COPIC Podcast: Within Normal Limits

COPIC Podcast: Within Normal Limits

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COPIC's Podcast—Within Normal Limits: Navigating Medical Risks

Within Normal Limits is a podcast produced by COPIC that focuses on a wide variety of risk management, patient safety, and professional liability issues. Hosted by Eric Zacharias, MD, an internal medicine doctor and physician risk manager with COPIC.

Within Normal Limits provides physicians and medical professionals with unfiltered insights that focus on pitfalls to avoid in medicine and best practices to improve patient care. The podcast centers around open conversations between physicians and medical experts. Each episode is around 20 minutes and dives into topics including practical guidance, detailed analysis, current issues, and case study reviews. Within Normal Limits is an opportunity to learn from others’ experience and gain knowledge that may help you be a better medical provider and deliver the best patient care possible.

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Special Episode: Requirements for Nebraska Physicians Who Prescribe Opioids/Controlled Substances
This episode focuses on Nebraska legislation that outlines rules for prescribing and continuing education around opioids and controlled substances. The legislation was passed in 2018, but its implementation was delayed because of COVID. However, these requirements are now in effect starting in October 2021. Among the requirements are that prescribers must obtain 3.0 hours of CME regarding prescribing opioids on a biennial basis (0.5 hours of which MUST cover Nebraska’s Prescription Drug Monitoring Program or PDMP). Dr. Zacharias outlines the details of meeting these requirements, including accessing a half-hour PDMP training video on the Nebraska Department of Health and Human Services’ website and upcoming online COPIC seminars that fulfill 2.0 hours of CME. There are two different COPIC seminars (each one is an hour) that provide risk management guidance around opioids, including the risks of addiction and overdose. The seminars are no-cost to attend, open to all Nebraska prescribers, and will be held on 9/28, 9/30, 10/12, and 10/14.

Episode 26: Talking with Patients Who Are Hesitant About the Vaccine
It’s an issue that many physicians are facing and something that continues to be a focus in public discourse—people who don’t want to take the COVID vaccine. The conversations providers are having on this topic can be emotionally charged, full of confusion and disinformation, and difficult to navigate. This episode’s guest, Dr. Dennis Boyle, is an expert on communication and shares some insight on how to approach these situations such as the idea of “developing a therapeutic alliance” as a framing point, inquisitive inquiries, and seeking first to understand why a patient is hesitant. In addition, the discussion touches on the benefit of highlighting the extensive research work done to develop mRNA vaccines and thoughts on what to say to younger patients who are anti-vaccine.


Episode 25: Medication Errors: The Potential Side Effects and Risks of Prescribing
Dr. Dennis Boyle, COPIC physician risk manager, joins the podcast again to talk with Dr. Zacharias about ongoing issues we see with medication errors. These include drug-to-drug interactions, medications that are most prevalent in medical liability lawsuits (antibiotics, pain medicine, and anticoagulants), and awareness about black box warnings. Dr. Boyle walks through some case studies to illustrate why errors occur and highlights steps physicians can take to proactively address these situations. The conversation also covers the importance of documenting your thought process when prescribing, the use of “read backs,” the “five rights” of medication use (right patient, right drug, right time, right dose, and right route), the challenges of drug monitoring.

Episode 24: Nonverbal Communication: How Your Body Talks and What Patients Hear
Dr. Zacharias is joined by Dr. Dennis Boyle, a COPIC physician risk manager, to talk about key elements of nonverbal communication that occur during physician-patient interactions such as touch, facial expressions, posture as well as the speed and tone of your voice. Dr. Boyle talks about nonverbal cues in both how we sent messages to patients and how “micro expressions” from patients can provide valuable insight into how our messages are being received and the patient’s state of mind. He also mentions the “golden minute” of when you first encounter a patient and have an opportunity to form a connection, how nonverbal communication may influence the likelihood of being sued, and the importance of nonverbal communication from other medical staff in a patient’s overall experience.

Episode 23: A Conversation with the Colorado Medical Society’s President—Dr. Sami Dia‪b‬
In this episode, we are proud to have Dr. Sami Diab, the president of the Colorado Medical Society (CMS). Dr. Diab describes his journey into medicine, from growing up in Syria to finding his calling as an oncologist to joining the leadership team at CMS. He talks about how his medical background is applied in his current role when dealing with public policy and state legislative issues, and how he approaches his work by thinking about the ways broader decisions may impact medical providers, patients, and the overall health care system. Other topics on his mind include managing the challenges of physician burnout, the value of talking to peer physicians, and access to care and affordability. In addition, Dr. Diab emphasizes the importance of energizing other physicians about their role within health care and how to sustain joy in your medical practice while cultivating resilience.

Episode 22: With Power Comes Responsibility—Ethical and Legal Issues That Physicians Fac‪e‬
Dr. Michael Victoroff joins the podcast again to talk about administrative or conduct issues that can create legal concerns for physicians. Many of these relate to the authority a medical license grants and the power of a physician’s signature (i.e., prescribing medications, signing off on medical charts, etc.). Dr. Victoroff makes the distinction between willful misconduct and inadvertent actions that can lead to accusations of billing fraud, disciplinary proceedings, and governmental investigations. He also highlights common situations where these issues occur such as supervising other medical staff, serving as a medical director, or providing patient coverage for other physicians. Dr. Victoroff notes that well-intentioned favors and a desire to help can sometimes place good physicians in bad situations, and he provides some guidance that includes staying within your scope of practice—things you do on a regular basis. In addition, the discussion turns to EHRs, the challenges of automated templates, and being aware that your notes accurately reflect the care you provided.

Episode 21: Considerations with Opioids and Pain Management—A Surgeon’s Perspectiv‪e
Dr. Sue Sgambati, COPIC’s medical director and a colorectal surgeon, joins Dr. Zacharias to talk about her personal experience in balancing the professional responsibility to treat pain with concerns over opioid addiction. Dr. Sgambati reviews the historical background of key factors that contributed to the overprescribing of opioids and what she saw and learned in her own practice. She then talks about the value of using tools such as a state’s prescription drug monitoring program, opioid risk assessment tools, and guidelines published by organizations such as the CDC. Dr. Sgambati also addresses alternatives to opioids that are being used, the challenges of having conversations with patients about opioids and how to document these, and the availability of naloxone to counter overdoses.

Episode 20: Telehealth: The Evolving World of Remote Car‪e
Dr. Zacharias welcomes Dr. Michael Victoroff, a COPIC consultant and health information technology expert, to talk about the increased use of telehealth driven by COVID-19 and how this has become a more permanent shift in health care. They discuss the applicable regulations and practical guidelines that are defining the telehealth environment and what physicians should know to effectively navigate these interactions. Dr. Victoroff shares his thoughts about how the perspectives of providers, patients, and regulatory agencies have changed, the importance of reimbursement, and why “telehealth is one of the best things to happen to medicine.” In addition, he highlights considerations with technical platforms, privacy and security standards, documentation elements unique to telehealth, and concerns with providing telehealth care to patients in other states.

Episode 19: Cultivating a Culture of Safet‪y
Dr. Benjamin Keidan, Boulder Community Health's Chief Medical Officer, joins us to share his thoughts on how to implement and reinforce a culture of safety. Dr. Keidan talks about his personal journey and how an MBA gave him a better understanding of the financial, human resources, and legal perspectives that impact health care. He highlights the importance of creating a system that values collaboration among all medical team members and a shared commitment to clearly defined patient safety goals. The conversation then focuses on the benefits of shifting away from a culture of blame to one that encourages reporting, continuous learning, and prevention. Dr. Keidan also talks about his experience with using a “systems perspective” to identify areas for improvement, making “the right thing the easiest to do” for staff, and ensuring that medical providers understand how to report incidents and that there is consistent follow up to explain how concerns are being addressed.

Episode 18: An Inside Look at How the Colorado Medical Board Responds to Complaint‪s
Dr. Zacharias is joined by Dr. Dennis Boyle, a COPIC physician risk manager, and Dr. Donald J. Lefkowits, the current president of the Colorado Medical Board. Dr. Lefkowits talks about his journey from working in emergency medicine to becoming part of the Board’s leadership. He then walks through the types of complaints the Board receives and how they manage the process of addressing these. This includes recommendations for physicians who receive complaints, from using an attorney to help draft a response (a no-cost service available with COPIC’s coverage) to using a factual, non-emotional tone in your response to adhering to the 30-day timeframe. Dr. Lefkowits also talks about the issue of physician wellness and the assistance programs available to support providers dealing with challenges.

Episode 17: COVID-19 and Its Potential Impact on Medical Liability Issue‪s
Dr. Zacharias welcomes Dr. Alan Lembitz, COPIC’s chief medical officer, to talk about what we are seeing in terms of the medical liability issues that may come in the wake of COVID-19. Dr. Lembitz highlights what initial claims data and trends is telling us, and how, due to the “long-tail” of incident reporting, the full impact of COVID-19 will take some time to emerge and understand. The discussion also looks at public perception of the challenges medical providers faced during the pandemic, concerns over patients with non-COVID-19 conditions that held off on treatment because of fears of the virus, and the benefits and limitations of telehealth. In addition, Dr. Lembitz mentions the importance of documenting shared decision making with patients during this time to detail the factors that may have impacted patient care.

Episode 16: Using Simulation Technology to Teach the Next Generation of Medical Professional‪s‬
In this episode, we look at medical education with two representatives from Pikes Peak Community College (PPCC)—Lisa James, Executive Director of PPCC’s Foundation, and Amber Lippincott, Associate Dean of Nursing. Their discussion explores health care trends that are influencing student programs in nursing and other allied health professional fields. In particular, they highlight simulation technology to teach students evidence-based practices, and the benefits of using an advanced birthing simulation mannequins funded by a grant from the COPIC Medical Foundation. This allows students to develop essential clinical skills and practice labor/delivery scenarios in an environment that allows them to learn from their mistakes and develop teamwork, communication, and decision-making skills.

Episode 15: Colorectal Cancer Screenings: A Shift in Guideline‪s‬
Dr. Sue Sgambati, a colorectal surgeon and COPIC’s medical director, discusses the recent recommendation from the U.S Preventive Services Task Force that colorectal cancer screening routinely begin at age 45, instead of age 50. This recommendation is in response to the sharp rise in the number of colorectal cancers in young adults. Dr. Sgambati draws upon her own experience to talk about considerations when evaluating symptoms and whether or not to include a colonoscopy as part of a workup. She also highlights her perspective on colonoscopies versus additional tests for patients that can identify signs of cancer based on stool samples.

Episode 14: A View from the Inside: Dr. Alan Lembitz, Chief Medical Officer at COPI‪C‬
Dr. Alan Lembitz joins us on this episode to talk about some of his key lessons learned over the years as COPIC’s chief medical officer. In particular, the conversation focuses on how and why COPIC developed its Practice Quality Reviews that help identify potential areas of risk. Dr. Lembitz discusses how claims data is distilled down to develop Level One Guidelines (best practices) about common areas where we see issues occur such as documentation, patient communication, and medication safety. He also highlights the importance of vital signs when care is reviewed and how physicians should view the terms “negligence” and “standard of care” from a medical liability perspective.

Episode 13: Addressing Adverse Outcomes Part II: A Deeper Dive Into Cando‪r‬
What is Candor? How does it benefit patients and providers? Dr. Zacharias is joined by Dr. Sue Sgambati, the medical director at COPIC, to answer these questions and provide some insight. In this context, Candor refers to a framework that emerged out of efforts by the Agency for Healthcare Research and Quality (AHRQ) to encourage an environment that supports open, honest conversations with patients after adverse outcomes occur. It is also designed to investigate and learn from what happened, to address the patients’ needs alongside providers’ needs, and to disseminate any lessons learned in order to improve future outcomes. Dr. Sgambati talks about how COPIC guides providers through Candor, especially In Colorado and Iowa where there is legislation that formalizes this process, and some of the key lessons learned from managing these types of cases.

Episode 12: Addressing Adverse Outcomes Part I: COPIC’s 3Rs and CANDOR Programs
Dr. Jeff Varnell, a surgeon and COPIC physician risk manager, is the guest for this episode that focuses on addressing adverse outcomes through COPIC’s 3Rs and CANDOR Programs. Dr. Varnell has managed the 3Rs (Recognize, Respond, and Resolve) process and highlights its origins and goals of maintaining the physician-patient relationship and improving the quality of medical care. He also talks about how 3Rs and CANDOR try to move away from an adversarial approach to one that guides physicians through managing difficult patient conversations and using best practices for disclosure that includes open and honest conversations. In addition, Dr. Varnell points to the positive results that have emerged from 3Rs and how these benefit both patients and physicians.

Episode 11: Physician Leaders: A Pediatrician’s Perspective on Care Integration and Improving Patient Safety
Dr. Zacharias welcomes Dr. Sophia Meharena, a pediatrician and member of COPIC’s Board of Directors, to talk about her personal journey into medicine and the transformative experience of doing her residency at Children’s Hospital Colorado. She also discusses her current role at a safety net clinic and highlights the value of integration that occurs with other specialists, health care navigators, and social services; along with her concerns about the pandemic’s impact on pediatric patients (i.e., social isolation, dietary health, financial constraints, etc.). In addition, Dr. Meharena talks about her involvement with the COPIC Medical Foundation and how its grant funding seeks to improve patient safety in measurable and meaningful ways such as support for simulation technology used for training medical providers.

Episode 10: A Brotherly Discussion on Cognitive Issues and Alzheimer's
Dr. Zacharias’s brother, Alan, is our guest, not just because he is related to our host, but because he is a neurologist and expert in cognitive impairment. The two discuss having patient conversations about memory issues associated with “normal aging” and differentiating these from possible early indicators of Alzheimer's disease. Alan then does a deep dive into diagnosing Alzheimer’s; the role of diet, physical activity, social engagement to improve functionality; and available treatments as well as potential new therapeutics on the horizon. Lastly, Eric finally learns the truth regarding his often used conjecture that there are no Grandmaster chess players over the age of 60.

Episode 9: Using the Mediterranean Diet as a Patient Wellness Tool
Coming off the holidays, this episode taps into Dr. Zacharias’s knowledge as a published author on the benefits of the Mediterranean diet. In a conversation with Dr. Sue Sgambati, COPIC’s Medical Director, Dr. Zacharias talks about how a six-month sabbatical traveling across countries such as France, Italy, and Spain, enabled him to research how dietary habits can reduce coronary heart disease and optimize your health. The discussion focuses on the eight principle areas of the Mediterranean diet and how physicians can incorporate these into recommendations for patients that encourage healthy habits and still allow them to enjoy the “pleasure of eating.”

Episode 8: The Senior Surgeon: Assessing Skills as We Age
As we get older, there is value in the wisdom and experience we gain. However, there is also a well-documented risk for cognitive and physical decline that accompanies aging. In this episode, Dr. Zacharias looks at the issue of assessing the skills of aging physicians with his guest, Dr, Jeffrey Varnell, a surgeon and COPIC physician risk manager. It’s a topic filled with gray areas (pun intended) that include evaluation through voluntary testing, mandatory retirement ages, and patient safety considerations. There is also a discussion of the fulfillment and identity that comes with being a physician and how this can influence when people finally decide to hang their white coats up.

Special Episode: A Good Outcome from a Patient's Perspective
In this episode, we hear from one of Dr. Zacharias’ patients who is doing well due to early recognition of an often-missed condition—epidural spinal lesion. The patient initially presented with symptoms that included back pain and mild saddle anesthesia. The episode provides an insightful perspective from the patient’s point-of-view and reinforces the importance of remaining hypervigilant to subtle signs that can escalate quickly.  

Episode 7: Navigating Conversations with Patients About Guns
Some providers may draw a strict boundary about discussing guns with their patients (or not think about it). But research has shown there are situations when access to firearms is a potential risk factor and raising this issue can be not only appropriate but necessary. Dr. Michael Victoroff, who is a firearms safety expert, addresses some scenarios associated with guns that can arise in the clinical setting. These range from imminent danger (e.g., suicide risk) to general considerations that vary from household to household (e.g., storage methods). Dr. Victoroff offers guidance on how to approach this topic with non-confrontational questions and suggestions for credible resources for healthcare providers.

Episode 6: Burnout from COVID-19: Moving Forward with Resilience
While burnout is a long-standing issue in health care, the compounded impact of COVID-19 has heightened its prevalence and the importance of efforts to address the well-being of medical providers. In this episode, Dr. Zacharias talks to one of COPIC’s experts on physician burnout, Dr. Dennis Boyle. They dissect the root causes of burnout and three key diameters to consider—depersonalization, emotional exhaustion, and feelings of low accomplishment. They also look at other influential factors such as EHRs, workplace culture, and personality traits as well as the omnipresence of grief in health care. In addition, they talk about how the trend of prescribing “simple mindfulness” can be a challenging practice to put into action, and what steps can be taken to effectively approach this.

Episode 5: A Frontline Doctor’s Perspective on COVID-19
Dr. Zacharias talks with Dr. Connor Graham, a frontline hospitalist at a critical care access hospital, about his direct experience in dealing with COVID-19. Dr. Graham discusses how patient cases have changed since March, the risk of exposure and the emotional strain medical providers face, and the ways treatment options have evolved. In addition, he addresses the challenging logistics of prolonged hospitalizations, from the delicate balance of staffing needs to the coordination that occurs between different facilities to managing patients with urgent, non-COVID-19 conditions. The two doctors also share insight on how they handle the personal stress and their cautious, yet optimistic view on how vaccines will be a game changer.

Episode 4: Informed Consent—The Joy (and Pain) of Shared Decisions
Informed consent shouldn’t be viewed as just an obligation to get a signed form, but rather, an opportunity to engage patients in shared decision-making. Dr. Jeffrey Varnell, a surgeon and COPIC physician risk manager, joins Dr. Zacharias to talk about the process of disclosing essential information during the informed consent process so that patients understand the recommended treatment and indications, risks, benefits, alternatives, and risks of not proceeding. In addition, they review the importance of not delegating this process to those who aren’t performing the procedure and assessing a patient’s understanding.

Episode 3: Sepsis—A Bad Infection That Can Get Worse
Sepsis is a common syndrome, and although our knowledge of how to treat it has improved significantly, this bacterial infection can be very lethal if not caught early. Dr. Susan Sgambati, a colorectal surgeon and COPIC’s medical director, joins Dr. Zacharias to review some sepsis case studies and discuss why early recognition is critical, the value of clinical judgement and vital signs, and how pain out of proportion to what you are seeing can be a key indicator.
BONUS CONTENT: COVID-19 Considerations During the Holidays
The latest developments in the COVID-19 saga include some good news (promising results from COVID-19 vaccines) and some not-so-good news (a spike in cases across the country). Dr. Zacharias offers an honest assessment about the risks in a clinical setting, the risks at home, realistic precautions to take, and why Clorox wipes may be the best Christmas present (if you can find them).

Episode 2: Spinal Epidural Abscess—A Difficult Diagnosis
Dr. Zacharias switches places with his peer, Dr. Boyle, who asks questions about a classic case study that involves…you guessed it—spinal epidural abscess. The conversation gets deep into the clinical aspects surrounding a patient who visits the emergency room several times in an eight-day period with complaints of a subjective fever and severe back pain. As Dr. Zacharias notes, this is a difficult case and “the standard of care is to miss it.” Using a step-by-step analysis, the two doctors offer guidance on where things can go wrong and the factors that should be examined to avoid a bad outcome.

Episode 1: Med Mal 101—Heads, Hearts, Bellies, and Bugs
Our first episode draws upon decades of medical liability experience to distill down the key areas where we consistently see malpractice lawsuits—heads (neurologic), hearts (chest pain), bellies (abdominal pain), and bugs (infections). We examine why physicians sometimes misdiagnose symptoms that seem obvious in hindsight, but in actual practice, are not so simple. Our guest is Dr. Dennis Boyle, a rheumatologist who also teaches at University of Colorado School of Medicine and is a physician risk manager with COPIC. Dr. Boyle and Dr. Zacharias walk through some sample scenarios and offer guidance on how to avoid common risks while enhancing patient safety. 
BONUS CONTENT: Dr. Zacharias talks about how medical residents are named in up to 30% of medical liability lawsuits, what types of lawsuits these are, and the long-term impact these can have on residents. He also highlights COPIC’s Resident Rotation Program that helps the next generation of physicians prepare for issues they will likely face during their careers.