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Abstract 1: Effect Of SDM On Complaint Or Lawsuit

Sanjay Arora, MD, Mike Menchine, MD, and Jess Monas, MD
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The Effect Of Shared Decision Making On Patients’ Likelihood Of Filing A Complaint Or Lawsuit: A Simulation Study Schoenfeld, E.M., et al, Ann Emerg Med Epub ahead of print January 3, 2019

BACKGROUND:  Shared decision making (SDM) is when clinicians share with patients the best available evidence to make an informed decision together. SDM is not appropriate when there is only one correct option and is not the same as informed consent. Proponents of SDM feel it will help reduce unnecessary testing as some evidence suggests that when patients fully understand risks and benefits, they are less likely to choose aggressive options.

ISSUE AT HAND: Does SDM impact the chance that a patient with a bad outcome will sue?

WHAT THE STUDY DID: This was a randomized controlled simulation experiment conducted by survey, using clinical vignettes featuring no SDM, brief shared decision making, or thorough SDM Participants were adult US citizens recruited through an online crowd-sourcing platform. Participants were randomized to vignettes portraying 1 of 3 levels of shared decision making. The clinical scenario for all patients was appendicitis and whether or not to CT. All other information given was identical, including the final clinical decision and the adverse outcome – no CT was done and the patient had a ruptured appy on a return visit. They also performed something called a manipulation check which asks participants directly about the manipulated variable in this case, the degree of shared decision making to ensure that the variable is truly perceived as different between groups.

WHAT THEY FOUND: 804 participants were included. The age ranged from 19 to 73, with a mean age 36, 46% were women, 79% were white.

  • Primary Outcome (likelihood of pursuing legal action):  In the no SDM group, 41% said they were somewhat/very likely to contact a lawyer compared with only 12% and 11% in the brief and thorough SDM groups respectively.
  • Secondary outcomes: SDM greatly decreased perception of fault and increased perceived quality of care and trust in physicians.

BOTTOM LINE: In the setting of an adverse outcome from a missed diagnosis, use of SDM may affect patients' perceptions of fault and liability. Patients exposed to any form of SDM were about 80% less likely to report a plan to contact a lawyer.

PMID: 30611638

EDITOR’S COMMENTARY: Although these weren’t real patients, this is still a pretty novel paper with a creative study design showing that patients with SDM were less likely to report blame, more likely to trust their provider, give the ED a better rating and less likely to call a lawyer even with a bad outcome – an interesting take on the benefits of “patient centered care” and SDM. Limitations of this study are that is it clinical vignettes, we have to assume that their responses to the simulated cases would mirror those they would make in real life, the subjects obtained by the crowd-sourcing platform had a higher education level and SES (may not represent your ED population), they only looked at appy (don’t know how the results would change for other conditions like PE) and contacting a lawyer is not the same as actually filing a lawsuit (but both are bad from a provider perspective).

 

Copyright 2019 by Emergency Medical Abstracts – All Rights Reserved   04/19 - #1

Paul J. V., D.O. -

I had this exact case. A child with abdominal pain and initial exam benign. I talked with family about CT, benefits and risks (US not available for appy in our hospital then) and used SDM. We didn't CT. Next day I called family and the child was worse. Had them return and the child had a ruptured appy. I felt horrible. The parents thanked me for calling them and giving good care. They even mentioned "we all decided not to get a CT yesterday". I'll never forget this case.

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