This is Lab Medicine Rounds, a curated podcast
for physicians, laboratory professionals and students.
I'm your host, Justin Kreuter, the Bow Tie Bandit of blood,
a transfusion medicine pathologist at Mayo Clinic.
Today we're rounding with Dr.
Ross Reichard, a forensic pathologist at Mayo Clinic
who is also the prior vice-chair of quality
for the Department of Laboratory Medicine and Pathology.
And current medical director
for Mayo Clinic Quality Academy and Associate Professor
of Laboratory Medicine and pathology.
Dr. Reichard is here
with us to discuss what every pathologist should know
about the legal system.
Thanks for joining us today
Dr. Reichard.
Thanks for having me.
I appreciate the opportunity.
Yeah, so I'm really interested, I
this is a topic that I'm gonna be learning a lot from.
Maybe you could kick it off for us and like why
is it important for pathologists to know a thing
or two about the legal system?
Well, as a practicing pathologist
whether you fully appreciate it or not
you're already engaged with the legal system, you know
primarily through quality assurance programs, you know
and that's really important to appreciate because
you know, statutes, they vary from state to state.
I mean, there are some things that are pretty consistent
you know, a across the country and, you know
in the quality assurance program
it could protect your organization
from liability or malpractice if you know
based on someone else who's practicing in your organization
if you're following it appropriately.
But also your quality assurance program
if not managed properly
you could also put your institution at risk.
So, you know, an example of that would be, you know
you have a, an event with a patient event or a safety event
or such and you know, you form a, a committee, you know, to
to evaluate what, what happened, you know, so this is a
a peer review group
and what that's called as a review organization.
And so, you know, our society has deemed it very important
for physicians to be able to have peer review
and to improve the care of medical practice
without the fear of being sued for malpractice.
But if you don't manage this properly, you may put you
your organization in that information at risk.
You know, you keep things
as a small group, it's confidential.
Re information from those works aren't, you know
released to large group, you're fine.
But you know what people may not understand and what, what
what I've seen is, oh, this is a great improvement
let's email everybody we know
about how we learned about this.
And when you do that
you've now removed the confidentiality component
and you might make this subpoena or discoverable.
So whether you, whether you appreciate it or not, you're
you're probably already engaged would be be one point
I guess.
Wow. That, that really, you know
it certainly hits home probably for most of our listeners
as we're a collection of our listeners are physicians
lab professionals and, and students.
So certainly the physicians laboratory professionals
quality is something that is really front
of mind and probably even more so than the legal system.
I, I hadn't really hadn't given as much thought to that.
And that's, given that I've been
to many of those, you know, morbidity, mortality meetings
we're reviewing cases and I know that that
and I guess I've always thought
about as that canned language about, you know
what we're talking about here is, is confidential
which is great for, as you say, really fostering some
of those critical discussions and how we go further.
And you're, I think, spot on
with that example of you learn something great
you really want to disseminate it as that natural reflux.
Maybe can you take in, maybe dive into some
of these points because I think this is starting to resonate
with our audience about, you know, even
though we're not going to a court of law
quality practices are something that all
of us are involved in.
Could you unpack those a little bit so
that listeners can think about how they're engaging in that?
Yeah, I mean, I think we're
we're doing it more often than we think.
We just haven't set it in the legal, the legal setting
of it before, because oftentimes it doesn't come up.
It's only when it comes up
that people think about it from that perspective.
And so, you know
if you have a solid quality assurance program, for example
and you're following that
if you have someone that does something erroneous
or larger organization, the third party would be protected.
If you have the program and you're not, you know, following
through correctly and you have someone who's, you know
failing PT and competencies and such, you know
your organization could be held liable
for the harm that that person did.
That would be one example.
And you know, and second point, sort of at a
at a larger level, you know, as
as a pathologist and a physician and
and hopefully as only through work related activities
and not personal, but you know, you you
there's a high probability eventually you'll be involved
in some sort of legal proceeding, you know, as a various
you know, whether you're a fact witness, an expert witness
or hopefully not a defendant, but there's a
there's a reasonable probability that you will
at some point engage very directly with the legal system.
And do you have any kind of tips or pointers
about if that comes to pass, how, how you proceed?
Because I mean that's, that's not something I remember learning
in medical school or, and you know, I certainly
got the chance to see some courtroom work when I was
on my forensic rotation in training
but probably most of us aren't, aren't too savvy on that.
Yeah. So I guess I think the
the number one thing is if you are involved in something
I would understand what your role is
which is very critical.
So, you know, there's really two types of witnesses.
And so one is a fact witness
and so this is a person that has, you know, you know
witnessed the crime so, so to speak, right?
So you're the, the stander by who saw something happen
and you're gonna testify to that.
And the role of pathology per specifically that would be
you're the one that made the diagnosis.
So you're just saying, I made the diagnosis of x, it's
you know, this, this type of neoplasm for example, that's
in contrast to an expert witness is usually not
initially directly involved in the case and has brought
in to issue their opinion about that particular case.
And so expert witnesses are, you know
being paid for their time and are doing this really at
at their own pleasure, if you will.
They've, they've willingly engaged to be
in this role as an expert.
So I think those are two really breaking, you know
big categories, but really knowing what your role is and
and what are the expectations
of what you're, you're gonna do.
Oh, that's really helpful.
If I could back up to an earlier point you were making
I think about the importance of, you know
having a good quality plan and following it.
Because I think that's something that probably, again, a lot
of the listeners that resonates with, you have been involved
in quality in, in many capacities
many leadership quality capacities here at Mayo Clinic.
And probably have seen
and thought about a lot of these quality plans.
Do you have thoughts like our listeners, you know
to give us maybe some fresh eyes if I say, gee
I maybe I should look at my quality plan, you know, how
how can I know it's good or, or you know, what are some kind
of first initial steps I can take to shoring it
up a little bit?
Yeah, I mean, I think, you know, making sure
that you really do have a robust plan and that you're
you're following what that plan is
at a very high level, that's easy to say.
But you know, when some groups get in trouble
as they have a plan and then they don't follow it
and they don't stick to what they're doing.
And you know, at times, you know, people think, oh
this is tedious, you know, why am I reviewing this s o p
why am I signing off on this?
Why am I checking these competencies?
Why did I have to come in and review this histology for
you know, it's quality and it seems kind of tedious
but each one of those parts is what puts together
a really robust quality plan.
I think, you know
I mean eventually I could expand on it if you want
but I think part of it is understanding what you know
really is the definition of malpractice and how
you would get to the, to understanding what malpractice is.
Because I think a lot
of people don't understand what that means.
They think, okay, I got the diagnosis wrong, shoot
that's malpractice, I'm gonna get sued, you know
or something happened here and that, oh, I'm gonna get sued.
And I think when you understand the different components
of it, it, it helps kind of ease you a little bit
but also helps you have a framework of how
you could approach developing a quality assurance program.
Oh, that's really, you know, probably
for our students it would be really helpful to
kind of elaborate on that.
Probably a, a good reminder for a lot of us in practice too
if you could kind of, what does that mean malpractice?
So there's really four key elements to, to meet that.
And the, the first is you have to have a duty
or an obligation to treat the patients
to a standard of care.
And so for pathologists, that specimens in our laboratories
and so really the key component is the duty
and the standard of care.
Standard of care is critical.
And I'll come back to that.
The second thing is there must be a dereliction from that
which just means negligence.
So you have to, there has to be proven
that there was negligence in providing the
the standard of care.
The third is during the dereliction of duty
the patient has to have been harmed
either by your actions or your inactions.
And then fourth is damages must be demonstrated.
there's a couple high level points I'll kind of focus in on.
And one is the standard of care, and that's the standard
of care at the time you're practicing medicine.
Okay? So like
if the standard is to evaluate this particular neoplasm
or this blood sample a certain way and you're following that
and there's some, you know, unfortunate outcome
you've been following the standard of care.
And, and that's a very, very important part of
of how this would be seen
through the courts and whether it would even proceed.
And that's, you know, if the lawsuit's filed, you know
years later and goes to court
they don't get to apply the new standard
of care now that there's been, you know
new molecular testing or what have you.
And so I think that's a really key element.
The other thing that I think is really important to
emphasize is a patient is harmed
by your actions or inactions.
And so one of the things that I've seen
from a practical standpoint is people are like, you know
oh this case got reviewed
or seen by something at a tumor board.
Like, you know, I'm not sure I agree, let's work it up
let's do some more stains, let's think about it.
And this is that huge rock
of a case that's hard to get moving.
And, and the reality is, from my perspective
at least is having been in these various roles is
that the longer you sit on something
the more likely there is for patient harm to be done, right?
You go, oh man, I missed this diagnosis
and someone looked at it the next day.
You want to fix that and get that out there as quickly
as possible cuz you don't want that person
getting chemotherapy that doesn't need it
or wrong chemotherapy or delay of treatment.
So when you know something
our tendency is to kind of hunker down.
In some organizations they call risk management
they do all these things that just take time and you know
I i I try to emphasize the sense
of urgency of we need to reconcile this issue
and get this to the patient as soon as possible.
Cuz you know, a day or two different might be, you know
whether the patient is harmed or not harmed.
I think those are great things to kind of
tee key our audience into, right?
So thinking about our SOPs and this can be, you know
really anybody in in laboratory medicine and
if you're listening from the clinical side also questioning
and engaging in these conversations
with your laboratory professionals about, you know
are we maintaining that i is our
our is our process that standard of care, you know
are have, have, has the state of care kind of moved
or advanced and are we keeping up with that?
And then that sense of urgency.
Because I hear you that, you know, you wanna
sometimes there's a wanting to be cautious, but certainly
in transfusion medicine there's some things we think about
you know, the, the sun cannot set on this.
Right, right.
You know, I think probably one of the best examples of that
and not to dabble close to your area
because I'll be way outta my league very quickly, but you know
like deep Venus thrombosis prevention, right?
Think about how much that's changed in the last 20 years
10 years, you know, even the last few years really.
But it's, you know, the standard
of care has dramatically evolved
and it varies by procedures and situations.
And so that
that's one where it doesn't mean you're not
gonna have a pulmonary thromboembolism and potentially
you know, harm or death from that
but are you following the standard
of care at that time with that particular patient?
So I imagine, so for some of us, you know
how we keep up with this is kind of should be second nature
to us in terms of maintaining our certification
getting our continuing education hours
hopefully bringing the education back
to advancing our policies, procedures.
Thanks. As a blood banker always makes my heart
go pitter patter to hear somebody talking
about making sure we actually follow our
our s o p I imagine keeping
up with the legal system or you know, are there things that
like you're saying that are the legal system
that's really quality changes.
I'm probably, if I'm honest with myself
I'm a little harder to update myself
on maybe more broader the legal system
as it pertains to quality management.
What do you recommend for people who want to take more
of an active or deliberate role in keeping up?
So there's a few things.
One is national and regional and local.
You know, organizations are following this
and they're looking for, you know, big changes
and they'll notify their members and so pay attention.
You know, sometimes people skip over that part of the
of the communications from those groups.
But that's a really good, you know, place to
to learn and which means you need to be involved and
and be part of those groups.
And that's one way to do it.
I think another one from like a
a practical standpoint is really understand your practice
from end to end
and ask questions that are informed questions.
So, you know, for example, hey, this specimen's coming
from across the state lines, does it matter?
Which state is it coming from?
Does that matter?
You know, was it sent to me directly
by the provider or did it come to go to pathologists
and then was referred to me, you know, you know
and big organizations like Mayo we often have people
behind the scenes that are asking those questions
and managing it so we don't see it bubble up.
But you know, you, if you understand your whole, you know
practice from beginning to end
and ask those thoughtful questions.
And I think another key point is, I mean
sometimes you can see things in the media
like I watch for big, you know
legal things that have made it to the media.
And then oftentimes because they've gone to court
those records are public.
So you can actually drill down into it
if you're really want to geek out on it, learn more.
But I think the other thing is
like you really need like a true like advisor, you know
an attorney that understands the questions you're asking
like someone for compliance is different than like civil
you know, malpractice, which is different than criminal.
And so I think knowing that, and, and from my perspective
the the last person you
you want to get legal advice from is like another physician.
I mean
I sort of joked there's a few things that physicians
they stick their toe in the water that I really don't want
I don't want my, you know, physician to be my pilot.
I don't want them to be my, my investment advisor.
I don't want them to be my attorney.
And so I say that, you know, jokingly sort of, but you know
there's a lot of misconceptions out there and, and you know
physicians are smart and so they think they understand it
but oftentimes they've gotten their information
on antidotes from their experiences or from friends and
and they don't quite have the
the whole breadth of the situation on your hand.
And so I would say make sure you get to a trusted source
You know, for some of us, I mean we might have, I know a lot
of people probably don't have attorneys necessarily
on retainer, but I imagine this show, this podcast
a lot of the big theme of it is
is connecting lab medicine in the clinical practice.
But I think this might be a nice example
of connecting lab medicine and
and maybe our legal team at our institution.
I guess can you kind of give that an example
of is there a connection there that you've kind of fostered
and developed a relationship about asking
for clarity and guidance on certain things?
Yes, I would, I would say the number of people
in the legal department know me pretty, pretty well and, and
for me for asking questions and bouncing things off of them.
So, you know, there's different within Mayo.
So first of all, most organizations are gonna have this
there's an on-call person for legal
and so you can basically call the operator and say
I need to speak to whoever's on call for the legal team.
Just like there's somebody
in charge for administration or nursing
there's somebody out there and they can find that.
So like if you have a pressing question that's often
a good place to go, they'll triage it
and maybe get it to the right subspecialty.
You know, I now know within Mayo system, you know
like I'm concerned about, you know
how something was managed.
I might direct it to, you know, one particular attorney
in general or if it's another one I might call them just
cuz I happen to know what their areas
of expertise are and what they're doing.
You know, and at least within the Mayo system
I don't wanna make this too Mayo eyes, but you know
you're having a attorney-client privilege when
you talk to them, so that's protected.
So just, you know, there's no need to be afraid to
of talking to them and there's no need to be afraid
that you're like causing problems
for other people when you raise this.
In fact, they very much appreciate being made aware
of things like when
when you're making an informed decision, like, okay
you know, this is what came through here and I saw this
or this patient did this and is saying this.
Sometimes notifying people and letting them start a file
on it, get some background, and again
allows them to be proactive instead
of reactive when something pops out either
in the media or like in a lawsuit or whatever, you know
weeks or months after the fact.
So, you know, I, as a forensic pathologist
I'm probably more comfortable than other physicians talking
to attorneys, but I, I think, you know, you gotta
look at 'em that are on your team as your friends and like
and the benefits that they can provide.
Brilliant. So making that connection as a positive thing.
And, and certainly, I I also keyed onto your response
about the fact that like at larger centers, you know
there are people that are working
behind the scenes to make a lot of things happen
but certainly a lot of our trainees might go
off into smaller practices and it's important to take notice
of these issues, to be thinking about these issues
and to develop the relationship with a, you know
who's the institutional legal system
or person as an important thing.
One last question I have is, you know
so you have an upcoming conference where you're
really gonna be elaborating on this further.
What are, what are the details on that?
Yeah, so it's a 2023 International Surgical
Pathology symposium that's hosted by Mayo this year.
It's gonna be in London the first week of May.
And the, the website
for registration will go live December 23rd.
So it's a, it's a very neat conference.
We'll be back in person.
It's tailored to give people some space to
explore whatever cities we're in
but have some really focused topics and it
it moves into quick pace.
So I think it's an engaging format.
Awesome. Thank you so much for rounding with us
Dr. Reichard.
My pleasure
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