharoplasty, 191–192breast augmentation, 191breast biopsy, 161–163

diagnostic errors, 162breast FNA, 160–163breast reduction, 191facelift, 191–192family physician risk manage-

ment, 93–94against family physician risk

management, 93–94frequency and severity of

causes of increase in, 234frequency of, 234impacts on frequency, 238losses, 207made vs occurrence coverage, 6

Index 291

patient and physician character-istics, 229

plastic and reconstructive sur-gery medical liability,190–194

rates, 231reproductive functions, 141resolution of, 257–258rhinoseptoplasty, 192scars, 190–191skin resurfacing, 194suction-assisted lipectomy, 193–194wrongful birth, 259

Malpractice compensationTexas case, 251–252

Malpractice crisis, 228in California, 213current, 234–235mid-1980s, 232

Malpractice indemnity, 116–117Malpractice insurers

bankruptcy of, 209Malpractice law, 228

mission, 236and patient safety, 235–236

Malpractice litigation, 11–33affecting physician behavior,

218–219alternatives to, 240, 266–268attorneys, 25–26breast cancer

clinical context, 153–160collateral source rule reform,

19–20compromising health care

examples of, 220–221consumer group views on, 228critics of, 238evolution of, 230explosion of, 203fear of, 218–222importance of strategy, 31–33industrial

liability and health systemchange, 252–253

judges, 26–27jury, 26lump sum judgment rule, 20–22medical malpractice changing

conventional rules, 17–22nonmeritorious, 206pap smear, 167–179, 169tprocedural and evidentiary rules,

17proponents of, 236rules fit, 22–29socials goals of, 228–229targeting bad physicians, ixtiming, 29–31witnesses, 26–29

Malpractice pressurereduced, 221

Malpractice reformcomprehensive

guiding principles, 263options, 237tproposals, 248–249

Malpractice resurrected, 248–250Malpractice suits

anesthesiologists, 135–137Malpractice system

exposed weaknesses, 254–262functioning of, 229–230

empirical research, 231–233liability, 254for Medicare and Medicaid,

273–274performance

indictment of, 233problems, 254t

Malpractice verdict, 205Mammography

cancer–detection sensitivity, 157malpractice claims, 156–157

Managed care, x, 235breast FNA, 161dissatisfaction with, 204pap smear liability, 170

Martindale-Hubbell, 26Martinez v. Ha, M.D. , 24

292 Index

Medicaid, 90Medi-Cal, 221Medical boards

state, 82Medical errors, 269, 270. See also

Patient safetyincidence of, ixIOM report, 235limited disclosure of, 271public awareness of, 234Texas case, 251–252

Medical Injury Compensation Re-form Act (MICRA)

California, 13, 17–22, 201, 214attorneys’ contingency fees

limit, 214caps, 213–217collateral source rule, 214effect on health care costs,

221noneconomic damage limit,

213–217periodic payments, 214provisions of, 213tsavings from, 215f

Ohio’s tort reforms, 214Oregon’s tort reforms, 215substantive liability rule of neg-

ligence, 18Medical innovation, 234Medical Insurance Feasibility Study

(MIFS), 231–232Medical liability. See also Plastic

and reconstructive surgerymedical liability

economic analysis of, 270expansion of, 203new directions in reform, 247–

275Medical malpractice, 248. See also

Malpracticeexpert driven cases, 28

Medical malpractice insurance. Seealso Medical practice insur-ance

crisis, 252rates, 256

and access to care, 222accounting for increases,

208–209affecting physician behavior,

218–219lowering, 222

Medical malpractice insurancecompanies

decline of, 212and legal defense cost, 206and markets, 211–213numbers of, 212role of, 207–213

Medical malpractice insuranceraters

determinants of, 211Medical malpractice law

links liability to negligent behav-ior, 261

Medical malpractice liabilityexacerbated by managed care,

204Medical malpractice litigation

changing conventional rules, 17–22

Medical malpractice reformsAmerican Academy of Actuar-

ies, 215Medical malpractice settlements,

211Medical malpractice tort cost, 205Medical meltdown

trends contributing to, xMedical miracles, 204Medical practice

contemporaryexacerbating medical mal-

practice liability, 204laws impact on, xi–xiiin new millennium, x–xiregulations impact on, xi–xii

Index 293

Medical practice insurance, 3–8.See also Medical malpracticeinsurance

actuarial science and financialmarkets, 5–6

claims made vs occurrencecoverage, 6

incurred loss, 6–7loss reserves, 6–7profit or loss, 7reinsurance, 8surplus, 7–8underwriting, 5

Medical practice pressures, ixMedical profession, xii–xiii

decreased autonomy, xii–xiiiMedical records

anesthesiology, 136fee-based online consultation

eRisk guidelines, 85online communications, 84

Medical standards of carereplaced by medical–legal stan-

dards of care, 217Medicare, 90

liability issues, 249price controls, 235

Medicare spending reductionfederal government, x

MEDLINE searchanesthesiology, 136

Meningitis, 95Methicillin-resistant staph aureus,

95Methylergonovine

for obstetric hemorrhage, 146MICRA. See Medical Injury Compen-

sation Reform Act (MICRA)Microsoft, 203MIFS, 231–232Migraine

emergency room, 110Milliman USA

medical malpractice claim analy-sis, 216

Minorsplastic and reconstructive sur-

gery medical liability, 184Misleading questions, 57Misoprostal

for obstetric hemorrhage, 146Monitored anesthesia care (MAC),

116Monitoring

anesthesia disasters, 126Motion for summary judgment, 30–

31Motivation, 57

plastic and reconstructive sur-gery medical liability, 195

Mutual insurance companies, 4

N

NAIC, 217Narcotic postoperative pain medica-

tion, 134–135National Association of Insurance

Commissioners (NAIC), 217National Practitioner Data Bank,

271National standards of care, 28Near misses, 272Negative defensive medicine, 257Negligence, 15

contributory, 23–24defined, 36proof of, 235substantive liability rule of, 15–

17MICRA, 18

Negligence per se, 16Negligent injuries, 233Neonatal injury, 259Neo-no-fault scheme, 266–267Neurosurgical services

in West Virginialoss of, 220–221

Newbornseizures, 147

294 Index

No-fault accident compensationsystems, 266–267

No-fault birth injury compensationfunds, 266–267

No-fault label, 240Noneconomic damages, 16

caps on, 216, 237flat caps on, 259recoverable

limitations on, 18–19Nonmeritorious litigation, 206, 210Nonpunitive patient safety theories,

256Nonverbal expression, 68–69Nuisance settlements, 211Nurse–physician communication

problems ofcases of, 70–71

Nursing notesdocumentation, 104–105

O

Obstetricsanesthesia disasters, 127–128hemorrhage, 147malpractice, 139–150

Obstructive sleep apnea, 134–135Occupational Safety and Health

Administration, 90Office anesthesia

anesthesia disasters, 128–129Ohio

MICRA-like reforms, 214On-call physicians, 79Online communications eRisk

Guidelines, 83–85Online diagnosis and treatment

vs fee-based online consultationeRisk guidelines, 86

Operating expensesfor insurance company, 4

Operating room fires, 131–132Oral deposition, 29–30Oregon

tort reforms, 215

Organizational liability, 268Oropharyngeal airway fires, 132Outlier verdicts

cost amplification of, 205Oxytocin

for obstetric hemorrhage, 146

P

Painmanagement, 95narcotic postoperative medica-

tion, 134–135Pal plaintiff attorneys, 58Pap smears

access to threatened, 220alerting physicians about inher-

ent false-negative rate, 174court issues, 175–176failure to detect abnormal cells, 172failure to recognize unsatisfac-

tory, 172–173false-negative, 168hyperchromatic crowded groups

of cells, 172importance, 170–171interpretation errors, 173–174liability, 174–175

limiting, 170–171managed care, 170

litigation, 167–179, 169tlong-term solutions, 177preventative measures, 176sources of error, 171–173

Partial summary adjudication, 30–31

Patient approach, 37–38Patient care, 255–257Patient confidence and trust, 234Patient dignity, 92Patient expectations

Internet-based care, 80–81plastic and reconstructive sur-

gery medical liability, 188Patient explanations

documentation, 38

Index 295

Patient–physician communicatione-mail, 80–81online, 86

Patientscommunication in emergency

room, 102–103disgruntled with managed care,

204interpersonal relationship with,

37–38mandate error disclosure to, 271ventilating, 102–103written questions from, 69

Patient safetycommunication, 65–74liability reform and, 255malpractice law, 235–236movement, 235nonpunitive theories, 256

Patient safety and tortclash between, 235–236

Patients’ Bill of Rights, 204Payors

disgruntled with managed care,204

Payoutsreducing size of, 236

Pediatric airway fires, 132Penicillin G

for GBS prophylaxis, 143Pennsylvania

error disclosure mandates, 271Periodic payments, 21–22, 237–238Personal injury law, 228Physician(s)

and attorneys, 249behavior affected by malpractice

litigation, 218–219difficult times, ixdisgruntled with managed care, 204erosion of authority, xexperience rating of, 229facing criminal penalties, xmalpractice histories

publicly available, 270

numbers sued, 12on-call, 79perspective on Internet-based

care, 80as policyholders, 4report cards, 270sharing liability costs, 261volunteer

community clinics, 221Physician extenders

family physician risk manage-ment, 93

Physician-hoodnature of, xiii

Physician–patient relationshiplistening, 66–68

Physician’s officee-medicine, 75–87

Physician witnesses, 41–51actions, 42–43attorney–client relationship, 46–

48humility, 41plaintiff judging effectiveness of,

58preliminary advice, 42–46prepared, 49

Plaintiff attorneysbutterfly, 59contingency fees, 18–19at deposition, 58–59freight train, 58–59pal, 58perspective

risk reduction, 35–40sliding contingency fee scale, 18

Plaintiffscausing injury to, 16defendants duty to, 16increases in payouts to, 234judging witness effectiveness, 58knowledge of defendant’s strate-

gies and information, 54–55summarizing defendant’s testi-

mony, 56–57

296 Index

Plastic and reconstructive surgerymedical liability, 181–198

anger, 196–197communication, 196consent-in-fact, 184disclosure, 182–183documentation, 185–186familial disapproval, 189immature patient, 188–189implied consent, 184indecisive patient, 188informed consent, 183legal principles, 181–187minors, 184most likely to generate claims,

190–194patient expectation, 188patient selection, 187–190, 195,

195fpsychological and psychiatric

aspects, 195–196refusals, 184religion, 184–185secretive patient, 189standards of care, 181–182surgiholic, 189–190therapeutic alliance, 186–187unlikable patients, 189warranty, 182

Players, 15importance in litigation game

and storytelling, 24–25Pleasantness

physician witness, 45Politics, 249–250Pooling, 260–261Poor compensation, 258–260Position

physician witness, 60Positioning, 68Postdeposition, 59–61Postoperative pain medication

narcotic, 134–135Postsubdural puncture headaches,

130–131

Preeclampsiaedema of, 149–150

Preexisting relationshipsfee-based online consultation

eRisk guidelines, 85Pregnancy

failed intubation, 149–150hypertension, 148in Mississippi

access to care, 221Premium investments, 5–6Prenatal care and delivery

malpractice, 143Preoperative sheet, 120Prescription errors

family physician risk manage-ment, 99

Presenting, 140Pretrial screening panels, 239tPricing insurance

according to legal risks, 261Privacy

Internet-based care, 82–86telephone-based care, 78

Private contracting, 270Procedural rules, 17Profession

meaning of, xiiiProfessional demeanor

physician witness, 61Professional guidelines

standard of care, 140Professionalism

core elements of, xiiiProfessional judgment, xProfessional liability

refusal to offer, 209Professional liability crisis

states facing, 215Professional liability insurance,

4Professional responsibilities, xiiiProfit or loss

medical practice insurance, 7Proof of negligence, 235

Index 297

Prophylactic oxygenon sedation case, 132

Prospective jurorsvoir dire, 26

Proximate cause, 16, 37Prudent patient test, 183Psychiatric patients

emergency room, 110Public awareness of medical error,

234Public expectations, 234Publicly traded commercial insur-

ance companies, 4Public skepticism about error, 234Pulse oximeters, 116

Q

Quality, xiQuestions

ambiguous, 55–56clarification for physician wit-

ness, 43compound, 56frequently asked, 87hypothetical, 56misleading, 57written

from patients, 69

R

Rationally reliable basis, 28Reciprocal insurance companies, 4Record keeping

telephone-based care, 79Recoverable noneconomic damage

limitations on, 18–19Reflective feedback, 67Refusals

informed, 96–97plastic and reconstructive sur-

gery medical liability, 184Regional anesthesia

labor and delivery, 150Regional blocks

anesthesia disasters, 129–131with general anesthesia, 130

Regional neurological blocks, 116Regulations

impact on medical practice, xi–xiiReimbursement

cost-based, 253Reinsurance, 8Reinsurance market, 209Religion

plastic and reconstructive sur-gery medical liability,184–185

Repetition, 69Report cards

physicians, 270Reporting requirements, 235Reproductive functions

malpractice claims, 141Research

establishing standards of care,136–137

malpractice system, 250Researching topics

anesthesiology, 136Reserve development, 7Res ipsa loquitur, 230, 237Respect

physician witness, 42Rhinoseptoplasty

generating malpractice claims, 192Rising liability costs

for skilled nursing facilities, 260Risk

attributes affecting, 5spread, 4–5

Risk management. See also Familyphysician risk management

activities, 235Risk reduction

deposition, 39educating attorneys about case,

38–39general concepts, 40patient approach, 37–38plaintiff attorney’s perspective,

35–40

298 Index

S

Safe environment, 272Safety. See Patient safetySampling errors

pap smears, 171Scars

generating malpractice claims,190–191

Scheduling damages, 267Scientific evidence

relevant and reliable, 28Sclerosing adenosis

misdiagnosis, 162Scope, 267Screening errors

pap smears, 171–172Security

Internet-based care, 82–86online communications, 83telephone-based care, 78

Self-funded reserves, 256Self-insurance arrangements

institutional, 231Sensitive subject matter

online communications, 84Settlements

medical malpractice, 211nuisance, 211

Severity, 205Shareholders

ownership, 4Shorter statute of limitations, 239tShoulder dystocia, 145SIL, 168Silence, 68Sincerity

physician witness, 61Sitting

physician witness, 60Skin resurfacing

generating malpractice claims, 194Sliding contingency fee scale

plaintiff attorneys, 18Smiles

physician witness, 46

SOAP (subjective, objective, as-sessment, and plan), 98

Speaking, 68Specialized medical courts, 265Speech

tempo of, 68Spin, 14–15Spinal blocks, 130Squamous intraepithelial lesion

(SIL)/carcinoma, 168Stabilization, 106Standards of care

consultants, 141defendant breaching, 16defined, 36family physician risk manage-

ment, 91Internet-based care, 82–83from local to national, xiimedical

replaced by medical–legalstandards of care, 217

national, 28plastic surgery, 181–182professional guidelines, 140telephone-based care, 77–78

Stare decisis, 22State

Statutes, 22State constitutions, 23State Department of Insurance, 7State medical boards, 82State statutes, 22Statute of limitations, 18–19

shorter, 239tStorytelling, 14–15

players importance in, 24–25Subarachnoid hemorrhage

emergency room, 110Subjective, objective, assessment,

and plan (SOAP), 98Subject matter

dismissing as uninteresting, 66Subject to authority

physician witness, 42

Index 299

Substantial evidence, 26Substantive liability rule of negli-

gence, 15–17MICRA, 18

Suction-assisted lipectomygenerating malpractice claims,

193–194Summary adjudication

time, 30–31Summary judgment

motion for, 30–31time, 30–31

Surplusmedical practice insurance, 7–8

Sutures, 220Sympathy

physician witness, 48System reform, 237t, 238–241

T

TDCbreast cancer claims, 154–160pap smear litigation, 167–179

Telephone, 71–74family physician risk manage-

ment, 98poor communication

cases of, 72–74Telephone-based care, 76–79

appropriateness, 76–77CPT, 79patient expectations, 77practical, technical, financial

considerations, 78–79record keeping, 79security and privacy, 78standards of care, 77–78

Telephone tag, 81Temper

physician witness, 43Template charts

documentation, 104Templates, 87Temporary holding orders

ACEP, 106emergency medicine, 106–107

Tension headacheemergency room, 110

Terminologyphysician witness, 61

Testimonydefendants

plaintiff summarizing, 56–57Texas

malpractice insurers decline, 212Textbooks

anesthesiology, 136authoritative, 56citing by physician witness, 43–

44The Doctors Company (TDC)

breast cancer claims, 154–163pap smear litigation, 167–179

Thought-speech speed, 67Thromboembolic disease

pregnancy, 148Tillinghast-Towers Perrin, 207Time

discovery process, 29–30summary adjudication, 30–31summary judgment, 30–31

Time bomb attorneys, 59Timing

litigation, 29–31To Err Is Human, 255Tone of voice, 68Tort and patient safety

clash between, 235–236Tort crisis, 233–235Tort law, 228

defined, 202expansion of, 202influencing provider behavior,

233Tort reforms, 236–238

Agency for Healthcare Researchand Quality, 219–220

conventional, 237tTort reforms of 1970s and early

1980simpact of, 239t

300 Index

Tort systemdirecting compensation to plain-

tiffs, 232Tort tax, 202Total damages

flat caps on, 259Tradeoffs, 267Treatment

online vs fee-based online consul-tation eRisk guidelines, 86

Trustpatient, 234

Truthphysician witness, 45, 47, 48, 51

Two cultures problem, 235–236

U

Unauthorized accessonline communications, 83

Underwritingpractice of medicine insurance, 5

Urologistsin Ohio

malpractice insurance cost,221

US Department of Health andHuman Services

health care reform savings, 218malpractice insurance cost re-

port, 208tort reform, 220

Usual and customary fees, 253

V

Vaccineschildhood

cost affected by tort tax, 202Vaginal birth

after C-sections, 148

Verbal expression, 68–69Verbose explanations

losing interest, 66Vicarious liability

doctrine of, 90–91Voice

tone of, 68Voir dire, 26Volunteer physicians

community clinics, 221

W

Warfarinepidural hematomas with, 130

Warrantyplastic and reconstructive sur-

gery medical liability, 182Web, 87Web-based malpractice informa-

tion, 270Weiler, Paul, 232Wellman, Francis L., 46Witnesses. See also Physician wit-

nessesadversarial, 27expert, 26–29, 230

necessity of, 50–51Workers’ compensation, 240Written questions

from patients, 69Wrongful birth malpractice claims,

259

X

X-raysdelayed reports in emergency

medicine, 105–106emergency room, 112

ABOUT THE EDITOR

Dr. Anderson is a medical oncologist who practiced for morethan 20 years at Scripps Hospital in San Diego where he was alsoa clinical professor of medicine at the University of CaliforniaSan Diego. He is currently chairman and chief executive officerof The Doctors Company, a national physician-owned medicalmalpractice insurance company.