Often, preventive medicine means warding off suits

'Just document what we discussed."

That was the advice my senior resident gave me after I saw a disgruntled patient.

The man had seen flashes of light and floaters, or small black dots, earlier that evening. These symptoms could indicate a retinal detachment.

It was a busy night in the Wills ER at Thomas Jefferson University. In the triage area, the patient threatened to leave because he did not want to wait. He had a two-hour drive home and it was already late. My colleagues and I pleaded with him to stay because if he had a retinal detachment and it went untreated, he could go blind.

He opted to leave. I "documented" our discussion, taking several minutes to craft a re-enactment of our exchange.

"That looks good," my resident told me. But "did you get him to sign the AMA form?"

The "Against Medical Advice" form essentially says you can't sue because you left of your own volition. It's protocol to get it signed when someone leaves after being at least partially seen. I had indeed forgotten.

Later that night, I worried. I hadn't dealt thoroughly with the situation from a legal perspective, and now visions of testifying in court ran through my head. The patient wore khakis and a polo - he looked a little lawyerish. Would he blame me if he went blind? Would my "documentation" hold up?

My resident reassured me. It's no big deal that I forgot about the AMA form as long as I documented well. So I thought it should be fine.

But fine for whom? Fine for me. And herein lies the problem. I spent all that effort worrying about myself when I should have been spending it focused on my patient. Would he be taken care of? Did he have a retinal detachment? Would he lose his sight?

My energy was also diverted from all the other patients in the waiting area. In the time it took to fine-tune my note and discuss it with my senior resident, I could have diagnosed a contact lens-related infection or an orbital fracture. Not to mention the emotional energy it took from me.

I recently spoke about this to one of my attendings, pediatric ophthalmologist Harold Koller. He had been sued in a case that eventually awarded $20 million to the parents of a child who became blind. Koller was found personally not responsible because, he says, he not only did nothing wrong, but he had clear documentation of the facts.

When he started practicing, Koller said he used to write just enough in his charts so he could follow his patient's course of treatment. Sometimes he didn't even sign his name. Now, he writes extensive notes: "80 percent for lawyers, 20 percent for doctors."

That demand has its downside. Under the dictum "If you don't write it down, it didn't happen," a doctor can end up transcribing all the minutiae of a conversation. And "covering yourself" consumes a lot of time in an already busy health system.

The threat of malpractice weighs heavily on us - even during early training - because we fear that going to court will undermine our life's work. We spend four years in medical school, then several more in residency and fellowship to build a foundation of knowledge and experience to care for patients.

The Institute of Medicine found in 1999 that almost 100,000 people a year die from medical mistakes in hospitals. But studies show that patients don't necessarily sue over a bad result. They sue when there is poor communication between physician and patient. These patients may feel victimized and turn to the court system for recourse.

In one of the last lectures in medical school, we were warned: It's not a matter of if you get sued but when. According to the Ophthalmic Mutual Insurance Co., the average ophthalmologist will face one malpractice claim about every 10 years. Only 3 percent will retire from a 35-year career without a claim.

Pennsylvania has been a hotbed for litigation. According to the Pennsylvania Medical Society, the average physician liability payout is 60 percent higher here than in the rest of the country.

So I worry. But I hope that my worrying will dissipate as I become more confident of my skills.

The morning after I saw that patient in the ER, my head was much clearer. I called him because I worried about him - not me. I left a message on his answering machine. "Please come in if you weren't able to make it to another doctor's office this morning," I said. "We would be happy to see you."