Teaching to the Tort by Stuart Swadron, M.D.

Stuart Swadron, M.D.I have noticed myself doing something a little suspect over the years. I will call it “teaching to the tort”.

At LAC+USC, like at most residency programs, we strive to infuse the available evidence into our teaching and our practice. We discuss the latest evidence for diagnostic tests and interventions at the bedside, in small groups, and during grand rounds.

But there are times at the bedside that I find that my directions and comments are based not on evidence, but on my knowledge of our medical malpractice system. I sometimes discourage practices that differ from what is customary because I fear that they will get our residents into hot water after they graduate.

Let me try to think of an example. Atropine is given as a premedication in the rapid sequence intubation of infants and small children. This practice is based on the theory that atropine will mitigate the risk of bradysystolic arrest during RSI. But we don’t have good clinical evidence to support this theory. In fact, the available evidence contradicts it.

Still, I find myself hedging. I know that in the event of a bad outcome that many “expert” reviewers will see the omission of atropine as a potential red flag. “We can omit it here at USC, but when you are in the community try not to make your practice patterns stand out too much – you don’t want to be the only person doing something different than what’s in the textbooks”. I want our graduates to be street-wise in this way and not put themselves at risk unnecessarily.

Mea culpa.

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