You don't have to spend a lot of money to get valuable protection against malpractice liability. Simple risk-reducing tactics abound. If you're committed to staying out of the courtroom, commit to applying the common-sense ideas and information-rich resources shared here.

There's no such thing as a perfect physician, and even if there were, there's no such thing as a lawsuit-proof practice. That offers physicians an opportunity to work continually on managing liability risk, both through better office procedures and better interactions with patients.

When proactive strategies are used, physicians are more likely to stay out of the courtroom. And because patients' motivation to sue can be based on visceral responses to events or attitudes that have nothing to do with clinical standards, there is room for physicians to intervene before patients call lawyers.

Timothy P. Gray, MD, an orthopedic surgeon in Riverside, believes sharing information can reduce risk. He makes a practice of forwarding a copy of his dictated office notes directly to patients. Those patients are generally private-pay patients, because the workers' compensation system has its own reporting rules. Also, much of his practice's patient population comes through referrals from primary care doctors. "My dictated notes are meant not only to convey medical information to the patient's primary care physician, but also to convey medical information and education to the patient after the visit," he says. "I have had several patients express their appreciation upon receiving copies of those letters."

Have patients been grateful enough to change their minds about suing? Maybe, maybe not. "I do not know if sending copies of notes has ever prevented a lawsuit," says Dr. Gray, a partner at Southern California Orthopaedic Specialists Medical Group along with Drs. John Portwood and Hiromu Shoji. "I do know that sending them helps prevent misunderstandings, which sometimes lead to malpractice actions."

When complications do arise or surgeries fail to achieve the anticipated results, it's best to be forthright, Dr. Gray says. "Face the issue head on and work with the patient to help him or her through the process," he says. It's critical that the doctor and staff refrain from blaming the patient for the complication, and it's even more critical to give no hint whatsoever of abandonment. "There is nothing that will make a patient more angry than feeling that the doctor has deserted him or her in the middle of a difficult situation," he says.

Dr. Gray has raised his malpractice liability savvy through participation on the Medical Review Advisory Committee with the Riverside County Medical Association. During committee meetings, attorneys work through sample cases with physicians, offering a legal perspective on clinical practice activities. "Physicians benefit by familiarizing themselves with the legal process, which makes it less intimidating," he says. "Also, by analyzing and listening to the discussion of other cases, you often discover areas of improvement that can be incorporated into your practice."

Indeed, most of the tactics doctors use to prevent malpractice suits aren't complicated, nor are they expensive. And there are all kinds of resources and people to help. Read on.

Fellow Physicians Share Practical Tips
Southern California Physician interviewed several doctors to find out what works for them when it comes to curbing liability. Here's what they shared:

Embrace technology. Lytton Smith, MD, a family practitioner in Yorba Linda, says a great risk management tool for general medicine is using an electronic medical record. "It gives a readable and more complete note, reducing the problems of legibility and inability to follow the pattern of care," he says.

Overreact. Steven Larson, MD, an infectious disease specialist in Riverside, advises treating every patient as a possible litigant. "Any and all risks must be overstated," he says. "And remember that if it isn't documented, it didn't happen."

Be honest. Ventura urologist Kristin Santangelo, MD, offers this: "No matter how busy I am, I try to be real with patients, explaining why I'm doing everything I am doing. And I make sure I'm honest if I don't know an answer to a problem."

Focus on customer satisfaction. Dr. Santangelo notes that physicians can't emphasize the personal touch too much. "My office staff and I try to give our patients the best experience when they come into the office," she says. "I really take the time to make sure my patients are well-informed before any type of procedure. The extra TLC goes a long way. We constantly get positive feedback from patients regarding our care."

Show some enthusiasm. "Part of being the type of doctor who goes the extra mile to produce the best result is projecting that you care greatly about how your patients do," says Dennis Patrick Flynn, MD, vice president for medical affairs at Epic Management LP in Redlands. "Patients do not appreciate a blase attitude where their health is involved." Indeed, patients and the general public--including potential jurors--expect kindness from caregivers. "Any hint of callousness or remoteness will engender anger and a desire for revenge," he says. "On the contrary, it is hard to be angry with someone who has consistently demonstrated caring and kindness."

Remember the tie between business processes and patient attitude. Office staffers need to be extra careful about billing issues when patients have had an unexpected poor outcome, Dr. Flynn says. "Certainly the process should involve discussion with the doctor before any action is taken," he says.

Insurance Carriers Pinpoint Prevention Strategies
Ask physicians where they turn for risk management advice and most will mention their insurance companies. Indeed, carriers consider it a key part of what they do. Here are ideas from insurance company representatives:

Update clinical skills. Los Angeles-based Cooperative of American Physicians-Mutual Protection Trust recently went on the offensive to reduce injuries that occur during childbirth by educating 550 California insureds how to plan for and treat shoulder dystocia. Although the condition occurs in fewer than 4 percent of deliveries, it is the focus of an increasing number of medical liability cases. "Our goal is to reduce claims costs, and a very effective way of doing that is preventing injuries in the first place," says Waldene Drake, MBA, RN, vice president of risk management and patient safety at CAP-MPT.

Standardize medical records practices. Kathleen M. Roman, clinical risk management education leader at Ft. Wayne, Ind.-based The Medical Protective Co., notes that some legal experts advocate lengthy, comprehensive records. "But that often forces overworked, stressed-out physicians to throw their hands up in despair," she says. "Rather than use the record as a defensive tool, doctors are better served by using it as a patient-focused document that focuses on patient safety and satisfaction."

Roman recommends the use of a standardized documentation system along the lines of SOAP notes as a relatively simple way of ensuring that the patient record includes the essentials of diagnosis, treatment, referral, follow-up and patient partnership. "The length of the note isn't always as important as its content," she says. "Standardized systems help doctors pull the details into an overall plan, remind them to look at the big as well as the small picture, and help eliminate extraneous detail."

Learn the hot button issues. There's value in knowing what malpractice insurers are cautious about, says Richard "Rick" Mortimer, Orange-based vice president at broker Brown & Brown of California Inc. "Many preferred underwriters are cracking down on telemedicine risk and physicians who are practicing what may be perceived as a little outside their specialty," he says. "They're looking closely at the medical spa market, medical directorships, team doctors, out-of-state exposures and locum tenens work."

Consider special needs of patient populations. Barbara Worsley, vice president of risk management at The SCPIE Companies in Los Angeles, says risk can vary according to demographic groups. Given that life spans are lengthening, doctors will be treating more elderly patients. Worsley suggests physicians make certain adjustments. For example, if an elderly patient is having trouble hearing, speak more slowly and distinctly than usual, but don't overdo either. Doctors should maintain a safe practice environment from the parking lot to the exam room. That includes ramps with handrails, grab bars in restrooms and extra seating in exam rooms for caretakers.

Polish communication skills. Jack Meyer, senior vice president for business development, and Robin Diamond, vice president for patient safety, at The Doctors Co. in Napa, emphasize the value of excellent communication--before and after the actual face-to-face contact with the doctor.

Because communication skills can be learned, physicians and staffers should take classes to ensure everyone is well trained, Meyer and Diamond say. If the receptionist, often the first person the patient sees, makes the patient angry, the relationship is off to a bad start. So ensure everyone uses basic etiquette and knows how to deal with difficult, angry patients.

In particular, doctors need to learn how to pay attention to patients who are waiting a long time, Meyer and Diamond say. Update these patients on how much longer the wait will be and even offer another appointment in extreme situations. Similarly, patients may become angry if they feel they weren't given enough time to ask questions. Physicians should ask patients to bring a list of questions to appointments, they say.

Manage prescription problems. Physicians' offices must have a system for controlling prescriptions and refills. "Medication errors are one of the leading causes of lawsuits, and the greatest risk is allowing staff too much leeway in refill judgment," Drake says. "A practitioner should approve every refill request."

To head off lawsuits, keep a separate list of prescriptions and refill dates in patients' records so it's always obvious what medications they're taking and how many times they have been refilled, Drake says.

All of the above tips, Worsley points out, reflect basic tenets of common sense. "The message is you don't have to spend a dime to implement and maintain good risk management programs in your practice," she says. But doctors do have to take a team approach to lawsuit prevention. Every member of the office staff--the receptionist, the medical records staff, the appointment scheduler, the medical assistant and the physician--must bring risk awareness to the table to provide the safest and highest-quality care to every patient.

FEATURE ARTICLE SIDEBARS

Risk Management Resources

Southern California Physician asked physicians, insurers and association executives for resources doctors can use to better manage risk. Here are their suggestions:

Books and Other Publications
1) Medical Malpractice: A Physician's Sourcebook, by Richard E. Anderson, MD, FACP, published by Humana Press is "informative and not bone dry," says Dennis Patrick Flynn, MD, of Epic Management LP in Redlands.

2) CAP-MPT offers several resources for doctors, including Risk Management: The Legal Side; The Physician's Guide to Employment Practices Liability; Best of Case of the Month: A Collection of Risk Management Lessons From CAP-MPT; The Medicare Compliance Plan Handbook; The CAP Casebook: Professional Liability Experiences and Lessons From the Files of CAP-MPT and its Executives; The 11 Greatest Physician Liability Risks and How to Avoid Them; Protect Your Practice! A Physician's Guide to Avoiding Malpractice Lawsuits; The Physician's Risk Management Collection; Risk Management Self-Assessment Kit: Reducing Liability Risk in Your Medical Office; Managing Risk in Your Medical Practice: Transcript Highlights of the CAP-MPT Risk Management Seminar; Avoiding Lawsuits: The Role Your Staff Plays; and Physician Practice Management Strategies in an Era of Managed Care.

3) The California Medical Association California Physician's Legal Handbook is, at its core, a risk management guidebook, says Susan L. Penney, legal counsel. The association also publishes an "Act Smart" series on the Health Insurance Portability and Accountability Act and on fraud and abuse, which it calls "roadmaps for how to avoid liability in those areas." In addition, the CMA offers a booklet titled "A Physician's Guide to Tracking and Communicating Test Results" and a series of brochures to help patients align their expectations with reality. Sample brochure titles include "Taking an Active Role in Your Healthcare" and "A Guide to Cardiopulmonary Resuscitation for Patients and Their Families."

4) The Doctors Co. offers a malpractice risk management booklet called "Risk Management Strategies for Health Care Providers," a brand-new newsletter called Progress Notes so members stay informed about claims and patient safety issues, and a quarterly booklet-sized newsletter called The Doctor's Advocate.

Online Resources
1) The Christian Medical and Dental Association's Web site at www.cmdahome.org offers information on its ministry to help doctors avoid litigation, according to Danielle Onstot, MD, FAAP, an Oxnard pediatrician. The medical malpractice ministry can be found under "Website Directory," then "Ministry Groups."

2) CAP-MPT's Web site includes a section on risk management services at www.cap-mpt.com/riskmanagement/riskmanagement_01.html, according to Waldene Drake, MBA, RN. It includes information for members on onsite office practice risk evaluations, arbitration implementation for office practice settings, risk management alerts on timely issues, a risk management continuing medical education program accredited by the California Medical Association for 3 Category I units, risk management programs for office managers and staff, and individualized practice evaluation programs for physicians needing directed risk management education.

3) The SCPIE Companies' Web site at www.scpie.com has a risk management section that includes a wealth of risk management articles, interactive quizzes and CME material, reports Barbara Worsley.

4) Other major malpractice carriers' Web sites have information at www.medpro.com, www.brown-n-brown.com, www.thedoctors.com and www.norcalmutual.com.

Other Resources
1) The CMA partners with NORCAL Mutual Insurance Co. to produce CD-ROMs for the carrier's insureds on risk management issues. It also produces a series of one- or two-sheet briefs with the carrier covering issues such as "Safe Medication Principles."

2) CAP-MPT makes available a laminated wall chart called "Preserving the Integrity of the Medical Record: Your Professional Responsibility."

3) The Doctors Co. offers a one-sheet brief from its "What You Should Know: Practice Guidelines" series called "Assessment Tool for Patient Selection: A Semaphore for Elective Surgeries."

4) Paul Gabel, vice president, claims, at NORCAL Mutual Insurance Co. in San Francisco, says doctors often fail to take advantage of the resources their malpractice insurers offer. A phone call directly to the carrier will connect a physician to valuable tools.


New Liability Threats

Times change, and liability expands. Here are some tips for heading off litigation in areas professors may not have touched on in medical school.

1) When communicating with patients by e-mail, include a disclaimer with your ground rules for such exchanges, advises The SCPIE Companies' Barbara Worsley. A standard disclaimer might read: "Electronic mail is not secure, may not be read every day and should not be used for urgent or sensitive issues."

2) Be careful of what you write, Worsley adds. Always follow this rule of thumb: "Never put in an e-mail what you wouldn't say in person."

3) Never use abbreviations in e-mails, Worsley says. They can lead to misunderstandings.

4) If an e-mail chain starts to develop, or if there is an emotionally charged issue involved in what you want to communicate, call the patient rather than sending an e-mail.

5) Don't assume that a chaperone is not needed if a patient is the same gender as you, Worsley says. Same-sex sexual harassment is sexual harassment just the same.

6) Adolescents generally have a lower embarrassment threshold than adults, Worsley adds. You might be wise to use chaperones when dealing with that population.

7) Take a patient's cultural and religious beliefs into account when considering using a chaperone.

8) Make sure the staff at a medical spa practice doesn't overstep its professional limitations, advises Waldene Drake, MBA, RN, of CAP-MPT. Develop job descriptions and make sure staffers work only inside their scope of practice. For example, there are restrictions on who can perform procedures such as laser hair removal, and some offices don't follow them.