reslawsuits_edited

All right. Hi, everyone. And welcome back to Behind the Knife. This is Nina Clark, and I'll be your host today. Most surgeons go through training, understanding that malpractice suits and legal risk management will be a part of their careers. We hear about getting malpractice insurance. We know that by picking a procedural specialty, we've got some unique risks inherent to our careers.

And we've all heard about some really well publicized cases where other surgeons have been found guilty of medical malpractice. Just scroll through the rest of your podcast feed and you'll find a couple of examples. What's less widely understood is that even trainees can actually be involved in these lawsuits.

While it's uncommon overall, it's a pretty terrifying idea and something that every trainee should generally be aware of. There are also some really concrete ways that we can reduce the risk of this happening that carry not only through our training, but into our careers as surgeons later on. To help us discuss these issues today, we are going to be joined by two representatives from the University of Washington, Cindy Hamra and Lisa Hamel.

Cindy Hamra is an associate dean in the GME office at the University of Washington School of

Medicine, where she leads the operational, administrative, and finance functions. The UW School of Medicine sponsors clinical training for over 1, 600 medical and dental residents and fellows in over 200 programs.

UW Medicine, through the School of Medicine, is the largest sponsor of GME programs in the five state WAMI region. That includes Washington, Wyoming, Alaska, Montana, and Idaho. Lisa Hamel is a Senior Director of Clinical Risk Management for UW Medicine. Prior to that, she spent over 20 years as a defense attorney, primarily working in medical malpractice and professional liability defense.

Cindy and Lisa, we're so glad to have you on Behind the Knife today, and I'm really looking forward to this conversation. Appreciate the opportunity. Thank you. Yeah, thanks for having us. So let's dive right in and just confirm for me, can fellows and residents be sued for medical malpractice? So the answer to that is yes, absolutely.

Typically, however, the attending is overall responsible for the residents and the work that they do as

kind of under a legal concept of respondeat superior. So it would be unusual for a resident to be sued in their own right. It's not it's not very common. But yes, they can be sued. Okay, and what about medical students?

I feel like, you know, we never heard about it at all as medical students, but we are still, you know, doing rotations on the wards and physically taking care of patients occasionally. Can medical students be involved in these lawsuits? They can and that's but that is very, very rare. And if you think about it from a plaintiff side, they want to, you know, get to the money, right?

And the most money is really suing a suing an institution and maybe naming the primary people involved. Typically, what will happen though, if an institution is being also being named, that the individuals will end up being dropped out. Unless there's something specifically egregious that plaintiffs want to keep the individuals involved as name parties.

Got it. Yeah, I can see that if somebody had sued me as a

medical student, they would only get, you know, more of my debt potentially than I already had. All right, so how big of a problem, you've mentioned that this is uncommon a couple of times for both trainees and for students, obviously, but how big of a problem are we talking about here?

How often are surgeons sued in the United States? And then how often does that kind of trickle down to trainees and their involvement in these lawsuits? So I've got some stats there, and it really depends on what source you look at. The National Institute of Health publishes some stats, American Medical Association publishes stats, JAMA publishes stats.

They're all pretty darn similar in terms of residents, fellows. The number ranges between 10 and 15%, but for surgeons in general, surgeons are among the highest, if not the highest, they are among the highest sued in, in any of the medical specialties. And that number, you know, it ranges depending upon, again, the source that you're looking at.

It's around 55 to 70 percent of surgeons will be sued at least once in their

lifetime. That's a much higher number than I even feel like I had a concept of. I think, you know, in medical school, I feel like I heard that OBGYN and anesthesia had really high malpractice insurance costs as presumably as a result of higher risks for being involved in these lawsuits.

But I feel like I heard about it a little less. Going into general surgery. So that's really helpful to know. Cindy, from a GME standpoint, how do you think about this as you work with trainees in these fields? And do you provide any additional, you know, support or education towards specifically trainees, maybe going into procedural specialties?

And how do you kind of conceptualize this as somebody who works with these trainees kind of every day? Yeah, it's a great question. You know, I think, It's interesting to hear the stats that Lisa has. My experience being in GME over the last eight, nine years is that we haven't seen a lot of trainees named in cases.

However, and Lisa, you may have more thoughts on this. It seems to be increasing and, you know, there may be reasons for that. But I think one of the things that that tells

us is that there's an increasing need for residents and fellows to know. You know about this and to sort of equip themselves with knowledge about what their institutional structure is and what where the infrastructure is what if they do see a situation like this, and we've tried to do a little bit more, I think, as it's come to our attention, both that it's happening more frequently and that our residents are really.

you know, nervous about it. I mean, it is terrifying. That's the word you used. We've talked about how we can provide more resources. I do think, and you know, Nina, tell me where to put this, but like the ACGME actually has requirements that institutions both provide liability insurance for residents and fellows and notify them about that.

And I think that's something For residents and fellows to know, you know, I mean, you guys hear so much, right? There's so much information all the time, but it's worth equipping yourself with that knowledge, right? What's your institution's policy? What does it mean for how you're covered? Where do you go?

If you get contacted by an attorney, all of those things, I think are, they're going to vary by institution and they're really important to know

now. And it's also just a good practice, right? Because then when you go into independent practice, you're going to want to know those things as well. So it's kind of a good habit to get into to start looking into that and being aware of it.

That's super helpful. And I actually didn't know that it was required by the ACGME that that that coverage was provided to us. I knew that I had it at some level, but I hadn't really dug into it very much. And we'll get a little bit into kind of the payment for all of this stuff when it does happen, if and when it does happen a little later too.

But that's really helpful kind of background to know that there is some, you know, baseline requirement for support for trainees in these programs. Lisa, maybe you can help us out with this. Can you walk us through kind of the typical steps that happen if a patient decides to sue their treatment team, maybe including a trainee?

I feel like, you know, I've mentioned this before we started recording that my. My knowledge of the legal system is pretty much limited to law and order SVU. So just kind of a brief, you know, broad strokes overview of what happens during one of these lawsuits and how it kind of comes to fruition. Sure.

So it depends on the state. Okay, every state has different rules in terms of statute of limitations and in the prerequisite. So here in Washington state, a patient would They've got essentially three years, and I'm just going to throw that number out. It's, it, there's so many variables on that number. If they're, if the injury happened during the pediatric years, they've got 18 years and then time.

So it could be a very long time but typically what would happen is they would go to an attorney, present their case, and an attorney would evaluate whether the case is worth taking on. I know we've seen a lot of press on the McDonald's and these other, you know, crazy injuries, but Medical malpractice cases are unique in that they typically do not come to fruition without having expert testimonies to support the plaintiff's case, and that can be very expensive.

I mean, when I practiced regularly, my expert witnesses would charge 400 to 700 an hour. So to have an expert evaluate records

and make an about, make a determination whether there's something legitimate there, it's expensive. So it's, these are it's very rare anymore to find a a MedMal case that is frivolous.

Okay, so, so plaintiff would come, a patient would come to attorney, they would typically get the records, make an evaluation, and then if they decide to take on the case, they would identify an institution, they would name an institution, and then most likely the surgeons or the physicians that were also involved with the care, and they would be named parties.

In the state of Washington, because we are a state institution, there is a prerequisite that plaintiff's attorneys have to file a notice of tort claim before they can actually file a lawsuit. So that provides us as a state institution notice of a potential claim that we have the opportunity then to evaluate and see whether it's something that's legitimate, that maybe it's something we want to settle, but it's, it provides us with notice before an actual

lawsuits file.

So if a lawsuit is filed, then when you asked about how would a trainee be notified, they have to be personally served. Okay, so somebody will come, and that's a, it's a really horrible situation, somebody comes knocking on your door, and it's a process server, and we've had this happen with folks, you know, right over Thanksgiving dinner, they answer the door, and they're served.

spouse, you know, receives this summons and complaint, it can be a really lousy situation. At the university and some other institutions, there's like a, there's a handful of plaintiff's attorneys that we know very well. And we have this, you know, unwritten courtesy rule where the plaintiff's counsel will, will contact our our claims officer, our attorneys and say, Hey, I'm gonna, would you accept service for these folks?

Right? So we avoid the embarrassment and that uncomfortableness. So we do have this sort of unwritten guideline, not in all, but in some instances, which that, and that really kind of helps to ease some of the stress and embarrassment. But you have to be personally served with the summons and complaint and then

the employer.

So here with the university, we would appoint legal counsel to represent you as a trainee. The cost of all of that is covered by the insurance for the institution. So you're not out of pocket any money. And then it would roll through the litigation process again, depending upon the jurisdiction and where you're at here in King County.

It'll be two to three years from the time that you're served with the lawsuit to the time resolution hits, if it goes the whole way through a trial. That process is a very long time. Criminal cases take priority. So we have trial setting a trial schedule that gets set pretty early out. And right now in King County, they're setting them out about a one and a half to two years out.

So, and that's excluding continuances and other things. So council will be represented and then they'll work with you through the discovery process. Sometimes you'll be dropped, you know, after they get the information they need, right. And the university or the institution is the only remaining defendant named defendant, but sometimes not sometimes they want

there may be political reasons or, you know, some sort of strategical reasons why they want to have.

Particular people specifically named as parties in the, in litigation. And then it'll go through the process in King County. There is a requirement that all cases go to an alternative dispute resolution process before a trial can be heard. They really try to clear out, you know, to get very few cases going to trial.

So we have to do an arbitration or mediation, something like that. Some sort of settlement negotiations. And then if that fails, then you get a trial date. So, they're really in and so about in King County, it's about 98 percent of cases that are tried or criminal. So very small percentage of civil cases actually go.

And then from that, that very small portion, an even smaller portion of that would be medical malpractice cases. That's a really helpful structure. And it sounds like, you know, you mentioned these expert witnesses who kind of come in and help to almost legitimize

the complaints that actually make it through this process.

So, it seems like there's some filtering that happens from the time that, you know, patients feel like they might have a complaint and then to each step along the way, there's some, you know, Things that will fall out of the wash, basically. So is there, do those expert witnesses typically, it sounds like they come in at the beginning to consult with the patient's potential lawyer and establish whether this is a legitimate, you know, complaint that should move forward.

And then I presume that they're also involved kind of throughout the decision making process from then on. Is that the case too? That it depends. So I think an important thing to note is that while plaintiff's counsel would retain experts, your defense counsel will too, right? So as you're represented, defense attorneys will retain competing experts, right?

And so they will evaluate the case from a defense standpoint, plaintiff's counsel will evaluate from a plaintiff's standpoint. And then there'll be some discovery, right? You'll get in some areas they're required to have an expert written report. It's not always the case. It depends on the

jurisdiction.

And then there will be usually it's a deposition, right? So one side will get deposed and then that transcript will be given to the other defense attorney who will, or the other defense expert. And then they'll nitpick through it and say, okay these are, this is untrue. So make sure that, you know, we highlight these areas or these are areas of vulnerabilities.

So, there, it, you don't necessarily consult with the expert the whole way through, but on certain, you know, certainly on the science, on the medical stuff, and you'll want to know what's weaknesses, you know, they'll be relying on, you know, statistics, on surveys, on, you know, what's standard practice.

It's very important to know that, you know, to be held liable in a medical negligence case. You're you have to be found to have breached a standard of care, which is what a reasonably prudent physician in the same circumstances, you know, practicing in the same type of medicine and same circumstances would have done in that situation.

So that standard of care may be different if you're practicing in a rural area and say eastern

Washington versus here at the university. There may be an entirely different standard because of the resources and things that you might have available to you. So those are the things, you know, the expert would work and help, help evaluate.

There's also, you know, both sides would also retain experts to help evaluate damages, right? So somebody might be permanently disabled. Okay, they might have a life care expert. What does that entail in terms of daily, you know, ADAs for daily living? You know, in lost wages, that sort of thing, and both sides would have that.

So if it gets to a damage phase both sides would have competing experts in terms of what, what the actual damages would be in the case. Got it. What are the different ways that you can be involved in a lawsuit? If you're say a resident trainee, obviously you could be included as a defendant or one of several defendants, it sounds like more typically, but are there other cases that your name might come up and you might be involved somehow in a lawsuit?

That doesn't necessarily mean that you're a defendant in that case. Yeah, and that's not uncommon

either. You could be a fact witness in a particular case. So perhaps you may not be named, but you might be might have been involved with the patient's care. And so you might be called as a fact witness to talk about.

Your particular part of the treatment, that's not an issue, but how, but it might be that piece that ties things together. The other thing that, that we see not as often but it is not uncommon is that you might be called as a witness on something altogether different. So for example, maybe an LNI case, right, that you might have some involvement in the treatment of the patient.

And so you might be called as a witness there. We also see that in custody battles. There might be an argument as to whether a parent would be fit. To be a caregiver whether it's a full time or part time and so they may be called to if you've had involvement with the patient to be called as a witness in those instances.

I think if I can add there a couple of other things I was thinking about we sometimes see trainees involved in matters where a patient may be need

to be held due to concerns about mental health or other and I think when that's the case it's When that happens frequently in training, I understand that our trainees get more, you know, they're more used to it.

They get more training about it and sometimes we see and maybe child abuse and neglect types of cases as well. Our trainees participate. I think those are more baked into the structure of the residency programs because those specialties focus on that kind of care. But we do have those. And I actually was thinking as Lisa was talking, you know, When our residents are involved in matters, maybe not as a defendant, but, you know, they need to be deposed or something like that, we actually do have an infrastructure of support for that too.

And so I think it's actually worth noting that, for example, when we've had residents reach out and say, Hey, you know, I heard from an attorney that they wanted to pose me in a case and, you know, what is this about? And even if we aren't necessarily providing counsel in those situations, UW has a litigation like consultant who will help prepare.

The resident for it. And so I say that because again, I think it's really worth either, you know, finding out now or if you're a resident fellow, or,

you know, should you get an inquiry like this, like, go to your institution and see what the infrastructure of support is, because, you know, we're not going to make it a pleasant situation, but we can certainly try to take away some of the difficulty and help you feel better prepared.

I think that's really important to know, because my sense is most of our residents and fellows wouldn't know that unless they had to write. And so, you know, If by asking you can get hooked up with the right resources, it's a really worthwhile, you know, ask. Absolutely. You, you stole my next question, which is like, if you get a message from a lawyer or if you get served or something like that, you know, what should your next step be basically as a trainee?

And it sounds like it should be talk to somebody at your institution, like immediately, and they will help you through the next steps. Yeah, that's definitely the guidance we give. At UW and we say, I think there's two things. One is, I mean, just go to your program director. To me, that's always the default, no matter where you are, because.

If they don't know the answer, they're going to likely at least be able to start the process of getting you connected with the right resources. We have at

UW, we put together some sort of some guidance for our residents and fellows because we found that, you know, people were hearing from things and sometimes the PDs didn't know either what to do.

And so what we asked them was, look, if you hear, if you get a subpoena, if you get you know, contacted by council, whatever, just contact GME, contact your program director, because what we want to be able to do is, you know, at least understand conceptually what's going on and then get you hooked up with the right.

Part of the institution that can support you here, whether that's a different office or whatever is the right place to go. And, you know, 1 of the things we think about is like, are part of our jobs to integrate our residents and fellows into the system. And these are resources that are available to our physicians.

So they should know about it. The other thing I will say, you know, 1 of the reasons that's important to me, for example, to hear from our trainees who are going through this is we also just want to provide support, right? Because it is stressful. I mean, there's technical support, but there's also like, whether it's wellness counseling or it's, you know, our EAP or a mentor, because I think when you start paying attention, you'll realize a lot of your colleagues have gone through

this.

Sometimes there's a peer to peer structure that supports physicians going through a, you know, legal matter. And so, We want to be able to make sure you've got whatever it is, right? Counsel or claim services, whoever is the right office, but we also just want to make sure that like you're feeling supported during the process because it's so stressful and, you know, training's hard enough without carrying this extra load.

Yeah, that's great. I, you know, this kind of brings up one of my anxieties about this whole system. And Lisa, you mentioned, you know, this standard of care is kind of what you are expected to meet if you're named in one of these malpractice suits. And you mentioned that there's different standards of care, right?

And there's, you know, depending on your resource availability, your practice environment your training and your expertise. Part of Surgical training and residency is the fact that we will make mistakes and that we do, and we have, you know, training as a result of that, right, is to hopefully make us less and less likely to make mistakes, but we do as interns and as junior residents and as senior residents, right?

So how is this

accounted for by the legal system? Is there some way that like basically acknowledges that we are Still on the learning curve for our eventual professions. And we're not, you know, necessarily held to the same standards as attending physicians. So from a legal standpoint, you're absolutely right.

And from a standard of care, you know, it would be, what would a first year resident do? You know, what would the position or, you know, what would a fellow do in this particular circumstance? And so the standard would be that that's, that's the legal answer. The practical answer is a jury looks at Who's, who's doing the treating, right?

And they're not going to go, Oh, well, you know, as a resident, so I'm going to kind of excuse that or like, so, you know, there's that I'm going to be, I'm just going to be frank. That's just, that's just how it is, right? So, but in those particular cases, that's why the attending is involved. And what we see in, in, you know, I mentioned National Institute of Health, JAMA, AMA, all of the, they will all say, Okay.

That when you've got a situation involving residents, more

than half of the time, the attending will be named and part of the issue would be inadequate supervision. And so, so they will say, you know, yes, we had a trainee, but that the supervision was inadequate and that should have, that the issue should have been addressed right away, corrected right away.

And so that's, you know, again, that's kind of how it, it falls overall to the attending. Interestingly, it might, you know, it was interesting to me when I did when I was doing some research under for surgeons in particular, and surgeon, surgical residents, but the AMA in 2023 published a a little, some statistics about surgical residents.

And what they determined was that puncture and lacerations during surgery accounted for about 11 percent of what. You know what the issue when when a resident was named and then inadequate supervision was about 25%. So, you know, those are, you know, published numbers. So those are the kinds of things that you see.

The other thing that that you'll see often in terms of residents in

particular, failure to obtain informed consent an absence of documentation of visiting the patient, right? Either pre procedure or after the procedure an absence of communication that's documented or inadequate communication between the care team members.

And so those are some pretty, you know, it when residents get sick, Sued as surgical residents get sued. Correct. That, but those are the big issues. Right. It's, it might be a technique, but it's a, but a lot of it has nothing to do with the actual surgery itself. It's really the pre-evaluation, the discussion and the post follow up, and then the documentation of that, of what you did when you did it.

Because what we see. If it's not documented in the medical record, it didn't occur. And we've had, we have cases like that, that, you know, where unfortunately residents, you know, are grilled, you know, well, well, yeah, you know, this is my standard practice and of course I'm there every, you know, two hours, whatever it is.

Well, geez, there's no documentation for 12 hours. So did you really go see the patient? So there, you know, and that's what,

what plaintiff's counsel will be hanging their head on. I think that that leads into, you know, probably the most important question. That we'll talk about today is, you know, how can we behaviorally kind of set ourselves up for as much success as is possible, right?

If you know, 50 to 75 percent of us are eventually going to get sued in our careers, ideally, I think most of us would like to prevent that. And we'd like to be in that 25 percent minority that doesn't. So, so what are some best practice? you know, methods to, to try to avoid being involved in these or if you are involved, you know, to try to protect yourself from as much liability as possible by, you know, presumably by doing good medicine and trying to avoid this sort of situation from happening.

Well, the easiest answer is to change the specialty. If your podiatrist don't get sued, so you're not going to be, you know, named, you're not going to be among a high number, but if you're going to stick with general surgery, great. You know, that's your risk. It's a high number because there's, you know, high risk for what you're doing.

I would say that the most important thing is to do a really good consent. Make sure that your

patient knows about the risks and benefits and you want to document that. You want to document a medical record, give them the opportunity to ask questions. If English is not their primary language, you want to make sure you have an interpreter.

And that that is documented and you really want to make sure that you have a it's a shared decision making, right, as to what what that process is going to be and that you get buy in from the patient. Don't be afraid to share the big risks, right? It, even if the percentage of it happening is small, you really want to know, you know, if there's a risk of losing a limb don't rely on the micro print in the consent form to convey that.

You won't, you really want to share. That being as a significant risk, because you want to make sure that the patient is going into the procedure with full knowledge as to, you know, what the risks and the benefits are. So number one, want to make sure that you have a really good robust consent discussion and that you document.

And then that leads to number two, document, document, document. You want to document everything, every time you see a patient. I personally

absolutely hate auto population. You know, was in defending cases, it would be a horrific thing when you would see the exact same, you know, H and P numbers when you knew darn well that the patient was deteriorating or certain things were changing, but things were auto populating.

So if you got that auto population, make sure you check to just make sure that stuff is right. So you want to make sure that everything is documented when you go see the patient, that that is. That's documented. You want to document if the patients express, you know, concerns or questions, those things are all documented.

Because as I mentioned, when we were talking about the process it here in the state of Washington and in King County, you might get sued two, three years after the procedure, and it may take another two, three years for it to get through the litigation process. And I don't know about you, but I have a hard time remembering what I did yesterday.

So you want to, if you're going to be, you're going to be asked about what is in the record, right? And, or what's not in the record, most importantly. So it's very, very important

to to document and supervision is a biggie thing. That's hard for you as trainees to control, but you know, certainly if you know, if you have questions that that's something that you want to, You know, you want to make sure that you feel comfortable expressing and having, you know, don't be afraid to speak up.

Don't be afraid to question things because it's that your gut might be right on, right? So, and so again, those are the big things. And if you make sure that you do all the really good communication with your patients, patients that like their doctors don't sue their doctors. I mean, that's the reality.

I mean, you know, you, you laugh, but it is absolutely true. Statistically if you've got a good rapport with your patient, if they like you. They're not gonna want to see you. That's great. I mean, and, you know, again, it goes back to being, you know, conscientious and ideally a good surgeon, right? Is, you know, a communicative one.

We all make mistakes, but if we're, you know, talking through the odds of those mistakes with our patients and we consent them for surgery and, you know, talking to them once things happen. Then it sounds like that's pretty effective potentially and in preventing some of this stuff.

I've heard a little bit about apology laws.

I think I've seen them called where you don't necessarily get dinged for expressing regret that something happened to a patient. You know, is there something or a script that either of you recommend that's You know, residents or, you know, attendings for that matter, use when something has gone wrong.

You know, if I have a patient with a perforation or a complication after a procedure that I was involved in, and I'm taking care of them for that complication, should I apologize for it happening? Is there wording that we should avoid to, to avoid, you know, potentially bringing, you know, litiginous things into play?

You know, how, how do we best, you know, communicate? That we've made a mistake without necessarily opening ourselves up to these lawsuits. So that's a really good question. And I will say you, you, the first thing is you need to default to your institution and what their policy is, right? So every institution is going to have different policies.

Every state's going to have different rules in terms of, or even if they have apology rules and what, you know, what those rules encompass. I will say at

the university, we have very particular guidelines that we ask the attendings to do the disclosure, the policy. We don't put that on the residents. We ask that the residents confer with their attending, you know, about the issue and that.

All of the communications, you know, from that point forward would come from the attending. That being said, yeah, the words that we like to hear are, you know, I'm really sorry this happened to you and we're going to investigate the cause or we're going to investigate what happened and how it happened.

And we will get back with you. We will, you know, we try to keep the communications open again, default to your organization, because at the university we have a very robust. We call the CRP communication resolution program where we really promote transparency with our patients. We do, we really promote the disclosure conversation being upfront, taking care of their bills.

You know, we don't bill them if there is, if there was medical error, so they don't get, you know, so, but again, that's institution specific, but

in terms of the apology itself, you don't want to say, I'm sorry, I screwed up boy. I really, you know, I, This I had a bad day, you know, those are words you want to avoid, but it's okay to, you know, absolutely.

You want to do a lot of listening and you just say, I am so sorry, this happened to you and we will, I'm committing to you that we will investigate, you know, investigate it. And, like I said from the university standpoint, we do that and we will, you know, do a robust investigation and then.

As a university, we share the results of that investigation with the patient and family, but every institution is different. So I really want to emphasize that you need to go to where you're practicing, go to your risk management group, patient safety group, and learn what your process is and how your approach is to potential medical error.

Lisa, I was thinking as you were saying that those types of investigations, like often, I think involve the resident fellow needing to talk with the institution's risk management about care. And I think that's another thing sometimes that. Residents may not, you know, I mean, you're contacted by someone in the institution.

That's not part of

your program and the clinical team. And so I think it's worth naming that there are these sort of institutional structures that often need to bring residents and fellows in and they're kind of part of how the institution works. Right? And they're, you know, Not adversarial, and they're not putting the resident at risk, but, you know, the resident fellow should sort of participate.

And I guess I don't know if you have thoughts about that, because I think that's worth knowing. That's another one to me. That's like, you get a call from an unknown person. And what do I do here? Right? Is this is this putting me at risk as a trainee? That's a, you know, that's a very good question and a very important way to think about this because when clinical risk and patient safety get involved in, and I'm only going to speak from knowledge of how things work in Washington and that, and the fact that we are a governmental entity as well.

So there's a little bit of extra twists and turns in here, but typically, as long as we are investigating this. Potential adverse event medical error through our quality improvement process through a QI process. Anything that we discuss

or investigate through that process is protected. So plaintiff's attorney would never get a copy of a standard of care review.

They would never get a copy of interview notes, anything like that. And I put a huge asterisk there because the risk and what is so important to emphasize and that you really want to work this through your clinical risk management patient safety teams is because the risk of emailing your buddy.

Oh my gosh, I had this really bad outcome. I'm so stressed. I don't know what to do. That's not QI protected. So if you end up getting sued, that's discoverable and that's going to be exhibit A in a plaintiff's case, right? So you want to make sure you limit your emails, you limit your texts, because what we find is that, you know, an experienced plaintiff's attorney is going to say, Hey, did you do any texts?

And they're going to confiscate your phone, especially if it's your personal phone and you don't want to be without your personal phone. Well, they have the opportunity to look through all your stuff, right? So you want to keep all of your communications surrounding a potential

adverse event through your clinical risk management team, through your patient safety team.

So it is protected under that very, very important QI process. That's, I think, really important to hear. I think we're so tied to our phones and to communicating with one another in that way that it's really critical to hear that we should be cautious about what we include in that and in those normal conversations that we all have about cases as we're training.

Yeah, I would just say as a general rule, but first of all, you want to delete stuff, right? Yeah, I'm gonna do it, right? You're not going to keep things because it's transitory, right? We're not hiding stuff, but just as a transitory. So it's okay to delete. But I would just, you know, it's so easy to use abbreviations and maybe have your conversations, you know, less than professional, but just imagine that that is exhibit A.

And you're in a courtroom defending the text that you sent to your colleague. And this is not theoretical, okay? I have defended physicians and nurses who have

had to have copies of their text blown up. And even if it's not damaging, it is so uncomfortable and it's so It's so embarrassing and it's, you know, it just sets it's, it's nasty.

It sets a stage that doesn't need to be there. Right. I think that a lot of, you know, jurors are probably more forgiving today as it becomes more common than it had been, you know, when I practiced, but it's still, it's not a good look. And you don't want to be there with what you wrote, you know, blown up on you know, on a board, right, or on a screen in a public setting and having and being questioned about that.

It's, that's just not fun. So just, you know, to the extent that you can be cognizant about what you're writing and then delete it, like when you're done, delete it. Right. And you just want to make sure you want to practice really good hygiene with your text. Are there any important things to consider if a resident is working outside their normal position at their hospital?

For example, I sometimes moonlight in our medical ICUs and we have residents who have moonlighted

outside institutions. Plus we get residents who work on our teams who come from other programs on rotation. Thanks, Nina. That's a great question, and I think it points out how important it is for residents and fellows to understand what their liability coverage is at their particular employer or institution. Our residents and fellows here at UW are covered by the university's liability insurance that covers negligent acts or omissions of the residents and fellows as employees. As long as they're acting in the course and scope of their duties at their university duties. And so for residents and fellows, there actually may be some.

Other sort of unique activities that they want to consider. For example, trainees may do visiting rotations at other institutions as part of their clinical training program. Some trainees like to moonlight either in their own institution or at another. Sometimes they want to do volunteering types of activities.

And those are situations where it's important to understand

what's the liability insurance coverage when I'm. Participating in an activity like that. So I definitely encourage residents and fellows to reach out to your program director or your GME office to try to understand what coverage is for these types of activities.

At UW, our GME office manages those approvals and it can feel really bureaucratic, like it's a lot of paperwork, but one of the benefits of our oversight of it is that we are accounting for important issues, including. Ensuring that either our liability insurance covers the training activity, or if it doesn't, that the resident or fellow is aware and proceeds with that understanding.

Cindy, maybe we can kind of close out by asking, you know, if trainees undergo this kind of nightmare situation and are named in these lawsuits and involved, to what degree does this go on their record, get reported to their board, their programs, you know, obviously, you know,

sounds like we should be talking to our program directors at minimum.

So the programs will know if this happens, but what happens and, you know, what if you get dropped from the suit? What if you're found liable, you know, all of these things, how does this kind of play out long term and impact people's careers? Yeah, it's a great question. You know, I think about it from a couple of places.

One is, yeah, I think it's worth notifying your program director both so that you have a guide through the process as a resident fellow but also because Your program director is often going to be asked to, you know, do training verifications and things like that. And sometimes those have questions like, was the resident named in a lawsuit?

And so we also want to make sure that the program director actually knows and can answer honestly, because that is an important requirement for them. I think the other thing that I, what I see in my role is, you know, when, when we bring on new residents and fellows. Which we do every year. We do an onboarding process, you know, to make sure that they can practice clinically in our hospitals.

And we'll ask questions like this, right? Have you been named in a lawsuit? Have you, things like that. And I appreciate

that it is stressful and it's worrisome. I, my rule of thumb that I always offer is like, be, answer honestly for a couple of reasons. A really difficult situation is if the resident fellow checks no, and then we pull like MPDB and it says yes, right?

And then we're saying, hey, what, you know, what you checked on this box looks different from what I found and help me explain. And I'd much rather just see someone be transparent than us have to kind of go back and say, why did you misrepresent or worry that someone misrepresented? I think the other thing is, you know.

We know these things happen, right? So it's not going to be totally stunning to see that a resident may have been named to a lawsuit before. I mean, it happens with some frequency. We understand that. And so we're, the fact of it alone is not necessarily going to be problematic. And in fact, we have conversations with trainees who come in and say, Hey, at my prior institution, I was involved in a case.

And then we try to figure out how do you get whatever it is, the release time to be involved or the support from our side of things. So I do want to offer that. It's, you know, it's not, I think, better to be

transparent than have something kind of come up, you know, later, and I think that's the case, even if you were named and dropped, and often what we'll do is say, you know, on our onboarding forms, we'll say, Were you involved?

And then there's a chance to explain. So you can say, I was named early on, and I was dropped before the case went to trial, or whatever. That's fine. I mean, those things happen. I do think there's a separate piece To your to answer your question, which is about reporting and typically, and Lisa, I think a few of some thoughts about this, too.

There are some instances where as an institution, I believe we have a requirement to report to MPDB and but I think we really try to make sure that as an institution, we are doing that in a thoughtful way, such that you know, we're not doing it if unnecessary. I guess, Lisa, do you have thoughts on that?

It's hard to, it's hard to say. I mean, it has, we do have to report, but I think your point earlier, Cindy, is that I don't want to de emphasize saying it's not that big of a deal, but as we talked about the commonality and, you know, we have become a litigious society. So it's, as Cindy indicated before, it is,

it's ever increasing.

And so because it's ever increasing, I don't it's not as concerning as maybe it might have been 20 years ago. Now if you come and you say, well, I've had five, that might be concerning. But, you know, given the fact that that it's just not that uncommon in general, it, you know, it's something, but it's not.

It really, it's not a black mark. That's a lot of times, especially with trainees, they think it's a black mark and they'll never get a job, or maybe they even think I don't ever want to practice again. And that's the toughest part when you get sued as a trainee, because you're just starting your career, you know, and to be hit with this, you know, right off the bat is, is a horrible, horrible experience.

But I think, you know, if you remember anything from this podcast and think about the stats. And to realize you are not alone and those numbers are growing. And so you're not you're really not going to be alone as the time goes by. And, you know, there, there is some solace in that. I mean, we at the university,

we have a, we just started a program at the end of February for physicians that have been sued that they get some peer support.

by other physicians who've been sued. So we have folks who've been there, done that, and they're there to support our physicians and they've walked in those shoes, which is really, really nice. And it's in, you know, and it's just kind of nice to know, you know, your peers have been in this position before and nobody's saying it's fun, nobody's saying it's going to be easy, but just to know somebody else has walked down there, down that road is really, really helpful, I think.

Yeah, if I can, I really agree with that. And at least I've heard you say that one in three physicians will be sued during their career. And, you know, a broader statistic, you know, than surgeons per se, but I think about that a lot. Not, you know, again, we are a litigious society. This is a thing that happens, but it's a helpful frame to remember.

I think as a trainee that This isn't a reflection on your, you know, your skill as a physician. It's not about, you know, whether you're good at what you do, how much you care because you know, you're so

invested in it. It's a fact of life and the better you can sort of equip yourself with knowledge and understanding, right?

And to recognize that it's not uniquely singling you out as a bad resident, right? It's part of practice and the best thing you can do is sort of know it and understand it. Right. And then be prepared if something does happen. I think that's a it's trying to reframe a little bit of this because I think that's, it's, it can be very vulnerable.

Otherwise, it can be very vulnerable regardless, but you can you know, think about it a little differently. Well, I, I don't know that there's a better note to end on than that. I think, you know, I've learned a ton from just meeting with you guys and talking with both of you over the course of preparing for this.

And hopefully this will, you know, expand and provide some baseline of knowledge for our listeners today about the fact that this happens and the fact that there are structures in, in play that can support people through it and that there are others who have been there before and have gotten through it just fine.

So I want to thank both of you for taking the time and effort to educate us all about this. This was incredible for me and

hopefully our listeners agree with that. Well, again, thank you for the opportunity. Really appreciate it. Yeah. Great. Thanks very much.