Carlo Reyes and Jim Schaeffer have been invited to speak as faculty at the California ACEP Annual Assembly in June of 2015 in Los Angeles.
Carlo Reyes, M.D. J.D. discusses Proposition 46 and why it must be defeated in Emergency Medicine News
At Your Defense: Raising Noneconomic Damages Cap Bad for EPs and Patients Alike
I recently gave a lecture attended by many emergency medicine residents, and afterwards ran into an attending I had not seen since training. “I think I might have scared the residents a little bit,” I said.
He agreed, noting that medical-legal talks can frighten residents into ordering too many tests. That's not good medicine either, he said.
His comment reminds us that the fear of litigation has the deleterious effect of inducing providers to practice defensive medicine. A California proposition on this November's ballot may have a similar effect, increasing health care waste and cost.
California voters will decide Nov. 4 whether the Medical Injury Compensation Reform Act (MICRA) deserves an overhaul. If passed, Proposition 46 will increase the noneconomic damages cap in medical negligence cases from $250,000 to more than $1.1 million, apparently to account for inflation since MICRA was enacted in 1978. The Proposition 46 author cleverly embedded the anti-MICRA provision with others that actually have substantial voter traction: mandatory drug and alcohol testing of all doctors, reporting positive tests to the state medical board, mandatory provider reporting of other providers suspected of drug or alcohol impairment and medical negligence, and requiring providers to consult drug databases before prescribing controlled substances to patients.
Proposition 46, formally named the Troy and Alana Pack Patient Safety Act of 2014, is named after two children killed by a driver under the influence of prescription drugs. It sounds like a real solution to voters, especially amid the prescription drug epidemic in which doctors have been asked to take responsibility for and decrease the ubiquitous misuse of prescription drugs. But keep reading.
The first, obvious, question is: How is the MICRA provision related to the other provisions? The hidden message for voters is that increasing the noneconomic damages cap will improve patient safety. How? I've yet to see a doctor stop, reflect on the high noneconomic damages cap in his state, and then order the right test. Rather, much like what that attending reminded me, the fear of litigation may induce doctors to order more tests to try to get the right diagnosis. Defensive medicine rears its ugly, expensive head, and fear of litigation does not make better doctors but more expensive ones who order unnecessary tests, draining health care of critical resources that the government cannot afford (and will not pay for).
The intent of Proposition 46 is singular: increase the noneconomic damages cap. Why else would this provision be inserted among the unrelated but enticing provisions? Remove the anti-MICRA provision, and Proposition 46 reads like a unified act, one that could pass on its merits. But if Proposition 46 passes, the anti-MICRA provision will have been snuck into law.
California, responding to the malpractice crisis, was the first state to enact a noneconomic damages cap in medical negligence cases. At least 35 states have enacted some form of noneconomic damages cap since 1978. Experts debate whether caps lead to decreased insurance premiums for physicians, but studies show that caps keep premium increases in check. Importantly, studies demonstrate that caps maintain a modest supply of physicians within a state and reduce wasteful defensive medicine practices. (New Engl J Med 2011;364:1564.)
Raising the cap would exacerbate the physician shortage because increasing premiums would decrease the number of practicing obstetricians, neurosurgeons, and other physicians already paying high malpractice premiums. The current health care climate under the Affordable Care Act, which failed to address the existing physician shortage, demands expansion of providers to care for the influx of insured. An increased cap would amplify the physician shortage and decrease subspecialist panel coverage because of an increase in insurance premiums.
The anti-MICRA provision, if passed, provides a template for the remaining states to raise or even eliminate their noneconomic damages cap. Like the ripple effect that MICRA had when it was enacted in 1978, passage of the anti-MICRA provision will induce other states to reconsider their caps. This may not be a good thing for health care or patients.
October , 2014
Carlo Reyes spoke at Los Robles Hospital for the Trauma Grand Rounds. His presentation is entitled, "EMTALA III".
Carlo Reyes spoke at the Southern California Association of Healthcare Risk Management. His presentation is entitled, "The CMS Physician Blacklist: A New Approach to Qui Tam?"
Carlo Reyes MD JD spoke at the UCLA Emergency Medicine Conference. His presentation is entitled, "Healthcare for Providers".
Carlo Reyes spoke at the California American College of Emergency Physicians Conference in Long Beach, California. His presentation is entitled, "Reducing Risk in Pediatric Emergency Medicine".
Carlo Reyes spoke at the Southern California Association of Healthcare Risk Management Meeting. His presentation is entitled, "Critical Value Reporting: Overcoming Barriers to Physician Communication."
Carlo Reyes, MD JD received the 2014 Chief of Staff Award for his services at Los Robles Hospital.
Black-Boxed Drugs We Still Use: Weigh the Risk
By Brady Pregerson, MD | October 17, 2013
Dr Pregerson is a staff emergency physician at Cedars-Sinai Medical Center in Los Angeles and Tri-City Medical Center in Oceanside. He is the author of the Tarascon Emergency Department Quick Reference Guide, the A to Z Pocket Pharmacopoeia, and Quick Essentials: Emergency Medicine. He is also Editor in Chief of EMresource.org, a free online medical education Web site for emergency medicine and urgent care practitioners.
According to Dr Carlo Reyes, clinicians need to be cautious with inappropriate use of drugs with or without black box warnings, but they also need to be skeptical of some of these warnings, which may lead to reduced use of effective medications.
Dr Reyes covered this and related topics during his lecture at the American College of Emergency Medicine 13th annual symposium in Seattle (ACEP13) entitled Black-Boxed Drugs We Still Use: What’s the Risk?
Medicinal drugs have 5 potential warning levels that the FDA can attach to them: the black box warning is the most serious of these. Dr Reyes noted that the science behind the decision to give a black box warning to a drug is often not always based on academically rigorous information, but rather sometimes only on case reports.
One of the most famous—or rather infamous—black box warnings was the one for droperidol(Drug information on droperidol) in 2001 covering its risk for prolongation of the QT interval and torsade de pointes. Following this scare, which many feel was a conspiracy to get clinicians to use more expensive alternative medications, droperidol use dropped significantly. By the time risks were found to be severely exaggerated, the damage had already been done and trends had been set using other agents such as ondansetron(Drug information on ondansetron) for nausea and haloperidol(Drug information on haloperidol) for acute psychosis.
Dr Reyes mentioned that the FDA gave black box warnings for increased suicide risk, especially in adolescents, after initiation of treatment with antidepressants. After this warning was publicized, the use of these drugs decreased, but unfortunately suicide rates in teens increased. The risk of suicide is probably a consequence of depression rather than the medication used to treat it, and though there may be a short-term increased risk soon after starting a new antidepressant, the long-term benefits outweigh this potential risk. Still, clinicians should warn patients and/or their parents of this and other potential adverse effects when starting a new medication.
Other examples of black box warnings that may surprise some include:
• Clindamycin(Drug information on clindamycin), which can cause Clostridium difficile diarrhea
• NSAIDs, which can cause GI bleeds or renal injury
• Fluoroquinolones, which can lead to tendon ruptures
• Acetaminophen/codeine, which can cause unpredictable respiratory depression in children
• Lamotrigine(Drug information on lamotrigine), which can cause Stevens-Johnson syndrome and/or toxic epidermal necrolysis
Dr Reyes gave the following advice regarding black box warnings and potential legal pitfalls:
• Avoid using drugs you are unfamiliar with.
• Avoid using drugs with black box warnings if alternative effective therapies exist that do not carry a black box warning.
• Inform patients not only of common potential adverse effects, but also of rare but possibly serious adverse effects.
• When unsure of what to prescribe, consider consultations with the physician who will be taking over care of the patient.
He also mentioned some recent non–black box warnings regarding significant complications that clinicians may not be aware of. These include:
• Acetaminophen and Stevens-Johnson syndrome
• Quinolones and irreversible peripheral neuropathy
• Ondansetron and QT prolongation
• Dabigatran, which is contraindicated in patients with mechanical heart valves
Dr Reyes also mentioned that prescription of opiates, even ones without black box warnings, can open a Pandora’s box of potential liabilities when appropriate precautions are not taken. Long-acting narcotics—including the fentanyl(Drug information on fentanyl) patch prescribed for opiate-naive patients—have led to respiratory arrest, hypoxic brain injury, and death. In addition, prescription of narcotics without adequate warnings about activity restrictions can put the clinician at risk if the patient injures a third party while under the influence of a drug he or she prescribed.
Carlo Reyes, MD JD to Present Two Sessions at the ACEP13 Scientific Assembly
Emergency medicine professionals from all around the world will be convening in
Seattle for the ACEP13 Scientific Assembly. Carlo Reyes, MD JD, an emergency physician,
pediatrician, and healthcare attorney, will be presenting two sessions at the conference titled
“Beware! The New Hotbed of Litigation” and “Black Boxed Drugs We Still Use: What’s The Risk?
on 10/14/13. The lecture on litigation risks will review new trends in medical malpractice, ranging
from third party liability to EMTALA. The lecture on black boxed drugs shall review the latest FDA
warnings regarding drugs emergency physicians use every day.
The conference promises to be a stimulating and educational event for all emergency medicine
professionals. The three and a half-day event takes place October 14-17, 2013, and
features advanced emergency medicine courses, many hands-on skills labs, a variety of preconference
options, and many exciting networking opportunities.
The ACEP13 Scientific Assembly is a great opportunity to expand your network and gain valuable
information from the most comprehensive and up-to-date emergency medicine education, says
Reyes. “I am greatly looking forward to leading discussions on medical-legal topics vitally
important to emergency physicians.”
The American College of Emergency Physicians promotes the highest quality of emergency care,
and is the leading advocate for emergency physicians, their patients, and the public.
Dr. Reyes won a gold award for best new column for his legal articles, At Your Defense. The American Society of Healthcare Publication Editors competition is the most prestigious in health care publishing. The organization is dedicated to fostering the highest ethical standards and excellence in health care publishing.
Carlo Reyes MD, Esq. and James Schaeffer, Esq. have been invited to speak at the California American College of Emergency Physicians Annual Assembly in June, 2013 in Manhattan Beach. Dr. Reyes has created a series of medical-legal course presentations for CAL-ACEP, designed to educate emergency physicians about the most important aspects of medical negligence law affecting emergency physicians today. To register for CAP-ACEP Annual Assembly, click this link: https://www.regonline.com/californiaaceps2013annualassembly
Carlo Reyes, MD, Esq. has been invited to speak at Children's Hospital, Los Angeles on April 24, 2013. Dr. Reyes shall utilize his unique background in Emergency Medicine, Pediatrics, and healthcare and professional malpractice law to present EMTALA issues affecting Children's Hospitals for the Pediatric Emergency Medicine Division.
Carlo Reyes, MD, Esq. is speaking at the Los Robles Trauma Grand Rounds on April 12th. Dr. Reyes will present EMTALA issues affecting trauma hospitals and trauma systems, focusing on liabilities affecting hospitals and panel subspecialty physicians and surgeons.
Carlo Reyes, MD, Esq. was invited to speak at this year's National ACEP Scientific Assembly in Seattle, Washington, October 14-17, 2013. The ACEP Scientific Assembly provides over 300 continuing medical education courses from top educators throughout the country to over 5,000 emergency physicians. Dr. Reyes will present the highly attended annual "Hot Topics in Litigation" course, and will also lecture on high-risk black box FDA warnings. To register for ACEP Scientific Assembly, click this link: http://www.acep.org/sa/
On November 16, 2012, Mr. Schaeffer obtained an 11-1 defense verdict on behalf of an emergency room physician and ER group in a birth injury case tried in Lancaster. In that case, a 25 week gestation patient presented to the local emergency department with a urinary tract infection. She was evaluated and discharged home. The patient went into pre term labor the following morning delivering a severely premature infant who thereafter suffered from profound neuro-developmental delays requiring full time attendant care. The jury found that Mr. Schaeffer's client appropriately evaluated the patient and determined that she was not in pre term labor while in the ER. The jury found that the patient's symptoms did not indicate a transfer to the labor and delivery department at that time.