Malpractice?

[hightower]

Just curious what others thoughts are on this.  This is a case I heard about recently.  I will present it in a hypothetical way...

A woman goes to her dermatologist's office for a "chemical peel" that was recommended to her by her dermatologist.  The procedure is performed by a non-physician, non-nurse staff member.  They did not test the chemical on her skin prior to putting it all over her face.  As a result, the procedure resulted in a fairly severe reaction (swelling, burning of the skin, etc).  The patient was briefly seen by a nurse practitioner after the procedure and given a script for steroids and sent home.  Never was a physician present.  The woman has to endure days of embarrassing swelling, redness, peeling, and is fearful it could result in scarring.

Should the woman pursue a lawsuit against the dermatology clinic?

[MPMD]

she won't get anywhere unless she has actual scarring.

the doc in question could likely easily and appropriately wiggle out unless it could be proven that she delegated a task to someone she hadn't properly trained to do it.

[Hatton]

No.  If she had permanent scarring yes.  I have had peels in a plastic surgery office before.  I thinks some are done by nurses others by aestheticians.  It would be better form to have the doctor see the patient if something was wrong of course.  Also better form to have the patient sign some sort of form as to risks of procedure.

[jfoxcpacfp]

MPMD wrote:

she won’t get anywhere unless she has actual scarring.

the doc in question could likely easily and appropriately wiggle out unless it could be proven that she delegated a task to someone she hadn’t properly trained to do it.

Click to expand...

Nothing for pain and suffering? What are all those stories I hear about ridiculous settlements? And if the doc in question owns the practice, isn't s/he somewhat responsible for the actions of his/her employees, at a minimum, some level of or procedure for oversight of their activities? I sure am at my office. Different profession - different definitions?

[janettebournes]

Did the woman pursue followup during the post-procedure period?

I'm not sure there's a lawsuit there if there is no scarring and no attempt was made at pursuing followup

On the other hand, if the patient requested followup and still never got through, I think this situation gets murkier

Was the swelling present immediately post-procedure? If present, then I also think this is a murky case if the NP allowed the patient to leave without consulting the MD

[hightower]

The pain and suffering thing is part of what I was concerned about.  The other being that the woman can not recall that they actually verbally explained to her that this could happen, though they did ask her to sign a consent (which I am certain says that it was explained, therefore she should not have signed it without getting the explanation in the first place).  The other of course being that it seems that testing the chemical in a non-conspicuous spot before applying it all over the face seems like common sense.

[hightower]

janettebournes wrote:

Did the woman pursue followup during the post-procedure period?

I’m not sure there’s a lawsuit there if there is no scarring and no attempt was made at pursuing followup

On the other hand, if the patient requested followup and still never got through, I think this situation gets murkier

Was the swelling present immediately post-procedure? If present, then I also think this is a murky case if the NP allowed the patient to leave without consulting the MD

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Swelling present immediately while in office.  Patient left without any physician oversight.  Not sure if the NP consulted with physician prior or not.  Follow up is being pursued as far as I am aware.

[janettebournes]

Sounds like a poorly run practice

Explaining risks and benefits to a patient is obviously important.

I've been told that medical consents (while so incredibly vital for the nursing and administrate teams that harass me daily for them) will not protect a physician when it comes to a lawsuit

A test spot also seems like a reasonable and appropriate part of the pre-procedure routine

That being said, if this is a chemical peel being administered by a non physician non nurse with no monitoring in the outpatient setting, pain and suffering is going to be a very subjective measure

The success of the lawsuit may depend on the ability of the lawyers to spin or defend it

[janettebournes]

Sorry, typing from my phone so I can't quote

If there was immediate post procedure swelling and the NP did not get the physician, that's not looking so good

If followup is being pursued and the patient is having a tough time reaching the physician, also not good

It would make sense for a well run practice to bend over backwards to appease this patient (even if not for legal reasons, for goodwill and patient satisfaction reasons)

[White.Beard.Doc]

A lawsuit?  It depends on the outcome.  A little burning and stinging to the skin for several days is inherent to the procedure, nothing needing a lawyer or compensable.  Severe ongoing symptoms with scarring would likely be compensable in a lawsuit.

It is scary these days with many docs delegating too much to physician extenders.  I think this is an area for all of us to apply a measure of prudence and caution.  If something goes wrong for the patient, we are definitely responsible for making sure that non-physician staff do not overstep the bounds of what is reasonable.

And often overuse of extenders is about money.  If a physician makes medical practice about money first and patient care second, this is a recipe for burnout.  Of course it is great to be financially well compensated, but it is even more important to be dedicated to putting patients and their needs first.  Putting patient first allows me to feel good about the work that I do and that helps me avoid burnout.  The minute we start measuring RVU's as our first priority, the profession of medicine becomes about money more than caring, and that would leave me with an empty feeling soul at the end of the day.

 

I value patient care needs >> I value financial compensation = I am a fulfilled physician (and still well compensated)

I value financial compensation >> I value patient care needs = Burnout and loss of professional self respect

 

I feel this is so important to our profession.  We don't talk about it enough.  Even if you put patients first, you can still be very highly compensated.  Why don't more of us talk about this?  Maybe it is easy for me to feel this way because I always saved a lot of my income and now in my later career I have extreme financial security.  But I still love my work as a healer.

 

[q-school]

should the woman pursue a lawsuit?

i don't know how to answer a should question.  it depends on what she is hoping to accomplish.  is that her mechanism for letting the office know of her dissatisfaction?  is she protecting other people?

i think it would be hard to prove any damages.  undoubtedly swelling is part of the listed complications she consented to.

from a financial standpoint, it's hard to imagine the case not being a loser for the lawyers.  if it's contingency based, she will likely not get too far.

of course what do i know about lawsuits? 

 

[hightower]

White.Beard.Doc wrote:

A lawsuit?  It depends on the outcome.  A little burning and stinging to the skin for several days is inherent to the procedure, nothing needing a lawyer or compensable.  Severe ongoing symptoms with scarring would likely be compensable in a lawsuit.

It is scary these days with many docs delegating too much to physician extenders.  I think this is an area for all of us to apply a measure of prudence and caution.  If something goes wrong for the patient, we are definitely responsible for making sure that non-physician staff do not overstep the bounds of what is reasonable.

And often overuse of extenders is about money.  If a physician makes medical practice about money first and patient care second, this is a recipe for burnout.  Of course it is great to be financially well compensated, but it is even more important to be dedicated to putting patients and their needs first.  Putting patient first allows me to feel good about the work that I do and that helps me avoid burnout.  The minute we start measuring RVU’s as our first priority, the profession of medicine becomes about money more than caring, and that would leave me with an empty feeling soul at the end of the day.

 

I value patient care needs >> I value financial compensation = I am a fulfilled physician (and still well compensated)

I value financial compensation >> I value patient care needs = Burnout and loss of professional self respect

 

I feel this is so important to our profession.  We don’t talk about it enough.  Even if you put patients first, you can still be very highly compensated.  Why don’t more of us talk about this?  Maybe it is easy for me to feel this way because I always saved a lot of my income and now in my later career I have extreme financial security.  But I still love my work as a healer.

 

Click to expand...

This is a big reason why I wanted to post this.  Delegating work to NPs and office staff in an effort to see more patients, leads to more risk.  The corporatization of doctoring is leading to a lot more of this.  As a hospitalist we are forced to work with NPs all the time with the assurance that they "will help you by doing H&P's, etc"  However, if you really think about it, they don't help you at all if you're doing the right thing.  You, as the physician, need to oversee every single thing they do and make sure that you are the one coming up with the appropriate diagnosis and treatment.  Otherwise, when they make a mistake and all you did was sign off on their work without putting much effort into it, you'll be the one on the hook.

[q-school]

hightower wrote:

White.Beard.Doc wrote:

A lawsuit?  It depends on the outcome.  A little burning and stinging to the skin for several days is inherent to the procedure, nothing needing a lawyer or compensable.  Severe ongoing symptoms with scarring would likely be compensable in a lawsuit.

It is scary these days with many docs delegating too much to physician extenders.  I think this is an area for all of us to apply a measure of prudence and caution.  If something goes wrong for the patient, we are definitely responsible for making sure that non-physician staff do not overstep the bounds of what is reasonable.

And often overuse of extenders is about money.  If a physician makes medical practice about money first and patient care second, this is a recipe for burnout.  Of course it is great to be financially well compensated, but it is even more important to be dedicated to putting patients and their needs first.  Putting patient first allows me to feel good about the work that I do and that helps me avoid burnout.  The minute we start measuring RVU’s as our first priority, the profession of medicine becomes about money more than caring, and that would leave me with an empty feeling soul at the end of the day.

 

I value patient care needs >> I value financial compensation = I am a fulfilled physician (and still well compensated)

I value financial compensation >> I value patient care needs = Burnout and loss of professional self respect

 

I feel this is so important to our profession.  We don’t talk about it enough.  Even if you put patients first, you can still be very highly compensated.  Why don’t more of us talk about this?  Maybe it is easy for me to feel this way because I always saved a lot of my income and now in my later career I have extreme financial security.  But I still love my work as a healer.

 

Click to expand…

This is a big reason why I wanted to post this.  Delegating work to NPs and office staff in an effort to see more patients, leads to more risk.  The corporatization of doctoring is leading to a lot more of this.  As a hospitalist we are forced to work with NPs all the time with the assurance that they “will help you by doing H&P’s, etc”  However, if you really think about it, they don’t help you at all if you’re doing the right thing.  You, as the physician, need to oversee every single thing they do and make sure that you are the one coming up with the appropriate diagnosis and treatment.  Otherwise, when they make a mistake and all you did was sign off on their work without putting much effort into it, you’ll be the one on the hook.

Click to expand...

Who is going to see all the follow ups after you discharge the patient from the hospital?



if you are busy overseeing the NP/PA, then you won't be seeing the patients.  but more patients get seen.  hopefully you have trained them well when to call for help.  hopefully you yourself know what you are doing if you have been busy overseeing rather than seeing patients as we all know clinical skills deteriorate eventually.

dilemma!

 

[Hatton]

I unfortunately know a lot about lawsuits being ob/gyn and serving on a panel that looks at them for my carrier to give input as to whether to settle or defend.  If the patient has no permanent scarring just discomfort and swelling there is no case.  Just like a surgical complication that is recognized and fixed with no permanent harm to the patient.  That all being said if this patient does have some sort of permanent scarring or other permanent problem then the fact she did not see the physician is huge.  There will be no defense really.  I agree this is an example of a poorly run practice too dependent on extenders.

[Zaphod]

Shed have to have an actual injury to successfully pursue any suit. I dont know what the peel was or what she was expecting, but peels result in slight swelling, definite redness, and peeling (as the name suggests). Thats literally the expected normal outcome depending on type/etc....We call it Zombie Face for the more serious peels, it is not pretty. It can burn, no shocker there either. Unless this was a level of peel that required being seen by a doctor, state laws vary, it wont matter.

While this place sounds poorly run and they didnt handle it very well, Im highly doubtful anything out of the ordinary occurred and it was just much more than expected for the pt.

The idea that everyone should think about a case after any little thing is so ridiculous. Also, no one cares if you go to get your face peeled and you dont like it. Very poor malpractice showings as juries dont care and see them poorly. Unless she has horrific obvious to a jury looking at her face scarring, none of this is even close to malpractice. Bad outcomes=/=to malpractice either. They happen.

This doesnt even sound like a serious peel really, this person sounds a bit over the top. She wasnt paying attention, didnt read the consents, and got more than she expected.

Nothing wrong with extenders, and it didnt contribute in this case. They go along with the culture, and again, betting that the reaction was 100% within normal limits.

You framed this very favorably, and maybe its because you know the pt. However, this is a one sided story, and I'd wager the fault is with an over reaction on the pts part and they are more to blame here. Not paying attention, doing any due diligence, or asking questions is the pts fault in these kinds of things (not legally, but in reality due to wild west nature). It is buyer beware like it or not, so you have to do your own work and be vigilant.