Book reviews – Bouncebacks medical and legal

Below are the book reviews from JAMA, EP monthly, and Annals of Emergency Medicine:
Book and Media Reviews|August 8, 2012
Bouncebacks! Medical and Legal
Randall S. Hanson, JD
JAMA. 2012;308(6):626-626. doi:10.1001/jama.308.6.626
By Michael B. Weinstock and Kevin M. Klauer
290 pp, $49  
Columbus, OH, Anadem Publishing, 2011    ISBN-13: 978-1-8900-1874-0
Bouncebacks! Medical and Legal is a thought-provoking book engaging a synoptic view of the intersection between law and medicine. The practice of law and the practice of medicine are inextricably intertwined; still, their respective methods of analysis suffer from a logical disconnect. The medical world uses retrospective review of care for the purpose of quality improvement—ie, to learn from prior outcomes and improve care in the future. Legal analysis seeks to evaluate the root cause of a problem, not for the purpose of quality improvement, but to redress perceived wrongs that have befallen the patient. Bouncebacks! addresses this issue head on through analysis of emergency department case studies.
The text opens and closes with a brief discussion of how a lawsuit works. Although the descriptions given are simplistic, they provide an overview of the process, the players, and the general time frame involved in medical malpractice litigation. For physicians fortunate enough to not have any personal experience in the courtroom, it is a primer on how the process works. It is not overburdened with legal vernacular but provides basic information that most physicians would find helpful.
The vast majority of the text is developed through case studies that provide in-depth analysis of 10 different emergency department presentations. Although this is not atypical of a book discussing emergency medicine, Bouncebacks! provides not only the medical analysis but also a multifactorial view of individual patient presentations. The authors astutely recognize that medical malpractice cases are rarely generated from the obvious presentation. Myocardial infarctions occurring in patients who present with classic signs and symptoms of an acute coronary syndrome are rarely missed. Patients who present atypically or who have commonly seen symptoms with uncommonly dangerous ramifications are the ones who tend to fall through the cracks. The case studies focus on subtle presentations of life-threatening illnesses.
Each case study contains references to (and sometimes scans of) the most important portions of the medical records to provide background and substance. The most intriguing aspects are the additional perspectives used in evaluating each case study. The authors bring in the perspectives of not only the physician caring for the patient but of other players in medical litigation. The authors use testimonial clips of key witnesses, including the plaintiffs and the defendant physicians, to provide context for the legal analysis. Each case study provides insight from the plaintiff ‘s and the defendant’s attorneys. This is accomplished through interviews with the attorneys and, in some cases, paraphrasing of opening statements and closing arguments. The perspective of the attorneys actually trying the case provides depth to the analysis of how the case may be perceived by a jury and not just how it will play out in a morbidity and mortality conference. Testimonial summaries illustrate the emotional pleas of plaintiffs and the factual medical analysis of the defendants—the stark contrast seen in nearly all medical malpractice litigation.
Medical malpractice claims typically turn on the testimony of expert witnesses. The authors of Bouncebacks!provide an objective analysis of the interplay between experts on both sides of each case. Along with the experts engaged by the parties in the case, the authors also call on other experienced emergency department physicians and malpractice attorneys to provide additional analysis of the care provided and the potential pitfalls at trial. Critical analysis is made of the risk factors for each patient and how the emergency department physician documented the patient’s presentation and differential diagnosis.
Last, the authors evaluate the overall care provided to the patient in the emergency department from several perspectives. The authors provide takeaway points for physicians to consider in balancing good medicine with risk avoidance. In most medical malpractice cases, good documentation and communication are an integral part of that discussion. The authors reveal the actual outcome of the litigation but independently analyze whether, in their opinion, the case should have been settled or tried by a jury—weighing the risk of an adverse verdict; the quality of experts; the dynamics of interplay between physicians, attorneys, and insurance companies; and the potential for sympathy and a runaway verdict.
Bouncebacks! Medical and Legal is an insightful and pragmatic analysis of emergency department malpractice litigation. The authors provide the reader with interpretive perspectives from all sides of patient care—the holistic view ultimately evaluated by a jury. The lessons presented are a good reminder for any practicing physician.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Book and Media Reviews Section Editor: John L. Zeller, MD, PhD, Contributing Editor.

“Bouncebacks” Book Offers Readers a Retrospectoscope

by William K. Mallon, M on March 26, 2012

// What would you do? A new book dissects “bouncebacks” in the emergency department, turning nightmare ED scenarios into Holmesian teaching cases.

The second installment of “Bouncebacks!” is now out with an all new format, and all new cases. All the cases are real with the actual ED chart, the contemporaneous nursing notes, the vital signs, the test results all laid out with the relevant time stamps. In each case the patient will return for an unscheduled ED follow-up visit and that bounceback visit is the beginning of a bad outcome that leads to a medical malpractice suit. The raw case presentation data is then integrated with the court transcripts, detailed medical analysis, expert witness testimony, and a legal analysis. What takes place over 2-5 years in real life is condensed into a chapter that reads in 10-15 minutes. The format mimics the TV series “Law and Order” where you get a look at the detectives working the case and making an arrest (that us, the EPs investigating a patients problem, treating them and making a disposition), and then the prosecutors go to trial (here it’s the legal analysis, court transcripts, expert witness analysis, and legal outcome).

The book is like an M&M (Morbidity and Mortality) Conference on steroids allowing unique insight to the cases and what went wrong. M&M, also known as Death and Doughnuts, is always a favorite during residency grand rounds (assuming its not your case) and this book brings it all back in full color. As each case unfolds you’ll hear echoes of your last shift, uncomfortable recollections of a patient you recently sent home, or maybe should have done an LP on, and now there is uncertainty buzzing in your head like a fly trapped against a window on a hot summer day. Pull up a comfy chair, and get some coffee while you delve into this non-fiction horror novel. Stephen King couldn’t cause a more ominous, profound sense of foreboding than Weinstock and Klauer do for their readers. With each case, you picture yourself trying to see 3 patients an hour, getting interrupted 10 times per patient visit, juggling lab critical values, fielding phone calls and paramedic runs, and in so doing missing a few key facts that change an “obvious” bronchitis into a sub-acute MI with failure, and a “benign” headache into a subarachnoid bleed.

Obviously, each case has a poor outcome for the patient because “damages” are necessary fuel for a legal action. This fact drives home the seriousness of every day medical decision-making and the responsibility we all bear providing emergency health care. Furthermore, these cases are NOT critically ill, obviously sick ones (those would all be admitted), but are instead relatively well appearing patients harboring a serious medical diagnosis needing prompt attention. They are the proverbial needle in the haystack. While it is true that most headaches ARE benign, and most people with a cough, sputum, and chest pain have bronchitis, these cases show just how subtle the clues to a more serious problem can be. As you read each case (with forewarning that its all going to blow up) you feel empathy for the physician who “missed” the diagnosis, and sympathy for the patient and family who faced the tragic result. It’s not easy to find a needle in a haystack, but if you don’t it may stab you!

Generally speaking, I think we spend too much time “teaching to the tort”, letting legal cases set the “standard of care”, and letting our fear of malpractice rob us of the joys of seeing and treating patients. Medico-legal fears cause some physicians to see their patients as “dangerous” or as the “enemy”. Having noted that, “Bouncebacks!” mitigates the damage by sharing personal backgrounds for the patients and humanizing them, and to be sure the plaintiff does NOT win every case (even though every outcome is bad). Teaching to the tort does have a role in medical education and “Bouncebacks!” does a good job. The book is particularly illuminating regarding the legal world which surrounds our practice. For most, that world is largely unknown (fortunately) since only about 1/15,000-20,000 ED cases result in a tort, and many of those do not go to court. You learn a lot about how an expert decides if the case is defendable and how the attorney puts the defense together. Sometimes very small details are critical to the legal outcome. Notable experts from our world weigh in as well including Greg Henry (you can hear his voice already), Bob Bitterman, Jerome Hoffman, Steve Colluciello, Dave Talan, and Amal Mattu to name just a few. The result is a very readable fast-paced expose of Emergency Medicine malpractice.

“The good doctor learns from their mistakes, and the great doctor learns from the mistakes of others”. If that is true, then “Bouncebacks!” is a must read.

Dr. Mallon is an Associate Professor of Emergency Medicine at the Keck School of Medicine at University of Southern California.
Disclosure: Two of the authors of Bouncebacks! Medical and Legal – Drs. Kevin Klauer and Greg Henry – are affiliated with Emergency Physicians Monthly as editors and writers.



Bouncebacks! Medical and Legal
Review by Nadia Huancahuari, MD
0196-0644/$-see front matter
Copyright © 2012 by the American College of Emergency Physicians
Bouncebacks! Medical and Legal
Weinstock MB, Klauer KM
Anadem Publishing, Inc, 2011
312 Pages, $49
ISBN-13: 978-1890018740
ISBN-10: 1890018740
Bouncebacks! Medical and Legal takes the reader along an
enlightening educational journey beginning with deceptively
well patient visits, followed by the feared patient “bouncebacks”
with their unexpected bad outcomes, and ultimately
revealing the courtroom proceedings that arose from the
encounters. The reader can expect to delve into cases beyond
the typical morbidity and mortality conference format and into
a detailed medicolegal reality that few emergency physicians
truly understand. Because casual conversations about personal
experiences with malpractice litigation are legally discoverable,
we often miss the opportunity to learn from one another’s
experiences in this essential and somewhat mysterious realm of
medical practice. This book offers just that: concise medical and
legal education about malpractice cases that is sorely needed and
desired by today’s emergency physicians.
In this second volume of the Bouncebacks! series, the authors
begin by summarizing data from the bounce-back literature and
providing malpractice statistics that reinforce the importance of
this topic. Each of the 10 cases offers a section on the patient’s
story, the physician’s version (including actual photocopies of
handwritten documentation), and the bounce-back with its
shocking outcome. The sections that follow the case explain the
malpractice accusation (cause for action), include expert
commentary on facts affecting the decision to proceed to trial or
settle, display subsequent transcripts from the proceedings, and
reveal the final judgment.
The medical section of each case can be anxiety provoking
because the patient descriptions remind readers of their own
daily encounters in the emergency department. Readers will
cringe as they turn the pages because of the anticipation that a
terrible outcome will soon be revealed. This section is packed
with pearls to improve patient safety, such as being aware of
diagnosis momentum, documentation contradictions, and
unaddressed abnormal vital signs, to name a few. These pearls
are followed by a brief and practical description that allows the
reader to implement them into their own practice at the very
next shift.
The legal section of each case allows the reader to enter into a
world in which terms such as “burden of proof” and “proximate
cause” are clearly defined while remaining open to
interpretation within the context of the case. The legal expert
commentaries methodically discuss the factors that influence the
decision to go to trial or not. It is surprising to learn that some
of these factors include nonmedical issues such as the
believability of the defendant or a plaintiff-sympathetic jury.
Last, the transcripts of the proceedings create a realistic
experience and give the reader clear insight about how events
may unfold when a case proceeds to litigation.
Bouncebacks! Medical and Legal should be mandatory reading
for all involved in emergency medicine. In a specialty that is
incredibly rewarding yet fraught with medicolegal danger at
every encounter, we often have only minutes to hours to
diagnose and properly treat a wide spectrum of disease
processes. Although this book emphasizes the importance of
skills such as communication, proper documentation, and
reassessing patients before discharge, it also pulls back the veil to
vividly describe the legal ramifications one may face if these
skills are neglected.
Nadia Huancahuari, MD
Department of Emergency Medicine
Brigham and Women’s Hospital
Boston, MA
248 Annals of Emergency Medicine Volume , .  : August 

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