Malpractice: 3 lessons I learned the hard way

I received my first notice letter while still a second-year resident.

Ignorant of what it meant, I ran down the hall to my chairperson's office in search of an explanation. He said that several states, including Ohio, required such letters when someone intended to file a malpractice claim against a doctor. His explanation made sense, but it did little to allay my fears over the allegations of malpractice against me. Nor was I comforted when I learned that the attending physician-who'd accompanied me during my patient evaluation-hadn't received a similar notice.

That day and the tortuous 18 months that followed marked the beginning of my interest in the medicolegal system. Today, several notice letters later, including four cases that almost proceeded to trial, I've learned a lot about that system and about myself. Here are the lessons I've learned about how to survive a malpractice suit. Although they all derive from my experience as an emergency physician, the lessons apply equally to every doctor.

Trust your attorneys, but verify the facts

The case that occurred during my residency involved a middle-aged woman who presented in the ED with abdominal pain. Over a six-plus-hour period, my evaluation of her resulted in normal labs, an unremarkable acute abdominal series, and a follow-up exam that showed no worsening.

Satisfied, I discharged her with a prescription for Compazine. Four days later, the woman called EMS to transport her to a nearby hospital, where she died. An autopsy identified her cause of death as fibrino-purulent peritonitis and pneumonia.

Several months after putting me on notice, the woman's family sued me, alleging negligence and failure to diagnose. I was angry at the possibility that I might have been wrong and angrier still over the plaintiff's accusations against me. Those emotions rapidly passed, though, as I redirected my energy into finding out whether her claim had any merit.

I put on my detective's cap, trying to review the situation as honestly and objectively as I could. The question of whether I'd met the standard of care was relevant, but, for the time being at least, subordinate to several questions that were more pressing. Among them were these:

After considering the questions above, I concluded that my documentation could have been clearer, especially the part covering my discharge instructions. But, overall, I was satisfied that I'd provided the patient with the proper care. Clearly, I would have to look somewhere else to determine the validity of her family's claim against me.

A review of the autopsy report seemed like the next logical step. There was a problem, however: I was far from experienced in reading autopsy reports, which meant, among other things, that I didn't know everything that they did, and should, contain. Certainly, the anatomical dissection/discussion was very interesting, but shouldn't the report also include a toxicological analysis?

My attorneys hadn't provided me with one-nor were they aware that such an analysis had been performed, although it had. When they finally located it for me, I discovered something interesting: The medication that I'd prescribed for the patient hadn't been found in her blood. What was found was evidence of Demerol and cocaine, in quantifiable levels. After consulting a forensic textbook, I calculated that-based on the average metabolism of the two drugs-the patient had taken them within eight hours of the time of her death.