or harm brought on by medical negligence.
Elements of malpractice
In the setting of medical negligence or “civil wrong,” four basic legal elements must be proven in a malpractice suit [4, 10]:
1 The physician had a duty to the patient (patient–physician relationship).
2 The physician breached the duty by violating the standard of care.
3 The breach resulted in injury.
4 The injury is compensable.
The standard of care is often determined through expert testimony, published data, and accepted practice guidelines, with the most important of these being expert testimony. It is important to note that this standard of care is what is customary among the majority of competent gastroenterologists and not what a few noted experts in the field would do in specific circumstances [10].
The best defense against malpractice suits is good medical practice. Perform procedures that are within the accepted indications and avoid risky cases when possible. Use the process of informed consent to educate the patient on the inherent risks and limitations of the procedure, thus transferring some of the responsibility to a well‐informed patient. Employ good documentation of adverse events, decision‐making, and patient communication. In the setting of complications, be vigilant in communicating honestly with the patient and their family and provide timely and appropriate management.
Training in quality assurance and improvement
It is important that trainers teach their trainees both the importance of quality and also methods of quality assurance and improvement. The apprenticeship model of postgraduate medical training means that the mentors must have the proper mindset and the institutions the proper support. Faculty must be good role models for their trainees in their adherence to best clinical practice. The institutions should establish QA and QI programs that include trainee participation. These are skills that trainees can then take with them into their own practices.
Specific curricula in quality assurance and improvement for trainees are unusual. Most institutions have lectures on obtaining informed consent and medicolegal responsibilities. It is also common to have morbidity and mortality conferences where complications and adverse events may be discussed with the goal of improving quality and patient outcomes. Most other aspects are learned through the apprenticeship of the training program: preprocedure patient assessment, proper indication, proper procedure performance, procedure reports, communication with referring providers, etc.
Specific curricula in QA and QI would include didactic lectures on quality assurance and improvement topics, drawing from the rapidly expanding literature. They should focus on the quality improvement cycle: measuring quality indicators to identify areas of underperformance, instituting an improvement plan, and then remeasurement to document improvement. Trainees could immediately begin to incorporate relevant quality indicators into their own training (e.g., cecal intubation). Measuring these indicators during training could be used to track performance improvement and ultimately to document attainment of procedural competency.
Conclusion
Quality measures are important in optimizing patient care and minimizing error, patient harm, and legal recourse. Trainees should familiarize themselves with the key quality measures required in the preprocedural, intraprocedural, and postprocedural time periods. Proper documentation, communication, and follow through are critical in maintaining the highest standards of care. These quality measures represent best clinical practice and may be used for continuous quality improvement.
References
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3 3 Balaguer F, Llach J, Castells A, et al.: The European panel on the appropriateness of gastrointestinal endoscopy guidelines colonoscopy in an open access endoscopy unit: a prospective study. Aliment Pharmacol Ther 2005; 21:609–613.
4 4 Feld AD: Informed consent: not just for procedures anymore. Am J Gastroenterol 2004; 99(2):977–980.
5 5 Zuckerman MJ, Shen B, Harrison ME, et al.: Guideline: informed consent for GI endoscopy. Gastrointest Endosc 2007; 66(2):213–217.
6 6 Schloendorff vs. Society of New York Hospital, 1914:211 NY 123.
7 7 Feld AD: Malpractice, tort reform, and you, an introduction to risk management. Am J Gastroenterol 2004; 99(2):977–980.
8 8 Berg JW: Informed Consent: Legal Theory and Clinical Practice. New York: Oxford University Press, 2001.
9 9 Louisiana Revised Statutes Tit. 9, § 2794.
10 10 Frakes JT: Medicolegal issues. In: ERCP. Philadelphia, PA: Saunders Publishing, 2008:3–11.
11 11 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non‐Anesthesiologists: Practice guidelines for sedation. Anesthesiology 2002; 96:1004–1017.
12 12 Sharma V, Nguyen C, Crowell M, et al.: A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66(1):27–34.
13 13 Vargo JJ, Holub JL, Faigel DO, et al.: Risk factors for cardiopulmonary events during propofol‐mediated upper endoscopy and colonoscopy. Aliment Pharmacol Ther 2006; 24:955–963.
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16 16 Shaffer AC: Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992–2014. JAMA 2018; 177(5):710–718.
17 17 Physician Insurers Association of America: PIAA Risk Management Review: Gastroenterology. Rockville, MD: Physician Insurers Association of America, 2005.
18 18 Physician Insurers Association of America: A Risk Management Review of Malpractice Claims: Gastroenterology Summary Report. Rockville, MD: Physician Insurers Association of America, 2005.
19 19 Levine EG: Informed consent: a survey of physician outcomes and practices. Gastrointest Endosc 1995; 41:448–452.
4 Training the Endoscopic Trainer
Catharine M. Walsh1 and Kevin A. Waschke2
1 Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
2 McGill University Health Centre, Montreal, QC, Canada
Introduction
Endoscopic training programs strive to develop individuals capable of providing safe, efficient, and effective endoscopic
