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Clinician Chronic Guilt Due to Inexperience, Poor Judgement and Mortality. No reference to specific company.

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Clinician Chronic Guilt Due to Inexperience, Poor Judgement and Mortality.

Robert M. Blumm, MA, PA, DFAAPA, PA-C Emeritus, PA Adviser for CM&F


I reflect on the famous words of a great president, John F. Kennedy: “When written in Chinese, the word crisis is composed of two characters. One represents danger and the other represents opportunity.” These two words are the opposite sides of the same coin and illustrate the focus of this article.

Fortunately, most healthcare practitioners are not in hazardous duty specialties and are not in a constant state of mental fatigue when performing their duties. The cause of this fatigue is stress. Some of us deal with stress during every shift - if we work in trauma, surgery, emergency medicine or intensive care. Hospitalists deal with daily stress as they inherit patients who are in guarded condition, require medications and life support in order to survive. This is not to demean our fellow clinicians - but the differences between dermatology and the SICU or other high-risk practitioners are significant.

The source of this stress problem? Inexperience. In my honest opinion there should never be a novice PA or NP in acute care areas without onsite supervision. There are too many new graduates, driven to find first employment so desperately - that they enter a field where they lack training, by both experience and mentorship. This can be deadly to the patient as well as to the careers of these well-intentioned clinicians. Experience is the cornerstone to quality healthcare and is won in the trenches by repetition, guidance from our peers, and continual study. An excellent medical provider, regardless of the initials after their name, must study every day of their life. Guidelines are always changing, and medical advances never cease.

Our second focus is on judgement or, rather, poor judgement. We face new situations every shift and try to maintain a state of readiness. But sometimes our decisions can be faulty because of our lack of experience. Every healthcare provider has made a poor decision or exercised poor judgement - this is how we are forged - in the crucible of pressure and heat. None of us is ever prepared for every eventuality. This is an odd admission but is, in fact, our reality. Our decision-making process is only advanced when we have been in the heat of the kitchen over time and have learned to respond to challenges in a methodic fashion. Such decision making cannot be taught in our schools exclusively but requires an official or unofficial residency. Mentorship and collegiality are essential. Value the time that a colleague works with you: learn to understand the critical thinking of their thought processes rather than following a script.

Limited experience and poor judgement can lead to negative outcomes including lengthy hospitalizations, medical complications, patient pain, family pain and most sadly - death. Death affects everyone; patient, family, primary provider and the rest of the medical team. Death represents not only our failures, but in reality, our limitations. We need to come to grips with our limitations: not every patient who receives the highest degree of care will survive the insult of surgery, trauma or illness. Perhaps Covid-19 has demonstrated this to us. I vividly remember my first patient death, a post-op patient from a urological surgery who had SOB and chest pain. I did an ECG, but the 12 lead on the floor was not working, I immediately sent the tracing to the SICU, where a physician promptly came for oversight. He asked the patient to take a big breath and he tried and then gazed upwards and went into asystole. We called a code immediately; six people appeared like genies from a lamp and they administered every treatment. Yet, ultimately, I heard those most dreaded words, “Time of death…” I felt that guilt personally for three weeks. Many colleagues tried to assuage my guilt until an anesthesiologist friend used some tough love: “Bobby, if it’s too hot in the kitchen, get out.” But I stayed. And I am glad that I did.

The loss of a patient is a deep loss. But we cannot surrender to guilt which only exacerbates self-doubt and renders us impotent in our roles as care givers. We can try our best to console the families, but must never yield to the emotion of saying, “It was my fault and I should have done more.” This does not create closure, but opens the door for what is called in legal terms, “discovery”.

To summarize this article, I need to point you to an important tool which helps to deal with insecurities, guilt and your professional future. The complexities spoken of here require more than study and mentorship, they require a plan. Part of that plan is to accept the realization that what I have written is the truth as so many of we healthcare providers have experienced. In a worst-case scenario, a patient’s family may not be able to bear the loss of their loved one and may seek compensation; and compensation means litigation against all those involved. You will be served with a blue document that informs you of the lawsuit which you are required to pass on to your malpractice insurance company. If that company is the same one that is defending the hospital and all its employees, they will look to share the burden or shift it to protect the interest of the policy owner - the hospital. This is certainly unfair and potentially very costly to you. But this inequity can be mitigated. You can purchase your own personal liability policy which covers only you - with your own defense team to fight a judgement against you. PA Malpractice Insurance is important to understand, easy to get and provides the stable and individualized protection your career demands. Accept the reality of our personal limitations and the possibility of making a poor judgement - but rest comfortably knowing that you have chosen the very best personal liability insurance. Career management is a very important lesson rarely taught in schools, but is increasingly vital in our litigious world!

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While I respect your years of leadership and experience in the field I do find myself ignoring your posts as the vast majority seem to be advertisements regarding insurance.

I get it, you may be passionate about it or you may just have a consulting fee you're working on, but it really does take away from your potential impact on the forum.

Just my 2 cents.

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For CJ and MediMike-

I have on numerous times disclosed my relationship to one of the insurance companies at the request of Administrators and a couple of colleagues. I have an agreement with the administration that I would not place any insurance company in the text and outside of something on Facebook or Linked-in I have been faithful to this request. The articles are meant for the practicing PA and deal with clinical, ethical and stressful situations where I can place an insight as an article with the last paragraph mentioning malpractice insurance in general. I have removed all mention of the company that I have written about for the last 25 years which is CM&F.

Back in the day, many PAs found themselves in lawsuits and had poor insurance that did not cover their litigation and which had caused a fair number to leave the profession early or be in a situation where they were dropped and could no longer get malpractice insurance.

When I was president of the AASPA , our board studied all of the companies selling insurance and we chose CM&F. When I chaired the Surgical Congress, now eliminated, I met with the presidents of all of the surgical specialties, and after research we decided to endorse CM&F because of their quality, longevity and excellent reputation and standing in the market. Yes, I am a paid PA Advisor to CM&F and deal with other issues relating to troubled surf in the PA waters. I am a consultant but have practiced every day as a PA and was never on salary but on a paid retainer for a monthly article.

If the Administrators would like me to drop any mention of malpractice insurance altogether and just eliminate the last paragraph I would submit to their request, but the purpose of the last paragraph is to remind all PAs that this is necessary for their protection.

I hope I have answered your questions and that you can look beyond the last paragraph, MediMike. Remember,"Don't throw out the baby with the bathwater." bob

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My observation on having a personal medical malpractice policy, based on a single episode of being a defendant:  since I was working at the time for a large EM staffing group, the attorneys retained to defend the company, the physician, and myself did defend both the doc and me very effectively.  I didn't experience any blame shifting or being thrown under the bus.  Rather, my experience with the attorneys was that by defending us, they were defending the medical staffing company.  In fact, they did far more than did the hospital's attorneys or those for the specialty practice I had consulted on the case.  So, at least in this case, having a personal policy wouldn't have had any incremental benefit.  I can't speak to how it would have played had I been a hospital employee.

Edited by ohiovolffemtp
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