Carlo L. Rosen M. D. Program Director


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  • Carlo L. Rosen M.D.

  • Program Director

  • Associate Director, GME

  • Beth Israel Deaconess Medical Center

  • Harvard Affiliated Emergency Medicine Residency


Understand examples of malpractice curricula which have worked in two programs

  • Understand examples of malpractice curricula which have worked in two programs

  • Discuss a QI/PS curriculum developed in collaboration with a malpractice insurance company

  • Learn about a unique interdisciplinary session co-developed and taught by emergency medicine faculty and law professors



Estimated that residents are named in 22% of lawsuits

  • Estimated that residents are named in 22% of lawsuits

  • < 1% of claims (with a payment) reported to National Practitioner Data Base between 1990-2012 named a resident

    • Bailey et al, Ann EM 2012
  • Residents may get named in suit

  • Decrease stress/anxiety levels by educating residents about the process



Teach residents about the process in case they get sued as an attending

  • Teach residents about the process in case they get sued as an attending

  • Methods to decrease chances of being sued

  • Learn good habits early

    • Documentation skills
    • Communication skills
    • Handoffs
  • No standard curriculum



Do residents get sued?

  • Do residents get sued?

  • What types of cases?

  • What are contributing factors?

  • What are the differences between resident and attending only cases?



Controlled Risk Insurance Company (CRICO)

  • Controlled Risk Insurance Company (CRICO)

  • Comparative Benchmarking System (CBS) database (2009-2013)

  • > 400 hospitals, > 165,000 physicians

  • > 30% of all malpractice cases in US

  • > 350,000 claims

  • 845 EM cases

  • 13% of cases included a resident

  • Gurley, et al SAEM 2016



Procedure involved in 32%

  • Procedure involved in 32%

  • Vascular access and LP were involved more frequently in resident cases than attending only cases

  • Average incurred losses smaller in resident cases ($51,163 vs. $156,212)

  • Higher injury severity in resident cases

    • 66% vs. 57% were High Injury Severity (major permanent injury)
    • Gurley, et al SAEM 2016


Most common diagnosis was cardiac related (19% [resident] vs. 10%)

  • Most common diagnosis was cardiac related (19% [resident] vs. 10%)

  • Most common contributing factors-clinical judgment (71% [resident] vs. 76%)

  • Gurley, et al SAEM 2016



The overall case profiles, including allegation categories, final diagnoses and contributing factors are similar

  • The overall case profiles, including allegation categories, final diagnoses and contributing factors are similar

  • Patient safety efforts should therefore encompass the entire care team

  • Most prevalent contributing factors: Clinical judgment, communication and documentation

    • targets for risk management strategies.


Based on similar experience in Denver program

  • Based on similar experience in Denver program

  • Collaborate with malpractice insurance company

  • Collaborative malpractice curriculum

  • Controlled Risk Insurance Company

    • > 12,400 physicians
    • 34 hospitals
    • 3,500 residents (100 are EM)


Two components:



5 hour seminar

  • 5 hour seminar

  • EM specific data about malpractice cases

  • Anatomy of a lawsuit

    • Role of attorney
    • Chronology of lawsuit
  • Attorney/risk adjustor’s perspective

  • Emergency physician input

  • Strategies on how to avoid a lawsuit

  • Review a case as a group



Topics covered

  • Topics covered

  • Role of CRICO (Controlled Risk Insurance Company)-malpractice provider

  • Patient safety overview

    • Malpractice data review
    • Resident malpractice data
    • Risk reduction strategies in EM
    • Closed malpractice case
  • EM Cases

  • Case Disposition



Topics covered

  • Topics covered

  • What to expect as a defendant

  • Chronology of a malpractice case

  • Disclosure and apology program

  • Missed and delayed diagnoses in EM

  • Top allegations in EM

  • Contributing factors in EM

    • Interpretation of diagnostic tests
    • Consultation management


Review EM specific malpractice cases including cost analyses, case rate statistics, allegation, contributing factors and case disposition

  • Review EM specific malpractice cases including cost analyses, case rate statistics, allegation, contributing factors and case disposition

  • Discuss malpractice case trends, their analyses and subsequent implemented risk mitigation strategies

  • Outline anatomy of a malpractice case presented by an attorney outlining the logistics and proceedings of a lawsuit



CRICO Cases

  • CRICO Cases

  • N=1,292 cases asserted between 1/1/09-8/31/14

  • EM is the 6th specialty in case frequency

  • 5th in cost

  • 79 cases resulting in $51.7 million in total incurred losses

    • (including reserves on open and payments on closed cases)




68% felt it impacted their documentation

  • 68% felt it impacted their documentation

    • 90% increased documentation of consultant discussions
    • 79% increased MDM documentation
  • 32% felt it impacted communication skills

  • 47% said test ordering would increase

  • 63% said avoiding a malpractice suit impacts their clinical decision-making

    • 74% impacted communication with nurses
    • 79% impacted their discharge plans


2.5 hour session at malpractice insurance company

  • 2.5 hour session at malpractice insurance company

  • Review a malpractice case-records, depositions, materials, legal materials

  • Discuss the case disposition with attorney, EP, and risk adjuster

  • Residents rave about the experience











Learn together

  • Learn together

    • Burden of proof and the “standard of care,”
    • Informed consent
    • Documentation and communication
    • The practice of defensive medicine
    • Procedures for taking and defending depositions
    • How to prepare for trial
    • Settlement or verdict
    • Licensing and regulatory bodies


Experience of handling a medical malpractice case from start to finish

  • Experience of handling a medical malpractice case from start to finish

  • Law students:

    • How to represent a physician
    • Take a deposition
    • Prepare for trial
  • Residents:

    • Insight into the legal field
    • Aid in the understanding of the mechanics of a lawsuit
    • Provide a practical understanding of how the legal system functions


Introduction and Course Overview; Medical Malpractice Basics

  • Introduction and Course Overview; Medical Malpractice Basics

  • Understanding the Practice of Medicine, QI Presentation

  • Mary Smith v. Tom Jones, M.D.; The Lawsuit is Filed

  • Perspectives from San Diego Medical Malpractice

  • Damages in Medical Malpractice Actions



Patient: Mary Smith

  • Patient: Mary Smith

  • Doctor: Thomas Jones, MD, FACEP

  • San Diego Memorial Hospital

  • June 11, 2016







Joining forces with your malpractice insurance company can facilitate the development of an EM resident curriculum to teach about patient safety and risk management.

  • Joining forces with your malpractice insurance company can facilitate the development of an EM resident curriculum to teach about patient safety and risk management.

  • Interdisciplinary training in Emergency Medicine need not be limited to critical event scenarios.

  • Interdisciplinary training between law students and EM residents can serve to expose trainees to a scary, poorly understood, yet frequent occurrence encountered in the practice of Emergency Medicine.

  • Joint training sessions can help learners better understand the others respective fields, aid in the understanding of the mechanics of a lawsuit and provide a practical understanding of how the tort system functions.




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