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 The "Big A" and the "25 C's"


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"

1. Competence

The sine qua non of quality medical care is a competent physician acting in the patient's best interest.

2. Communication

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 complication.

3. Consent

"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 states."

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 Publishing Company.

4. Compassion

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 at:

5. Consultations

Whenever there is:

a) Doubt by physician of diagnosis or treatment

b) Dissatisfaction by patient

c) Distrust by patient

6. Chaperone

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.

7. Confirmation

Remember my CATO rule:

-Complete/Accurate/Timely/Objective (and legible!)

- Initial test results before placing in chart.

-Medical Records:

"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, M.D.,

8. Corrections

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.

9. Caution

Do not boldly go where "angels fear to tread" unless you have researched carefully and prepared for new and bold innovative therapy.

10. Contract

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 opinion.

12. Complaints

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 raging lawsuit.

13. Checklist

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.

14. Coordination

With other doctors treating patient

15. Collections

Avoid harassment

16. Calls

Document conversation with patient especially after hours Document advice given to patient

17. Customer

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.

18. Courage

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

19. Credentials

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 photocopy equipment.

20. Confidentiality

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 information.


Avoid critical comments about the patient that would embarrass you or the patient if printed on the front page of a newspaper.

22. Counsel

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.

23. Current

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.

24. Cancel

If you cancel the doctor/patient relationship, notify the patient and remain available for a reasonable period of time to avoid claim of abandonment.

25. Calm

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


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