Maintaining a low threshold for discharging angry or disruptive patients from a practice and documenting in detail all encounters with these patients can help physicians lower their risk of malpractice suits or lessen damage awards, according to speakers at the Large Urology Group Practice Association (LUGPA) 2020 virtual annual meeting.

“From my perspective, it’s very, very important to deal with these patients in a very systematic way,” said medical malpractice lawyer Nicholas A. Riewer, an attorney at Ruberry Stalmack & Garvey who has defended doctors in malpractice cases for 37 years. Many times a patient will take out their frustrations on front office staff, he said.

“By the time they get to the urologist, they have already probably caused all kinds of chaos in the front office,” said Tobey Williams, MD, chief executive officer and co-founder of SCRUBS RRG, a medical malpractice insurer for practicing urologists.

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Riewer emphasized the importance of having front office personnel inform physicians early as to what is going on with respect to the patient. “We don’t want to turn this angry patient into a plaintiff,” he said.

To deal with difficult patients, Riewer said, “I think it is very important from a legal point of view to designate one person to deal with this patient going forward. I would suggest your office manager,” he told attendees.

When the patient checks in, the urologist would just contact the office manager, who would be in charge of interacting with the patient, whether setting up a new appointment or discussing prescriptions or follow-up care, Riewer said. The office manager needs to be told that all communications with this patient have to be “charted with clarity.”

In addition to the date of the patient encounter and content of discussions with the patient, the chart needs to include the name of the office manager and others involved in the discussions.

Dr Williams suggests preparing standardized letters in advance that could be sent to patients being discharged from a practice. The letter should explain why the patient is being discharged and instruct the patient to find another urologist. It also should provide guidance in finding another urologist, noting that if the patient has trouble finding one, they should contact their primary care physician for another referral or contact the county medical society. Riewer advises putting the name of the primary care physician and their phone number in the letter and provide the phone number for the county medical society.

If lawsuits are filed, plaintiff’s attorneys are going to look for “holes” in the chart information to which they can attribute the eventual treatment outcome, Riewer said.

Every interaction an office manager has with difficult patients, such as leaving voice mails or sending emails or certified letters, must be documented in patients’ charts. This is important “because I guarantee you at some point, if they do turn into a plaintiff, they are going to try to blame you for anything that’s not contained in that chart,” Riewer said.

Keeping cool when dealing with a difficult patient is paramount, he said. “Part of practicing risk management is to have better control over your emotions when you’re dealing with the angry, whiny patient,” Riewer said.

Physicians should avoid saying things like “stop your whining,” he said. A plaintiff’s attorney would use language like that “to make you as a physician look like you don’t care,” Riewer said. “And if the plaintiff’s attorney can make you the physician look like you don’t care, the likelihood that they get a verdict in favor of the plaintiff is going to go up substantially.” 

Because procedures are performed by doctors, it is their obligation to obtain informed consent. “It’s always important for the doctor to do the [informed] consent. You can’t have your [physician assistant] do it, you can’t have your triage nurse do it,” Riewer said.

Dr Williams reviewed 5 crucial elements that should be included in an informed consent form, all of which should be explained to patients in detail: reason for the procedure, the procedure itself, material risks associated with the procedure, alternatives to the procedure, and the likely outcome with no treatment. Riewer advised not having informed consent discussions in the hospital before a procedure, as patients could be stressed or on medication and might not recall what the doctor told them.

If something adverse happens during an operation, urologists should explain this to the patient soon after the procedure, but after anesthesia wears off. Urologists should dictate clear and concise notes about the nature of the complication, how it occurred, what they told the patient, and what remedial action, if any, is available to correct the problem, Riewer said.

“It’s important to make sure your charting is accurate, but don’t admit that you did anything wrong,” he said.

He told attendees, “Even if you think you may have made a mistake, I want your notes to be very technical as to what occurred: a bowel was nicked, not mistakenly nicked. If you use the word inadvertent or mistakenly, most of the time there’s going to be a verdict against that physician.”