The "Big A" and the "25 C's"
RISK MANAGEMENT IN A CAPSULE
A. The "Big A" is ANTICIPATE
Anticipate what could go wrong with medical therapy or an operation. Be
sure the patient is informed and be prepared to take care of any
complication. Avoid surprises and lack of preparation.
B. The "25 C's"
The sine qua non of quality medical care is a competent physician acting in the patient's best interest.
Effective communication skills enhance the doctor-patient relationship
and decrease the risk of a suit if treatment results are not optimal.
If the patient gets a complication, communication is especially
important. Never let the patient believe he or she was abandoned even
if the patient was referred to another physician for treatment of the
"Alleged failure to obtain informed consent continues to occupy a high
position on the medical-legal hit parade of recurrent themes that
result in litigation. A very specific communication must occur between
the physician and the patient before the physician can treat the
patient. That communication must result in proper informed consent,
namely, adequate disclosure, if the treatment is to start.
"Informed consent is derived from the principle that each individual
has the right to determine what shall be done to his or her own body.
This doctrine has imposed on physicians and surgeons a duty to fully
inform a patient about the proposed treatment or operation, including
the risk, as well as the alternatives to a proposed operation or
treatment. Laws dealing with informed consent vary significantly among
From The Medical Risk Manager newsletter, July 1991, Hawaii HAPI/PIP
edition, Volume 3, Number 3, ©1991 Donald J. Palmisano, M.D., J.D.
A reference source is INFORMED CONSENT / A SURVIVAL GUIDE by Donald J.
Palmisano, M.D., and Herbert J. Mang, Jr., J.D. published by Invictus
The caring physician who communicates interest in the patient's welfare
not only enhances the patient-physician relationship but also greatly
diminishes the risk of a suit. Compassion is one of the commandments of
Medicine. (See DJP May 2002 Commencement Address to LSU HSC graduates
Whenever there is:
a) Doubt by physician of diagnosis or treatment
b) Dissatisfaction by patient
c) Distrust by patient
Always have a female chaperone present during examination of a female
patient by a male physician. A sexual familiarity charge is difficult
to defend without a witness. Failure to adhere to this advice has
caused great grief among some physicians. These tips are not
theoretical. Each represents a list of physicians, who now are like the
ancient mariner, sadder but wiser.
Remember my CATO rule:
-Complete/Accurate/Timely/Objective (and legible!)
- Initial test results before placing in chart.
"Medical records continue to be one of the most important items in
malpractice litigation. Because we don't have the time machine of H.G.
Wells to take us back in time to determine exactly what happened, the
medical record is considered the best witness to the past. Memories
fade, people lie, witnesses die, but the medical record lives on. It
should be complete, accurate, timely completed, and objective. Avoid
subjective comments or name-calling. Imagine whatever you write being
published in the newspaper."
From The Medical Risk Manager newsletter, November 1989, Hawaii
HAPI/PIP Edition Volume 1 Number 3, ©1989 Donald J. Palmisano,
A recurrent theme in malpractice litigation, fatal to the defense of
the case, is incorrect alteration of the record. If an error is written
or typed in the record, draw a line through it, date it, and initial
it. Then write in the correction. Do not "white it out", cover it up
with ink, or tear it out. If the correction is done incorrectly, the
plaintiff attorney usually alleges concealment and fraud and tries to
get the jury to believe that the doctor is not trustworthy. Never add
anything to the record after a suit is filed. If you remember something
that should have been in the record, dictate it in a confidential memo
to your defense attorney and he or she will then advise you of the best
way to present that information.
Do not boldly go where "angels fear to tread" unless you have
researched carefully and prepared for new and bold innovative therapy.
Avoid promises. Remember the example of the plastic surgeon who
promised to make his female patient's face "a model of harmonious
perfection." The jury looked at his patient and awarded her damages for
breach of contract by the physician.
11. Common Sense
If a planned treatment does not sound correct or if you have uneasiness
about it, do not start it blindly. Research it and obtain another
Be certain you have access to patient complaints and investigate them.
It is better to put out a spark of discontent before it becomes a
A checklist of important items prevents forgetting an important item.
Use this in getting a patient ready for an operation as well as for
other important events. Another example is a procedure for admission
to, or discharge from, a hospital.
With other doctors treating patient
Document conversation with patient especially after hours Document advice given to patient
The doctor-patient relationship is rarely thought of as a physician
treating a customer. However, in today's competitive environment,
thinking of the patient as a customer you want to keep happy will
decrease the risk of a patient becoming unhappy and wanting to sue if
treatment doesn't progress satisfactorily.
Read the writings of Deming and Juran to get a better perspective on
Continual Quality Improvement. This does not mean that you do something
to keep the patient happy if that something is not consistent with
quality medical care or is not in the best interest of the patient.
Do not panic if you are sued and point fingers at other treating
physicians or the hospital. Always be honest and give medical opinions
based on the facts rather than fear. Lack of courage only guarantees a
plaintiff win. Remember that a NAIC study from 1975 to 1978 of 72,000
cases showed 62% of malpractice claims are closed without any payment
only 18% go to trial and the doctor wins 89% of the time. By 2006 the
closure rate without payment was 80%.
Also, courage to advocate for the patient's best interest is one of the
commandments of Medicine. (See DJP May 2002 Commencement Address to LSU
HSC graduates, entitled The Six Commandments of Medicine at: http://www.intrepidresources.com/html/commencement_address.pdf
Always check credentials of applicants, especially doctors and nurses,
who wish to join your staff. Go to the source: medical school, state
medical licensing board, etc. Do not rely on photocopies brought to you
by the applicant. Some outstanding forgeries are possible with today's
Communications between the patient and doctor are confidential. Doctors
know this but it is essential that all members of the doctor's staff
also know this. Physicians have been successfully sued because their
staff revealed confidential information about patients outside of the
office. Have a confidential policy statement signed by all employees.
This can be a defense if the staff person reveals confidential
Avoid critical comments about the patient that would embarrass you or the patient if printed on the front page of a newspaper.
Listen to your attorney in a deposition or suit. If your attorney
instructs you not to answer a question, obey! Never say, "Oh, don't
worry, I know the answer to that." Remember your expertise is in
medicine, and not in deposition or trial tactics.
Insist that your attorney meet with you prior to a deposition. This
means some days before and not the morning of the deposition. It is
normal to be nervous before your first deposition - especially when you
are the target of the suit. However, proper preparation will reduce
anxiety and you will do well.
If you are uncomfortable with your defense counsel, identify this early
in the case and switch to another attorney. Insurance companies rarely
insist you stay with an attorney if you are uncomfortable. Of course,
you must be reasonable in your dealings with the attorney. Remember, if
all else fails, you always have the right to hire a private attorney at
your expense as your personal attorney even though the insurance
company may assign someone else as the lead attorney. It is
understandable that your stress will increase, if after talking with
the assigned attorney, he or she thinks a platelet is a small plate or
fibroplasia is a Walt Disney movie.
Keep up to date with medical knowledge. The age of the electronic
highway is here. Have available medical literature searches via
electronic retrieval with the aid of a computer and modem tapping into
many databases. An example is a Medline search at the National Library
of Medicine via the Internet. Of course, don't forget the infinite
resources of the Internet and home pages like Intrepid Resources that
can lead you to other medical information home pages.
If you cancel the doctor/patient relationship, notify the patient and
remain available for a reasonable period of time to avoid claim of
Avoid "Type A" behavior. "Type A" behavior is hurry sickness. It is
trying to do more and more things in less and less time. There is no
time for innovative thought. "Type A" behavior is a potent culture
medium for the germs of disaster. Rushing and stress combine to
encourage shortcuts and the routine checklist is skipped with resulting
error: operating on the wrong limb, failing to document properly, etc.
Copyright 1993, 1995 Donald J. Palmisano, MD, JD