Minnesota Physician cover stories

November 2017

Past MP cover stories

Reducing failure to diagnose claims

What to do when patients decline cancer screening

 

By Ginny Adams, RN, BSN, MPH, CPHRM

 

Diagnostic error is the most frequent allegation in medical professional liability (MPL) claims involving death, according to the National Patient Safety Foundation in 2014. It is the number one cause of MPL claims for all primary care specialties, radiology, and emergency medicine. Claims alleging a failure to diagnose cancer are among the most numerous and most costly examples of diagnostic error. Several issues underlie many of these cancer claims, including the failure to offer or provide appropriate cancer screening.

 

A better way to treat chronic pain

Alternatives to opioids

 

By Nima Adimi MD, MS

 

Chronic pain is one of the biggest medical problems facing the world today. As medicine advances and people live longer the incidence and prevalence of chronic pain will only increase given the inevitable degeneration of our bodies. Chronic pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage for at least three months. As a physician I have always been interested in statistics. Numbers put things into perspective for me so here are some alarming statistics regarding chronic pain:

 

The value of Medicaid

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Opioid Prescribing Improvement Project

A safety net for children

 

By Kelly Wolfe

 

Imagine you’re pregnant and you unexpectedly go into premature labor, delivering your baby two months early. While you have health care coverage through your employer, you discover upon discharge from the hospital that your insurance won’t cover the 24-hour nursing care your baby will require, nor does it cover the equipment or medications your infant will need to survive. Thankfully, your child is eligible for Medicaid and you can now access these services.

 

Quality reporting

The importance of accounting for social conditions

 

By Paul Kleeberg, MD, and Phil Deering, BA

 

Like many Minnesota physicians, Dr. Lynne Ogawa first saw her Minnesota Statewide Quality Reporting and Measurement System (SQRMS) outcomes toward the end of the last decade. At the time, the family practice doctor saw patients at the Fremont Clinic, located in the heart of North Minneapolis.

 

Why just retire?

Consider physician emeritus

 

By Michael J. Weber, JD, and Nancy Lee Nelson, JD, MPH, RN

 

If you are like many other Minnesota-licensed physicians, you might be unaware of the option to retire as a “physician emeritus.” To retire as a physician emeritus, a physician has to complete a short application with the Minnesota Board of Medical Practice.

 

Regenerative Medicine Minnesota

Transforming the future of health care

 

By Jakub Tolar, MD, PhD, and Andre Terzic, MD, PhD, FAHA

 

We have grown accustomed to the medical miracles—antibiotics to combat infection; transplantation to replace failed organs; and biologics to control high cholesterol, rheumatoid arthritis, or psoriasis—that have transformed patient care. Despite remarkable advances, many serious health problems resist conventional medicine and surgery, causing suffering and shortening lives.

 

The Minnesota Adult Abuse Reporting Center

Protecting the vulnerable

 

By Commissioner Emily Piper, JD

 

An older adult woman living in northern Minnesota was at her most vulnerable—recovering from surgery after a stroke—when she became the victim of financial exploitation by her own daughter.

 

The CARES Model

A way to engage your patients

 

By Archelle Georgiou, MD

 

Sixty-two percent of Americans say they want to deliberate with their physician about their treatment options. And, to help make the right choices, consumers have been armed with an array of health information sites, symptom checkers, cost calculators, and provider quality scores and report cards.

 

Minnesota Prescription Monitoring Program

Important updates responding to an epidemic

 

By Barbara A. Carter

 

In a recent survey conducted by the American Medical Association, in which 44 of the 49 state prescription drug monitoring programs (PDMP/PMP) responded there was a 180 percent increase, between 2014 and 2016, in the number of physicians’ and other health care professionals that had registered for an account with a PDMP/PMP.

 

the opioid epidemic:

Complex problems, complex solutions

Get your tickets now

and be a part of the discussion.

Tuesday, April 26, 2018, 1-4 pm

The Minnesota Health Care Roundtable is a semi-annual conference featuring a panel of stakeholder group experts in a moderated discussion before a live audience covering topics that affect the evolution of health care policy.

Requesting Nominations

Seeking exceptionally designed health facilities

Before May 4th, 2018

Nominate a physician or team of physicians

Before January 10th, 2018

Recognizing Minnesota physician volunteers

Reducing failure to diagnose claims

What to do when patients decline cancer screening

 

By Ginny Adams, RN, BSN, MPH, CPHRM

 

Diagnostic error is the most frequent allegation in medical professional liability (MPL) claims involving death, according to the National Patient Safety Foundation in 2014. It is the number one cause of MPL claims for all primary care specialties, radiology, and emergency medicine. Claims alleging a failure to diagnose cancer are among the most numerous and most costly examples of diagnostic error. Several issues underlie many of these cancer claims, including the failure to offer or provide appropriate cancer screening.

 

There are multiple reasons to provide cancer screening for patients, beyond the fact that physicians are in the business of improving and safeguarding the health of their patients. Best practice standards are established by the American Cancer Society and the Centers for Disease Control and Prevention, along with numerous specialty organizations that provide recommendations in their respective fields. In Minnesota, mandatory reporting of quality measures through MN Community Measurement includes screening for colorectal, breast, and cervical cancer. Provider and clinic/medical group success rates for providing this screening is publically available on the Minnesota HealthScores website (mnhealthscores.org).

 

Safeguarding patients and physicians

What happens when a patient refuses the cancer screening tests? How do practitioners ensure that they are supporting their patient’s individual needs and goals while also protecting themselves from becoming another MPL claim statistic?

 

The following are important steps practitioners can take to safeguard both patients and themselves:

Establish and adhere to the practice’s cancer screening guidelines. Stay up to date with guidelines.

Document the patient’s family and personal history of cancer.

 

Recommend appropriate screening exams, using shared decision-making.

Don’t take the first “no” as the answer. Assess the reasons for a refusal and consider the possibility of a breakdown in communication.

 

Accept that the patient has the right to make informed decisions about his or her care.

If screening is refused, look for opportunities for compromise or to otherwise promote health.

Document all screening tests suggested and performed. Meticulously document the informed refusal of screening tests.

 

Follow up with the patient.

Sources vary on cancer screening, sometimes to the point of controversy and confusion. Practitioners are not obligated to adopt the guidelines of a particular group; however, if the practice’s guidelines differ significantly from those commonly accepted, the practice should be prepared to defend its reasoning.

 

An individual’s family history of cancer is crucial in determining his or her risk for developing cancer. It facilitates the stratification of patients into risk groups, allowing practitioners to tailor their discussions regarding individual risks, benefits, and alternatives for a particular screening exam with a patient.

 

Shared decision-making

In January 2017, the U.S. Preventive Services Task Force (USPSTF) published its position in Shared Decision making About Screening and Chemoprevention. This consensus paper states: “The USPSTF places a high value on informed and joint decisions about screening and chemoprevention; such decisions are essential for making recommendations to individual patients concerning interventions that have net benefit for some patients, but not for others. One approach to encouraging informed and joint decisions is shared decision-making.”

 

Shared decision-making is recognized as the ethical model for most encounters in medical practice. It is particularly important when there is more than one reasonable option, as with screening exams. In shared decision-making, the practitioner strives to provide patients enough understandable information so that they can partner with the practitioner in making care decisions. Both the practitioner and the patient have a role and voice in balancing the risks and expected outcomes of a test with the patient’s preferences and values. The standardized decision aides often used in the shared decision-making process can serve as excellent documentation of the information provided to the patient and the process followed in reaching a decision.

 

Understanding screening refusal

If the patient declines an exam, the practitioner should go the extra mile to understand what may be driving that decision. Patients may refuse a screening exam for a whole host of reasons. Some patients do not understand, and indeed fear, the screening process, particularly when it involves an invasive procedure, such as a colonoscopy. Still others fear the results and prefer to believe that in the absence of symptoms, everything is all right. Financial concerns can also lead to patient refusal. Discussing the known costs of a screening exam, assisting the patient in determining whether a portion is paid by insurance, and helping the patient investigate other options can help alleviate financial concerns.

It is also important to discuss available alternatives, along with their risks and benefits, even though they may not be as effective. If an alternative plan is developed, the practitioner needs to document the compromise and note that it is due to patient preference and not provider preference.

 

A patient has the right to weigh all the information provided and to decide against a treatment or procedure. The practitioner may not agree with the patient’s perception of the risks and benefits; however, it is imperative to respect the patient’s wishes once he or she has received information upon which to make an informed decision, understands the implications, and has had an opportunity to ask questions and have them answered.

 

Documenting the refusal

Then comes the important task of documenting the patient’s refusal to undergo the suggested cancer screening test. Practitioners need to document exactly which test was recommended and why, the alternatives that were presented and discussed, and any teaching regarding the potential consequences of refusing the screening. A form may be used to document the patient’s refusal.

 

As an example, a note stating that “routine screening was discussed” is a good start, but it is much more powerful for the practitioner to state: “A colonoscopy was recommended to the patient based on his age and family history of colon cancer. The patient verbalized understanding of the risks and benefits of the exam as described in the decision aide provided. The patient also understands the risks of not doing the exam. The patient refuses a colonoscopy at this time, due to concerns regarding the invasive nature of the procedure. Alternative screening methods were offered and explained, including a fecal occult blood test and fecal immunochemical testing. The patient has decided against any screening exams at this time. It was agreed to revisit the issue next year.”

 

Documentation showing that the patient was fully informed of the risks of refusing the test makes a subsequent malpractice claim more defensible. It serves as proof years later, when a lawsuit would arise, that the interaction actually did occur.

It is not enough to have the discussion once; screening recommendations should be revisited regularly. If the patient continues to refuse screening, the patient’s refusal needs to be documented each and every time.

 

Tracking scheduled exams

The practice should have a system in place to track patients who fail to appear for scheduled screening exams. Patients need to be called to determine why they did not follow through. It is also very important to address any barriers the patient may face to completing the exam and, when appropriate, convey the risks of failing to follow through on the recommended screening. If the practitioner or designee is unable to reach the patient after several attempts, a letter with the same information should be sent. All conversations and letters, as well as attempted telephone contacts should be thoroughly documented.

 

If an allegation of malpractice is made for failure to diagnose cancer through a screening exam, it is important to note that Minnesota follows the principle of “comparative fault,” as defined in Minnesota Statutes §604.01. Simply put, comparative fault means that the defendant’s liability may be reduced in proportion to the plaintiff’s fault. If the informed refusal of a screening exam is well documented, the documentation can serve as support for shifting some of the blame to the patient for failure to obtain the recommended exams or treatment.

 

Cancer screening exams may be viewed as a routine part of patient care, but that does not diminish their significance. A structured process for discussing these tests with patients is important, and when a patient refuses a practitioner’s recommendation, thorough documentation is essential. It not only serves as legal protection, but can also provide the practitioner with peace of mind that the options have been presented in a balanced way and that patient’s right to make his or her own decision has been supported.

 

Ginny Adams, RN, BSN, MPH, CPHRM, is a senior risk consultant for Coverys, a medical professional liability insurance company. She has a background in critical care nursing, nursing administration, performance improvement, regulatory compliance, and risk management.

 

Minnesota Physician Publishing Inc. © 2017