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1 the Reporter | Q1

Quarter 1, 2017

MANAGING DIFFICULT PATIENTS

CME ACTIVITY: COMBATING PHYSICIAN STRESS AND BURNOUT

MEDEFENSE COVERAGE: NOW AVAILABLE AT HIGHER LIMITS

CLOSED CLAIM 1: DELAY IN DIAGNOSING BREAST CANCER

CLOSED CLAIM 2: FAILURE TO CONFIRM DIAGNOSIS OF POLYCYTHEMIA VERA

2 the Reporter | Q1

By Steve Taylor andWayne Wenske, Communications Coordinator

MANAGING DIFFICULT PATIENTS

Scenarios• A patient waits in the exam room. He angrily and

loudly complains to staff that the wait is too long and that he is missing an important work meeting.

• The next day, a patient arrives in your office without an appointment. She becomes combative—insisting that she be seen due to her intense pain. She finally throws the sign-in clipboard across the waiting room, narrowly missing another patient, before storming out.

• After looking up symptoms online, a patient insists that he has accurately identified his ailment and demands to be treated for it. He becomes belligerent when the physician orders tests, and refuses to comply. The patient also wants a prescription for a medication he heard about on television.

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They are noncompliant, hostile, and demanding. They yell, curse, and may even threaten violence. Unfortunately, difficult patients and effectively managing their care is an all-too-real and important part of today’s health care environment. Knowing how to identify, understand, and respond to difficult patients can make your work life safer and less stressful.

THE FOUR-STEP PROCESSWhen managing a difficult patient, TMLT’s Risk Management department suggests taking a “four-step” process to problem solving. This process takes a logical, solution-oriented approach that can be used to work out problems of all types or levels of difficulty. This method helps to reduce the emotion of the situation to more manageable levels, while creating a safe, respectful environment for you and your patient.1

The four steps are:

1. Listen attentively: Spend several minutes letting your patient tell the whole story, without interruption. Maintain good eye contact and take notes. If the patient gets derailed or lost in details, use phrases such as, “Tell me more about that….” “Then what happened?” “How did you feel then?” Phrases and questions such as these help your patient focus so you can gain as much pertinent information as possible, while also demonstrating to the patient that you care and are fully engaged.

2. Show concern: When the patient has finished, show appropriate empathy or understanding for his or her situation. You don’t have to fully agree with your patient’s interpretation of the facts, but show that you understand what is being expressed to you – the emotion and the reasons behind it. Use phrases such as, “I understand why you are so angry.” “I would feel the same way if I were in your shoes.” This will help the patient feel heard, understood, and respected. This can go a long way towards improving the situation, and allowing you and your patient to move forward in a calmer, more productive way.

3. Clarify details: Get clarification on any important details or information to help reach resolution with the patient.

4. Respond assertively: Once you have a clear understanding of the facts and the emotions of the situation, you can move forward with an appropriate response. Lead the discussion by asking your patient for their “ideal solution,” such as:

• “What would you like me to do to solve this problem?”

• “What would be your ideal solution to this problem?”1

With your patient’s response as a starting point, negotiate the best possible agreement. Be clear about your policies and possible exceptions, outline the patient’s choices, and work toward a viable solution.

If you find yourself still not able to bring the patient into a productive conversation or if the situation escalates, consider responding to the patient using the following three-step assertive response:

1. “Show empathy for the patient’s situation.2. State how you can help them resolve the problem.3. Describe the benefit to patients if they take your

suggestions.” 1

Here are two examples:

“Mr. Jones, I understand why you’re upset. I would be, too, in your situation. Anybody would be. Let’s step into my office for a few minutes so I can answer your questions and fully explain why I believe this treatment plan is the best option for you. I want to be sure that you’re comfortable with your treatment going forward.”

“I understand that the wait time has been too long. I’m sorry. I’m here now, and you have my full attention. Let’s discuss how I can help you.”

By showing empathy, being calm, and describing the benefits to your patient, you help soothe the situation and gain his or her confidence and cooperation.1

When using either the four-step process or three-step assertive response, be careful to adopt a tone and posture that demonstrates your control of the situation.

• Maintain a slightly firmer tone of voice; be calm and businesslike.

• Avoid sarcasm, and take care that your tone couldn’t be conceived as patronizing by your patient.

• Maintain direct eye contact and put yourself at the same eye level as the patient.

• Move an angry or disruptive patient to a private office, so other patients and staff members are not disturbed or upset.1

CONTRIBUTING FACTORS: WHY IS THE PATIENT DIFFICULT IN THE FIRST PLACE?Why is the patient seeking treatment? This simple question may be the most helpful indicator in identifying the source of your patient’s behavior. The patient’s condition may involve chronic, even acute pain. Or treatment to date has been fruitless, or only partially successful. Perhaps the patient is in denial about his or her ailment or injury.

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Another factor can be the patient’s support system – or lack thereof. Family conflicts, finances, bad habits, time pressures, and interruptions to daily routines can weigh on a patient already suffering physically.

Maybe there are indications of Alzheimer’s Disease, dementia, or clinical depression. Communication issues may also be at play, such as language barriers, literacy issues, or cross-cultural misunderstandings.

Finally, if a provider brings his or her burdens into the exam room, such as running late, missing lunch, feeling fatigued or frustrated, this can have a negative effect on the patient. Providers are only human, and often endure stressors that can trigger a difficult interaction with a patient.

The result of a poorly managed patient interaction? Valuable time wasted by both provider and patient. Anxiety, anger, and helplessness may occur on both sides.

In their 2014 article, Difficult Patient Encounters, Dr. Denise M. Dudzinski and Dr. Diane Timberlake write, “Difficult patients can be seen as a problem to be tolerated or terminated from practice, however the difficulty is in the relationship not simply the patient, and there are techniques and strategies to help clinicians improve that relationship and retain its therapeutic nature.” 2

“It may be difficult to see some of these patients as vulnerable, but without a clinician’s help their vulnerability would only be compounded. While their medical, social, and psychiatric conditions may be complex, patients benefit both from a therapeutic relationship and from medical treatments and advice.” 2

STRATEGIES FOR MANAGING DIFFICULT PATIENTSHere are some strategies that can help you manage relationships with difficult patients: 1,2

• If a waiting patient won’t be seen in a timely manner, make sure office staff keeps the patient informed of their appointment status and how soon they will be seen by the physician. Apologies and brief explanations can stave off problems during the examination.

• If the wait time is excessive, give your patient choices like rescheduling or going for coffee or lunch while they wait. If they live or work nearby, offer to call them at their home or office when you are available. These concessions may not keep the patient from getting frustrated, but it might reduce anger. Providing choices also demonstrates that your office is attempting to remedy the situation and you are mindful of the patient’s time and feelings.

• If necessary, remind yourself at the beginning and during an exam with a difficult patient to be

compassionate and empathetic.

• Monitor your physical and emotional reactions. Body language or facial expressions can betray your feelings. Learn to recognize any potentially negative physical signs, such as grimacing or crossing arms, so you can adapt and make changes as soon as they appear during a patient visit.

• Keep in mind that patients often take what you do or say, as a physician, very seriously. They are often looking for unspoken cues to bring added meaning to what is actually being said. They are often not used to speaking in medical terms, and may be more attuned to how a situation or conversation “feels.”

• Maintain eye contact; speak clearly and firmly; and be careful to respect a patient’s personal space.

• Pay attention if the patient is speaking loudly, using profanity, or otherwise exhibiting growing anger. These behaviors may point to an underlying issue, such as anxiety caused a family conflict, a possible mental health concern, or complications caused by another illness.

• Prioritize the patient’s immediate concerns and discern the patient’s expectations for treatment and their relationship with you. Clearly establish expectations, ground rules, and boundaries.

• Remember that negativity directed at you actually may be meant for others or simply at the overall situation (illness, poor prognosis, chronic condition, lack of familial support, lack of financial resources, etc.). You may become a misplaced target of the patient’s frustration due merely to your proximity.

• A patient who repeatedly directs angry or emotional outbursts at you is not exhibiting typical or normal behavior. This kind of behavior is generally not a reflection on you or your skills, but instead a reflection of the patient’s emotional well being. Most patients recognize and appreciate what you do for them, so try not to take one patient’s negativity personally.

• The best way to respond to rudeness or hostility is to remain as professional and calm as possible, while still showing appropriate concern and empathy for the patient’s situation.

• Focus on potential solutions, not areas of disagreement. Encourage the patient to propose treatment options, discuss and compare them with your proposals, and foster a situation where you are working together to solve the patient’s problems.

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• Make every effort to address all of the patient’s questions and concerns before concluding a discussion.

• If you’re already familiar with a difficult patient, prepare for their upcoming visit. Keep in mind your care goals and plan how you will manage the encounter.

• Debrief with colleagues after a difficult exam. They may have helpful guidance or provide context or other insights into the encounter.

• Consider allotting more time for a difficult patient’s visit. This can reduce the need for frequent follow-up visits.

• Alternatively, consider scheduling difficult patients more often. Frequent interactions can be shorter in duration, but they build trust, encourage patients to comply with treatment plans, and avoid crises that lead to sudden appointments or emergency department visits.

• If you feel it is necessary, plan an appropriate response if there is potential that the patient may yell at you, threaten you, or attempt to assault you.

• Note of caution: If you have any reason to fear physical violence or if you suspect the patient is carrying a weapon, contact a security guard or the police. Often the presence of an officer will tone down the emotions and help you solve the patient’s problem.

• Remember that you provide something these patients may lack: a dependable relationship with someone who genuinely wants to help them.

Despite your best efforts, a relationship with a difficult patient may not be possible. A clinician should not terminate the patient relationship without first attempting to attain a positive outcome. But sometimes seeking another provider is best for the patient. When terminating a patient relationship, physicians need to follow a process of proper documentation and adequate notice to avoid allegations of patient abandonment.

More information, including information on terminating patient relationships, is found below.

ADDITIONAL READING• Brockway, Laura, “Terminating patient relationships:

How to dismiss without abandoning,” TMLT website. June 19, 2009. Available at https://www.tmlt.org/tmlt/tmlt-resources/newscenter/blog/2009/Terminating-patient-relationships.html.

• “What every physician needs to know: Terminating the physician-patient relationship,” TMLT website. July 20, 2016. Available at https://www.tmlt.org/tmlt/tmlt-resources/newscenter/blog/2016/terminating-physician-patient-relationship.html.

• Toerner, Kassie, “CME: Managing patient complaints,” the Reporter, Q1 2016. Available at http://resources.tmlt.org/PDFs/Reporter/2016_Quarter%201.pdf.

SOURCES1. Pickelman, Barbara E., Rx for success: Communicating to reduce

risk, Texas Medical Liability Trust, 2004 revision.2. Dudzinski D.M., PhD; Timberlake D.,MD MA. Difficult patient

encounters, Ethics in Medicine, University of Washington School of Medicine. Available at: https://depts.washington.edu/bioethx/topics/diff_pt.html. Accessed January 26, 2017.

Steve Taylor is a medical writer and former Communications Manager with Seton Healthcare Family in Austin, Texas. He can be reached at [email protected].

Wayne Wenske can be reached at [email protected].

6 the Reporter | Q1

CME

By Wayne Wenske, Communications Coordinator

COMBATING PHYSICIAN STRESS AND BURNOUT

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CME

Upon completion of this course, the physician will be able to:1. discuss the difference between

stress and burnout;2. summarize the three components

that determine physician burnout, per the Maslach Burnout Inventory;

3. describe the various stressors that may contribute to physician stress and burnout;

4. list a variety of techniques and resources to help individual physicians combat stress and burnout; and

5. discuss the benefits of mindfulness and self-compassion.

COURSE AUTHORWayne Wenske is Communications Coordinator at Texas Medical Liability Trust (TMLT).

DISCLOSUREWayne Wenske has no commercial affiliations/interests to disclose related to this activity. TMLT staff, planners, and reviewers have no commercial affiliations/interests to disclose related to this activity.

TARGET AUDIENCEThis 1-hour activity is intended for physicians of all specialties who are interested in practical ways to reduce the potential for medical liability.

CME CREDIT STATEMENTPhysicians are required to complete and pass a test following a CME activity in order to earn CME credit. A passing score of 70% or better earns the physician 1 CME credit.

TMLT is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. TMLT designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit.™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.

PRICINGThe following fee will be charged when accessing this CME course online at http://tmlt.inreachce.com.

Policyholders: $10 Non-policyholders: $75

ETHICS CREDIT STATEMENTThis course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.

INSTRUCTIONSthe Reporter CME test and evaluation forms must be completed online. After reading the article, go to http://tmlt.inreachce.com. Log in using your myTMLT account information to take the course. Follow the online instructions to complete the forms and download your certificate. To create a myTMLT account, please follow the on-screen instructions.

Questions about the CME course? Please call TMLT Risk Management at 800-580-8658.

ESTIMATED TIME TO COMPLETE ACTIVITYIt should take approximately 1 hour to read this article and complete the questions and evaluation form.

RELEASE/REVIEW DATEThis activity is released on March 27, 2017, and will expire on March 27, 2020.

Please note that this CME activity does not meet TMLT’s discount criteria. Physicians completing this CME activity will not receive a premium discount.

N othing is perfect. There may be “dream jobs” out there, but there’s usually something that keeps them from being ideal. Some may pursue a life

in mechanical engineering because of a desire to solve problems and build things, only to find hazardous working conditions and impossible time constraints. Others may pursue a legal career and be confronted by shifting laws, demanding clients, and a poor public image. While others may dream of a life in the arts, but must weigh the prospect of spotty employment or income.

But becoming a physician is more than just a dream job. For many, it’s often a true “calling” that represents a lifelong commitment to serve others on a grand scale—one weighted

in matters of life and death. It’s a commitment and passion to help people, to be challenged on a daily, even moment-to-moment, basis, and to learn throughout a lifetime.

And the drawbacks for physicians can be equally powerful. Stresses come from the deep responsibilities inherent in health care: working long hours; lack of work/life balance; decision making with potentially devastating consequences; difficult conversations with patients or their families; potential malpractice claims; and the fear of a patient’s death.

Unfortunately all of these possible drawbacks—and more—can create a flood of difficulties and fears that contribute

OBJECTIVES

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CME

to the growing epidemic of physician stress and burnout. “Epidemic” may seem like a strong word, but a recent study conducted in 2014 and published in December 2015 by the Mayo Clinic shows that more than half of U.S. physicians are experiencing professional burnout.1

This article will identify the primary causes and consequences of stress and burnout for physicians; catalog a variety of resources available to help reduce stress and burnout; and provide practical instruction on such stress-reducing tactics and exercises as mindfulness, meditation, and self-compassion.

WHAT IS THE DIFFERENCE BETWEEN STRESS AND BURNOUT?In simple terms, feelings of stress are the result of “too much”—too many daily pressures, responsibilities, tasks, activities, or meetings. People who are under stress usually feel that they are still in control of their situation, and reducing stress is well within the realm of possibility. Stress is often relatively short-term; however, prolonged stress can lead to a number of ailments ranging from loss of energy and headaches to high blood pressure and anxiety disorders.2

Stress can also take a costly toll on the economy. According to one study, work-related stress is estimated to cost the U.S. economy more than $300 billion annually as a result of stress-related absenteeism, employee turnover, and diminished productivity.3

Stress can also lead to burnout. While stress comes from feelings of “too much to handle,” burnout can come from feelings of “not enough to give.” Being burned out means feeling empty, unmotivated, and uncaring. People who feel burned out feel like they don’t have any control, and they feel little hope that they can change the sources of their burnout. Burnout often takes place over a long period and can be characterized by feelings of hopelessness, detachment, and depression. And while one is usually aware of being under a lot of stress, recognizing burnout may not be obvious when it happens.2

In health care, the consequences of burnout can equate to lower quality of care, lower patient satisfaction, increased errors, a decreased ability to empathize with patients, and a growing number of physicians either retiring early or leaving the medical field altogether. Recent college graduates are also declining to choose a career in medicine because of long hours and overwhelming workloads. This attrition has created significant problems for patients seeking health care and for current physicians attempting to keep up with the growing workload.

ASSESSING PHYSICIAN BURNOUT USING THE MASLACH BURNOUT INVENTORYBurnout is described in the study “Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014” as “a syndrome of emotional exhaustion, loss of meaning in work, feelings of ineffectiveness, and a tendency to view people as objects rather than as human beings.” 1

The study assessed physician burnout using the Maslach Burnout Inventory (MBI), considered the most widely used measurement system for assessing burnout. Three general scales, corresponding to the three components of burnout, are measured to create an MBI score:

• “Emotional exhaustion measures feelings of being emotionally overextended and exhausted by one’s work.

• Depersonalization measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction.

• Personal accomplishment measures feelings of competence and successful achievement in one’s work.” 4

The results of the study, when looking at each component, showed 46.9% of U.S. physicians were measured with high emotional exhaustion; 34.6% with high depersonalization; and 16.3% with a low sense of personal accomplishment. In aggregate, 54.4% of the physicians had at least one symptom of burnout. (The researchers behind the study considered physicians with a high score on the depersonalization and/or emotional exhaustion subscales as having at least one manifestation of professional burnout.)1

In addition, only 40.9% of U.S. physicians felt that their work schedule allowed enough time for an adequate personal/family life; 14.6% were neutral on this matter; and 44.5% disagreed with this assertion.1

Also troubling is the increasing rate of burnout for physicians. This 2014 study is an update to an analogous study conducted in 2011 that employed the same MBI method. When compared with the 2011 study results, the measurement of U.S. physicians experiencing at least 1 symptom of burnout saw a 19.56% increase in three years (54.4% in 2014 vs. 45.5% in 2011).1, 5

Burnout also varied by specialty, with the highest rates of burnout seen in 1.) Emergency Medicine, 2.) Urology, 3.) Physical Medicine and Rehabilitation, and 4.) Family Medicine.1 There were some changes from the 2011 study, which saw the highest rates of burnout in 1.) Emergency Medicine, 2.) General Internal Medicine, 3.) Neurology, and 4.) Family Medicine.5

The lowest rates of burnout in 2014 were seen in 1.) Preventative Medicine/Occupational Medicine,

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2.) Radiation Oncology, 3.) General Pediatrics, and 4.) physicians with a pediatric subspecialty.1 While in 2011, the lowest rates of burnout were in 1.) Preventative Medicine, Occupational Medicine, or Environmental Medicine, 2.) Dermatology, 3.) General Pediatrics, and 4.) Pathology.5

WHAT ARE THE PRIMARY CAUSES OF STRESS AND BURNOUT FOR PHYSICIANS?In a 2011 study conducted by Physician Wellness Services and Cejka Search, a health care recruitment and search firm, more than 2,000 physicians were asked to identify the top three causes of workplace stress and burnout. “Paperwork” was the leading cause at 40%; followed by “too many hours” at 33%; “internal conflicts” at 28%; “on call issues” at 26%; and “medical liability concerns” at 20%.6

An article published by the American Medical Association (AMA) suggests that physicians most susceptible to stress and burnout are often “the most dedicated, conscientious, responsible, and motivated.” 7

In other words, physicians with the most honorable and desirable traits often find themselves so devoted to their work and patients that they have nothing left to give to their families or to their own well-being. Thus, the very traits that define a good physician—being dedicated to patients, putting high attention to detail, and recognizing the

responsibility associated with patients’ trust—also put these physicians at a greater risk for stress and burnout.7

Most physicians face chronic and substantial stressors in their work environment, which can result in depression and decreased job satisfaction. Additional stressors for physicians include, but are not limited to:

• length of school or training;• working in acute, chaotic, or high-pressure

environments, such as an emergency department or neonatal intensive care unit;

• difficulty in creating a satisfying work/life balance;• long working hours, enormous workloads, and high

patient volume;• being sleep deprived;• a lack of autonomy or limited control over the

provision of medical services;• excessive administrative tasks;• feeling isolated or not having time to connect with

colleagues;• lack of close, supportive relationships;• lack of recognition or reward for good work;• inefficient and/or hostile work environment;• increased threats of litigation; and• grief and/or guilt about a patient prognosis,

unsatisfactory outcome, or death.6, 7, 8

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Long hours and lack of control over one’s schedule during medical school, residency, and fellowship have also instilled in physicians a set of work habits that are inconsistent with creating a satisfying work/life balance—even after training is complete.

During their academic lives, many medical students adopt the coping strategy of putting their personal lives on hold until they finish their residencies. A mentality of “delayed gratification” is fostered that can carry over into their professional careers. Unfortunately, many physicians who maintain this strategy of delayed gratification in their careers may never be able to reclaim a personal life.7

A 2015 AMA article reported that while most physicians work between 40 and 60 hours per week, nearly one-quarter of physicians work 61 to more than 80 hours per week.9

The article also cites a 2011 research letter that noted “specialists caring for more acutely ill patients or those requiring intensive monitoring, usually in hospital settings, work longer hours than physicians focused on more stable, chronically ill patients…in ambulatory settings.” The letter also stated that “exceptions were physicians practicing emergency medicine or hospital medicine because both of these specialties are characterized by fixed hourly shifts.” Not surprisingly, the specialties that require working longer hours were found to have lower physician job satisfaction, and vice versa.9

DEPRESSION AND SUICIDE RISK FOR PHYSICIANSLeft unaddressed, burnout can result in dire personal consequences, such as failed relationships, substance abuse, depression, and even suicide.

Several studies show that physicians have a far greater suicide completion rate than the general public. Completion rates are often attributed to physicians having a greater knowledge of and better access to lethal means. Alarming statistics show that the “suicide rate among women physicians is approximately 130 percent higher than that of the general female population. For male physicians, the suicide rate is approximately 40 percent higher than that of the general male population.” 10

Unfortunately, physicians are often reluctant to seek treatment for personal illness; this may be especially true in the case of a potential mental illness involving depression or suicidal thoughts. According to a 2016 Medscape article on physician depression, “A survey of American surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychologic help.” Furthermore, “There was a strong correlation between depressive symptoms, as well

as indicators of burnout, with the incidence of suicidal ideation.” 11

The article also noted that “physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others.” There is also reluctance among physicians to recognize symptoms of depression or burnout in their colleagues. To reach out, unsolicited, to a colleague who seems troubled “may seem like an affront to a colleague’s self-sufficiency.” 11

Physicians are considered a “high control” population (along with law enforcement, lawyers, and clergy). Situations, such as increased workload and regulatory requirements, that decrease a physician’s ability to control his or her environment, workplace, or employment conditions can lead to higher levels of stress, burnout, and depression.11

RESOURCES FOR PHYSICIANSWhat are the possible solutions to the growing and very real problem of physician stress and burnout? More than 75% of physicians are now employed by large health care organizations,1 and any progress to combat burnout and stress will require effort at both the individual level and at the organization level.

Health care organizations are being called upon to improve “support [found] in the practice environment, select and develop leaders with the skills to foster physician engagement, help physicians optimize ‘career fit,’ and create an environment that nurtures community, flexibility, and control, all of which help cultivate meaning in work.” 1

Thankfully, there are a number of resources and steps physicians can take to nurture a sense of well being in their practice so that stress and burnout don’t get the upper hand.

AMA STEPS ForwardThe AMA, in partnership with the Medical Group Management Association (MGMA), launched a program in 2015 called STEPS Forward to help physicians create a work environment that minimizes stress, builds teamwork, and restores professional fulfillment. STEPS Forward offers an interactive series of modules designed to provide physicians with “proven strategies that can improve practice efficiency and help you reach the Quadruple Aim—better patient experience, better population health and lower overall costs with improved professional satisfaction.” 12

STEPS Forward offers more than 40 modules available for download, ranging in topics from patient care, such as “Listening with empathy” and “Preventing type 2 diabetes in at-risk patients,” to workflow, such as “Creating strong team culture” and “Pre-visit laboratory testing.” STEPS Forward also offers modules on professional well-being

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CMEthat formally address physician stress, burnout, and suicide prevention.13

A “Complete burnout toolkit” 14 is available for download with the following tools:

• The “Preventing physician burnout” module14 provides printable PDFs of the following articles and a corresponding presentation to help users share the information with colleagues or staff members:

○ “Seven key steps to help you prevent provider burnout,” includes instructions on starting a wellness committee and/or choosing a designated “wellness champion” in your practice to promote wellness goals; survey staff to get a feel for their morale and levels of stress; and meet regularly to foster a more livable and productive practice environment.

○ “Ten-item survey designed to assist you in assessing burnout,” where participants are asked to reply to questions about burnout on a 5 point scale. A sample of questions in this quick and easy survey, referred to as the “Mini Z burnout survey,” includes: “My control over my workload is 1 – poor, 2 – marginal, 3 – satisfactory, 4 – good, 5 – optimal” and “Sufficiency of time for documentation is 1 – poor, 2 – marginal, 3 – satisfactory, 4 – good, 5 – optimal.” Physicians are encouraged to survey staff members annually, collect the data, and respond in ways to help improve the work environments.

○ “Examples of successful burnout prevention programs in a variety of practice/organization settings,” documents organization efforts to reduce stress and burnout. One such example is Boston Medical Center’s (BMC) development of a wellness program and website, www.bumc.bu.edu/wellness, that provides information on existing services at BMC and Boston University to help physicians, instructors, and staff cope with work and personal problems.

Another example is Kaiser Permanente of Northern California, which launched a wellness program that includes mentoring programs; weekly catered lunches with staff discussions on such topics as financial management or how to save for a child’s college tuition; and health festivals that include preventative health screenings, blood pressure checks, and dietary evaluations.

• “Talking points for leaders” 14 are provided to help physicians publicly support wellness efforts in their practices with concrete examples of how wellness can affect practice or system effectiveness and profitability. Talking points include:

○ “Implementing strategies to improve provider wellness can help the organization save money, improve the quality of care provided to patients, improve morale and maintain satisfied providers.

○ Wellness efforts can save money by retaining providers. High turnover is costly—$250,000 per provider—and stressful for the providers that stay.

○ Providers who practice in happier, less stressed environments also provide better quality care. They tend to make fewer medical errors and are more engaged in their work than stressed out providers.” 14

• “Tactics to reduce burnout” 14 are designed to improve teamwork and communication and reduce feelings of confusion or being overwhelmed. Tactics include:

○ “Outsource time-consuming tasks, such as coding, to other departments or other staff members in the organization.”

○ “Work with your electronic health record (EHR) vendor or IT department to provide better EHR templates that are consistent, easy to read and clinically meaningful.”

○ “Begin meetings by sharing patient case studies.” 14

STEPS Forward emphasizes the importance of measuring and re-measuring levels of stress and burnout, so that areas that need attention can be identified and wellness programs applied as appropriate.

STEPS Forward also offers a module entitled “Preventing physician distress and suicide” that provides four steps for identifying at-risk physicians and facilitating their access to care; an FAQ; and a toolkit of helpful materials. The toolkit includes a suicide prevention resource list; a self-assessment for “medical malpractice stress syndrome;” and a sample script for approaching a colleague you fear is distressed or potentially suicidal. The tools are available at www.stepsforward.org/modules/preventing-physician-suicide.10

To learn more about STEPS Forward, visit their website at www.stepsforward.org. You may also call (800) 987-1106 or send an email message to [email protected].

Stanford Medicine WellMD websiteOne “graduate” of the STEPS Forward program is the Stanford University Medical Center in Palo Alto, California. After taking part in the program, they initiated their own staff committee dedicated to professional fulfillment, work/life balance, and personal health.

One of their initiatives has been to launch the WellMD website, with online tools such as self-assessment tests,


CME

contact information for support groups and classes, and resources to help promote mindfulness, physical fitness, and resilience.

On the “Test Yourself” page of the website,15 physicians are invited to take part in anonymous online self-tests with links to various sites. Many of these tools are available to all visitors to the site. Topics include depression, burnout, empathy, mindfulness, and work/life balance. Tools include:

• Workplace Burnout Quiz, courtesy of Scientific American.16 This short self-assessment concentrates on six areas—workload, control, reward, community, fairness, and values—to identify potential workplace burnout. This quiz is available at www.scientificamerican.com/article/quiz-are-you-on-the-path-to-burnout/. Sample questions include:

○ “Objectivity of decisions on work schedule and assignments is 1. Just right; 2. Sometimes a problem; 3. A major problem”

○ “The extent to which people interact with civility and respect is 1. Just right; 2. Sometimes a problem; 3. A major problem”

○ “The amount of time I do work that I truly enjoy is 1. Just right; 2. Sometimes a problem; 3. A major problem”

• Stress Screener, courtesy of Mental Health America.17 This quiz is available at www.mentalhealthamerica.net/stress-screener. Sample questions on this short quiz include:

○ “Do you ever have trouble sleeping?” ○ “Are you experiencing any digestive problems,

such as indigestion, irritable bowel syndrome, or ulcers?”

○ “Do you have a supportive social network, and take time for relationships in your life?”

• A depression screen courtesy of the Depression and Bipolar Support Alliance (DBSA) uses a sixteen question self-survey to quickly assess your level of depression—from “no depression likely” to “very severe depression.” The screening tool is available at www.dbsalliance.org/site/PageServer?pagename=education_screeningcenter_depression.

The DBSA site offers other tools, including brochures on topics such as suicide prevention, finding a mental health professional, men and depression, and post-partum depression.18

Mindful meditation“Mindfulness” is rooted in 2500-year-old Buddhist meditation practices that are used to help one pay attention and be fully present or engaged in the moment. Rather than worrying about the future or dwelling on the past, “mindful meditation” helps you maintain a focus on what’s happening right now.

Recent studies have shown that physicians who practice mindful meditation have seen short-term and sustained improvements in their physical and mental well-being, and demonstrated improvements in interpersonal characteristics, such as empathy, associated with better patient care.19

Mindful meditation can be used to reduce stress, anxiety, fear, depression, or other negative thoughts or feelings. Mindfulness also improves physical health by helping to lower blood pressure, improve sleep, and reduce chronic pain. Focusing on a single repetitive action, such as breathing, a few repeated words or mantra, or a flickering candle can help bring you to a peaceful place where distractions are gone and you are fully in the moment. Other forms of mindful meditation may involve concentration on walking, eating, or exercising.

A basic mindfulness exercise:

1. Sit on a straight-backed chair or cross-legged on the floor.

2. Focus solely on your breathing. Pay attention to the experience of air flowing into your nostrils and out of your mouth, or your chest rising and falling as you inhale and exhale.

3. Once you’ve narrowed your concentration to your breathing, begin to widen your focus. Become aware of sounds in the room, such as the sound of the air conditioning; sensations, like the feeling of the floor on the soles of your feet; and any ideas you have about the current experience of the exercise.

4. Embrace and consider each thought or sensation without judging it good or bad. If your mind starts to race or become distracted by worrying thoughts, return your focus to your breathing. Then try to expand your awareness again.20

Resources for mindful meditationsJay Winner, MD, is the founder and director of the Stress Management Program for Sansum Clinic, one of the largest medical clinics in California. Dr. Winner also hosts StressRemedy.com, a website with guided meditation audio clips. Clips include a walking meditation, eating meditation, stretching meditation, a relaxation exercise for insomnia, an exercise on “loving kindness,” and many more. This resource is found at http://stressremedy.com/audio/.

The Yoga Journal magazine and website is another useful resource for guided mindful meditations. The website offers

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CMEa beginners’ guide to meditation; a get started guide to help you identify a meditation style that’s best for you and even how to sit for meditation; meditation basics, such as how to start a daily routine; and guided meditations for deep sleep and focusing on the positive. These resources are found at www.yogajournal.com/category/meditation/.

Stanford’s WellMD website has a page devoted to mindfulness with a self-assessment; a series of videos; and tips on being more mindful including “How to practice mindfulness throughout the workday,” “Opportunities for ‘pausing’ during the day,” and “Mindful eating.”https://wellmd.stanford.edu/healthy/mindfulness.html

The University of California at Los Angeles (UCLA) also offers free guided meditations on its UCLA Health website in both English and Spanish. Meditations, part of the UCLA Mindful Awareness Research Center, include “Breath, Sound, Body Meditation,” “Meditation for Working with Difficulties,” and “Body Scan for Sleep.” http://marc.ucla.edu/mindful-meditations

There are several helpful apps that can be downloaded to your mobile device to help reduce stress and burnout.

• Calm calls itself a “meditation app for beginners, but also includes hundreds of programs for intermediate and advanced meditators and gurus.” Topics include calming anxiety, managing stress, focus and concentration, non-judgment, and deep sleep. This app also includes the capability to track your progress. This app is free to download and use, but some content is only available with a paid subscription.

• Headspace provides guided meditations, including a free entry-level course, called Take10 that provides instruction on the basics of meditation with reminders to help you develop the habit of

meditation. There is also a “buddy system” feature that allows you and a friend to encourage each other to meditate. Additional features and options are available with a paid subscription.

• Buddhify offers more than 11 hours of custom meditations for the various times, locations, and activities of the day, including traveling, being online, going to sleep, and being at work. There is small fee to download this app.

Self-care and compassionPracticing mindful meditation is only one strategy or coping mechanism to help you mitigate stress and burnout and promote well being. There are a number of meaningful strategies everyone can use to increase their own well being through self-care and compassion. Besides, how well can physicians care for patients, if they do not initiate or practice care for themselves? “Having compassion for oneself is really no different than having compassion for others,” writes Kristin Neff, PhD on her website Self-Compassion.org.21 When you see a person struggling—emotionally, financially, physically—you may feel a need to help them, to take away their pain or difficulty. Struggle is human, and we are all human. To care for oneself is to recognize your own humanity, and your own need for help.

Self-compassion involves responding the same way to yourself in times of difficulty as you would to a patient under your care. Dr. Neff continues, “Instead of mercilessly judging and criticizing yourself for various [perceived] inadequacies or shortcomings, self-compassion means you are kind and understanding when confronted with personal failings—after all, who ever said you were supposed to be perfect?” 21


CME

Dr. Neff includes a variety of exercises and tips for practicing self-compassion. One exercise, called “How would you treat a friend?,” asks you to think of a time when a friend was struggling in some way and to write down a description of your response, what you might have said, and in what tone. Next, think of a time when you were personally struggling or having negative feelings; write down how you responded, including what you may have said to yourself and in what tone. Then compare your responses — to your friend and to yourself. What are the differences? Did you treat your friend with more kindness or compassion? The last portion of the exercise is to describe how your actions, attitude, and results may have differed if you had responded to yourself in the same way you would have typically responded to a struggling friend.22

Other ways to ensure you are taking care of yourself in your professional life and personal life include:

• Identify the people, places, and activities in your life that you enjoy. Stay away from people or relationships that drain you.

• Take breaks throughout the day, even if you have to schedule them. Use a quick 10-minute break to do a mindful meditation or to step outside and get some fresh air.

• Allow yourself enough time to get to appointments. The added stress of not giving yourself enough time to complete an assignment or to meet with a patient increases your stress and can reduce your efficiency.

• Set boundaries. Don’t overcommit yourself. If possible, cut activities out of your schedule that cause you stress, such as attending unnecessary meetings. Learn to say, “No.”

• Do something for yourself each day. Eat well and get enough sleep and exercise.

• Take time off. Go on vacation and “recharge your batteries.”

• Gain control where you can. This can mean keeping simple goals, such as being on time to work, taking the stairs at work, or maintaining a weekly “standing date” with a friend or partner. For example, have dinner every Friday at 6 with your best friend.

Practicing self-compassion isn’t self-indulgent, it’s a way to remind yourself there will be times that you will need to take care of yourself to avoid stress and burnout and maintain a high level of patient care.

Additional resourcesSeveral resources, in the form of books, websites, blogs, videos, and articles, are available to help you or your practice manage stress and burnout.

Websites and blogs• The Federation of State Physician Health

Programs provides a list of physician health programs by state. The programs focus on such issues as stress management, mental health, physical illness, and substance abuse. A full listing is available at http://www.fsphp.org/state-programs.

• The American College of Emergency Physicians has a Wellness Resource page on its website with several papers and resources compiled by its own Well-being Committee, including “Litigation stress – a primer” and “Wellness in the workplace.” https://www.acep.org/content.aspx?id=32184

• The American College of Physicians, New Mexico Chapter, provides a Physician Burnout and Wellness Information and Resources webpage that includes helpful articles and presentations to download, such as “The Epidemic of Clinician Burnout: We Can Turn This Around!” which offers suggestions on creating more livable practice policies, such as decreasing EHR stress by “right sizing” EHR-related work, by scheduling longer visits and studying the impact of scribes. https://www.acponline.org/about-acp/chapters-regions/united-states/new-mexico-chapter/physician-burnout-and-wellness-information-and-resources

• The American Academy of Family Physicians includes a Physician Burnout resource page on its website with articles and a listing of support organizations. http://www.aafp.org/about/constituencies/resources/new-physicians/burnout.html

• Self-Compassion.org by Associate Professor Kristin Neff at The University of Texas at Austin offers a number of resources including videos, research, a self-assessment, guided meditations, and tips for practicing compassion for oneself. http://self-compassion.org.

• Dike Drummond, MD, a family physician, is also a trainer and writer focused solely on addressing physician burnout. His website, “The Happy MD,” includes a blog with an archive of useful articles. www.thehappymd.com.

BooksThe following books can help you assess your current levels of stress and burnout, identify the sources, and find solutions to help you rediscover your passion for helping others.

• “Physician Burnout: A Guide to Recognition and Recovery” by Tom Murphy, MD

• “Stop Physician Burnout: What to Do When Working Harder Isn’t Working” by Dike Drummond, MD

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CME• “Remedy for Burnout: 7 Prescriptions Doctors Use to Find Meaning in Medicine” by Starla Fitch, MD

• “Preventing Physician Burnout: Curing the Chaos and Returning Joy to the Practice of Medicine” by Paul DeChant, MD, MBA and Diane W. Shannon, MD, MPH

• “Wherever You Go, There You Are” by Jon Kabat-Zinn explores mindfulness and meditation and explains what different meditations can do for the practitioner.

VideosThe following videos are available on Ted.com.

• “How to make stress your friend” is a 14-minute video in which psychologist Kelly McGonigal introduces the idea that stress can be turned into a positive. Specifically, she discusses how a biological reaction to stress, the release of oxytocin, encourages more social interaction and works as a natural response to stress by helping you reach out to others for help. http://www.ted.com/talks/kelly_mcgonigal_how_to_make_stress_your_friend

• In “All it takes is 10 mindful minutes,” Andy Puddicombe describes the power and benefit of doing “absolutely nothing” for 10 whole minutes. Simply being mindful and in the moment for 10 minutes a day will help refresh your mind and reduce stress. http://www.ted.com/talks/andy_puddicombe_all_it_takes_is_10_mindful_minutes

• In “How to stay calm when you know you’ll be stressed,” neuroscientist Daniel Levitin, PhD, describes the science and brain chemistry of stress, and how to avoid making mistakes in stressful situations. http://www.ted.com/talks/daniel_levitin_how_to_stay_calm_when_you_know_you_ll_be_stressed

Additional reading• American Medical Association, “Burnout busters:

How to boost satisfaction in personal life, practice” by Lyndra Vassar. From 2015, this article provides advice on how to take responsibility for self-care and happiness and how to establish a work environment that promotes wellness. https://wire.ama-assn.org/ama-news/burnout-busters-how-boost-satisfaction-personal-life-practice

• Mayo Clinic, “Job burnout: How to spot it and take action.” Also from 2015, this article provides a “how to” on getting started with handling job burnout, including how to seek support, adjust your attitude, or evaluate your options. http://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/art-20046642?pg=1

• The Happy MD, “Physician burnout—the three symptoms, three phases and three cures” by Dike Drummond, MD. This article provides a “physician burnout prevention matrix.” https://www.thehappymd.com/blog/bid/290755/physician-burnout-the-three-symptoms-three-phases-and-three-cures

• The Happy MD, “Physician burnout: Why it’s not a fair fight” by Dike Drummond, MD. Defines burnout and offers a partial list of “invisible daily stresses” that can contribute to burnout, such as being assigned a leadership role that you do not want or the emotionally draining reality of spending every day with people who are sick, scared, or in pain. https://www.thehappymd.com/blog/bid/295048/Physician-Burnout-Why-its-not-a-Fair-Fight

• U.S. News & World Report, “Doctor burnout, stress and depression: Not an easy fix” by Elaine Cox, MD. This article recognizes the idea of a “second victim” when treating a terminal patient: the physician. Recognizing that the physician will need to grieve or emotionally process a patient’s death is a concept that is gaining acceptance. http://health.usnews.com/health-news/patient-advice/articles/2016-04-12/doctor-burnout-stress-and-depression-not-an-easy-fix

If you feel overstressed or if you’re experiencing burnout, you can find help by calling your county medical society or your hospital risk manager. If available, contact your hospital’s physician wellness committee.

Texas Medical Liability Trust (TMLT) policyholders may also contact TMLT’s Risk Management department by calling 800-580-8658. “If you find yourself frustrated or becoming stressed by your day-to-day operations, TMLT is here to help,” said Robin Desrocher, Risk Management Manager. “We can help you with researching and finding the right resource or service for you and your specific needs.”

SOURCES1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout

and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings, Vol. 90, Issue 12. Available at http://www.mayoclinicproceedings.org/article/S0025-6196(15)00716-8/abstract. Accessed March 2, 2017.

2. Smith M, Segal J, Robinson L, et al. Burnout prevention and recovery. December 2016. HelpGuide.org. Available at https://www.helpguide.org/articles/stress/preventing-burnout.htm#difference. Accessed March 8, 2017.


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3. Workplace stress. American Institute of Stress. Available at https://www.stress.org/workplace-stress/. Accessed March 8, 2017.

4. Maslach C, Jackson SE, Leiter MP, et al. Maslach Burnout Inventory. Mind Garden website. Available at http://www.mindgarden.com/117-maslach-burnout-inventory. Accessed March 1, 2017.

5. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. JAMA Internal Medicine, Vol 172, October 8, 2012. Available at http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1351351. Accessed March 1, 2017.

6. Rosenstein AH.Physician stress and burnout: prevalence, cause, and effect. AAOS Now, August 2012. American Academy of Orthopaedic Surgeons. Available with login at http://www.aaos.org/AAOSNow/2012/Aug/managing/managing4/. Or as PDF at http://www.physiciandisruptivebehavior.com/admin/articles/31.pdf. Accessed March 4, 2017.

7. Balch CM, Freischlag JA, Shanafelt TD. Stress and burnout among surgeons: Understanding and managing the syndrome and avoiding adverse consequences. American Medical Association. April 2009. Available at http://jamanetwork.com/journals/jamasurgery/fullarticle/404847?resultClick=1. Accessed March 4, 2017.

8. Brown SD, Goske MJ, Johnson CM. Beyond substance abuse: stress, burnout, and depression as causes of physician impairment and disruptive behavior. Journal of the American College of Radiology. Vol. 6, Issue 7. July 2009. Available http://www.jacr.org/article/S1546-1440(08)00594-2/fulltext. Accessed March 4, 2017.

9. How many hours are in the average physician workweek? AMA Wire. American Medical Association. January 6, 2015. Available at https://wire.ama-assn.org/life-career/how-many-hours-are-average-physician-workweek. Accessed March 6, 2017.

10. Brooks E. Preventing physician distress and suicide. STEPS Forward. American Medical Association. Available at https://www.stepsforward.org/modules/preventing-physician-suicide. Accessed March 6, 2017.

11. Andrew LB.Physician suicide. Medscape website. Available at http://emedicine.medscape.com/article/806779-overview#showall. Accessed March 4, 2017.

12. About the AMA’s STEPS Forward. American Medical Association. Available at https://www.stepsforward.org/about-steps-forward. Accessed March 7, 2017.

13. How it works. STEPS Forward. American Medical Association. Available at https://www.stepsforward.org/how-it-works. Accessed March 10, 2017.

14. Linzer M, Guzman-Corrales L, Poplau S. Preventing physician burnout. Downloadable tools. Available at https://www.stepsforward.org/modules/physician-burnout. Accessed March 7, 2017.

15. Test yourself. WellMD website. Stanford medicine. Available at http://wellmd.stanford.edu/test-yourself.html. Accessed March 7, 2017.

16. Leiter MP, Maslach C. Quiz: Are you on the path to burnout? Scientific American Mind. Available at https://www.scientificamerican.com/article/quiz-are-you-on-the-path-to-burnout/. Accessed March 7, 2017.

17. Stress Screener. Mental Health America website. Available at http://www.mentalhealthamerica.net/stress-screener. Accessed March 7, 2017.

18. Education. Depression and Bipolar Support Alliance website. Available at http://www.dbsalliance.org/site/PageServer?pagename=education_landing. Accessed March 7, 2017.

19. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. American Medical Association. September 23, 2009. Available at http://jamanetwork.com/journals/jama/fullarticle/184621. Accessed March 10, 2017.

20. Robinson L, Segal R, Segal J, Smith M.Relaxation techniques for stress relief. HelpGuide.org. February 2017. Available at https://www.helpguide.org/articles/stress/relaxation-techniques-for-stress-relief.htm. Accessed March 10, 2017.

21. Neff K. Definition of self-compassion. Self-compassion.org. Available at http://self-compassion.org/the-three-elements-of-self-compassion-2/. Accessed March 10, 2017.

22. Neff K. Exercise 1: How would you treat a friend? Self-compassion guided meditations and exercises. Self-compassion.org. Available at http://self-compassion.org/category/exercises/#exercises. Accessed March 10, 2017.


ADDITIONAL CME AVAILABLE FROM TMLTCME: “You’re not alone! Managing litigation stress, 2nd edition”

This 1-hour program is intended for physicians of all specialties interested in learning to cope with the stress associated with a lawsuit. Earn 1 AMA PRA Category 1 Credits™ (Internet Enduring) and 1 Medical Ethics and/or Professional Responsibility. Available as an on-demand webinar at https://tmlt.inreachce.com, or you may contact TMLT’s Risk Management department at 800-580-8658 to schedule this CME as a live, in-person seminar for your group.

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MEDEFENSE COVERAGE: NOW AVAILABLE AT HIGHER LIMITS

Beyond a medical liability claim, nothing can threaten your livelihood more than a disciplinary proceeding. For this reason, every TMLT policy includes Medefense —coverage for legal expenses, fines, and penalties associated with disciplinary actions (such as an investigation by the Texas Medical Board).

In 2017, we’ve enhanced our Medefense coverage and now offer higher limits for purchase when you renew your TMLT policy.

Current limits — included with every TMLT policy$50,000 per claim

New limits for purchase*$100,000 per claim — for $250$200,000 per claim — for $350$500,000 per claim — for $550

Medefense covers expenses related to:• actions by a state medical licensing authority;• a professional review action regarding clinical

privileges;• a proceeding instituted by a state department of

insurance, state workers’ compensation commission, state department of health and human services, the U.S. Department of Health and Human Services, or

Centers for Medicare and Medicaid Services alleging medical services were performed in violation of guidelines;

• Medicare billing audits conducted by Recovery Audit Contractors (RAC) or other private contractors as well as allegations of non-compliance with Medicare/Medicaid regulations or procedures;

• proceedings alleging violations of EMTALA, HIPAA, Stark law; and

• a tax practitioner’s fees to assist a policyholder in an IRS audit of a federal tax return. There is a sublimit of $5,000 per tax expense.

Medefense claims are subject to a $1,000 deductible per claim.

Policyholders can choose their own attorney. However, we will waive the deductible and pay legal expenses directly to your attorney if you hire an attorney from a panel provided by TMLT.

New limits can be purchased when you renew your policy. For more information, please contact your underwriter at 800-580-8658 or visit www.tmlt.org.

*Subject to approval by the TMLT Underwriting Department.


This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.

CLOSED CLAIM STUDY 1

DELAY IN DIAGNOSING BREAST CANCER

By Laura Hale Brockway, ELS, Assistant Vice President, Marketing, and Louise Walling, Senior Risk Management Representative

PRESENTATIONA 77-year-old woman with a medical history of cigarette smoking and COPD came to her family physician reporting a lump in her right breast.

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CLOSED CLAIM STUDYPHYSICIAN ACTIONThe family physician ordered a diagnostic mammogram, and the patient went to a local hospital for the test. The results of the mammogram were normal, so the radiology technician requested an ultrasound. The order was obtained from the family physician’s group.

The ultrasound revealed a complex mass suspicious for a neoplastic process. A chest CT was suggested for further evaluation.

The radiology reports for the mammogram and the ultrasound were sent to the physician’s group practice where an employee filed them in the electronic health record (EHR). The family physician reviewed the mammogram results, but was unaware that an ultrasound had been completed. He did not see the ultrasound report.

One week later, the patient returned for a follow-up visit related to her COPD. There was no discussion of the breast lump or the recent testing.

The patient continued to see the family physician over the next year for her COPD and other chronic health issues. There was no mention of the breast mass or of a breast examination. Eighteen months after the mammogram and ultrasound, the family physician ordered another screening mammogram. The test revealed the mass and it was discovered that the mass had been identified in previous testing. The diagnosis was breast cancer with possible metastasis to the lungs.

Two weeks later, the patient was hospitalized for shortness of breath. She was noted to have advanced COPD, bipolar disorder, hypertension, diabetes, prior colonic perforation, GI bleed, and thrombocytopenia. An oncologist evaluated the patient, but the patient and her family “made a decision not to have any intervention done.” She was discharged to hospice and died within three weeks of her diagnosis.

ALLEGATIONSA lawsuit was filed against the family physician and his group, alleging failure to timely diagnose breast cancer.

LEGAL IMPLICATIONSPhysicians who reviewed this case for the defense were critical of the oversight regarding the ultrasound report. It was argued that since the patient had a palpable lump with a normal mammogram, the family physician should have requested additional studies rather than being satisfied with the mammogram results. The family physician had multiple subsequent patient visits that presented opportunities to review the medical records and discover that the ultrasound findings had been missed.

There was disagreement between the family physician and the group regarding the proper procedures for reviewing test results. The group’s administrator believed the system

in place was adequate and that the family physician should have discovered the ultrasound report when he received and reviewed the mammogram report.

The family physician did not like to use the EHR and relied on staff members to alert him to positive test results. In this case, a staff member indexed the reports to the family physician’s EHR dashboard, but did not notify him directly.

Causation was also an issue in this claim. An oncologist who reviewed this case stated that the patient’s co-morbidities were dramatic and that her quality of life was poor. It was likely that the cancer diagnosis did not affect the outcome and that COPD was the cause of death.

DISPOSITIONThis case was settled on behalf of the family physician and his group. The lapse in communication regarding the test results led to the decision to settle this case.

RISK MANAGEMENT CONSIDERATIONSIt is clear that the family physician was not reviewing the entire record; therefore treatment decisions were based on the presenting symptoms with minimal attention given to the patient’s history. Reviewing notes from previous visits or maintaining an updated problem list can help physicians deliver timely patient care. Each health care professional needs to have a system in place to ensure that abnormal findings that require further studies or referrals are reviewed and acted upon. In this case, the physician relied on staff members to alert him to positive test results, but this process was not commonly accepted among the group.

Develop and follow a written policy regarding follow-up on test results. A written policy establishes how test results are handled and eliminates misunderstandings of responsibility or process. When implemented, the policy should be dated and signed by the physician, indicating authorization of the policy. The date should then be updated each time the policy is revised or reviewed. All staff members should sign and date their acknowledgement and understanding of the policy.

Laura Hale Brockway can be reached at [email protected].

Louise Walling can be reached at [email protected].



This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.


FAILURE TO CONFIRM DIAGNOSIS OF POLYCYTHEMIA VERA

By Wayne Wenske, Communications Coordinator, andLouise Walling, Senior Risk Management Representative

PRESENTATIONIn November 2007, a 40-year-old man was referred to an internal medicine physician by his primary care physician. The patient reported feeling weak and tired.

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CLOSED CLAIM STUDY

PHYSICIAN ACTIONThe internal medicine physician noted that the patient had a high white blood cell count, high hemoglobin, and high hematocrit. It was her impression that these values were due to a myeloproliferative disorder such as polycythemia vera (PV).

PV is a slow-growing type of blood cancer in which the bone marrow makes too many blood cells. It may result in overproduction of white blood cells and platelets. Treatment reduces the number of cells and decreases blood volume via phlebotomy.

The physician intended to conduct a JAK2 mutation study of the patient’s blood to confirm PV, but there was no documentation that this study was performed. The patient was diagnosed with PV approximately two months later.

The physician continued to treat the patient for the next five years. During that time, the patient’s primary complaint was feeling tired and weak. There were also reports of anxiety, dizziness, nausea, vomiting, shortness of breath, abdominal pain, headaches, muscle pain, bone pain, and leg pain.

The physician routinely ordered lab work and, depending on the patient’s hemoglobin and hematocrit values, a phlebotomy was performed to reduce the number of cells and decrease blood volume. Over this five-year period, lab work was conducted approximately 100 times and phlebotomy performed approximately 50 times.

In July 2012, the patient went to a hospital ED with complaints of intense stomach pain. The on-call physician

referred the patient to an oncologist, who ordered a JAK2 mutation study, arterial blood gas test, erythropoietin level, and iron studies. The oncologist also requested the patient’s records from the internal medicine physician.

The JAK2 mutation study was negative, ruling out PV. Instead, the patient was diagnosed with iron deficiency anemia secondary to multiple phlebotomies and leukocytosis of unknown etiology.

ALLEGATIONSThe patient filed a lawsuit against the internal medicine physician alleging:

• failure to properly diagnose his condition; • failure to properly interpret blood test results; and• failure to obtain JAK2 mutation test to rule out PV.

The patient further alleged that he suffered mental anguish, anxiety, and concern because he believed he had a terminal illness. He also underwent five years of unnecessary phlebotomies.

LEGAL IMPLICATIONSTwo internal medicine physicians consulted with TMLT to provide their opinions of the case. Both consultants were critical of the lack of testing to confirm the diagnosis of PV. They each stressed that the plaintiff should have obtained a thorough history and detailed examination; at a minimum the JAK2 test should have been completed to confirm the PV diagnosis. A bone marrow biopsy, erythropoietin level, and endogenous erythroid colony formation in vitro testing could also have been performed.



CLOSED CLAIM STUDY 2The consultants felt that the lack of proper testing to confirm the PV diagnosis and then performing ongoing treatment for an unconfirmed, terminal condition fell below the standard of care.

DISPOSITIONThe case was settled on behalf of the internal medicine physician. The main weakness of the case was the lack of a positive JAK2 test to confirm the diagnosis of PV. The physician was also using a billing code for PV that was damaging to his case.

RISK MANAGEMENT CONSIDERATIONSTwo risk management issues can be identified in this claim. Documenting the patient care and treatment rationale and decision-making are required for good medical records. The missing piece in this patient’s care was the validation for the diagnosis of PV, due to the failure to follow through with the JAK2 mutation study. Had the physician ordered the study, the patient, believing he had a terminal illness, would have been spared five years of unnecessary treatment and emotional distress.

Internal medicine physicians face a multitude of complex patient conditions, and knowing when to refer is a key component of their practice. An early referral to a hematologist/oncologist may have made a difference in ruling out PV and identifying the patient’s anemia. In this case, sending the patient to a specialist may have reduced the time the patient waited for the correct diagnosis and resulting treatment.


Louise Walling can be reached at [email protected].

TMLT’s Risk Management Department conducts on-site practice reviews to help determine risk exposures in your practice. Reviews can be conducted without disrupting patient appointments or normal business operations.

Because we offer practice reviews as an unbundled service, you don’t have to be a TMLT policyholder to receive this service.

TMLT policyholders who complete a practice review may earn a 5% premium discount after review recommendations are met.

TOUR AND ASSESS THE PRACTICE FOR PATIENT SAFETY CONCERNS

REVIEW MEDICAL RECORDS FOR STRENGTHS AND WEAKNESSES

REVIEW POLICIES AND PROCEDURES

MEET WITH PHYSICIANS TO DISCUSS FINDINGS

PREPARE A RECOMMENDATION REPORT

REQUEST A PRACTICE REVIEW AT www.tmlt.org/practicereview

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EDITORIAL COMMITTEERobert Donohoe | President and Chief Executive OfficerJohn Devin | Chief Operating OfficerSue Mills | Senior Vice President, Claim Operations Laura Hale Brockway, ELS | Assistant Vice President, Marketing

EDITORWayne Wenske

ASSOCIATE EDITORLouise Walling

STAFFDiane AdamsTanya BabitchRobin DesrocherStephanie DowningOlga Maystruk Robin RobinsonLesley Viner

CONTRIBUTORSteve Taylor

DESIGNOlga Maystruk

the Reporter is published by Texas Medical Liability Trust as an information and educational service to TMLT policyholders. The information and opinions in this publication should not be used or referred to as primary legal sources or construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalizations can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor its affiliates are engaged in rendering legal services.

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