Full Transcript Conflict in Healthcare and the SPARC Framework 0:03 If [music] you work in healthcare, you already know this. Conflict is 0:07 everywhere. In the O, [music] in labor and delivery, in committee meetings, 0:14 between physicians, nurses, administrators, and teams that are all 0:20 trying to do the right thing. But here's [music] the problem. Most of us were 0:25 never trained to handle conflict well. We learned procedures. We learned 0:31 diagnostics. But we didn't learn how to [music] 0:34 navigate the moment when Q professionals strongly disagree. 0:40 That's why I developed the SPARC framework. Spark stands for stop, pause, 0:49 ask, don't assume, reflect, and respond, 0:54 and create a path forward. It's a practical [music] system designed 0:59 specifically for highstakes healthc care environments 1:03 through keynote [music] talks, residency workshops, and spark master classes. I 1:09 teach physicians, [music] nurses, and healthcare teams how to turn 1:13 destructive conflict into productive [music] conversations that strengthen 1:18 teams and improve care. If your hospital, residency program, or medical 1:24 conference is looking for a speaker on conflict, communication, [music] 1:28 and leadership in healthcare, I'd love to work with you. You can learn more in 1:34 the show notes. Because in medicine, conflict is inevitable, 1:40 but handled well, it can make teams stronger.
Episode Introduction and Guest Background 1:51 Quick question. Are you paying more in taxes than you should? Most high earning 1:57 physicians overpay by tens of thousands [music] because their CPA only looks 2:01 backward, not forward. Guilt is different. Dedicated CPAs powered by AI 2:09 [music] that work year round, not just at filing time. tax [music] strategy and 2:14 proactive planning for practice owners, investors, [music] 2:18 and physicians with complex financial lives. Built specifically for 2:24 professionals who want to keep more of what they earn. Check out joing 2:30 guilt.com. That's j o i n gt.com. 2:37 Before we begin today's conversation, I have one important request. If you 2:42 haven't already listened to episode 51, the invisible hands on the scalpel, I 2:48 encourage you to pause this episode and start there. In that episode, we explore 2:53 a powerful idea that the forces that are shaping medicine today are far more 2:59 reaching than what goes on in the operating room, the office, or the 3:04 hallways in hospitals. There's malpractice, 3:09 administration, insurance, all affecting the decisions that we make every single 3:14 day. Those unseen influences affect not only patient care, but also our 3:19 relationships with our colleagues, our leadership, and the conflicts we 3:24 experience in medicine. Today's guest, Dr. Steven Cohen, brings this concept to 3:30 life. Our conversation today builds directly on the foundation laid in 3:35 episode 51, exploring how the world of medical malpractice affects our surgical 3:40 judgment, our communication, our professional growth in our ability to 3:46 provide care to patients. If you've already listened to episode 51, welcome 3:51 back. You're exactly where you need to be. This is part one of my conversation 3:58 with Dr. Steven Cohen. 4:04 >> [music] 4:08 >> In every operating room, in every [music] ward, in every clinic and every 4:12 team meeting, a silent battle bruise, conflict, negotiation, 4:19 identity. [music] Welcome to the Scalpel and Sword 4:22 podcast, where I, Dr. Lee Chararma, physician and conflict analyst, [music] 4:26 explore the hidden negotiations beyond modern medicine. Let's trade burnout for 4:31 boundaries and learn the art of healing with precision and [music] power. 4:41 Hello my peaceful warriors and welcome to the Scalpel and Sword podcast. I'm 4:46 your host Dr. Lee Chararma, physician and conflict analyst. And if this is 4:51 your first time listening to the Scout of the Sword, welcome. I'm so glad 4:54 you're here and joining our ranks. But if you've never listened before, I would 4:59 love for you to pause this episode and go back and listen to episode 51, which 5:04 is called the invisible hand on the scalpel. And we get in that episode into 5:10 the idea that there are so many forces that are shaping medicine. And 5:14 unfortunately, these are forces that are not just led and directed by us as 5:19 health care professionals. It's administration, it's insurance, and 5:24 very, very importantly, medical malpractice and the concept of it. And 5:30 there is nobody I can think of that I'd rather have the conversation about how 5:33 this is shaping healthcare than our guest today, Dr. Steven Cohen. Dr. Cohen 5:38 also has an MBA. He is well-versed as an expert witness. He is the chief of 5:45 general surgery at the Veteran Administration Hospital in Richmond, 5:48 Virginia. He's also on faculty at the Virginia Commonwealth University. He has 5:53 spoken to numerous audiences and if you do not follow him on LinkedIn, please go 5:58 follow him. We will put his LinkedIn tag in the show notes because the things 6:02 that he talks about definitely are things that we all need to be looking at 6:06 as physicians. Stephen, welcome. >> Thank you. I'm excited to be back again 6:11 for another fun episode. >> You are the first repeat guest on 6:16 scalpel and sword. So, you are the first to get that designation. When I did this 6:21 episode on the invisible hand on the scalpel, I don't think I was prepared 6:24 for the amount of attention that episode would draw. I had so many people reach
How Malpractice Changes Physician Behavior 6:30 out to me saying that episode resonated with them. I actually did have a guest 6:34 say, "I want to do an episode with you talking about the effect of insurance." 6:38 But that guest is anonymous. That person would not identify themselves because 6:42 they were really giving very insightful comments about the effects of insurance. 6:46 And when I floated this idea to you, we were talking about this before we 6:49 started recording. You sent me a two-page document about all of the ways 6:55 that you see that medical malpractice has shaped healthcare. So, this is 6:59 something that you've obviously spent time thinking about. 7:02 >> Yeah, I've now been in practice 33 years. I have been on plaintiff cases. 7:08 I've been on defense cases. And oh, by the way, I have been suited five times. 7:13 So, I've seen the emotional toll that it takes on all of us. And one of the 7:18 problems is this is a topic that nobody wants to talk about, right? Because when 7:23 you get served the lawsuit, you're told, "Don't talk to anybody." And the shame 7:29 and the fear and the disappointment. I mean, you go down a rabbit hole of I'm 7:34 the worst doctor ever. You feel like you did everything right because, as you 7:39 know, most malpractice cases are bad outcome. They look at it with 7:43 retrospective analysis and they don't put themselves in the provider at the 7:48 time what he or she knew. And that's the only way that you should look at these 7:52 cases because I've said it a hundred times, outcome is irrelevant in standard 7:57 of care. you can do everything right and you can still have a bad outcome. 8:02 >> There's so much in there that I think really does and we talked about this, 8:06 you know, the effect of medical malpractice is not just systemic. It's 8:10 on the individual and it's a profound effect on the individual. And I think 8:16 people like you, people like Gita Pensa and the work that you guys are doing, 8:20 you are really shining a light on that very concept. The idea that going 8:25 through a medical malpractice process, we feel so much shame. We are so hard on 8:31 ourselves, we really do like, I really thought I did everything right, but then 8:35 you start to question every decision you make after that because it's like, well, 8:39 if I did everything right and this can still happen to me, I mean, my gosh, how 8:44 can I do anything else? And I think especially as surgeons, that resonates 8:48 so hard with us. So, you've spent a lot of time not just being the witness, but 8:54 you've also been in that place as well. Which one of those do you feel like had 8:59 a bigger impact on you as a physician? Being the witness or going through that 9:03 malpractice process? >> Oh boy. I mean certainly going through 9:07 the process you understand and you know the first one's the hardest but after 9:12 that you realize and I've said this a lot much to the chagrin of both sides 9:17 defense or plaintiff it's a game to now right it's a game because the rule and 9:23 the object for either side is to win even if it's on a technicality and the 9:29 problem I've done a ton of defense cases where the outcome is the patient died 9:35 that's a problem, right? Again, I can do everything right. Patient dies, it's a 9:40 problem. So, it's the catastrophic outcome. And remember, as a surgeon, I'm 9:45 the one that told the patient they need an operation. They walked into the 9:48 office to me, they have a colon cancer. We talk about the risks and benefits of 9:54 surgery. We see them pre-operatively. We see them through surgery. They're in the 9:59 hospital two to a week. We see them in the outpatient. And when there's a 10:03 problem, we feel that, right? No physician goes out to harm a patient, 10:07 right? But sometimes on the plaintiff's side, they make it seem like you 10:11 purposely harmed the patient, right? Because they're using the emotional 10:15 connection if and when they get to a jury to make their case. 10:20 >> And that emotionality, that emotional connection that they're using for that, 10:25 that is something we feel so deeply for our patients. But as you said, for the 10:29 attorneys, it's literally the game. And I think the first time that I really had 10:34 this sort of light shine on this. I was talking with you before, my daughter's 10:38 an attorney, and before she started when just living in in all of area, there 10:43 were attorneys who were kind enough to let her follow them. So, she's in 10:48 probably early college and she's following these two attorneys that are 10:52 doing a divorce proceeding and they're screaming at each other. They're yelling 10:56 at each other and Rachel's, "Oh my gosh, this is so toxic. This is so terrible." 11:00 And then after it's over, the attorney that she was shadowing says, "Hey, do 11:04 you want to get lunch?" And Rachel's like, "Okay." And who comes with them? 11:07 The other attorney that she was yelling at 10 minutes ago. And they're joking 11:12 over having chicken salad, nice tea, just like they're big friends because 11:15 they are. And then they go right back into it in the afternoon. And those are 11:18 the things that we don't see as doctors. That transparency. We understand the 11:22 idea that transparency is necessary in medicine. I think I agree with you that 11:27 early on with malpractice, we were told to shut up. If that's something you're 11:30 going through, don't talk about it. Don't tell it. And so when your 11:33 colleague would come to you and say, "Hey, I need to share with you I'm going 11:36 through this malpractice process." And they're not sharing that with anybody 11:39 else cuz they were told not to. That lack of transparency just compounds the 11:43 shame and the isolated feeling that we get from going through that process. But 11:48 we don't get to see the gamification that the attorneys have going through 11:52 that. >> Exactly. And again, I feel more 11:55 comfortable in an operating room than I do in a courtroom. Right. It's not my 12:00 world, right? I don't understand all the legal terms. They throw out these things 12:04 and the different jurisdictions have different rules, things they can bring 12:07 up, things they can't bring up. And we've all watched TV, right? You see 12:10 these Law and Order shows. Why can't they talk about that? that might be 12:14 relevant to one side or the other, but it's an unknown for people. I actually 12:19 give a talk every year to the residents about what it's like to get sued. 12:23 They're all scared to death, and that translates to how we take care of 12:26 patients. And we talked about that before. It's ordering more tests. It's 12:31 getting more of the medical doctors involved. They have a fever, get 12:35 infectious disease. That doesn't prevent lawsuits, but certainly the way I
Documentation, Training, and Informed Consent 12:40 practice now that my previous lawsuits has shaped how I do it, when I do it, 12:45 what I tell the patient, my documentation has gotten a lot better. I 12:49 can tell you that some of the cases I review, that's the thing that saved the 12:53 surgeon. They documented so detailed. Not just abdominal pain, I'm treating 12:58 one, but how are you ruling out the other things, right? That's really, 13:02 really important. And I try to emphasize that to the residents that someday that 13:07 routine operation, somebody may blow it up on a screen and have 12 people that 13:13 have no idea about medicine, which is not their fault, to determine what you 13:17 did and why they did it. >> Yeah. So this is one of the things that 13:21 I think this also too when you talk to a lot of plaintiff attorneys that do this 13:26 work. One of the things I've heard some of them say is that they have had 13:30 physicians that have called them after being sued by them and said, you know, I 13:36 forever now change how I document how I practice. I change how I do X thing 13:41 because this was the thing I was sued about and now I no longer do it this 13:44 way. And so one of the arguments that I think that comes out of the medical 13:47 malpractice industry and specifically with claim attorneys is that they do 13:52 help to make the clinical practice of medicine better and more precise. 13:57 They're essentially making us better doctors. And so I don't want to call it 14:00 a justification, but that's sort of the reason why that they do what they do. So 14:03 you definitely sound like you've seen that in your own practice, not just as a 14:07 physician, but as a witness. >> Oh, absolutely. And one of the things I 14:10 talk about to the residents and everybody thinks that when you get sued 14:13 the first time, you're done. Your career is over. If there's a settlement, you 14:18 get reported to the National Practitioner Data Bank. That's a black 14:21 mark. That is really not true. Again, I've been sued five times. Two of them 14:26 were dropped. Three of them were settlements. And remember, settlement 14:30 doesn't mean you did anything wrong, right? 90% of medical malpractice cases 14:35 in this country settle. There's a lot of different reasons for that, right? One 14:40 of the reasons is it's a business decision for them. For the defense 14:44 attorneys, they're paid hourly. Plaintiff attorneys usually are not paid 14:48 unless they win, right? So, they're usually more aggressive. And I've talked 14:53 to defense attorneys and I want them to be a bulldog, especially if they're 14:56 defending me. I feel like when I'm on the defense side, I'm defending myself, 15:00 right? Electomy. I did two recent cases, diverticulitis, surgery was indicated, 15:06 everything was perfect in surgery. Patient went home on day four. Two days 15:10 later, leak at the anastmosis, sepsis, and died. And I had to tell the 15:14 plaintiff attorney, there's no breach. I know it's a bad outcome. It's a terrible 15:19 outcome, but most leaks serve days 7 to 10. The patient met discharge criteria. 15:25 Operation was indicated. They did everything right. What I'll tell you is 15:29 I get some criticism obviously from my colleagues for talking to plaintiff 15:32 attorneys, but about 40 to 50% of the time, like the case I just said, they're 15:38 not going to get sued, right? Because it's not a breach in the standard of 15:42 care. But there's a lot of different reasons why cases are settled and we can 15:46 go into that even if you do everything right. A lot of times it's not up to us. 15:51 I said to my defense attorney, I did nothing wrong. I have experts on my side 15:55 that said this is how we manage patients. Yes, it's a bad outcome. 15:59 Defense attorney and the insurance adjuster which is usually make the 16:03 decision says we can save money if we just so and you don't have a lot of say. 16:10 They told me if you want to go to trial and the jury finds against you and it's 16:13 above your maximum, you're writing a check for that. What doctor is going to 16:17 say that? >> Right? There's no way, right? Just like 16:20 car insurance. That's why you have it. Another colleague said to me, "If you 16:23 can solve a problem by writing a check, definitely write the check." And it's 16:27 not your money. You're paying the money in. But 16:30 >> right, >> certainly it's not the end of your 16:32 career being on the national practitioner datab bank. Patients don't 16:36 have access. It's only people have access to that if I get asked on 16:40 deposition or if I go to apply to another job, another hospital. I've been 16:44 on credentiing committees. I've seen lots of doctors sue. you justify it. 16:48 What happened? Why? And it's really not the end of your career. And that's 16:52 important because everybody feels like it's going to be. 16:55 >> Yes. And I also think it's so great that you actually talk about that because I 16:58 do think so many people carry that fear with them into the operating room. They 17:02 carry it with them into the clinic. And so the message of yes, this industry 17:08 exists, yes, this happens is not career ending. It is not something that's going 17:13 to take that away from you. I think is a really important message. So people 17:16 don't know that. also because you we're talking about the economics of this 17:19 process and I think that's something that if you're talking about the effect 17:22 of medical malpractice and litigation on health care you have to get into the 17:25 economics of it the idea that if we are ordering more tests if we are doing more 17:31 things if we are getting more consultants doing a little more of this 17:34 than maybe we did before maybe had that awareness of hey I had a colleague who 17:38 got sued for X so let me just go ahead and make sure that I've thought through 17:41 that is that a significant financial pressure on our healthare system what 17:48 medical malpractice has created >> there has been studies that's looked at 17:52 that it's not significant it is a driver of health care costs but it's low it's 17:57 not as high as you would think and I think the reason being is that even in 18:02 training right if you have somebody with abdominal pain comes to the emergency 18:05 room they're getting a cat scan right I think the process in the last 30 years 18:10 has changed of how we manage how we work up what we look at 30 years ago we never 18:15 did a cat scan for a app to appendicitis, right? It's a clinical 18:18 diagnosis. Yes, we took out a lot more negative appendecttomies, but we didn't 18:23 miss it. >> Back 30 years ago, 20% negative 18:26 appendecttomy rate was reasonable. We didn't do cat scans. We did them 18:30 occasionally. But now everybody gets them. But even then, right, I recent 18:35 case patient came in with classic signs of appendicitis. CAT scan was normal. 18:41 Patient got better with a GI cocktail. went home two days later a perforated 18:45 appendix. Right? So you could do all the rag tests and still miss it. I don't 18:49 think that's a breach of the standard of care. Patient met discharge criteria. 18:53 The ER doctor did everything right. Ran it by the surgeon said, "Look, it's 18:56 normal. Patient's better. CAT scan's normal. White count's normal. Their pain 19:00 got better. What else are you supposed to do?" Yet that's going to be a 19:04 malpractice case because they're going to look at it retrospective reasoning 19:08 that came back two days later, obviously miss it. 19:11 >> Yeah. And I think it's so important to 19:14 emphasize and I'm glad you emphasized it. This idea that outcome is not 19:19 necessarily an indicator of malpractice that clinical courses are clinical 19:24 courses, things happen, presentations occur. And what our most important thing 19:28 is that we do as clinicians is we do our due diligence with workup with history 19:34 and especially in terms of surgery that we are making sure that we are bringing 19:38 the patient into that collaborative decision-making process. That's it. 19:41 Probably one of the things that she talked about when you had sent me your 19:44 response that I was like, "Oh my gosh, I can't wait to talk to you about this is 19:47 the concept of medical malpractice changing us from a more paternalistic 19:52 style of medical practice to something that's more inclusive in terms of 19:56 informed consent with the patient. So do you see Medau as being a driver of how 20:02 that occurred because it definitely occurs now." 20:05 >> Oh, there's no doubt joint decision-m is very important. You have to explain and 20:11 this has come up in some other cases I reviewed where you know it's risk 20:14 benefit ratio of the procedure itself whatever we're doing but also what's the 20:19 outcome if you don't do the procedure right does a patient have enough 20:22 informed decision of what happens and I another recent case that I did a patient 20:28 had a very small carcinoid tumor of the distal appendix it was completely 20:34 excised there was some question of this t-staging 20:39 And the surgeon said you need a right callectomy. 20:43 What happened? Right callectctomy bleak sepsis death. Right? But again I'm not 20:49 looking at the outcome based on the guidelines. When you look at that 20:53 informed consent we know a carcinoid tumor less than 2 cm there's no outcome 20:59 in life expectancy. Nobody was told that. He was just told he needed 21:03 surgery. So that became an informed consent 21:06 >> issue where you didn't explain what happens if I don't have surgery right
Checklists and Surgical Safety 21:10 and that's very important obviously if they have colon cancer there's no option 21:14 right certain things there's no option but I do a lot of benign disease I do 21:18 rectal prolapse surgery I do fecal incontinence I do functional 21:21 constipation you don't need surgery you can live forever with that and I think 21:26 that's really important especially in surgery when you're talking to patients 21:30 about what the risks of surgery are but what are the risks of not doing the 21:34 surgery. That's really important that you need to document that and that has 21:38 saved a lot of physicians when they did have a bad outcome that it was a 21:41 collaborative joint decisionmaking and the patient opted for that. That's fine. 21:46 Both of those are within the standard of care for sure. 21:49 >> We've come back to this topic and you've mentioned that is it made you a better 21:54 document. I had mentioned before we went on mic about one of my daughter's law 21:58 school classmates Trevor Allen who is now in St. Lewis who was an EMS provider 22:03 before he went to went to law school and actually did some medal work and when he 22:08 was on the podcast that was one of the things that he talked about is like he 22:11 honestly had such a better eye to documentation because he had been 22:16 through a process of legal education. He understood how important it was and as 22:21 an expert witness having been through this process you understand it as well. 22:25 Is it possible to communicate that to clinicians who haven't been through this 22:29 process? More or less just because I've been through it. I know how scary it is. 22:35 Yes, I'm an expert witness. I would still rather be in an O than a 22:37 courtroom. Let me show you how you can document so that this doesn't happen to 22:41 you. Is that a message that people receive when you give these lectures? 22:46 >> Oh, absolutely. But I really think that goes back to the teaching, training, and 22:50 educating that I do every day to the surgery residents because that was 22:54 taught to us when we were a resident, right? And I think part of the problem 22:58 is the way that most of us practice, not me now in the VA system, 23:04 >> but if you're an RVU based and you're working with residents and it's mortases 23:08 or surgery and your salary sides that you may not let the resident do a lot of 23:13 that stuff, right? In our facility, I want the resident to dictate it. I'm not 23:18 signing off on it till I read it, make sure it's accurate. They miss lots of 23:24 things because they're not used to dictating cases and then I go over it 23:27 with them. So, that really needs to go back to the education. But we should 23:31 give them that, right? They should know that there's certain things in surgery 23:35 with procedures, what standard of care, you're doing a right callectomy, did you 23:40 see the right urer, did you see the douadum, right? Did you make sure all 23:43 the lap pads were out at the end of the case? Those types of things that are to 23:48 me surgery 101 when you're teaching residents how to do surgery should be 23:52 taught at that level. But the problem is a lot of the cheap residents that come 23:56 through, you know, even at month 58, 59, 60, the last three months, they don't 24:01 know how to dictate an operation. And that's a problem, right? Because they 24:06 haven't done it, >> right? It's a problem because now you're 24:09 in practice. Now you're in charge. You have to dictate. you miss some key 24:13 steps, there's going to be the problem. So, I think it goes back to the 24:17 educators to really emphasize that and teach them. I mean, my only job when 24:23 they spend five plus years with me and the rest of the group is to create safe 24:28 surgeons. Well, creating safe surgeons is knowing the preop indication, knowing 24:32 what to do in surgery, knowing to look for the posttop complications, right? 24:36 and learning who's sick because you could have a patient on posttop day 24:40 three that doesn't look so bad. Well, the creatine's up a little bit. They 24:44 have a little bit hypotension. They relate it to dehydration. 24:48 Dehydration, your posttop day three, you've been giving them three liters a 24:51 day. They're not dehydrated. What are you missing? Are you missing the PE? Are 24:54 you missing the little leak? Are you missing the abscess? So, I think it goes 24:58 back to education. And I think we need to do a better job when we have them to 25:03 prepare them for day one. they're ready to go. And I think it's different now. I 25:09 hate to say it was better 30 years ago, but I think it was better 30 years ago 25:13 because we were given a lot more autonomy. Believe it or not, 30 years 25:17 ago when I was in the operating room, the attending surgeon did not have to be 25:21 in the hospital. God helped the patients when I was an intern doing something on 25:25 my own. The chief resident would take me through it. But now that's impossible. I 25:29 have to be in the room the whole time just about. Right. So it's not 25:34 different. And if I'm in the room, I'm old and cranky and I have no tolerance 25:39 and I'm impatient, I'll take over the case, right? But that's not good 25:43 training for them, right? So surgical training, I think, has suffered 25:48 somewhat. We do the best we can to try to prepare them so they're safe, 25:53 reliable surgeons at the end of the day once they graduate. 25:57 >> I'm going to 100% agree with you. I get medical students. I actually have a 26:01 medical student starting in my service tomorrow and I had a bit of a gap in 26:04 having them because the medical students I was getting that were fourth years. 26:08 They couldn't write a progress note. They didn't know how to write a 26:13 prescription. So, you know, I have them in clinic and you know, we're seeing, 26:17 let's say, for example, a vulvar lesion and it's like, okay, so I'm going to 26:20 document in my note that they have no crepitus or no anesthesia. Tell me why 26:23 I'm documenting that. >> And they kind of look at you. It's like, 26:27 >> yeah, >> okay, let's talk about necroizing 26:28 fasciitis. Let's talk about why you need to make sure that that's not what the 26:31 patient has because that would be the worst case scenario. Whoever's reading 26:34 this note 20 years from now needs to know that I thought about that and this 26:37 is why I'm putting this in the note. And then the first time I sit them down when 26:41 they're coming with me to surgery and it's like, okay, have you written an 26:43 optoote? No, we're going to learn. And the problem is that does take you longer 26:48 if you are the person who's the educator. It does take you longer. Yes, 26:52 you could do it in a minute and a half, but this person needs to learn how. And 26:56 that means you do have to stand there for a few minutes. And I actually had a 27:00 guest on the podcast a few months ago who said that the five or 10 minutes you 27:04 are investing in that person's training is going to be your work release 15 or 27:10 20 years from now. >> And you need to look at it that way. You 27:14 need to look at it as you're taking the sum of your life experience, whatever 27:18 experience you've had with medical malpractice, everything. You are going 27:20 to take that extra 10 minutes and you are going to teach that to that medical 27:24 student, intern or resident because you know that the dividend for that is 10 or 27:28 20 years from now. You are creating an independent safe practitioner. And we 27:33 have to make that switch as educators that tag Nebbit, I could do this in 10 27:38 minutes. I really can. And then you really have to say to yourself, but dang 27:42 it, I'm not gonna be practicing 10 years from now. I need to have safe people who 27:46 can replace me. So, I 100% agree with you. I think that the way that we 27:51 provide medical education has changed, but it doesn't mean that we can't still 27:55 create safe, effective clinicians. It's just a question of how we're doing that 28:00 in our current system. >> Well, I think you have to look at it. If 28:04 you decide to be an educator at a teaching hospital, that is one of your 28:08 responsibilities. You don't have to be in a teaching hospital. I spent 20 years 28:12 in private practice. I did have some residents come through. When I was in 28:15 Atlanta, but I was at the private hospital half the time. I didn't have 28:19 residence. So, that's a whole different ballgame. You don't have to be an 28:22 educator. You don't have to be a teacher, but if you're going to do it, 28:25 you need to take that responsibility seriously. One of the things I say every 28:29 month when I see the new nursing students on the floor, I always stop, 28:33 introduce myself. I say, "Make sure you all know how to put the folding catheter 28:38 in. One day you're going to do that to me and I want you to do it right." Hey, 28:42 L. That's funny, but it's the truth. >> Right. 28:45 >> It's the truth. I'm going to be on the table someday and I want to make sure 28:48 when I'm looking up that person knows what they're doing. 28:50 >> 100%. Another thing you talked about when you sent me this document is the 28:55 idea that the presence of lawsuits accelerated adoption of processes that 29:00 helped with surgical safety. But one of the things that you mentioned was the 29:04 WHO surgical safety checklist. So how do you see that those two are connected 29:09 that lawsuits actually accelerate the application and the use of those kind of 29:13 checklists? >> Yeah, that's an interesting concept 29:16 because when I review surgical cases, remember everybody documents 29:20 differently, right? And you have it together and I'm putting myself in the 29:25 position of the provider what they knew and they should have not at the same 29:28 time. Surgeon's going to document something. Anesthesia's got to document 29:32 something. The nursing document something, right? I recently reviewed a 29:36 case where there was a routine laparoscopic surgery. The varys needle 29:41 went in, blood came out, the patient immediately CO2, entitle CO2 crashed. 29:48 >> Yeah. >> And nobody knew what to do, right? I 29:50 mean, that is a CO2 embolis. There's nothing else that does that. They didn't 29:54 do the right thing. The patient wind up dying. It was a disaster. But everybody 29:58 documented something different, right? The timeline was messed up depending on 30:03 who you talked about. So it made it very difficult to go through to see what the 30:06 heck happened. Now I know things happen very quickly in the operating room. I 30:10 get that. But some of those checklists are very important. You know the time 30:14 out before surgery to make sure there's no wrong side surgery, which still 30:18 happens in this country. I don't know how that can happen, but it still does. 30:22 Yeah. Retain sponges. Who's responsible if there's a retained sponge? every 30:26 retained foreign body case that I have reviewed, guess what? The count is 30:32 always correct, right? Because if you tell me the count's not correct, I'm not 30:37 stopping, right? >> Yep. 30:38 >> Well, I think those checklists are very important. It's just patient safety, 30:42 right? Sometimes it seems redundant. We didn't do this 30 years ago, but we had 30:47 drugs, right? So by doing this is definitely increase patient safety to do 30:52 the right thing for the right patient at the right time and make sure everybody's 30:56 on the same page. How many times have you had a patient in the preop area want 31:00 to add something to the procedure? They've already been given their preop 31:04 medication. Doc, I got this lesion on thing. Can you just No. Absolutely not. 31:10 Right. That's important. And again, I can't put every resident in a situation 31:15 they're going to be in when they're by themselves. 31:18 >> So the checklists are important for preops, for interop, for posttop. Did 31:23 you take out the right specimen? I've done cases where they went in for a 31:27 right colon cancer. The right colon was taken out. Nobody looked at the 31:32 specimen. Guess what? The colon, the lesion was in the left side of the 31:37 colon. That's a problem, right? So, we have a process where the specimen is
Closing Remarks and Part Two Preview 31:41 open. It is verified by the doctor, by the nurse, and those things are very 31:45 helpful. The residents look at me like I'm crazy while do that. We could feel 31:49 the lesion maybe. I said, "No, it was marked. Let's make sure. Let's open the 31:53 specimen. It takes a second and everybody sees it." So, those checklists 31:58 I think are very important. If if you don't do them, you're cutting corners 32:01 and you're have to make a mistake. Not on purpose, but you have to make a 32:04 mistake. The defense of that case of the right colon that was taken out was well 32:09 the gastronurologist told me it was on the right side. Okay, the 32:13 gastronurologist is not in the surgery. Once they go through those doors in the 32:17 operating room, it is my responsibility, not the gastronurologist, right? I mean, 32:21 we can't always tell and I do a lot of colonoscopy where the lesion is. I've 32:26 had GI doctors tell me it's apatic flexure, it's in the sigmoid. I've had 32:30 them tell me sigmoid, it's in the apatic flex. the colon telescopes. It's hard 32:34 for me to tell. I can tell terminal ilium. I can tell rectum. Anything in 32:39 between, I don't know. So, those checklists are very important to make 32:43 sure you do the right thing at the right time for the right patient to prevent 32:47 easy preventable complications, which should never happen. 32:51 >> As we close part one of my conversation with Dr. Steven Cohen. I hope this 32:56 discussion has given you a deeper appreciation for the profound ways 33:00 medical malpractice has shaped the practice of medicine beyond the 33:04 courtroom. It influences how we communicate with patients, how we 33:09 document, how we make decisions, and even how we experience the joy and 33:14 purpose of being a physician. These are not easy conversations, but they're 33:19 essential ones. We can't change what we refuse to examine. And understanding 33:24 these forces is the first step toward building a healthier culture for both 33:29 physicians and patients. Next week, we'll release part two of my 33:34 conversation with Dr. Cohen. We'll live beyond how medical malpractice has 33:38 changed medicine and explore where we go from here. If you enjoyed today's 33:44 episode, be sure to subscribe so part two appears in your podcast feed as soon 33:49 as it's released. And if this conversation sparked new thoughts or 33:54 reminded you of your own experiences, please share this episode with a 33:58 colleague and leave us a review. Those simple actions help us reach more 34:03 healthc care professionals who care deeply about the future of medicine. 34:08 Until next time, peaceful warriors. I am Dr. Lee Chararma and this is the scalpel 34:14 and sword. be at peace. [music] >> Every episode is an invitation to speak, 34:23 [music] to negotiate, to choose. I'm Dr. Lee Chararma. Join the dialogue by 34:30 subscribing [music] to Scalpel and Sword. Until next time, peaceful 34:34 warriors, may your choices be sharp [music] and your voice be even sharper. 34:43 This podcast is a reflection of lived experience and [music] research in 34:47 conflict resolution. The scalpel and sword is not intended as [music] medical 34:51 or legal guidance. For personal matters, please consult a qualified professional.
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