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1 New-to-Practice Reporter | 2016

CLOSED CLAIM STUDY: FAILURE TO PROPERLY OR TIMELY DIAGNOSE SEPTIC JOINT

10 THINGS THAT GETPHYSICIANS SUED

HOW TO RESPOND TO A TMB (OR OTHER DISCIPLINARY) COMPLAINT

SIX TYPES OF LIABILITY INSURANCE

BENEFITS TO GROW ON

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2016

TMLT is thrilled to introduce the New-to-Practice Reporter.

This publication has been designed with you in mind - the young physician beginning his or her career. We want to help you navigate the waters of a new profession, with useful, valuable information written to address your concerns. Look to the New-to-Practice Reporter to offer news, articles, and analysis to help you manage risk and stay up-to-date about new medical liability concerns and legislation that affects your practice.

The New-to-Practice Reporter will also connect you to TMLT, so that you can take advantage of our rich educational resources and coverage features.

We want to be your partner as you begin your career, and we want to progress with you through your successes and challenges as a physician. Please let us know what kind of articles and topics would benefit you the most. Send your suggestions to [email protected].

We hope you enjoy this inaugural issue of the New-to-Practice Reporter.

- Robert Donohoe, President and CEO

32016 | New-to-Practice Reporter

FAILURE TO PROPERLY OR TIMELY DIAGNOSE SEPTIC JOINTBy Laura Hale Brockway, ELS

PRESENTATIONAn 8-year-old girl was brought to the emergency department (ED) of a local hospital. The patient’s mother reported that the child had a fever for four days and pain, swelling, and redness of the right knee with streaking up the leg. The patient’s history was notable for a hospital admission 18 months earlier for septic bursitis in the left ankle that was successfully treated following orthopedic surgical debridement.

PHYSICIAN ACTIONEmergency Physician A saw the child at 7:45 p.m. She noted that the knee was red and warm, but the child had full range of motion and was able to walk with a limp. The area was non-tender and there was no fluid appreciated. The girl’s vital signs were temperature of 104 degrees; heart rate of 130-140 bpm; blood pressure 106/65 mm Hg; and respiratory rate in the 20s. Laboratory data indicated a white blood cell count of 11.5 with 46% Polys, 40% bands, 13% Lymphs, and 1% Monos. C-reactive protein was elevated at 8.1.

Plain x-ray films of the right knee were non-diagnostic. An MRI of the right knee was ordered, and the results

were obtained after Emergency Physician A went off shift. Emergency Physician B took over. The MRI showed moderate joint effusion and extensive lateral soft tissue swelling. Emergency Physician B discussed the case with Orthopedic Surgeon A at 1:25 a.m. Orthopedic Surgeon A told him to “hold off antibiotics ” and that he would perform an arthrocentesis early in the morning. Emergency Physician B’s final diagnosis included “right knee effusion/pain; concern for septic joint.”

The patient was admitted to the hospital under the care of Pediatrician A. The patient had a temperature of 101.6 degrees at 2:30 a.m., and 102.3 degrees at 4:40 a.m. Pediatrician A saw Orthopedic Surgeon A in the hallway

CLOSED CLAIM STUDY


outside the patient’s room later that morning, and asked him if he had completed the arthrocentesis. When he stated that he had not done the arthrocentesis, Pediatrician A invited him to examine the patient. Orthopedic Surgeon A refused, stating he had an emergency to attend and could not perform the procedure. He told Pediatrician A that he would ask his partner, Orthopedic Surgeon B, to perform the arthrocentesis.

At 9 a.m. Orthopedic Surgeon A called his office to let his partner know that the patient was in the hospital and required an arthrocentesis of the knee. Since Orthopedic Surgeon B had a clinic full of patients when she was notified about this patient, she decided to complete the clinic and then go to the hospital.

Orthopedic Surgeon B saw the patient at 1 p.m. She noted that the patient had a pulse rate of 135, a temperature of 102 degrees, and that she looked sick. The patient’s left lower leg — previously uninvolved — appeared dusky, and the patient exhibited a petechial rash around the knee. Orthopedic Surgeon B felt the patient either had an embolic event from endocarditis or was manifesting signs of sepsis. She transferred the patient to the ICU and consulted an intensivist, infectious disease specialist, and cardiologist.

At 1:50 p.m., Pediatrician A ordered a repeat CBC, blood culture, a DIC and renal panel, and an echocardiogram. The child was started on vancomycin and gentamycin. At 2:35 p.m., her blood pressure dropped to 82/42 mm Hg. The infectious disease specialist ordered a fluid bolus of normal saline and an empiric dose of ceftriaxone 500 mg IV. The patient’s blood pressure improved, but dropped again to 73/40 mm Hg at 3:30 p.m., prompting an additional fluid bolus of 500 cc normal saline.

From 3 p.m. to approximately 6:15 p.m., the patient’s blood pressure remained in the 90s/30s. Dopamine infusion was started, and the patient received multiple fluid boluses. She was intubated at 5:15 p.m., and one hour later large amounts of blood came through the endotracheal tube. A chest x-ray showed bilateral fluffy infiltrates, consistent with a pulmonary hemorrhage. The patient received platelet and red cell transfusions.

At 7 p.m., the patient became bradycardic and required chest compressions. She was given bicarbonate, calcium, insulin, glucose, and epinephrine. Although she was briefly stabilized, she coded again at 7:40 p.m. Resuscitation efforts continued, but they were not successful. The patient was pronounced dead at 8:55 p.m.

An autopsy was performed and the pathologist concluded that the patient died from Group A Beta hemolytic streptococcal sepsis that resulted in acute infectious purpura fulminans and marantic endocarditis.

ALLEGATIONSLawsuits were filed against the hospital, Emergency Physicians A and B, Pediatrician A, and Orthopedic Surgeons A and B. The allegations included:

• failure to institute antibiotic therapy after receiving the first lab results (Emergency Physician A);

• failure to call in the orthopedic surgeon on a “stat” basis and failure to stress the septic condition of the patient to prompt Orthopedic Surgeon A to come in immediately (Emergency Physician B);

• failure to obtain an emergent consult from another physician when Orthopedic Surgeon A failed to come in (Pediatrician A and Emergency Physician B); and

• failure to make themselves present in a case where a patient had labs indicative of a septic joint and developing septicemia (Orthopedic Surgeons A and B).

LEGAL IMPLICATIONSThe plaintiffs were able to obtain support for their allegations from a pediatric infectious disease specialist. He stated that the ED physicians should have considered septic arthritis as the first diagnosis in their differential diagnosis and arranged urgent orthopedic consultation for aspiration of the child’s right knee. Once the fluid was sent for culture, he further opined that the standard of care required the child be started immediately on IV antibiotics pending the results of the culture and rheumatologic studies.

He also felt that the ED physicians and the pediatrician should have insisted that Orthopedic Surgeon A or another orthopedic surgeon perform an arthrocentesis promptly, and failure to do this was a violation of the standard of care. Further, he stated this failure was a direct cause of the child’s bacteremia and septic shock. If antibiotics had been started in the ED, this patient likely would have survived.

An orthopedic surgeon who testified for the plaintiffs stated that the orthopedic standard of care for a possible infected knee joint is to aspirate the joint. This procedure should be performed either by the treating physician or, if competent, the ED physician.

The orthopedic consult opined that antibiotics should then be promptly started until the culture growth can be established. The consult felt that aspiration of the joint before starting antibiotics in a possible infected joint is the standard of care, rather than empirically starting antibiotics without this culture or ordering the blood culture only. According to this expert, Orthopedic Surgeon A did not meet the standard of care.

Several consultants reviewed this case for the defense. The orthopedic surgeons who reviewed the case felt the responsibility lay with Pediatrician A and Emergency Physicians A and B. Conversely, the pediatric consultants felt that Orthopedic Surgeon A held the bulk of the


responsibility. The emergency medicine physicians who reviewed this case were critical of everyone. They felt that had antibiotics been started in the ED, and had the ED physicians been trained to do arthrocentesis, they could have prevented the death of this patient.

The pediatric infectious disease consultants who reviewed the case were all concerned that with a severe left shift, antibiotics should have been started sooner. Only one physician who reviewed this case stated that the patient’s survival was unlikely, and the addition of antibiotics early in the morning would not have made much difference in the outcome.

Finger pointing among the physicians involved in the case further complicated the defense. Emergency Physician B stated that, if asked, he would testify that he spoke with Orthopedic Surgeon A twice between 1:30 and 2:30 a.m. During the first conversation, he said the patient had a severe left shift in her labs and looked to have a septic joint. He asked Orthopedic Surgeon A to do an arthrocentesis immediately. Orthopedic Surgeon A said he would perform it in the morning, and he ordered no antibiotics be given so the culture would be accurate. Orthopedic Surgeon A told Emergency Physician B not to call him back.

After obtaining the results of the MRI, Emergency Physician B called Orthopedic Surgeon A to give him the results. He still did not come in. Emergency Physician B then alerted Pediatrician A to this fact, but Pediatrician A did not order an arthrocentesis from another physician. She agreed to wait until morning for Orthopedic Surgeon A to perform the arthrocentesis.

When Pediatrician A arrived at the hospital at 8 a.m., she expected that the arthrocentesis had been completed. When she learned that it had not, she was concerned. Orthopedic Surgeon B testified that had Pediatrician A or Orthopedic Surgeon A reported the patient’s urgent condition, she would have seen the patient sooner. Orthopedic Surgeon B was surprised that Pediatrician A and the nurses waited so long to call her and failed to involve an intensivist and infectious disease specialist earlier.

DISPOSITIONThis case was settled on behalf of Pediatrician A and Orthopedic Surgeon A. The hospital also settled its case. The cases against Emergency Physicians A and B and Orthopedic Surgeon B were dismissed.

RISK MANAGEMENT CONSIDERATIONSThis case involves numerous communication breakdowns. For example, many of the physicians were unaware that the patient was hospitalized for a similar condition 18 months earlier. Emergency Physician B did not communicate the urgency of the arthrocentesis. Pediatrician A failed to insist that Orthopedic Surgeon A see the patient when the procedure had not been performed by morning. Orthopedic Surgeon A did not communicate to his partner the urgency of the arthrocentesis.

It would appear there were several occasions in which no physician accepted clear responsibility for the patient. When Orthopedic Surgeon A did not come in and perform the requested procedure, there were potentially multiple ways that the arthrocentesis could have been performed. If comfortable performing arthrocentesis, Emergency Physician B could have performed it himself; another affiliated orthopedist could have been called in; or a hospital administrator could have required Orthopedic Surgeon A to respond earlier. The fact that Pediatrician A did not see the patient until morning, did not require the arthrocentesis to be performed immediately, and failed to frequently assess the patient’s condition and insist on treatment was a challenge to the defense.

Reluctance to challenge the decision-making process of another professional may have contributed to some communication errors. Orthopedic Surgeon A decided to “hold off antibiotics” and to perform the arthrocentesis in the morning, more than 12 hours after the child was admitted to the ED. Emergency Physician B’s failure to challenge these decisions may have contributed to a breach of the standard of care for a septic joint, which mandates arthrocentesis and early antibiotic therapy with possible surgical debridement.

The failures of the physicians to communicate effectively, accept responsibility, or question other physicians’ medical decisions are symptoms of broader system issues that need careful evaluation to meet the standard of care.

Laura Hale Brockway 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.


10 THINGS THAT GET PHYSICIANS SUED By Laura Hale Brockway, ELS


Not all medical liability suits filed against physicians are prompted by medical errors. Patients often cite the interpersonal aspects of care, such as poor communication or feeling rushed, as central to their decision to sue.

This article describes 10 common errors that can increase the risk of a malpractice suit and offers risk management techniques to address these issues.

1. FAILING TO LISTEN TO PATIENTS, SPEND ADEQUATE TIME WITH THEM, AND COMMUNICATE EMPATHETICALLY WITH THEM. Research on why patients sue physicians has repeatedly shown that basic interpersonal skills such as listening and showing respect can be just as important as clinical skills in preventing lawsuits.1 However, given the time and economic constraints placed on physicians, it is easy to see how these skills can become overlooked.

A key factor in patient satisfaction involves the quality of time spent with the physician, not just the quantity. Short visits can be effective if you sit down, listen to the patient, ask appropriate questions, and allow time for the patient to fully express him or herself and to ask questions. If you spend the entire visit with your hand on the doorknob, patients may feel rushed and may not give complete information.

But many physicians rightfully ask, “How can I improve a patient’s perception of a satisfactory visit when time is limited?” Here are some tips:

• Schedule the length of the appointment based on patient needs.

• During the appointment, spend time connecting with patients on a personal level.

• Before patients are taken to the exam room, it may be helpful to ask them to complete a form that prompts them to state the reason for their visit.

2. MAINTAINING ILLEGIBLE OR INCOMPLETE DOCUMENTATIONAccurate, legible, and complete documentation can be the best defense against a malpractice claim. What would your medical records look like to another physician, a plaintiff’s attorney, or a jury? Poor documentation practices can impede care and may signal that you are careless or do not care to follow the patient closely.

Poor documentation alone will not generally send a patient to an attorney, but could lead to a suit once the attorney sees the records. Poor documentation also makes the case more difficult to defend.

Physicians should also be aware that the Texas Medical Board can discipline you if your medical records are incomplete, incorrect, or illegible. Physicians should review their records, including electronic templates, to ensure that their documentation includes the TMB’s required elements.

The TMB rules for medical records can be found at http://www.tmb.state.tx.us/page/board-rules.

Another documentation pitfall involves “correcting” medical records after an unexpected outcome or notice of a claim. Altering the medical record after the event — even if you believe the information will assist in your defense — is detrimental.

An addendum to the medical record may be allowed if done in a timely manner and clearly identified. Include the date and time, a reference to the date and time of the actual encounter, reason for the addendum, the added information, and your signature. Be aware that if using an electronic record, any changes will likely be “time stamped” electronically. As with paper records, addendums should be clearly identified.

3. FAILURE TO ESTABLISH STANDARDS OF CONDUCT FOR OFFICE STAFFRude behavior by office staff and a bad outcome may be all it takes to initiate a lawsuit or complaint to the Texas Medical Board — even if the rudeness and the bad outcome have nothing to do with each other. These behaviors can also include insensitivity or inattention to patients.

To address this problem, develop a policy and procedures manual for your practice. This manual can help ensure that staff members behave in accordance with the policies in place. A policy and procedures manual can also reinforce staff accountability and serve as a staff orientation tool.

Maintain an office culture that is patient friendly. To evaluate the “friendliness” of your practice, consider using patient satisfaction surveys or have a friend or colleague call or visit and report the experience to you.

4. BEING INACCESSIBLE TO PATIENTSPerceived “inaccessibility” can occur when patients experience any of the following: long wait times for appointments; failure to return phone calls and messages; long automated phone messages when calling the office; and inattention during hospitalization.

Patients may believe this inaccessibility means you don’t care. Have policies in place for returning patient phone calls and ensuring these calls are documented. It is also important to tell patients what to expect regarding returned calls and to meet those expectations. Many practices inform patients when they can expect returned phone calls.

To minimize wait times for patient appointments, instruct staff on triaging and assigning priority appointments. Staff can ask callers a set of standard questions and then schedule appropriate appointment times. Patients who cannot be accommodated should be referred to another practice or to the emergency department (ED).

10 THINGS THAT GET PHYSICIANS SUED By Laura Hale Brockway, ELS


Your accessibility when a patient is in the hospital is another issue. Family members may wait all day at the hospital to ask the physician questions. When they do see the physician, they often feel rushed and that their questions were not fully answered.

This can be addressed by clear communication with the family about what to expect; when the physician will be there; or by arranging a time to talk to the family.

5. FAILURE TO ORDER AND FOLLOW UP ON TESTS OR DELAY IN ORDERING TESTSEmploy a tracking system to ensure that patients have obtained recommended tests. A tracking system can minimize exposure to allegations of failure to diagnose and treat and can lead to better patient care.

Sometimes patients just need a reminder. A tracking system can remind both patients and physicians that tests need to be completed.

Tracking systems do not need to be complicated. They can be as simple as a “tickler” sheet that staff members use to make phone calls. Also, most electronic medical records have electronic order entry and tracking features that can be used. The important thing is to make tracking a routine procedure in your practice.

Along with tracking, develop a written procedure for handling test results when they are received, and for following up on results that have not been received. This procedure should specify that test results have been thoroughly reviewed before they are filed or scanned into a patient’s chart. Ideally, the reviewer initials and dates the report and documents what needs to be done — either electronically or in the paper record.

Some patients who sue their physicians claim that test results were never communicated to them, or that the physician was delinquent in providing those results. Make it a high priority to notify patients of their test results in a timely manner. Routinely documenting in the record that the patient was provided with results, including the date and initials of the person who contacted the patient, can help to prevent such allegations.

6. FAILURE TO REFER WHEN APPROPRIATE; FAILURE TO TRACK REFERRALS; AND FAILURE TO COMMUNICATE WITH REFERRING PHYSICIANWhile it is true that patients have a duty to comply with your recommendations, including following through with referrals, it is common for them to claim that the physician did not stress the importance or did not explain the reason for the referral. In fact, they sometimes claim that they were given an option, as opposed to a recommendation, to see a consultant.

Implementing a system to track referrals can improve patient care and reduce liability exposure. The system can provide a method for:

• verifying that the patient keeps the appointment; • confirming receipt of the consultant report; • prompting a call to the consultant if a report is not

received; • making sure the physician sees the report; and • arranging for a follow-up appointment if necessary.

If the patient fails to keep the appointment with the specialist, a staff member can then remind the patient of the importance of following through. These steps should be documented in the patient’s chart.

As with reports of test results, written procedures for handling consultant reports can prevent problems and improve patient compliance. Initialing and dating reports or electronically signing after careful review can provide useful documentation if a lawsuit is filed.

Another problem that frequently occurs involves communication between physicians. While written communication will often suffice, there are some situations in which a discussion needs to take place. It is also important to document your discussions with other physicians and any joint treatment plans resulting from the referral.

7. INAPPROPRIATELY PRESCRIBING MEDICATIONSWhen patients experience adverse reactions to or lack of benefit from medications, lawsuits can result. These suits allege such errors as: failing to check the patient’s chart when prescribing medication; prescribing improper dosages; failing to consider and advise patients of potential

SOMETIMES PATIENTS JUST NEED A REMINDER. A TRACKING SYSTEM CAN REMIND BOTH PATIENTS AND PHYSICIANS THAT TESTS NEED TO BE COMPLETED.


side effects or interactions with other drugs; prescribing drugs outside the physician’s specialty; and prescribing drugs for non-patients.

To avoid allegations related to improper prescribing, consider the following guidelines.

• Check the patient’s medical record when prescribing or refilling a medication. Request that the patient come for an office visit, if appropriate, before authorizing a refill.

• In the patient’s chart, record medications and allergies in a central location or be sure to include all medications in the electronic record. Update this information at each visit.

• Provide the patient with information about the drug, and document discussions and any handouts given.

• Be familiar with the drug prescribed. Refer the patient to a specialist if he or she requires a drug that is outside your scope of practice.

• When prescribing drugs off-label or in dosages exceeding those recommended, document your rationale. Also document that you discussed the risks and benefits of the treatment with the patient.

• When a patient calls with complaints of unusual symptoms, the prescribing physician should be alerted.

• If a pharmacy calls to question a prescription, check the original order.

• Make sure any handwritten prescriptions are legible and that dosages are correctly noted.

8. IMPROPER CARE OF PATIENTS DURING EMERGENCY SITUATIONSTreating patients by phone when an examination is warranted can be risky. Patients can be poor historians or may inaccurately describe their symptoms. Additionally, you cannot assess the patient’s appearance, body language, or symptoms by phone.

Careful judgment should be used when deciding whether phone advice and treatment is sufficient. When possible, check the record. Has the patient experienced the problem before? When was the patient last seen in the office? Is this a recurring issue for the patient?

Follow written protocols for telephone triage that include:

• which staff members can answer patient questions;• specific questions to ask the caller;• when to notify the physician; and• which calls warrant a visit to the office or ED.

Document the patient’s request, symptoms, and any advice given. If the patient is told to go to the ED, document this in the medical record.

Another situation that warrants discussion involves interaction between treating physicians and the caregivers


in the ED. Many times, claims allege that the patient’s primary care physician or specialist inappropriately relied on the ED physician or resident because the physician did not want to come to the hospital.

Other claims involving emergency care have alleged lack of adequate communication between the physicians at the hospital, such as emergency physicians or residents, and others such as radiologists or specialists.

When contacted by an ED physician, documenting any advice given over the phone can correct any confusion about what was communicated. Additionally, if you are asked to send copies of medical records or reports, confirm that the ED received the materials. Document the confirmation in the medical record.

9. FAILURE TO OBTAIN INFORMED CONSENT Informed consent is not a piece of paper. It is a discussion between the patient and the physician regarding the risks and benefits of a procedure, treatment, test, or medication.

In Texas, informed consent is governed by statute and is overseen by the Texas Medical Disclosure Panel (TMDP). The panel includes six physicians and three attorneys who review all treatments and procedures to determine which risks must be disclosed by health care providers to their patients. Procedures and treatments are then assigned to a list. Those requiring disclosure of risks and benefits are put on List A. Those that do not require disclosure of specific risks are identified on List B. Information about the panel can be viewed at http://www.dshs.state.tx.us/facilities/medical-disclosure/default.aspx.

The panel periodically examines new treatments or procedures and assigns them to one of the lists. The lists, TMDP rules, and forms can be viewed at Title 25, Texas Administrative Code, Part 7 at http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=25&pt=7&ch=601&rl=Y.

When offering any treatment or procedure to a patient, the physician must make these determinations:

• if the treatment or procedure appears on List A, then disclosure specified by the panel must be followed;

• if the treatment or procedure appears on List B, no specified disclosure is legally required;

• if the treatment or procedure does not appear on either List A or List B, the physician must disclose all material and inherent risks that could influence a patient in making decisions.

Obtaining informed consent is a non-delegable duty. The physician is responsible for discussing the risks and benefits and obtaining consent. A signed form is not a substitute for a detailed discussion.

Document the informed consent discussion in the medical record. The notes should indicate that the patient was informed of the risks, benefits, and alternatives of the offered treatment, and that the patient expressed a desire to proceed.

It is important to note that a physician may not be required to disclose the risks of certain surgeries, procedures, or medications. However, it is best to disclose the risks that a reasonable person would want to know in making a decision about his or her care.

10. ALLOWING NONCOMPLIANT PATIENTS TO TAKE CHARGEThese situations can include a patient leaving the ED when you suggest admission or a patient leaving the hospital before his or her condition is stabilized.

Resist attempts by patients to talk you into anything other than what your best medical judgment deems appropriate.

Physician recommendations and patient noncompliance should be objectively and adequately documented. If patients suffer a bad outcome as the result of noncompliance, they may try to shift the blame to their physician.

Patients often claim that the physician did not explain the severity of their condition or the potential consequences of going against medical advice. Thorough, contemporaneous documentation can help dispel these allegations.

Another risk management strategy for these situations includes requiring that the patient sign informed refusal or “Against Medical Advice” forms.

SOURCE1. Ambady N, et al. Surgeon’s tone of voice: a clue to malpractice

history. Surgery. 2002; 132:1; 5-9.



HOW TO RESPOND TO A TMB (OR OTHER DISCIPLINARY) COMPLAINTBy Laura Hale Brockway, ELS


In Texas, there are roughly 300 pages of rules and regulations that govern the actions of physicians.1 And any violation of these rules and regulations can lead to disciplinary action by the Texas Medical Board (TMB).

The consequences of a single TMB complaint can range from dismissal of the complaint to revocation of your license. And don’t forget the enormous expenditure of stress and time and possible damage to your professional reputation that can result from a Board action. A TMB complaint should not be taken lightly.

If you do receive a board (or any other disciplinary) complaint, follow these steps to respond appropriately.

1. Hire an attorney with experience dealing with the Board. You should hire an attorney knowledgeable about the TMB investigation process and its rules and procedures. Dealing with the laws governing state agencies (known as administrative law) is a rule-specific process, and hiring an experienced attorney will help you greatly.

2. Cooperate. There is no reason to be difficult with the Board. The TMB has tremendous authority to gather information and is able to gather the information it needs with or without your help. Why make the Board members angry?

3. Be honest. If you made a mistake, it is better to admit it. Board members understand that mistakes are made. (Perfection is not the standard of care.) There is no reason to make them think you have something to hide.

4. Keep good records. Good records can make all the difference in quality of care cases.

5. Communicate. Most complaints submitted to the Board are the result of poor communication with patients, their families, staff, and colleagues. The better communicator you are, the less likely you will experience a Board complaint.

TMLT policyholders have coverage for disciplinary proceedings within their policies. This coverage, called Medefense, pays for legal expenses, fines, and penalties associated with disciplinary actions, such as actions by the TMB, a hospital review committee, or a federal regulatory agency.

If you are a TMLT policyholder and you receive a disciplinary complaint, please do the following.

1. Notify TMLT as soon as you receive the initial letter from the TMB or other disciplinary authority. You have 60 days to report an insured event to receive reimbursement for covered expenses.

2. Consider retaining an attorney to help draft your initial response to the TMB. Upon request, TMLT can provide you with the contact information of attorneys who have experience handling disciplinary proceedings.

Working with an attorney who is knowledgeable of TMB proceedings may result in early dismissal of the complaint.

SOURCE1. The laws governing Texas physicians are found in the Texas

Medical Practice Act, which is in the Texas Occupations Code, Section 101 to 168. The regulations created by the TMB are found in Title 22, Part 9, Chapters 161-185, 187, and 189-200 of the Texas Administrative Code.



Purchasing medical malpractice insurance can be an intensive, time-consuming process. Therefore, it is essential to understand medical liability and the insurance you need to protect your career and reputation.

Here’s a look at the types of liability insurance you should be looking at and why.

CLAIMS-MADE COVERAGE — insurance that protects you from incidents that occur and are reported as claims during the time the policy is in force. If you don’t renew your claims-made policy when it expires, you are no longer covered for any future claims alleged to have occurred during the time your policy was in force.

OCCURRENCE COVERAGE — coverage that provides ongoing insurance protection for events that occur during the policy period, even if they are reported after the policy is canceled. Occurrence policies are generally more expensive.

PER PATIENT COVERAGE — malpractice coverage designed for emergency medicine and urgent care groups, as well as other groups that are structured on a per-

encounter basis. Pricing for this type of coverage is based on the number of patient visits rather than the number of physicians in the group.

CYBER LIABILITY COVERAGE — coverage for privacy-related claims that occur as a result of lost laptops, theft of hardware or data, improper disposal of medical records, hacking or virus attacks, and rogue employees. All TMLT policies include cyber liability coverage.

DISCIPLINARY EVENTS COVERAGE — coverage for legal expenses, fines, and penalties arising out of a medical board or other disciplinary proceeding. TMLT provides disciplinary events coverage, called Medefense, in all policies.

EMPLOYMENT PRACTICES LIABILITY (EPLI) COVERAGE — protects against employment-related claims such as harassment, wrongful termination, and discrimination. EPLI coverage is included with all TMLT policies.

For more information about medical malpractice coverage, please visit www.tmlt.org.

SIX TYPES OF LIABILITY INSURANCE


As you progress in your career, TMLT’s medical liability coverage progresses with you. From residency to retirement, TMLT has you covered.

CLAIMS-MADE COVERAGE TMLT offers “Moonlighting” coverage for residents or fellows who work 30 hours or less per week outside their training program.

Once your training is complete, TMLT will waive the tail coverage cost if your Moonlighting policy is converted to a standard policy.

NEW-TO-PRACTICE DISCOUNTThis discount is available to physicians who are entering practice for the first time immediately upon completion of graduate training, military service, or an academic position. This discount is 40% for the first year in practice and 20% for the second year. Generally, no other discount is given other than CME and practice review in conjunction with the new-to-practice discount.

EXPERIENCE DISCOUNTTMLT offers an automatic premium discount to physicians with favorable claim experience. This discount ranges from 3% to 20%, depending on length of time with TMLT. This discount greatly benefits new-to-practice physicians, as it grows over time.

TRUST REWARDS — GET AHEAD ON YOUR RETIREMENT SAVINGSIt’s never too soon to start planning for retirement. TMLT provides the Trust Rewards program, the strongest “reward” program of its kind available to Texas physicians. Each year, upon renewal of your policy, TMLT sets aside funds in your Trust Rewards account. These funds will be allocated to you at retirement or other qualifying event. It’s our way of thanking you for your loyalty to TMLT.

TMLT has allocated $175 million to the program since its inception in 2012. TMLT has already paid more than $6.5 million in benefits and the distributions keep growing.

BENEFITS TO GROW ON


CLAIMS — SUPPORTING YOU EVERY STEP OF THE WAY

TMLT is notified of a

claim

Response letter sent to

policyholder and plaintiff’s attorney Claim

supervisor performs

preliminary investigation

If a lawsuit is filed, a defense

attorney is appointed

Under direction of a TMLT claim supervisor, the defense attorney

prepares the case with a strategy for mediation

and trial

Post mediation, if a decision is

made to proceed with the trial, a trial date is

scheduled

In the event of a trial, a claim supervisor will

attend every court date with you

When you need us most, our experienced claim staff and attorneys are here to defend your good name, reputation, and career. After 37 years of fighting claims in Texas, TMLT maintains a deep understanding of the state’s legal system and medical liability system.

All medical liability claims are different, and each has its own special needs and requirements. The claim resolution process usually takes several months, but can last years. TMLT manages this process for you and keeps you updated and informed about your claim’s progress.

TMLT claim representatives are available 24 hours a day, 7 days a week to answer questions or discuss a claim.

CLAIM PROCESS


EDITORIAL COMMITTEERobert Donohoe | President and CEOJohn Devin | Senior Vice President, OperationsSue Mills | Senior Vice President, Claim Operations

EDITORLaura Hale Brockway, ELS

MANAGING EDITORWayne Wenske

STAFFDiane AdamsBrandice DaveyStephanie DowningOlga Maystruk Robin RobinsonLesley VinerLouise Walling

DESIGNOlga Maystruk

The New-to-Practice 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.

© Copyright 2016 TMLT

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PAIDPermit No. 90Austin, Texas

TEXAS MEDICAL LIABILITY TRUSTP.O. Box 160140 Austin, TX 78716-0140 800-580-8658 or 512-425-5800www.tmlt.org

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