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Sleep disorders, including obstructive sleep apnea (OSA), have become a significant health issue in the United States. When left untreated, OSA can lead to high blood pressure, chronic heart failure, atrial fibrillation, stroke, and other cardiovascular problems. OSA is associated with type 2 diabetes and depression, and it is a factor in many traffic accidents. OSA has also been associated with increased perioperative risk and postoperative complications. 1

This article will provide a brief overview of sleep apnea, describe two closed claim studies that feature sleep apnea, and discuss ways to reduce liability when treating patients with sleep apnea.

Introduction

OSA is the most common sleep disorder in the U.S. An estimated 26 percent of U.S. adults are at high risk for OSA. “The prevalence of OSA in the general popula-tion is approximately 20 percent if defined as an apnea

hypopnea index (AHI) greater than five events per hour (the AHI is the number of apneas and hypopneas per hour of sleep). In contrast, it is 2 to 9 percent if defined as an AHI greater than five events per hour, accompa-nied by at least one symptom that is known to respond to treatment (eg, daytime sleepiness).” 2

It has been estimated that more than 80% of men and 90% of women with OSA do not have a documented diagnosis. 1

The main symptoms of OSA are loud snoring, fatigue, and daytime sleepiness. Other symptoms include:

• restless sleep;

• awakening with choking, gasping, or smothering;

• morning headaches, dry mouth, or sore throat;

• waking frequently to urinate;

• awakening unrested, groggy; and

• memory impairment, difficulty concentrating, low energy. 2

Sleep apnea and surgical complicationsby Laura Hale Brockway, ELS

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2 | the Reporter 2013 Volume 2

Risk factors for OSA include:

• increasing age — OSA is more common in middle-age and older adults;

• male sex;

• obesity;

• increased neck circumference (greater than 17 inches in men or 16 inches in women); and

• abnormality of the airway. 2

Types of apnea

“Obstructive sleep apnea is caused by a blockage of the airway, usually when the tongue collapses against the soft palate and the soft palate collapses against the back of the throat during sleep, and the airway is closed. In central sleep apnea, the airway is not blocked, but the brain fails to signal the muscles to breathe. Complex sleep apnea, as the name implies, is a combination of the two conditions.” 3

Patients are classified as having mild, moderate, or severe disease based on the following AHI:

Mild — an AHI between 5 and 15 respiratory events per hour of sleep.

Moderate — an AHI between 15 and 30 respiratory events per hour of sleep.

Severe — an AHI greater than 30 respiratory events per hour of sleep and/or an oxyhemoglobin saturation below 90 percent for more than 20 percent of the total sleep time. 2

Diagnosis and treatment

The diagnosis of sleep apnea begins with taking a careful history about symptoms of snoring or daytime sleepiness and an evalu-ation for the presence of other risk factors for OSA (obesity, increased neck circumference, abnormality of the airway). 4 Positive screening results should lead to a more comprehensive sleep history and examination.

“Those patients deemed high risk should have the diagnosis confirmed and severity determined with objective testing in an expedited manner in order to initiate treatment. For other patients, the time of further testing is determined by the risk of OSA and the presence of daytime impairment or associated morbidity.” 4

Polysomnography (PSG) is the definitive tool for diagnosing sleep apnea. “PSG is considered the gold standard diagnostic test when it is performed overnight in a sleep laboratory with a technologist in attendance. In some patients, the diagnostic evaluation may be performed at home without a technician in attendance.” 2

“OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. There are medical, behav-ioral, and surgical options for the treatment of OSA.” 2 These include behavioral modifications, weight loss, and OSA-specific

therapies, such as positive airway pressure, oral appliances, and surgery.

Closed claim studies

Patients with OSA are at a greater risk for complications during the perioperative period, including difficult airways, sensitiv-ity to anesthetic agents, and postoperative adverse events, as the following closed claim studies illustrate.

Case 1Presentation

Following a sleep study that confirmed she had sleep apnea, a 41-year-old woman was referred to an otorhinolaryngologist (ENT). The patient weighed 200 pounds and was 5’2”. She had 3+ enlarged tonsils, bilateral inferior turbinate hypertrophy, 90% bilateral nasal obstruction, and an S-shaped deviation of her nasal septum.

Physician action

The ENT discussed treatment options, including continuing CPAP or surgery. The patient opted for surgery.

Several weeks later, the ENT performed a uvulopalatopharyngo-plasty (UPPP); tonsillectomy; a nasal septoplasty; and a bilateral partial inferior turbinectomy. The procedures were performed in an outpatient surgery center.

The patient did well postoperatively. In the PACU, her initial O2 saturation was 96%. It went up to 100% after an oxygen tent was placed. The patient was given promethazine and 12.5 mg of meperidine. The anesthesiologist ordered labetalol for increased blood pressure. A second 12.5 mg dose of meperidine was admin-istered.

After 90 minutes in the PACU, the patient was discharged home. Her vital signs at discharge were documented as blood pressure 153/99 mm Hg; pulse 78; respirations 16; and O2 saturations of 91% on room air. Her post-anesthesia recovery score was 10/10.

Two hours after her discharge, the patient’s brother called a nurse at the surgery center asking if the patient should use her continuous positive airway pressure (CPAP) machine. The nurse re-emphasized that the patient should use the CPAP machine and told the patient’s brother to contact the ENT with any further questions.

Later that evening, the patient’s mother checked on her. The patient was snoring and not using her CPAP. Her mother checked her once again in the early morning and found that the patient was unresponsive and was not breathing. EMS was called and the patient was taken to a local hospital. She was pronounced dead at the hospital.

An autopsy listed the cause of death as cardiomegaly associ-ated with hypertensive cardiovascular disease, obesity, and sleep apnea, recent surgical treatment with multiple sedative medica-tions. The medications listed in the pathology report were hydro-codone, venlafaxine, and meperidine.

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Allegations

Lawsuits were filed against the ENT and the anesthesiologist, alleging that the surgery should not have been performed in the outpatient setting and that the patient was not properly managed after the surgery.

Legal implications

The defense had a difficult time finding expert support for the ENT’s decision to perform surgery in the outpatient setting. One ENT who reviewed the case stated that the outpatient setting was reasonable, but the patient required more extensive postoperative monitoring. The patient’s discharge with a 91% O2 saturation was inappropriate.

An anesthesiologist who reviewed this case indicated that the surgery should have been performed in a hospital due to the patient’s ASA 3 classification. He agreed the discharge was inappropriate and stated the patient required 23- to 24-hour observation at the surgery center or transfer to a hospital.

The defendant stated he would not have discharged the patient if he had been aware of the 91% O2 saturation. A nurse testified that the O2 saturations were fluctuating between 91% and 94%, but only the 91% was documented.

Disposition

This case was settled on behalf of the anesthesiologist and the ENT.

Case 2Presentation

A 37-year-old man was referred to a pulmonologist for a polysomnogram. He was found to have an AHI of 129.5 and was diagnosed with severe sleep apnea. The patient reported that he used tobacco products and drank beer daily. He also reported using a CPAP machine during sleep. The pulmonologist referred the patient to an ENT.

The ENT examined the patient and performed a laryngoscopy that showed floppy, redundant tissue in the arytenoid cartilage and medial aryepiglottic fold that collapsed with inspiration. He diagnosed the patient with severe obstructive sleep apnea and adult laryngomalacia. The ENT recommended UPP and laryngoplasty.

On October 1, the patient was admitted to a local hospital. The procedures were performed without complication. The patient was taken to the ICU where he was kept intubated due to airway edema. He was extubated on October 2, and his vital signs were stable. He was placed on BiPAP for respiratory support.

The pulmonologist saw the patient on October 2. A chest x-ray showed a left lobe infiltrate concerning for pneumonia, and the pulmonologist prescribed an antibiotic.

Throughout the early morning hours of October 3, the nurses documented that the patient continued to have a productive cough and thick, blood-tinged secretions.

At 5:40 a.m., the nurse contacted the ENT to report the bleed-ing. No respiratory distress was noted until 7 a.m. when it was documented that the patient had coarse crackles and rhonchi in the lungs.

The ENT saw the patient at 8:30 a.m. and noted that he was hypertensive and slightly tachycardic. The physician noted some mild bleeding from trauma to the palate as a result of suctioning. The patient was told to gently suction his mouth.

The ENT gave an order to start the patient on lorazepem for his history of alcohol use. The first dose of lorazepem was given at 10 a.m.

At 10 a.m. the patient’s blood pressure increased to 168/122 mm Hg. The pulmonologist was paged and he ordered labetalol. At 10:06 a.m., the patient received 1 mg of morphine and at 10:15 he received labetalol. His oxygen saturations dropped to 82% on 4L NC. A respiratory therapist was called. The ENT was paged and while the nurse was speaking to him on the phone, the patient stopped breathing and went into cardiac arrest. A code was called. Initially an ambubag was used until the patient was intubated, approximately seven minutes after the code was called.

The patient suffered an anoxic brain injury as a result of the cardiac arrest. He underwent a tracheostomy on October 6 and a PEG tube placement on October 17. He was transferred to a nursing home for further custodial care in November.

Allegations

A lawsuit was filed against the ENT, alleging:

• failure to properly determine whether the patient was a proper surgical candidate;

• failure to consider non-operative treatment methods; and

• failure to educate the patient about the risks associated with the procedure.

The pulmonologist was also sued. The allegations included failure to monitor the patient and failure to order appropriate medication during the postoperative period.

Legal implications

The plaintiff’s expert criticized the pulmonologist for not recog-nizing the potential side effects the prescribed drugs would have on the patient’s respiratory status. He stated the administration of morphine shortly after the lorazepam was a “critical” mistake and caused the patient’s respiratory distress.

Regarding the actions of the ENT, the plaintiff’s expert believed the UPP was overly aggressive. He stated that UPP is only used when a patient declines oral airway pressure or an oral appliance, or the therapy has been ineffective for three months. He was also critical of the ENT for not investigating and repairing the opened suture line in the patient’s pharynx. This expert believed the patient aspirated blood from the open suture contributing to the acute respiratory failure.

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Defense experts reviewing this case had concerns about sedatives given to the patient. When the patient developed postopera-tive delirium, the assumption was made that it was due to his alcohol withdrawal. This led to the administration of sedatives that exacerbated his condition. The combination of sedatives in a compromised patient soon after extubation can cause respiratory distress and may have been a factor in the patient’s cardiopulmo-nary arrest.

Regarding the decision to proceed with the UPP rather than treat the patient with CPAP or bi-level positive airway pressure (BiPAP), the ENT testified that he discussed the options of CPAP and BiPAP and surgery with the patient. The patient wanted surgery so he would not have to be on CPAP for the rest of his life.

Disposition

During the investigation of this claim, it was discovered that a nurse used her judgment in giving the patient lorazepam and 8 mg of morphine at the same time. In light of this information, the cases against the ENT and the pulmonologist were dismissed.

Risk management considerations

Physicians can consider the following guidelines to help reduce liability when treating patients with sleep apnea.

Screening for sleep apnea

Patients with OSA may present significant problems in the perioperative and postoperative period. Because a significant proportion of OSA patients remain undiagnosed when they present for surgery, proposed guidelines from the American Academy of Sleep Medicine suggest that questions regarding OSA should be included in routine health screenings. If OSA is suspected, the patient should undergo a comprehensive sleep evaluation. 1

If a patient is found to have OSA, ensure that everyone involved in the patient’s treatment is aware of the diagnosis of OSA.

Preoperative

According to the American Society of Anesthesiologists, “Patients with known or suspected OSA may have difficult airways and therefore should be managed according to the ‘Practice Guidelines for Management of the Difficult Airway.’ In patients at risk for perioperative complications from OSA, a preoperative determination must be made regarding whether surgery should be performed on an inpatient or outpatient basis.” 5

Postoperative

Because episodes of critical obstruction may occur unpredictably — only minutes after a normal respiratory rate has been observed — the Anesthesia Patient Safety Foundation urges health care professionals to “give consideration to the potential safety value of continuous monitoring of oxygenation (pulse oximetry) and ventilation in patients receiving PCA or neuraxial opioids in the postoperative periods.” 5

Patients who use CPAP devices at home should be advised to bring the mask to the hospital and to use it while in the hospital.

Postoperative instructions should clearly indicate whether or not the patient should continue use of CPAP once discharged from the hospital.

Narcotics

Narcotics may profoundly impair respiration in the postoperative period in patients with OSA.1 Therefore, the administration of narcotic pain medication in patients with OSA should be closely monitored, according to recommendations from the American Society of Anesthesiologists. 5

One issue is that multiple physicians may write pain medica-tion orders for a single patient and they may not be aware of the diagnosis of OSA. One suggestion is to flag the records of these patients to warn of the risks of narcotics usage.

Conclusion

“While there may not be a consensus regarding the best and most cost effective methods to ensuring fewer perioperative complica-tions from OSA, there continues to be a need for informed clini-cians, as patients are typically presenting with undiagnosed or misdiagnosed cases.” 1 Awareness of the risk factors and compli-cations associated with OSA, along with adherence to applicable guidelines, can help enhance patient safety when treating patients with OSA.

Sources

1. uC San Diego School of medicine, university of Toronto. Perioper-ative management of oSA Patients. April 2011. Available at http://cme.ucsd.edu/oSAonline. Accessed January 18, 2013.

2. Kingman PS. overview of obstructive sleep apnea in adults. uptoDate. July 3, 2012. Available at http://www.uptodate.com/contents/overview-of-obstructive-sleep-apnea-in-adults?source=search_result&search=sleep+apnea&selectedTitle=1~150. Accessed January 18, 2013.

3. American Sleep Apnea Association. A very short course on sleep apnea. Available at http://sleepapnea.org/i-am-a-health-care-profes-sional.html. Accessed January 18, 2013.

4. Adult obstructive Sleep Apnea Task Force of the American Academy of Sleep medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine. 2009; 5(3): 263-276.

5. American Society of Anesthesiologists Task Force on Perioperative management of Patients with obstructive Sleep Apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104: 1081-93.

Laura Hale Brockway can be reached at [email protected].


TMLT in the News

TMLT CME — now just a click away

TMLT has made it even easier for you to earn CME credit. Beginning March 25, we will provide all CME courses through one online catalog available at www.tmlt.org/cme.

The new CME site will provide 24-hour access to course content, testing, receipts, and certifi-cates so you can work as your schedule permits.

We currently offer 30 courses, including Reporter CME, Case Closed CME, videos, and podcasts. Courses include:

•“10 things that get physicians sued”

•“Terminating the physician-patient relationship”

•“Understanding and preventing diagnostic errors”

•“Physician-patient communication”

•“Pain management”

In order to deliver courses through the new CME site, we will now be charging a slight fee to cover the cost of the new online catalog. Policyholder and non-policyholder pricing will be available. Log on with your myTMLT username and password to receive member pricing.

As of March 25, 2013, CME prices are as follows.

Publications offering 2.5 CME credits or more (the Reporter CME, Case Closed CME, other online courses)

$25 for policyholders $100 for non-policyholders

Publications and videos offering 1 CME credit (the Reporter, video courses)

$10 for policyholders $75 for non-policyholders

Spring and Fall seminars

$45 for policyholders $145 for policyholders

All courses are available for CME credit and ethics hours. Complete a 2.5-hour CME course and you may be eligible for a 3% premium discount (up to $1,000 per course). You can take two courses for the discount per year.

The physical copies of the Reporter and Case Closed will continue to be available at no cost.

For more information about CME pricing, please email [email protected] or call 800-580-8658 and ask for the Risk Management Department.

To take a course, visit www.tmlt.org/cme.


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Social media for physicians

Course author

Shannon Quinn is a risk management representative with TMLT.

Disclosure

Shannon Quinn has no commercial affiliations/interests to disclose related to this activity.

Target audience

This one-hour activity is intended for physicians of all specialties who are interested in practical ways to reduce the potential for malpractice liability.

CME credit statement

Physicians are required to complete and pass a test in order to earn CME credit. A passing score of 70% or better earns the physician 1 CME credit. Physicians will be allowed two attempts to pass the test.

TMLT is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. TMLT designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Pricing

The following fee will be assessed when accessing this CME course online at www.tmlt.org/cme.

Policyholders: $10 Non-policyholders: $75

Ethics statement

This course has been designated by TMLT for 1 credit in medical ethics and/or professional responsibility.

Instructions

Complete Reporter CME test and evaluation forms online. After reading the article, go to www.tmlt.org/cme. Log on with your myTMLT user name and password to gain access to the course. Follow the online instructions to complete the forms and download your certificate.

If you do not have a myTMLT account, please call customer service at 800-580-8658 ext. 5050.

Questions about the CME course, please call 877-880-1335.

Estimated time to complete activity

It should take approximately 1 hour to read this article and complete the questions.

Release/review date

This activity is released on April 1, 2013 and will expire on April 1, 2016. Please note that this CME activity does not meet TMLT’s discount criteria. Physicians completing this CME activ-ity will not receive a premium discount.

Editor’s note: The information in this article is based on the technology and software capability at the time of publication.

Objectives

• describe common social media tools such as blogs, Twitter, FaceBook, and Yelp;

• discuss how social media can affect the physician-patient relationship;

• identify key issues to address before engaging in social media; and

• explain the importance of developing a social media policy for medical practices.


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Introduction

Social media allows people to share ideas and communicate electronically in different forums and networks. Although the use of social media has been widespread for many years, it has only recently begun to gain acceptance in the medical commu-nity. Physicians are writing blogs, creating Facebook pages, and posting articles on Twitter. Patients have begun researching physicians online and do not hesitate to post reviews of physi-cians for others to read. Many patients attempt to communicate with their physicians through online venues rather than calling the offices directly.

“A survey of 1,060 U.S. adults by the PwC Health Research Institute found that a third of respondents are gravitating toward social media as a place for discussions of health care. Patients’ attraction to these online communities is prompting many health care organizations to reshape their social media strategy from one focused on marketing to one that is part of an overall business strategy to engage patients, interact with them and even provide services in an attempt to help bring down the costs of provid-ing care. And physicians are playing a major role in this revised strategy.” 1

Social media and physicians

When a patient or potential patient contacts a physician online, the lines of the relationship become blurred. “The physician-patient relationship can begin without a personal encounter, which allows for online interactions to constitute the beginning of the relationship. Physicians should remember that when using electronic communications they may be unable to verify that the person on the other end is truly the patient. Likewise, the patient may not be able to verify that a physician is on the other end of the communication. For that reason, the standards of medical care do not change by virtue of the medium in which physicians and their patients choose to interact.” 2

There are also a number of pitfalls associated with social media. Physicians are urged not to post about patients. There is also a permanency to content posted on social media. Although items posted can be deleted later, a picture of what was posted — known as a screen shot — can be taken with the click of a button and posted by other people. Additionally, it takes time to maintain an online presence. Physicians must be willing to devote time to not only post content, but review content and monitor privacy settings.

“Social media has enormous potential for both physicians and their patients. It can be used to disseminate information and forge meaningful professional relationships. However, these benefits must occur within the proper framework of professional ethics, and physicians need information on the importance of maintain-ing the same professional and ethical standards in their online activity or communications, using other forms of electronic media.” 2

Popular social media outlets

There are several social media tools that are changing and

expanding at a rapid rate. This article will touch on the advan-tages and disadvantages of the most popular tools currently avail-able. It is recommended that physicians who participate in social media stay current with trends and changes as they develop.

Blogs

A blog is a discussion or informational web site consisting of discrete entries (called posts) typically appearing in reverse chronological order. There are a great variety of medical blogs available. Blogs are a good forum for reading about topics of interest, staying current with trends, and sharing within the medical community.

When writing blogs, physicians should not disclose any patient information, should not give medical advice, and should not make unsubstantiated medical claims. Blogging anonymously is also not recommended.

A malpractice claim in Massachusetts ended in a settlement in 2007 when it was discovered that the physician was blogging about his own case under the pseudonym, Flea. The plaintiff’s attorney learned about the blog during the trial, and asked the physician on the witness stand if he was Flea. The case settled the next day. 3

Blog tips:

• Never post about patients.

• Do not give medical advice or make unsubstantiated medical claims.

• Do not blog anonymously.

Facebook

Facebook is a site that allows people to network by posting text, photos, and videos that appear in a timeline. When used correctly, Facebook can be a great way to keep patients notified about events in your practice, changes in office hours due to holidays or inclement weather, and pertinent health articles.

Facebook users can view information others post in a variety of ways. A “friend request” can be sent to request permission to share information with another user (also referred to as “friend-ing”) or users can view pages without friend requests. Users can “like” a page (by clicking on the “like” button) and can choose to have posts made on that page appear in their timeline.

In a 2010 survey of online social network use, about one-third of practicing physicians reported receiving friend requests from patients or their family members. About two-thirds of the physi-cians said accepting such invitations would be unethical. 4

When setting up a Facebook profile, it is recommended that the physician create a separate Page for the practice instead of posting information from a personal Facebook account. This is the primary difference between a personal account and a Page for a business (or practice). If a Facebook Page is set up for the practice, it eliminates the worry of receiving a friend request from

Social media for physicians


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a patient. Any friend requests that a physician receives from a patient for a personal account should be declined.

The difference between Pages and personal timelines is explained by Facebook. “Timelines are for personal, non-commercial use only. They represent individuals and must be held under an individual name. Pages are for professional or official use, and allow an organization, business, celebrity or band to maintain a presence on Facebook. You may only create Facebook Pages to represent real organizations of which you are an authorized representative.

In addition, Pages are managed by admins who have personal Facebook timelines. Pages are not separate Facebook accounts and do not have separate login information from your timeline. They are merely different entities on our site, similar to how Groups and Events function. Once you have set up a Page within your timeline, you may add other admins to help you manage this Page. People who choose to connect to your Page won’t be able to see that you are the Page admin or have any access to your personal account.”

Personal Facebook accounts should be set up with the highest privacy levels to ensure that personal content posted is not visible to the public. Even with strict privacy settings, keep in mind that anything posted can be copied and pasted or have a screen shot taken, and then re-posted by other users.

Physicians can inadvertently violate patient privacy with Facebook posts. A physician in Rhode Island was reprimanded by the state board over a post on her personal account. The physician wrote about some of her work experiences, taking care to leave out any patient information. But, based on the description of the patient’s injuries, the patient could be identified by a third party. The physician was fined $500 and had her hospital privileges terminated. 5

In her blog posting titled “Tips to keep a clean social media profile,” Dr. Adriana Tobar writes, “Take a moment to reflect before every post and update. It’s so easy to quickly and mindlessly post things to social media sites. From updates about your day to comments on a friend’s vacation photos, there are so many opportunities to communicate.

Here’s something I highly suggest: Train yourself to take a small ‘mindfulness moment’ — it only needs to be 5-10 seconds — before you post anything, no matter how mundane. In that moment, ask yourself if you could potentially be violating any patient privacy laws. If you have even a smidgen of doubt, don’t click ‘post.’ Think of something else to write, or don’t write anything at all.” 6

When creating a Facebook account, there are many settings that need to be considered: allowing others to post to your wall; allowing others to comment on things you post; who can see posts to your timeline; and who can tag you in pictures and postings. For personal accounts, it is recommended that only friends view your posts and comments. Privacy and account

settings should be carefully reviewed and monitored often, as Facebook changes its privacy policies and settings frequently.

Randi Zuckerberg — sister of Facebook founder Mark Zucker-berg — learned this lesson the hard way. Ms. Zuckerberg posted a family photo on her personal Facebook account, meant to be shared with her friends only. A stranger was able to view the photo because he and Ms. Zuckerberg shared a mutual friend. This person then copied the photo and posted it on a Twitter account for 40,000 people to see. 7

The settings for creating a Facebook Page are different from those for a personal account. The ability for others to post to your timeline, send you a message, add photos, or tag the business in photos should be disabled. If you allow postings on your timeline, postings need to be closely monitored for potential privacy viola-tions. Additionally, setting up a Page for your practice allows others to serve as a Page administrator. Be sure to revoke these permissions upon termination of employment.

If a patient posts something about his or her own treatment to your timeline, it could still be considered a privacy breach. Postings of this nature need to be removed immediately. Additionally, patients should not be permitted to send you messages through your Facebook Page. If any messages are received, send a reply telling the patient to call the office. Under no circumstances should medical advice be given through Facebook.

Although learning how to appropriately use Facebook can seem overwhelming, physicians can also consult the Facebook help section for additional guidance.

Facebook tips:


• Keep personal and business accounts separate.

• Decline friend requests from patients on personal accounts.

• Set both accounts for the highest levels of security.

• Review Facebook’s privacy and security settings thoroughly and often.

• Do not allow patients to post on your timeline.

• Do not provide medical advice via Facebook.

Twitter

Twitter allows a user to post very small entries, known as “tweets.” With only room for 140 characters, Twitter can seem harmless enough, but the previous recommendations apply. Separate personal and professional accounts should be maintained if any non-professional tweeting is to be done, such as posting vacation photos or political opinions. Personal accounts should be set to private and followers should be accepted carefully. It is acceptable for patients to follow a physician’s professional account, but not acceptable for them to follow a physician’s personal account.


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In a research letter published in The Journal of the American Medical Association, 5,156 tweets from 160 physicians were analyzed and “one hundred forty-four tweets (3%) were catego-rized as unprofessional. Thirty-eight tweets (0.7%) represented potential patient privacy violations, 33 (0.6%) contained profan-ity, 14 (0.3%) included sexually explicit material, and 4 (0.1%) included discriminatory statements. Of the 27 users (10%) in our sample responsible for the potential privacy violations, 92% (25/27) were identifiable by full listed name on the profile, profile photograph, or full listed name on a linked web site. Fifty-five tweets (1%) were coded as “other unprofessional,” including 12 possible conflicts of interest, such as making unsupported claims about a product they were selling on their web site or repeat-edly promoting specific health products, and 10 statements about medical therapies that were counter to existing medical knowl-edge.” 8

In researching this article, tweets from random physicians in Texas were reviewed. It was observed that some physicians were dispensing unsolicited medical advice based on keyword or hashtag (#) searches. For example, @stranger tweeted “I just had my tonsils out! My throat is so sore! #NoMoreTonsils” then @randomdoctor replied “don’t worry, that’s normal after a tonsil-lectomy.” While that appears to be an innocent exchange, several things need to be considered. Does reaching out to a person unsolicited establish a patient/physician relationship? Is this person over 18 years of age? If not, could the advice potentially keep them from relaying dangerous symptoms to an adult? Could the advice keep them from seeking emergent care? Could the advice be considered providing health care in a state where the physician is not licensed?

A final item to consider before posting a tweet — public tweets are archived by the Library of Congress. “In April 2010, the Library and Twitter signed an agreement providing the Library the public tweets from the company’s inception through the date of the agreement, an archive of tweets from 2006 through April 2010. Additionally, the Library and Twitter agreed that Twitter would provide all public tweets on an ongoing basis under the same terms.” 9

Twitter tips:


• Keep personal and business accounts separate.

• Accept followers on personal accounts carefully.

• Do not provide unsolicited medical advice based on keywords.

Yelp

Yelp is a review site where users can post reviews of anything from restaurants to medical practices. While Yelp does encour-age users to identify themselves by first name, there is nothing keeping users from posting anonymously. Yelp also filters reviews, a practice that causes confusion among users and businesses alike. Filtered reviews do not appear with the

business’s list of reviews, but requires the user to click on the “filtered reviews” link and then enter a computer-generated code called a “Captcha” to view the remaining reviews. Many businesses may not even know they are receiving reviews on Yelp.

Yelp’s Frequently Asked Questions page notes “How did my business information end up on Yelp?

We license basic business information from third party data providers who gather this type of information from public records and other sources. We also get business information from our users, who are helpful enough to correct the info we have, or let us know about a new spot that just opened down the street.” 10

Unfortunately, when a patient or person posing as a patient posts a negative review about a physician, there is not much that can be done about it. While Yelp does give a business the opportunity to respond to the review, doing so can be considered a privacy viola-tion for a physician. Any rebuttal could confirm that the reviewer is a patient. Several medical professionals have filed lawsuits against Yelp, but these have been unsuccessful.

“Internet sites contend that because they merely post comments, they are protected by the federal Communications Decency Act of 1996. The legislation, which was intended to encourage devel-opment of the Internet, immunizes providers of an‘interactive computer service’ from liability for defamatory statements made by a third party through their websites.

Yelp recently argued successfully for such protections to a New York trial court. In a September decision, New York Supreme Court Judge Jane S. Solomon ruled that the federal statute [Communications Decency Act of 1996] barred a dentist from suing Yelp for defamation and deceptive business practices. The dentist alleged that the web site selectively removed positive reviews of his practice after he asked the website to remove what he said was a false and defamatory anonymous review. Yelp denied any wrongdoing. The dentist is considering an appeal.

Solomon said in Reit v. Yelp that under the statute, ‘No provider or user of an interactive computer service shall be treated as the publisher or speaker of any information provided by another information content provider.’ Congress granted such entities immunity from liability for publishing false or defamatory materi-al ‘so long as the information was provided by another party.’

But the federal law was not meant to protect websites that are actively involved in how the information on their site is presented publicly, said Gregory S. Weston, a lead attorney in a class-action lawsuit a group of California businesses filed in March against Yelp. The group alleges that the website manipulated placement of negative reviews and leveraged them to solicit ad money, in violation of state unfair competition laws. The case, which awaits class certification, is pending in the U.S. District Court for the Central District of California.


the REPORTER

Online review sites ‘do say something, and they are not acting passively when they filter reviews or order them in a certain way,’ said Weston, of The Weston Firm in San Diego.

Yelp denied any wrongdoing, saying businesses cannot pay to move or remove reviews. The company stands by its review filter, which is ‘entirely automated to avoid human bias, and it affects both positive and negative reviews,’ Yelp’s web site says.

Still, federal law makes it difficult for doctors to sue for Internet defamation, said Donald Moy, chief legal counsel to the Medical Society of the State of New York. The society has been monitor-ing the issue and seeking legislative and regulatory oversight at state and national levels.

Because most reviews are anonymous, tracking the identity of a reviewer can prove difficult, Moy said. Although state laws generally allow defamation claims, ‘an opinion cannot be found to be defamatory. In order to be defamatory, the statement that causes injury must be false. However, an opinion can neither be proven to be true or false.’

Constitutional issues may arise in trying to restrict online communication, said Alan J. Howard, a constitutional law profes-sor at Saint Louis University School of Law. If a reviewer ‘says something that’s wrong or you think is wrong, you can rebut it. Normally what the First Amendment requires is more speech, not regulation of speech.’” 11

So what should you do if someone posts a negative review about you on Yelp? Do not reply publicly. If the reviewer posted enough information for you to identify the patient, you can contact the patient personally to discuss his or her concerns. Often, this is enough for the patient to edit or remove the negative review.

If you are not sure who the patient is, you can reply publicly with a general statement such as “We are unable to reply as we take patient privacy very seriously. If you are a patient and wish to discuss your concerns with the doctor, please contact our office directly.” Again, a direct, public reply should be avoided.

Some businesses request that customers leave a review on Yelp if they’ve had a good experience. While this will increase your overall rating, it can cause a problem if a patient posts detailed information about his or her health. This practice could also be viewed as encouraging a patient to violate his or her own privacy. If Yelp believes that a business is soliciting positive reviews in exchange for money or services, they will add a consumer alert advising that the business was caught trying to buy reviews. The alert will stay on your business’s page for 90 days. 12

It is a good idea to check Yelp often to see if you have any reviews. Take note of any concerns that could be easily correct-ed. Are people complaining about a long wait time? Did they feel your front desk staff was rude? Do they feel it is difficult to schedule an appointment? These reviews can help identify

problems with your practice and when corrected, can lead to an improved overall experience.

Yelp tips:

• Avoid replying publicly.

• Contact patients directly to discuss concerns.

• Check reviews often — consider improving on the general concerns about the practice.

Creating a social media policy for your office

Even if you do not have a social media presence for your practice, it is recommended that you develop a policy for your employees to follow. Many employees will likely have some sort of social media involvement outside of the office, and steps must be taken to ensure that employees understand that their personal posts can cause privacy violations for the practice. A written policy should be developed and kept in your policy and procedure manual. You may also wish to have employees sign an agreement and keep it in their employment file.

Blogger Elizabeth Hipp offers this advice: “employees need to be aware that even friending patients on social media sites can violate HIPAA. And answering their questions posted online is also a big no-no. Instead, make it clear that your staff is not to engage with any patient through their personal social media profile, and that if a question is asked of them online a return phone call to the patient is the only way to answer it. And, perhaps most importantly, designate a person in the office that employees can question as to what is appropriate online behavior.

Although most medical programs now cover the subject of patient confidentiality online, if a team member hasn’t been formally trained in the medical field or hasn’t been to school within the last two years, chances are they might not even be aware of these issues. Having a contact person and open commu-nication will ensure employees are 100% aware of what is appro-priate behavior online.” 13

Conclusion

For physicians unfamiliar with social media, learning to use these tools can seem overwhelming. Fortunately, one does not have to be considered “tech-savvy” to begin creating a social media presence. More than likely, there is someone on your staff experienced in social media who can assist you. There are also resources available online.

Helpful articles and tips are available at the Texas Medical Association’s web site via the “Social Media” link. You may also visit their Social Media Resource Center, http://www.texmed.org/template.aspx?id=7654.

Another excellent resource is the medical blog, KevinMD.com (www.kevinmd.com), founded by Dr. Kevin Pho. This web site also has a social media link that has many articles about current social media trends in the medical field.


cme ACTIVITY

It is clear that social media is not merely a passing fad, but something that has become integral to doing business. While the medical field has been slow to adapt to social media, its popular-ity within the field is increasing. When done properly, maintain-ing an online presence can be a useful tool for physicians to grow their practices.

Sources

1. Dolan Pl. Patients want to use social media tools to manage health care. American Medical News. April 30, 2012. Available at http://www.ama-assn.org/amednews/2012/04/30/bisa0430.htm . Accessed February 11, 2013.

2. Federation of State medical Boards. model policy guidelines for the appropriate use of social media and social networking in medical practice. 2012. Available at http://www.fsmb.org/pdf/pub-social-media-guidelines.pdf. Accessed February 12, 2013.

3. Saltzman J. Blogger unmasked, court case upended. Boston Globe. march 31, 2007. Available at http://www.boston.com/news/local/articles/2007/05/31/blogger_unmasked_court_case_upended/?page=full . Accessed February 12, 2013.

4. Ravn K. The Doctor’s in, on Twitter. Los Angeles Times. December 15, 2012. Available at http://www.latimes.com/health/la-he-doctors-social-media-20121215,0,5753417.story .

5. Accessed February 11, 2013. NBC News. Doctor busted for patient info spill on Facebook. April 18, 2011. Available at http://www.nbcnews.com/id/42652527/ns/technology_and_science-security/t/doctor-busted-patient-info-spill-facebook/. Accessed February 12, 2013.

6. Tobar A. medical residents: tips to keep a clean social media profile. KevinMD. November 3, 2012. Available at http://www.

kevinmd.com/blog/2012/11/medical-residents-tips-clean-social-media-profile.html. Accessed February 12, 2013.

7. CBS News. Zuckerberg family pic stirs Facebook privacy debate. December 27, 2012. Available at http://www.cbsnews.com/8301-205_162-57560923/zuckerberg-family-pic-stirs-facebook-privacy-debate/ . Accessed February 12, 2013.

8. Chretien KC, Azar J, Kind T. Research letter: physicians on Twitter. JAMA. February 9, 2011 – Vol 305, No 6 566-567.

9. osterberg G. update on Twitter archive at the library of Congress. January 4, 2013. Available at http://blogs.loc.gov/loc/2013/01/update-on-the-twitter-archive-at-the-library-of-congress/. Accessed February 12, 2013.

10. Yelp.com. Frequently asked questions. Available at http://www.yelp.com/faq#business_info_on_yelp. Accessed February 12, 2013.

11. Sorrel Al. Negative online reviews leave doctors with little recourse. American Medical News. october 4, 2010. Available at http://www.ama-assn.org/amednews/2010/10/04/prca1004.htm. Accessed February 12, 2013.

12. Yelp.com. Consumer alerts: because you might like to know. October 18, 2012. Available at http://officialblog.yelp.com/2012/10/consumer-alerts-because-you-might-like-to-know.html. Accessed February 12, 2013.

13. Hipp E. Does your medical office have a social media policy? December 15, 2012. Available at http://www.kevinmd.com/blog/2012/12/medical-office-social-media-policy.html. Accessed February 12, 2013.

Shannon Quinn can be reached at [email protected].

Privacy and security updateHB 300-compliant authorization form now available

When HB 300 passed in 2011, it made changes to existing Texas privacy laws that are more stringent than those found in HIPAA and HITECH.

HB 300 also required the Texas Attorney General to develop an Authorization to Disclose Protected Health Information form that would comply with HIPAA, HB 300, and other applicable laws. This form is available at the Texas Attorney General’s web site at https://www.oag.state.tx.us/AG_Publications/pdfs/hb300_auth_form.pdf. It is also available at www.tmlt.org.

The use of this form is not mandatory. But if you use a different form, it must comply with the applicable privacy laws. If you have already modified your form, you may want to compare it to the attorney general’s form.

Authorization is not required for disclosures related to treatment, payment, health care operations, performing an insurance or health maintenance organization function, or as may be otherwise authorized by law.

.


If you do not have a myTMLT account, please call customer service at 800-580-8658, ext. 5050.

Need help with a CME course? Call (877) 880-1335.

We are now offering all CME courses

through TMLT’s new CME site,

www.tmlt.org/cme. We will no longer

offer the option to complete Reporter

CME in paper format. All CME

completions will now be through the

web site, which will provide 24-hour

access to content, testing, receipts,

and certificates.

In order to deliver courses through

the new CME site, we will now be

charging a slight fee to cover the cost

of the new online catalog. Policyholder

and non-policyholder pricing will be

in effect. Simply visit the site and log

on with your myTMLT username and

password to receive policyholder

pricing.

They’re at www.tmlt.org/cme

Hey, where are

my paper test forms?

www.t

mlt.o

rg/cm

e


closed claim STUDIES

Presentation

A 49-year-old woman began seeing a new family physician in 2003. The patient had a history of hysterectomy, knee replace-ment, and reported that her mother had breast cancer.

Physician action

During a visit on January 21, 2004, a screening mammogram was ordered, but there was no documented breast exam. The mammo-gram was done on February 26 and was interpreted as normal.

The patient continued to see the family physician through 2005 for arthritis, chest pain, knee pain, hypothyroidism, high blood pressure, and diabetes. Her labs were within the target range and the family physician frequently checked a box on the chart that stated “chart reviewed and updated.”

The next mammogram was ordered on January 3, 2006, again without a documented breast exam. The mammogram was taken on February 25, 2006. The report indicated there were two new lesions, one in each breast. The radiologist recommended a diagnostic mammogram. This mammogram — done on March 13, 2006 — indicated a cyst in the right breast and a solid nodule in the left breast. The left breast nodule was classified as smooth and indeterminate, with a recommendation for a follow-up mammogram in 6 months.

The patient’s follow-up visit on March 18, 2006, was with the nurse practitioner (NP). The NP discussed the mammogram with the patient and documented that the patient complained of burning in both breasts. This was the patient’s first documented breast exam, with the right breast having a small, palpable lesion and the left breast with no lesion. The NP diagnosed cystic breasts and recommended a follow-up mammogram in six months.

The patient continued to be seen several times through Novem-ber 2007 without any breast exam or follow-up mammogram. A mammogram was completed on December 26, 2008 and was interpreted as “no change except for benign calcifications of the left breast.” The radiologist recommended a clinical correlation for significant palpable findings.

The mammogram was discussed with the patient during an office visit on March 6, 2008. There was no breast exam at this visit.

Though she had several office visits, the next mammogram was not completed until February 15, 2009. This mammogram was interpreted as showing an increased clustered micro-calcification in the central portion of the left breast, “probably a benign

finding.” Short-term follow up was recommended. The mammo-gram report had a note documenting that on March 12 the NP and the family physician told the patient and her husband to repeat the mammogram in 6 months. No breast exam was documented on the March 12 visit.

During an office visit on July 13, 2009, there was a note indicat-ing that a mammogram was due in September. The patient was seen several times in 2009 and a mammogram was done on April 21, 2010. There was no documented breast exam at that time. The mammogram indicated an increasing nodular density in the left breast and an ultrasound was recommended for clarification. The patient was informed of the results of the mammogram.

On May 2, 2010, the patient had an ultrasound of her left breast that demonstrated a complex cyst in the retroaeolar that measured 6 x 5 mm with mildly dilated retroareolar structures. The radiolo-gist stated the cyst probably accounted for the density seen on the mammogram, but it was also entirely non-specific. Another mammogram was recommended in six months. The family physi-cian signed the report and noted follow up in six months.

The NP saw the patient on February 3, 2011. She complained of a hard knot on the right breast and reported it had been there for 3 weeks. A breast exam indicated a 7- to 8-mm tender mass in the right breast. The NP ordered a diagnostic mammogram and referred the patient to a surgeon.

The mammogram was completed on February 6, 2011. It was interpreted as “right breast unchanged, and left breast has a speculated mass deep into the retroareolar, measuring 1.5 cm and is new since last mammogram. This finding was suspicious for malignancy. The family physician discussed the findings with the patient on February 9, 2011. She was referred to a surgeon.

The surgeon performed a core needle biopsy of the left breast on March 15, 2011. The biopsy showed an invasive breast carci-noma, ductal type, grade III, plus DCIS. Two months later the patient underwent a lumpectomy and left axillary dissection. She underwent radiation and chemotherapy. A CT scan and a PET scan revealed the patient had a lesion in her sternum. The patient’s prognosis was very poor.

Allegations

A lawsuit was filed against the family physician for failure to timely diagnose breast cancer. The plaintiffs alleged that the family physician breached the standard of care by failing to perform breast exams during the five years the patient had

Failure to timely diagnose breast cancerby Louise Walling and Laura Hale Brockway, ELS

These closed claim studies are based on actual malpractice claims from Texas Medical Liability Trust. These cases illustrate how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. An attempt has been made to make the material less easy to identify. If you recognize your own case, please be assured it is presented solely to emphasize the issues of the case.

continued on page 15

the REPORTER


Presentation

On September 23, a 39-year-old man came to his family physi-cian with complaints of a skin lesion on the right side of his head. The patient reported redness, pain, and puss discharge from the lesion for four days.

Physician action

The patient was seen by the physician’s assistant (PA). She examined the patient and documented that the lesion was approx-imately 1x1 cm, and was red and inflamed. The center of the lesion was scabbed with mild bloody exudate.

The PA obtained a culture of the lesion and sent it off to the lab. The culture results revealed Methicillin-resistant Staphylococcus Aureus (MRSA), sensitive to sulfamethoxazole and trimethoprim. The patient was prescribed sulfamethoxazole and trimethoprim, two pills, twice a day for 14 days and mupirocin ointment. He was given a handout about staph infections and told to return to the clinic in seven days.

The PA did not incise and pack the lesion since the patient popped the lesion before the visit.

The patient returned to the clinic on October 2 and was seen by the PA. He complained of diarrhea and an episode of vomiting that morning. The patient’s vital signs were normal, his heart rate was regular, and his lungs were clear. He tested positive for Influenza Type A. The PA prescribed diphenoxylate/atropine, promethazine, and zanamivir inhalations.

Returning to the clinic again on October 11, the patient was seen by the family physician. He documented that the patient’s vital signs were normal and the scalp lesion was crusted and healing. The patient had completed his sulfamethoxazole and trime-thoprim prescription and appeared to be recovering from the flu.

The patient was seen again at the clinic on October 28. He complained of right groin and leg pain. The patient reported that eight days earlier he had stepped in a hole while mowing the lawn and this caused his leg pain. The pain increased with walking and sleeping and the patient was using a cane to walk. The family physician suspected a pulled muscle and prescribed methylpred-nisolone, anti-inflammatories, and hydrocodone. He documented that if there was no change in the patient’s condition, he would order x-rays.

The patient’s leg pain continued and he returned to the family physician on October 31. The patient reported the pain was 6 out of 10 and he was walking with a limp. X-rays of the hip and femur were obtained and the results were negative. The family physician diagnosed a pulled muscle, told the patient to continue his medication, and ordered physical therapy. He planned to refer the patient to an orthopedic surgeon if he was not better in a week.

On November 2, the patient’s father contacted the clinic indicat-ing that his son was incoherent and in terrible pain. The father was instructed to take the patient to the emergency department (ED). The patient coded in the ED, but was successfully revived and placed in ICU. Multiple specialists examined the patient and he was found to have multisystem organ failure due to suspected sepsis. Extensive efforts to save the patient’s life were unsuccess-ful. He died on November 3. An autopsy determined the cause of death to be from staphylococcal bronchopneumonia complicated by myocarditis.

Allegations

A lawsuit was filed against the family physician alleging failure to timely diagnose a MRSA staph infection and provide the appropriate antibiotic coverage.

Legal implications

The plaintiff’s expert claimed the patient’s MRSA scalp lesion was improperly treated and this led to the patient’s pneumonia and death. Specifically, the expert alleged that the lesion should have been incised and packed. He criticized the choice of sulfa-methoxazole/trimethoprim and said vancomycin or clindamycin should have been used to treat the infection. Further, the MRSA infection was spreading to the blood and organs of the patient and the subsequent leg complaints were a symptom of the ongoing infection. This should have prompted the family physician to hospitalize the patient so he could receive intravenous antibiotics.

Defense experts pointed out that the patient’s MRSA infection on his head was sensitive to sulfamethoxazole/trimethoprim and the decision to prescribe this antibiotic was appropriate. There was evidence that the scalp lesion was improving with treatment. During the five visits from September 23 to October 31, the patient’s vital signs were stable and he did not have any fever.

Regarding the complaint of groin pain, there was a reasonable explanation in that the patient reported he stepped in a hole while mowing the yard. Defense experts believed the MRSA infec-tion on the head resolved and the patient developed a separate subsequent infection that led to his death. It was unlikely that a patient with a systemic MRSA infection would be out mowing the yard and as active as the patient was in the days before his death. The medical examiner did not autopsy the patient’s legs, so there was no way to know if the leg pain was associated with the staph infection.

Disposition

This case was taken to trial and the jury reached a verdict in favor of the family physician.


The outcome of this case is viewed as a success for the defen-dant and it is useful to feature a claim that concluded with a jury

Failure to prescribe appropriate antibioticby Louise Walling and Laura Hale Brockway, ELS


exoneration of the defendant. However, this case still offers the opportunity to comment on some practice protocols that could be improved.

Two physicians who reviewed this case for the defense were criti-cal of the family physician’s documentation, which was described as “indecipherable.” The records were also incomplete as to examination and reasoning for specific treatment or lack thereof. According to the Texas Medical Board rules for medical records, “Each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporane-ous and legible.”

Illegible handwriting and incomplete record keeping are common weaknesses. Documentation or lack thereof can be subject to broad interpretations of actual meaning as well as the quality of patient care. A plaintiff’s attorney may use this to question whether the physician was within the standard of care. All entries in a medical record need to be complete and legible.

Louise Walling can be reached at [email protected] and Laura Hale Brockway can be reached at [email protected].

suspicious mammograms. It was also claimed that an earlier diagnosis would have improved the patient’s long-term prognosis.

Legal implications

This case was reviewed by two family physicians. Both review-ers commented that the defendant’s medical records were of poor quality. They were in a template style and very hard to read. There were no documented routine breast exams, gynecologic exams, or any other preventative screenings.

One family physician stated that the defendant deviated from the standard of care regarding screening and early detection of breast cancer. The defendant and her NP relied entirely on mammo-gram reports from the radiologist and did not appear to have a deeper understanding of the clinical presentation in a patient with multiple risk factors for breast cancer.

An oncologist who reviewed the case stated that the patient developed an interval cancer during the nine months between the last exam and diagnosis. He did not believe that an earlier diagnosis would have made a difference in the patient’s outcome.

Overall, it was felt this case would be difficult to defend due to the family physician’s poor documentation and failure to document breast exams in accordance with the standard of care.

Disposition

This case was settled on behalf of the defendant.


Poor quality record keeping and lack of documentation of breast exams created a substantial challenge for the defense. If pre-formatted templates are used in the medical record, they may need to be re-designed, particularly if too many blank spaces are left unanswered. If the blank area is not relevant for that particu-lar visit, simply documenting “N/A” indicates that area was not bypassed during the visit.

If the physician performed a breast exam at any of the patient visits, it was not documented in the medical record. Since the mammogram findings were an ongoing issue in this patient’s care and relevant to the patient’s medical history, asking focused questions and documenting the subsequent examinations would have been useful. Over a period of years the physician continued to order mammograms, yet the medical record was silent about any breast examination findings. A thorough medical record may be one of the physician’s best defenses against allegations of negligence.

Louise Walling can be reached at [email protected]. Laura Brockway can be reached at [email protected].

breast cancer ... continued from page 12

Texas Medical Liability TrustP.O. Box 160140 Austin, TX 78716-0140 800-580-8658 or 512-425-5800 E-mail: [email protected] www.tmlt.org

Editorial committeeCharles R. Ott, Jr., President and CEOJohn Alexander, Chief Operations OfficerJill McLain, Executive Vice President, Governmental RelationsDon Chow, Senior Vice President, Sales & Business DevelopmentSue Mills, Senior Vice President, Claim Operations & Risk Management

Editor Laura Hale Brockway, ELS

Associate Editor Louise Walling

Staff William MalamonShannon QuinnKatie Stotts

Graphic DesignerKaren Hardwick

the Reporter is published by Texas Medical Liability Trust as an information and educational service to TMLT policyholders. The information and opinions in this publication should not be used or referred to as primary legal sources or construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalizations can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust or Texas Medical Insurance Company is engaged in rendering legal services.

© Copyright 2013 TMLT

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