Episode 074: A Site for Sore Eyes

Speaker 1: You're listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals, brought to you by SVMIC.

Brian: Hello, thanks for joining us today. My name is Brian Fortenberry and on today's podcast, we're going to have an opportunity to talk to an individual who knows a little bit about medical malpractice and cases. He's going to be able to give us some incredible information. First, let me introduce him to you, joining us today is Eric Funk. Eric, thanks for being with us.

Eric: Brian, thanks for having me on the show today. It's good to talk to you.

Brian: Well the same here, and before we really get into the information that we're going to discuss today, start by telling our listeners a little bit about yourself and about your background, Eric.

Eric: Sure, I'd be happy to. I am an Emergency Medicine doctor, I practice full-time in Emergency Medicine. I did my training in medical school at the University of Kansas and then went ahead and did my residency in Emergency Medicine at the Mayo Clinic in Rochester, Minnesota and did a year as the chief resident there as well. And now I'm practicing in the state of Missouri as a full-time ER doctor at a level one trauma center here. So that's what I'm up to with my day-to-day job.

Brian: That sounds fantastic, and then on top of that my understanding is you are the founder and the editor of a website.

Eric: Yes that's correct.

Brian: That's called medmalreviewer.com, correct?

Eric: That's correct, medmalreviewer.com is the name of the website.

Brian: Tell us a little bit about that, how that came into fruition?

Eric: Sure, medmalreviewer.com is a website that publishes once a month a malpractice case and right now we're focused pretty much solely on Emergency Medicine malpractice cases since that's my area of expertise. So what we do once a month is we take a malpractice case, and were able to pull them from some legal databases, and we can pull the medical record and take a look at what exactly was documented on the case, what the physician wrote about the case, what the nurses wrote, what the triage notes were.

So we're able to walk through that information and show the readers literally exactly what happened with the case. And then we're also able to pull some accessory information too, so for example if a consult was obtained for a physician of another specialty, we're able to see their recommendations, and their consult note, if unfortunately the patient tragically died we can take a look at the autopsy and see what the ultimate cause of death was.

So we can essentially pull all of the medical information to show the readers exactly what happened and then once we've shown the readers the medical information about what happened, we can also go ahead and pull the legal outcome for the case too. Sometimes this as simple as being a settlement which is often times concealed and not visible to the public, but sometimes these are cases that can go to a jury trial as well so we can see the process that happened with the jury trial and see what the verdict was and then if any damages were awarded as well.

So then once we've walked through kind of the medical documentation and the outcome and the legal outcome of the case, then I go ahead and do an analysis of two different things. The first thing is an analysis of the physician's documentation. So there's a pretty wide range of how physicians document and sometimes a fairly minimalistic documentation style's appropriate but in some cases, there needs to be more of an explanation made. So I have a documentation rubric that just helps go through their documentation in a standardized format and essentially assign a grade to it and point out some areas that were good and possibly some areas of improvement.

And then the final thing I do is do an analysis of the medical care that’s provided to the patient during the case and we take a look at what decisions were made, what the thought process behind them, if there were some things that could have been tested or should've been done differently, or maybe tests that shouldn't have been run. We show how those things could potentially influence the outcome of the case. So that's kind of the basic rundown of how medmalreviewer works.

Brian: So Eric whenever you're gaining information and pulling all of this, are you pulling the cases from just a database out there and it's regional to your area in around Missouri or is it from anywhere in the country or in the world?

Eric: The cases come from anywhere within the United States. I've limited it to the US just because that's the geographic area I'm most familiar with and will be most applicable to my readers. The way that most of the malpractice cases work for the most part is that they're filed in courts essentially at the state level. So you essentially just have to just go and look through different states' databases and there're also some at the federal level that can be accessed through the PACER database. So essentially you just have to go and do a lot of digging by hand to go through and find a medical malpractice case that is applicable to Emergency Medicine and also some of the times, the medical record itself isn't included in all of the cases. So it does take a significant amount of digging to dig through and find a case that meets your specifications and then also includes the full documentation from the case as well.

Brian: So are most of these then public record type documents that you're able to dig, eventually find?

Eric: Yeah, that's correct. All of the documents included are in the public record which is something we, of course, have to be careful about with patient privacy laws so all of the information on the website is in the public domain and can be accessed by anyone at any time.

Brian: It is fascinating to be able to have this type of information out there and then compiled in one place because you know, you learn a lot. They call it practicing medicine not perfecting medicine. You can learn a lot from what went right and you can learn a lot, unfortunately, from what went wrong. What is unique about your particular website, Eric?

Eric: Well Brian, I think there are a lot of different resources out there for both physicians and attorneys about medical malpractice cases and at least from the physician side, which is what I'm most familiar with, most of those are resources that do walk you through some of the basics of a case. So people can see these resources out there but most of them are essentially kind of a couple of paragraphs summary of the case and someone is essentially reading their opinions into it and their interpretation when they type up this summary.

So what I think is different about my website compared to really any other resource out there on medical malpractice is that we are showing you the actual, real documentation that the physicians wrote down, that the nurses wrote down, in real time so that you can make your own judgment or decision about what went well or what went poorly in the case. I do offer my own commentary on those things but my resource is really the only one that is fully disclosing the entire medical record itself. I think that's been kind of a big reason why I've had such a good response here at the very beginning of starting this project is that people aren't able to access anything like this anywhere else. So it's really pretty unique within the medical malpractice community.

Brian: The amount of digging as you've pointed out earlier that you have to do to be able to get all of the information at one spot is time-consuming and to be able to come to a site and have all of the groundwork done for you is very, very valuable.

Eric: Correct, I'm able to dig through all of this myself and spend a decent amount of time doing this so that when my readers come there they don't have to replicate the same hours and hours of work to be able to see this information. It's all prepared and packaged nicely so that people can read through it in 15 or 20 minutes as opposed to spending hours looking at the information and gathering it themselves.

Brian: Before you began this project, what brought you to the point of "Hey, I want to do this. This is something that I want to do,"? Was there an event, was there a situation, was it just a space that you wanted to be able to fill? And then the second part of that is what is the purpose and what is your vision for medmalreviewer.com?

Eric: In regard to kind of the impetus or the reasons behind starting this project, I can't say there was really one particular event that happened to me that made me want to do this. I do think that my experience in my training and shortly after residency is that often times when there are bad outcomes or things that could've gone better, physicians get together and have what's called an M & M conference, a Morbidity & Mortality conference. We'll take a look at cases where something could have gone better and kind of think through as a group what those exact elements were that could have gone better.

I think it's a really great learning experience for everyone involved and so that's something that's obviously done in a completely private setting and it isn't publicly available. So part of this is making almost an online M & M curriculum for physicians to look through. And then kind of the second part of things is that when I started looking for something similar to that and looking specifically within the medical malpractice case, just like you said there was no one doing anything where the actual medical record was being disclosed to the public. So that was kind of the impetus behind starting it.

In regards to the purpose of medmalreviewer, I have essentially kind of a mission statement on my website but it boils down to three different things. The first is exposing physicians, and any other healthcare worker is gonna find this an interesting and useful site for them to read, but the first purpose is essentially to expose physicians and those other healthcare workers to what real life medical malpractice cases are. There's a lot of hearsay and there's a lot of fear and rumors that float around within the medical community, a lot of rumors about what you need to document or what you don't need to document, or what you're going to get sued for or what you aren't going to get sued for. So as opposed to having that be essentially rumors kind of floating around in the ether, I think this site is a good way to show people concrete examples of what you can get sued for and what the outcomes are going to be for those cases. That's kind of the first purpose.

The second purpose is to help improve physicians' care. Like you said before, we're all practicing medicine and even once you're board certified and an expert in your field there are certainly all those ways you can be improving your practice and staying up to date on the literature. So seeing mistakes that other physicians have made or even seeing just bad outcomes that happen even if the physician didn't make any mistakes whatsoever, it's always an informative experience and any physician can learn from looking through those cases. And then the third purpose is to help improve physicians' documentation which I think is a little bit of an overlooked area within medical training. There's a lot of resources out there for physicians about writing notes, especially in regards to how do you write a good note to satisfy the billing or coding requirements, but not a lot out there about writing good, defensible documentation. So my website has some resources for people and all these examples to help show physicians how they can write good defensible notes. So those are essentially kind of the three reasons or purposes of medmalreviewer.

Brian: All three great reasons and very needed reasons out there in the medical community for this to be a resource that people can come to improve in those areas. That last part you talked about, the defensible documentation, this is a term that we are familiar with and we have heard before, it is important. Why is it challenging to write defensible documentation?

Eric: Well I think to help people understand why it's challenging sometimes to write defensible documentation, you first have to think about why doctors are writing notes. And when you think about why doctors are writing notes or why anyone's writing any piece of text, you first have to think about, “what is the audience that they're writing for?” So often times, maybe a fiction author is writing a book and essentially the point of the book is to entertain or to communicate a main thesis. For physicians, it's a little bit more complicated ‘cause we don't have just one audience that is going to be reading our notes and that significantly complicates how we write documentation.

For physicians, there’s really three essential main categories that we are writing in. The first one is to communicate our care to subsequent healthcare providers. Many physicians would say this is the most important reason because we need to be able to explain to other physicians what we did and why we did it. For example, as an Emergency Medicine doctor when I take care of a patient, I want the primary care doctor who has taken care of this patient over the long term, is going to see them in a follow up appointment hopefully a couple days after I've seen them, I want them to be able to look at my note and understand what the problem was and what I did, and any medications that were prescribed or tests that were ordered so that they can take over the care from that point and continue taking care of their patient. So that's kind of the first purpose.

The second purpose is for billing. Anytime anyone's in the emergency department they are going to be billed for the care that they were given and part of billing the patient appropriately is going to be figuring out what you did, the level of complexity of care that was provided to them. So the billers are going to have to look through at the note to be able to decide what the bill is going to be, essentially. And if physicians don't document in a capable fashion in this regard then the billers aren't going to know what to bill or what's an appropriate bill for the patient. So that's really kind of what the second purpose is for billing.

Then the third purpose is for defense, and that's really where my website comes in particular. Anytime a physician writes a note, they want to be able to explain clearly and concisely what they did and why they did it. No physician is hoping for a bad outcome for their patient but unfortunately, bad outcomes do occur and when they do occur you want anyone looking back at your chart to be able to tell what you did and why you did it and why it made sense at that time.

Brian: You're talking about three very different things with three very different audiences, and that gets tricky doesn't it?

Eric: Correct, it does get tricky because the people who are looking for what level of billing your chart needs to be are looking at it for a completely different purpose than people who may be looking at your chart to figure out if a lawsuit is appropriate or not. You really have to gear your documentation to satisfy three different readers which is something not a lot of authors or people writing documentation have to do, so that is what really makes it challenging.

Brian: So is there a technique that you can use to kind of accommodate that?

Eric: There's definitely a technique. I think the easiest way to think about the technique that I've proposed on my website, which is called the documentation template, is to essentially see it as kind of almost a checklist of kind of cemental steps that you need to hit when you're writing the note for patients you're taking care of. The simple analogy I have for this is that any Emergency Medicine doctor will recognize is that for billing there's a couple particular requirements that you have to have depending on what level of billing you have. For example, having four elements in your history of the present illness is a big checkpoint that has to be hit in order to bill appropriately for your patient. In my documentation template, which helps physicians document in a defensible way, I essentially have a couple categories set up and I'll just run through them kind of briefly here.

Brian: Okay, that'd be great.

Eric: The documentation template is up on the website and they can look through it themselves or download it and use it on a shift, but essentially it's walking through a couple different things. The first thing is to write about the differential. And what I mean by that the differential, as any physician knows, is essentially the list of things that could be causing the patients complaints for why they came into the emergency department. So for example, if someone's having chest pain we're thinking about things like pneumonia, heart attack, a blood clot in the lungs. Those are three quick examples of what would be on the differential for a patient with chest pain and that's certainly not all-encompassing but it's just sort of a simple example. So the differential allows the physician to illustrate what they were actually thinking about and really having physicians write down their thought process is really one of the things that is going to help make your chart defensible because if you thought about something but you didn't write it down on your chart, it's going to be hard for people to show that you ever even considered some of those diagnoses. So having a good differential is important.

The next thing is writing about testing that needs to be done or doesn't need to be done. The testing often times flows pretty logically from the differential. For example, if you're worried about someone having a heart attack then you're going to need to get an EKG, a heart tracing, and at a bare minimum a troponin to see if there are any signs of the heart attack. Just as importantly as documenting the testing that needs to be done, and probably even more importantly would be documenting testing that doesn't need to be done.

So if you thought about a particular condition but you don't think the patient has it based off of the history that they've provided and your physical examination, it's often times helpful to write down why certain testing isn't important. This is actually one of the things that I see physicians get into the biggest trouble with is that they assume that people reading the chart are going to understand exactly what they were thinking and why certain testing wasn't going to be needed done. But if you actually take a look at their chart, sometimes it's really hard to understand that. So writing down why certain testing doesn't need to be done ends up being pretty important.

The next category is writing about the treatment that was given and any response. Again, this is fairly logical in many cases, for example, a patient with abdominal pain may be given a dose of morphine to help with their pain and not much needs to be written about that but it's useful when a physician goes back and re-evaluates the patient if they can show that maybe the morphine either was or wasn't improving their discomfort which can provide some clues about what the final diagnosis may be.

And then towards the end of the case then you're starting to think about narrowing the differentials. So at the very beginning, you thought about multiple things, usually, three to five items would probably be an average, so you have started with those different things that could be causing the patient's complaints and by the end, you're starting to cross off some of those things. Now in Emergency Medicine, we think pretty much only about the emergencies so we're not necessarily always diagnosing the final diagnosis for what's causing the patient's symptoms but we need to at least be crossing off the emergency items on the differential before we let a patient go home.

And then that kind of leads us to the very last thing on the documentation template which is the aftercare plan, and what I mean by the aftercare plan is essentially the plan of care for what the patient is going to be doing once they leave the emergency department. This is really important because it's essentially the link back to their primary care doctor. And there’s essentially three key components of the aftercare.

The first one is the treatment plan, so the treatment plan is things like, for example, if they have pneumonia maybe I've started them on an antibiotic and given them something for a cough. So that is essentially what the treatment plan is, is the medication that they're going to be taking or any instructions that the physician has given them.

The next part is the follow-up, and what I mean by follow-up is who they're going to see and when they're going to see them after they've left the emergency department. So again, we'll take the example of the patient with pneumonia who's well enough to go home. They need to be set up with a follow-up appointment with their primary care doctor and in particular, they need to know when they need to follow-up with this physician. Is it in two days, is it in five days, is it at the next available appointment? All those details about the follow-up are very important.

And then the third thing that is also important are return precautions. What I mean by that is that the patient needs to be equipped with the knowledge of when do I need to come back to the emergency department. So if the patient with pneumonia goes home and all of a sudden their breathing is getting much worse and they're feeling confused, and their heart is racing, then they need to know if those things are happening you need to immediately come back to the emergency department even if you haven't seen your primary care physician in the meantime. Giving that information to patients really helps kind of equip them to take control of managing their disease and helps you partner with your patients so that they can get better, and it also provides some defensibility for the physician.

The important thing about the aftercare too is that each of those items, the treatment plan, the follow-up, and the return precautions need to have pretty clear cut timelines associated with them. For the treatment plan, say “how many days do I need to be taking this antibiotic?”, okay we'll make it for seven days is the timeline. For the follow-up, maybe you've instructed them they need to see their primary care doctor within three days. And for the return precautions, any of those things that we tell patients to look out for when they go home they usually need to immediately come back to the ER if any of those things happen. So that's essentially kind of the quick rundown of the documentation template.

Brian: That's a fantastic template to go by and what we can do, certainly in our show notes for this podcast put a link to your website and you said that they can get to that template from your website, correct?

Eric: Yes, that's correct. If you just go to medmalreviewer.com and look up at the very top there's a tab that says 'template' and if you click that it will show you the documentation template.

Brian: Well fantastic, once again our guest on this episode has been Eric Funk. Thank you so much for being here.

Eric: Thanks for having me, Brian.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast and find show notes at SVMIC.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.