Published research

Background: Previous research suggests that medico-legal complaints often arise from various factors influencing patient dissatisfaction, including medical errors, physician-patient relationships, communication, trust, informed consent, perceived quality of care, and continuity of care. However, these findings are not typically derived from actual patients’ cases. This study aims to identify factors impacting the interpersonal dynamics between physicians and patients using real patient cases to understand how patients perceive doctor-patient relational problems that can lead to dissatisfaction and subsequent medico-legal complaints.

Methods: We conducted a retrospective study using data from closed medical regulatory authority complaint cases from the Canadian Medical Protective Association (CMPA) between January 1, 2015, and December 31, 2020. The study population included patients who experienced sepsis and survived, with complaints written by the patients themselves. A multi-stage standardized thematic analysis using Braun and Clarke’s approach was employed. Two researchers independently coded the files to ensure the reliability of the identified codes and themes.

Results: Thematic analysis of 50 patient cases revealed four broad themes: (1) Ethics in physician’s work, (2) Quality of care, (3) Communication, and (4) Healthcare system/policy impacting patient satisfaction. Key sub-themes included confidentiality, honesty, patient involvement, perceived negligence, perceived lack of concern, active engagement and empathy, transparency and clarity, informed consent, respect and demeanor, lack of resources, long wait times, and insufficient time with physicians.

Conclusions: This study identifies and categorizes various factors impacting relational issues between physicians and patients, aiming to increase patient satisfaction and reduce medico-legal cases. Improving physicians’ skills in areas such as communication, ethical practices, and patient involvement, as well as addressing systemic problems like long wait times, can enhance the quality of care and reduce medico-legal complaints. Additional training in communication and other skills may help promote stronger relationships between physicians and patients.

Mostafapour M, Smith JD, Fortier JH, Garber GE. Beyond medical errors: exploring the interpersonal dynamics in physician-patient relationships linked to medico-legal complaints. BMC Health Serv Res 24, 1003 (29 Aug 2024). https://doi.org/10.1186/s12913-024-11457-3

Background: With the rapid evolution of artificial intelligence (AI), particularly large language models (LLMs) such as ChatGPT-4 (OpenAI), there is an increasing interest in their potential to assist in scholarly tasks, including conducting literature reviews. However, the efficacy of AI-generated reviews compared with traditional human-led approaches remains underexplored.

Objective: This study aims to compare the quality of literature reviews conducted by the ChatGPT-4 model with those conducted by human researchers, focusing on the relational dynamics between physicians and patients.

Methods: We included 2 literature reviews in the study on the same topic, namely, exploring factors affecting relational dynamics between physicians and patients in medicolegal contexts. One review used GPT-4, last updated in September 2021, and the other was conducted by human researchers. The human review involved a comprehensive literature search using medical subject headings and keywords in Ovid MEDLINE, followed by a thematic analysis of the literature to synthesize information from selected articles. The AI-generated review used a new prompt engineering approach, using iterative and sequential prompts to generate results. Comparative analysis was based on qualitative measures such as accuracy, response time, consistency, breadth and depth of knowledge, contextual understanding, and transparency.

Results: GPT-4 produced an extensive list of relational factors rapidly. The AI model demonstrated an impressive breadth of knowledge but exhibited limitations in in-depth and contextual understanding, occasionally producing irrelevant or incorrect information. In comparison, human researchers provided a more nuanced and contextually relevant review. The comparative analysis assessed the reviews based on criteria including accuracy, response time, consistency, breadth and depth of knowledge, contextual understanding, and transparency. While GPT-4 showed advantages in response time and breadth of knowledge, human-led reviews excelled in accuracy, depth of knowledge, and contextual understanding.

Conclusions: The study suggests that GPT-4, with structured prompt engineering, can be a valuable tool for conducting preliminary literature reviews by providing a broad overview of topics quickly. However, its limitations necessitate careful expert evaluation and refinement, making it an assistant rather than a substitute for human expertise in comprehensive literature reviews. Moreover, this research highlights the potential and limitations of using AI tools like GPT-4 in academic research, particularly in the fields of health services and medical research. It underscores the necessity of combining AI’s rapid information retrieval capabilities with human expertise for more accurate and contextually rich scholarly outputs.

Mostafapour M, Fortier JH, Pacheco K, Murray H, Garber G. Evaluating Literature Reviews Conducted by Humans Versus ChatGPT: Comparative Study, JMIR AI 2024;3:e56537 (19 Aug 2024). doi: 10.2196/56537

Purpose: Adolescent and young adult patients occupy a clinically transitional space between pediatric and adult care. Youth with chronic conditions and special healthcare needs may have trouble accessing and receiving appropriate care in this transition, which may lead to patient safety issues and medicolegal risks for physicians. The objectives of this article were to explore patient safety issues and identify medicolegal risks for physicians.

Methods: A national repository was retrospectively searched for medicolegal cases (MLCs) involving complaints from youth. The study included MLCs closed at the Canadian Medical Protective Association between 2013 and 2022 involving youth. The study participants were adolescents and young adults aged ≥ 15 and ≤ 21 years with medical complexity. The frequencies and proportions of patient safety events and medicolegal risks for physicians were calculated by exploring factors that contributed to each incident using established frameworks.

Results: A total of 182 eligible MLCs were identified. Of 206 involved physicians, 55 were psychiatrists. The most common reasons for patient complaints were deficient assessment, diagnostic error, and communication breakdown with the patient and/or family. More than half of the cases were related to a harmful incident. Peer experts reviewed the cases and identified factors such as a deficient assessment, a failure to perform a test or intervention, failure to refer the patient, and insufficient provider knowledge/skill as contributing to the patient safety event.

Discussion: The impact of our findings is to identify gaps in care delivery to youth that can inform practitioners of ways to mitigate the gaps and improve patient care and health outcomes.

Aslanova R, Payant L, Liu R, Pacheco K, Fortier JH, Garber GE. Lessons learned from a retrospective analysis of medico-legal risks for physicians treating adolescents and young adults with medical complexity. Journal of Adolescent Health 0.0 (16 Aug 2024). Available from: https://www.jahonline.org/article/S1054-139X(24)00311-2/fulltext

Introduction: The Canadian Medical Protective Association (CMPA)'s Commitment to Change in Test-Results Follow-Up (CTC-TRFU) program aims to provide physicians with resources to enhance their test results follow-up systems for improved patient safety. Framed around the Transtheoretical Model, the program involves a 6-month multimodal educational intervention involving individual and group coaching sessions, action planning, and reflection surveys.

Methods: This study evaluates the CTC-TRFU program's impact by analyzing survey responses and course documents, focusing on three main outcomes: physicians' perceived barriers and challenges, changes in their confidence and commitment, and implemented practice changes with perceived impact on patient safety. Participants were Canadian physicians who enrolled through the CMPA's open-access registration, with a particular emphasis on those facing challenges in test result follow-up.

Results: One hundred two physicians have enrolled in the program. Of these physicians, 34 (33.3%) have successfully completed the program and 28 (27.5%) are actively enrolled. Among the 34 physicians who successfully completed the program, an overwhelming majority of 97.1% (n = 33) expressed their belief that the improvements made to their test follow-up system significantly enhance patient safety within their practice. We observed a significant increase in confidence in the robustness of the physician's follow-up system from program registration to completion (P < .001). Physicians reported catching specific missed test results (55.9%, n = 19), including various laboratory reports and diagnostic imaging like abnormal mammograms or missing MRI/CT results.

Discussion: Physicians who participated in the CTC-TRFU program reported meaningful practice changes, which we believe underscores the value of comprehensive, longitudinal continuing patient safety CPD initiatives. These findings indicate the potential for future studies to explore the long-term impact of similar programs and their scalability.

Normand E, Ramsey H, Mimeault R, Lemay K, Heroux D, McDougall A. Strengthening the chain: A continuing medical education program for Test Results Follow-up. Journal of Continuing Education in the Health Professions. DOI: 10.1097/CEH.0000000000000568 (8 August 2024).

Zaslow J, Fortier JH, Garber GE. The problem with never events. BMJ Quality & Safety 2024;33:613-616 (15 Jul 2024). Available from: https://qualitysafety.bmj.com/content/33/9/613

This review identifies the factors influencing the relationship between physicians and patients that can lead to patients' dissatisfaction and medical complaints. Utilizing a systemic approach 92 studies were retrieved which included quantitative, qualitative, and mixed method studies. Through a thematic analysis of the literature, we identified three interrelated main themes that can influence the relationship between physicians and patients, patients' satisfaction, and the decision to file a medico-legal complaint. The main themes include patient and physician characteristics; the interpersonal relationship between physicians and patients; and the health care system and policies, with relevant subthemes. These themes are demonstrated in a descriptive model. The review suggests areas of focus for physicians who may wish to increase their awareness around the potential sources of relational problems with their patients. Identifying these issues may assist in improvements in the therapeutic relationship with patients, can reduce their medico-legal risk, and enhance the quality of their clinical practice. The findings can also be utilized to support andragogical principles for medical learners. The article can serve as a structured framework to identify potential problems and gaps to design and test effective interventions to mitigate these potential relational problems between physician-patient.

Mostafapour M, Fortier JH, Garber G. Exploring the dynamics of physician-patient relationships: Factors affecting patient satisfaction and complaints. Journal of Healthcare Risk Management [Internet]. 2024 May 5 [cited 2024 May 15]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jhrm.21567

Background: Point-of-care ultrasound (POCUS) has become a core diagnostic tool for many physicians due to its portability, excellent safety profile, and diagnostic utility. Despite its growing use, the potential risks of POCUS use should be considered by providers. We analyzed the Canadian Medical Protective Association (CMPA) repository to identify medico-legal cases arising from the use of POCUS.

Methods: We retrospectively searched the CMPA closed-case repository for cases involving diagnostic POCUS between January 1^st, 2012 and December 31^st, 2021. Cases included civil-legal actions, medical regulatory authority (College) cases, and hospital complaints. Patient and physician demographics, outcomes, reason for complaint, and expert-identified contributing factors were analyzed.

Results: From 2012 to 2021, there were 58,626 closed medico-legal cases in the CMPA repository with POCUS determined to be a contributing factor for medico-legal action in 15 cases; in all cases the medico-legal outcome was decided against the physicians. The most common reasons for patient complaints were diagnostic error, deficient assessment, and failure to perform a test or intervention. Expert analysis of these cases determined the most common contributing factors for medico-legal action was failure to perform POCUS when indicated (7 cases, 47%); however, medico-legal action also resulted from diagnostic error, incorrect sonographic approach, deficient assessment, inadequate skill, inadequate documentation, or inadequate reporting.

Conclusions: Although the most common reason associated with the medico-legal action in these cases is failure to perform POCUS when indicated, inappropriate use of POCUS may lead to medico-legal action. Due to limitations in granularity of data, the exact number of civil-legal, College cases, and hospital complaints for each contributing factor is unavailable. To enhance patient care and mitigate risk for providers, POCUS should be carefully integrated with other clinical information, performed by providers with adequate skill, and carefully documented.

Prager R, Wu D, Garber G, Finestone PJ, Zang C, Aslanova R, Arntfield R. Medico-legal risks of point-of-care ultrasound: a closed-case analysis of Canadian Medical Protective Association medico-legal cases. The Ultrasound Journal. 2024 Feb 23; 16, 16. https://doi.org/10.1186/s13089-024-00364-7

Background: Dementia increases as individuals age. Aging physicians represent a growing population. Studies have demonstrated there are physicians with cognitive impairments practicing medicine. The medico-legal consequences of physicians with cognitive impairments have not been investigated.

Methods: The Canadian Medical Protective Association (CMPA) is a national medical association with 108,000 members who advise and assist doctors with medico-legal matters. They maintain a national repository of legal actions and complaints to regulatory bodies and hospitals. We looked at civil-legal and regulatory college cases closed over a 10-year period associated with physicians aged ≥55. A word search of the cases was conducted using “Dementia, Alzheimer, Cognitive impairment, Cognitive decline, Memory loss, Memory issues, Fit for/to practice.”

Results: The CMPA closed 67,566 cases between 2012 and 2021 and 16% (10,599) involved members ≥55. A mixed methodology approach identified 65 cases associated with physician's cognitive ability to practice medicine. Of these 65 cases, the average age of physician was 71.3 (56.1–88.5). The proportion of cases where concern was associated with a physician's cognitive ability to practice medicine increased, from 0.2% of cases in 55–60-year-olds, to 7.7% in physicians over 80.

Interpretation: As physicians age, concerns about cognitive impairment are more likely to contribute to medico-legal matters.

Casey G, Lemay K, Ji J, Yang Q, MacIntyre A, Heroux D, Garber G. Medico-legal cases associated with older physicians’ cognitive ability to practice medicine. Journal of Healthcare Risk Management [Internet]. 2023 November 22 [cited 2023 December 5]. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jhrm.21562

Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?

Bowman CL, de Gorter R, Zaslow J, Fortier JH, Garber G. Identifying a list of healthcare “never events” to effect system change: A systematic review and narrative synthesis. British Medical Journal (BMJ) Open Quality [Internet]. 2023 June 26;12:e002264. doi: 10.1136/bmjoq-2023-002264

Objective: Although rapid treatment improves outcomes for patients presenting with sepsis, early detection can be difficult, especially in otherwise healthy adults. Using medico-legal data, we aimed to identify areas of focus to assist with early recognition of sepsis.

Subjects: The study included cases closed between 2011-2020 that had documented peer expert criticism of a diagnostic issue related to sepsis or relevant infections.

Conclusions: Sepsis continues to be a challenging diagnosis for clinicians. Multiple visits to outpatient care may be an early warning sign requiring vigilance in the patient assessment.

Neilson H, Fortier J, Finestone PJ, Ogilby C, Liu R, Bridges E, Garber G. Diagnostic delays in sepsis: Lessons learned from a retrospective study of Canadian medico-legal claims. Critical Care Explorations [Internet]. 2023 Feb 3 [cited 2023 Feb 6];5(2):E0841. Available from: https://journals.lww.com/ccejournal/Fulltext/2023/02000/Diagnostic_Delays_in_Sepsis__Lessons_Learned_From.2.aspx

A never event is the most egregious of patient safety incidents. It refers to events that should theoretically never happen, such as amputating the wrong limb.

The term “never event” is used around the world by a variety of medical and patient safety organizations and is synonymous with sentinel events and serious reportable events. Unfortunately, there is little consensus about which events, in particular, are never events. These differing lists hinder potential collaboration or large-scale analyses.

A recent systematic review by Hegarty et al. (2020) identified the need for a standardized definition for serious reportable events. The objective of our systematic review is to build on this by identifying those events that are consistently or frequently labelled as never events, which will allow organizations and researchers to direct resources to the events most amenable to reduction efforts.

Zaslow J, Fortier J, Bowman C, de Gorter R, Tsai E, Desai D, O’Neill P, Mimeault R, Garber G. Defining healthcare never events to effect system change: A protocol for systematic review. PLOS ONE [Internet]. 2022 Dec 15 [cited 2023 Jan 9];17(12)E0279113. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0279113

Fortier JH, McDougall A, Zhang C, Ehrat C, Ficara G, Cranney A, Garber G. COVID-19 related physician questions and concerns: A content analysis of 3800 advice calls to a medico-legal helpline. CMAJ Open [Internet]. 2022 Aug 2 [cited 2022 Aug 2];10(3):E714-20. Available from: http://www.cmajopen.ca/lookup/doi/10.9778/cmajo.20210256

Zaslow J, Lee S. Optimizing your diagnostic reasoning – themes from CMPA medico-legal cases. HiQuiPs [Internet]. 2022 Jul 6 [cited 2022 Jul 11]; Available from: https://www.hiquips.com/post/optimizing-diagnostic-reasoning-cmpa-medico-legal-cases

McCleery A, Devenny K, Ogilby C, Dunn C, Steen A, Whyte E, et al. Using medicolegal data to support safe medical care: a contributing factor coding framework. J Healthc Risk Manag [Internet]. 2018 Aug 3 [cited 2018 Nov 19]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/30074677

Yang Q, Zhang C, Hines K, Calder LA. Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases. CMAJ Open [Internet]. 2018 Nov 19 [cited 2018 Nov 23];6(4):E561–6. Available from: http://cmajopen.ca/lookup/doi/10.9778/cmajo.20180077

McDougall A, Zhang C, Yang Q, Taylor T, Neilson HK, Nuth J, Tsai E, Lee S, Lefebvre G, Calder LA. Patterns and trends among physicians-in-training named in civil legal cases. CMAJ Open [Internet]. 2022 Sept 13 [cited 2022 Sept 13];10(3)E781-E788. Available from: https://www.cmajopen.ca/content/10/3/E781

Crosbie C, McDougall A, Pangli H, Abu-Laban RB, Calder LA. College complaints against resident physicians in Canada: a retrospective analysis of CMPA data from 2013 to 2017. CMAJ Open. 2022 Jan 18;10(1):E35-E42. doi: 10.9778/cmajo.20210026

McDougall A, Zaslow J, Zhang C, Yang Q, Nuth J, Tsai E, Lee S, Lefebvre G, Calder L. The medico-legal helpline: A content analysis of postgraduate medical trainee advice calls. Medical Education. 2020; 00:1-7.

Zaslow J, Murray H, Savoy T. Test Result Follow-up in the Emergency Department. CanadiEMs [Internet]. 2024 Sept 3. Available from: https://canadiem.org/hiquips-test-result-follow-up-in-the-emergency-department/

Zaslow J, Lee S. Resource issues in the emergency department. CanadiEMs [Internet]. 2024 Apr 16 [cited 2024 May 1]. Available from: https://canadiem.org/hiquips-resource-issues-in-the-emergency-department/

Objectives: Physician documentation plays a central role in the delivery of safe patient care. It describes a physician’s clinical decision-making and supports essential communication between healthcare providers within the patient’s circle of care. Good documentation can potentially also decrease a physicians’ medico-legal risk. This study provides examples of documentation issues attributed to physicians practicing emergency medicine as identified by peer experts in civil legal actions, regulatory authority complaints (College) and hospital complaints (collectively, medico-legal cases) in Canada.

Methods: We conducted a descriptive study and content analysis of medico-legal cases involving emergency department physicians from a national repository at the Canadian Medical Protective Association. Cases with peer expert criticism of an emergency physicians’ documentation, which were closed between 2016 and 2020, and occurred in an emergency department were included in our analysis.

Results: Of the 1,628 cases involving emergency medicine, our inclusion criteria identified that absent or insufficiently detailed documentation was present in 24% of cases (391/1,628). A detailed review of 20% of cases (79/391), selected randomly, found that documentation issues were most often associated with the assessment and investigation stage of care. This pertained to documenting details of the clinical examination, relevant medical history, diagnosis, and differential diagnosis.

Conclusions: For physicians practicing emergency medicine, criticism of documentation was frequently observed in medico-legal cases. Based on the findings of this study and the expert criticism related to documentation, emergency medicine physicians may consider reflecting upon their documentation of the care provided to determine if their documentation provides a clear and accurate chronicle of the care and the rationale for their clinical decisions.

Smith JD, Lemay K, Lee S, Nuth J, Ji J, Montague K, Garber G. Medico-legal issues related to emergency physicians’ documentation in Canadian emergency departments. Canadian Journal of Emergency Medicine [Internet]. 2023 August 30 [cited 2023 September 15]. Available from: https://link.springer.com/article/10.1007/s43678-023-00576-1

Cortel-LeBlanc MA, Lemay K, Woods S, Bakewell F, Liu R, Garber G. Medico-legal risk and use of medical directives in the emergency department. Canadian Journal of Emergency Medicine [Internet]. 2023 May 12 [cited 2023 May 24]; Available from: https://link.springer.com/article/10.1007/s43678-023-00522-1

Payant L, Finestone PJ, Ji J, Garber G, Leader A. Promoting best practices in Assisted Human Reproduction. Journal of Obstetrics and Gynaecology Canada [Internet]. 2023 June 12 [cited 2023 June 23]; Available from: https://www.jogc.com/article/S1701-2163(23)00434-6/fulltext#secsectitle0080

Calder LA, Bowman CL, De Gorter R, Wright E, Yang Q, Lefebvre G. 2020. Quality improvement initiatives in areas of practice with high medical-legal risk in obstetrical care: A systematic review. Unpublished manuscript, Canadian Medical Protective Association.

Lefebvre G, Honey L, Hines K, Keough A, Roye C, Bellemare S, Piscione TD, Falconer A, Shepherd L, Thorne S, Wallace G, Calder LA. Implementing Obstetrics Quality Improvement, Driven by Medico-legal Risk, is Associated With Improved Workplace Culture. J Obstet Gynaecol Canada [Internet]. 2020 January [cited 2020 January 14]; 42(1): 38-47.e5. Available from: https://doi.org/10.1016/j.jogc.2019.05.011

Calder LA, Bowman CL, Yang Q, Gondocz T, Young C, Zhang C, MacIntyre A, Darling R, O’Neill JP, Roye C, Lefebvre, G. 2019. A quality indicator framework for high-risk areas in obstetrical care. Unpublished manuscript, Canadian Medical Protective Association.

Background: Diagnostic errors lead to significant patient harm; however, most research has been conducted in non-surgical disciplines. We sought to characterize diagnostic error in the pre-, intra-, and post-operative surgical phases, describe their contributing factors, and quantify their impact related to patient harm.

Methods: We performed a retrospective analysis of closed medico-legal cases and complaints using a database representing over 95% of all Canadian physicians. We included cases if they involved a legal action or complaint that closed between 2014 and 2018 and involved a diagnostic error assigned by peer expert review to a surgeon.

Results: We identified 387 surgical cases that involved a diagnostic error. The surgical specialties most often associated with diagnostic error were general surgery (n = 151, 39.0%), gynecology (n = 71, 18.3%), and orthopedic surgery (n = 48, 12.4%), but most surgical specialties were represented. Errors occurred more often in the postoperative phase (n = 171, 44.2%) than in the pre- (n = 127, 32.8%) or intra-operative (n = 120, 31.0%) phases of surgical care. More than 80% of the contributing factors for diagnostic errors were related to providers, with clinical decision-making being the principal contributing factor. Half of the contributing factors were related to the health care team (n = 194, 50.1%), the most common of which was communication breakdown. More than half of patients involved in a surgical diagnostic error experienced at least moderate harm, with 1 in 7 cases resulting in death.

Conclusions: In our cohort, diagnostic errors occurred in most surgical disciplines and across all surgical phases of care; contributing factors were commonly attributed to provider clinical decision-making and communication breakdown. Surgical patient safety efforts should include diagnostic errors with a focus on understanding and reducing errors in surgical clinical decision-making and improving communication.

Kwan JL, Calder LA, Bowman CL, MacIntyre A, Mimeault R, Honey L, Dunn C, Garber G, Singh H. Characteristics and contributing factors of diagnostic error in surgery: Analysis of closed medico-legal cases and complaints in Canada. Canadian Journal of Surgery [Internet]. 2024 February 6, 67 (1) E58-E65. doi: 10.1503/cjs.003523

Calder LA, Whyte EM, Neilson HK, et al. Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery. Spine. 2022 Jun 1;47(11):E469-E476. doi: 10.1097/BRS.0000000000004332

Zhang Z, Calder LA, Finestone PJ, Liu R, Bucevska M, Arneja JS. Medico-legal closed case trends in Canadian plastic surgery: a Retrospective Descriptive Study. PRS Global Open. 2021; 9(8): e3754. doi: 10.1097/GOX.0000000000003754

Lefebvre G, Devenny KA, Héroux DL, Bowman CL, Neilson HK, Mimeault R, Singh SS, Calder LA. Intraoperative injuries from abdominopelvic surgery: An analysis of national medicolegal data. Can J Surg. 2021 Mar 5;64(2):E127-E134. doi: 10.1503/cjs.010219

Calder L, Héroux D, Bernard C, Liu R, Gilchrist A, Neilson HK, Gilchrist AD, Fish J. Surgical fires and burns: a 5-year analysis of medico-legal cases. J Burn Care Res. 2019:1-7. [epub ahead of print]

Background: Medico-legal complaints against physicians are a significant source of anxiety and could be associated with defensive medical practices that may correlate with poor patient outcomes. Little is known about patient concerns brought to regulatory bodies and courts against dermatologists in Canada.

Objective: To characterize factors contributing to medico-legal complaints brought against dermatologists in Canada.

Methods: The Canadian Medical Protective Association (CMPA) repository was queried for all closed cases involving dermatologists over the past decade. Aggregate, anonymized data was reviewed and case outcomes, patient harm, and contributing factors were extracted.

Results: Nearly one-fifth of all dermatologists who are CMPA members have been named in at least one medico-legal case between 2013 to 2022. A total of 396 civil-legal actions or College complaint cases involving dermatologists were closed at the CMPA during this timeframe. The most common patient allegations were deficient assessment (34%), diagnostic error (28%), and unprofessional manner (22%). Nearly half of patients experienced a harmful event, the majority of which were asymptomatic or mild. The most frequently identified contributing factors related to providers were poor clinical decision making (n = 73), lack of situational awareness (n = 67), and conduct and boundary issues (n = 59). Team factors included a breakdown of communication with patients (n = 124).

Conclusions: Improved communication with patients for informed consent, treatment plans, clinical follow-up, and documentation of thorough clinical patient assessments can improve patient satisfaction and health outcomes, and mitigate dermatologists’ medico-legal risk.

Ma B, Park Y-J, Han J, Gandhi M, Ramien M, Klassen D, Payant L, Rose E, Garber G, Probst M, Hardin J. Medico-Legal complaints against dermatologists: Data from the Canadian Medical Protective Association, 2013 to 2022. Journal of Cutaneous Medicine and Surgery. 2024;28(6):554-560. doi:10.1177/12034754241275989

Despite the importance of independent medical examinations (IMEs), there is virtually no literature on the risks to the IME assessor nor the learning needs of psychiatrists in this area. To address this deficit, a retrospective chart review of nearly 38,000 cases from the Canadian Medical Protective Association (CMPA) identified 108 files involving complaints or legal actions against psychiatrists performing IMEs. Most complaints identified by the CMPA were to regulatory bodies, including biased opinion, inadequate assessment, inappropriately relying on a requester’s information without independent evaluation, nonadherence to regulatory body policies, cursory documentation lacking relevant details, and communication breakdowns. A survey by the Canadian Academy of Psychiatry and the Law (CAPL) and the Canadian Psychiatric Association (CPA) had 306 Canadian psychiatrist respondents. About 37 percent of psychiatrists completing IMEs reported medico-legal consequences, including complaints to regulatory authorities. Only 40 percent of those doing IMEs and 20 percent of all psychiatrists had formal training in doing IMEs. The studies confirm that despite a low but important risk of medico-legal consequences, many psychiatrists performing IMEs do not have formalized training. Using the new CAPL Canadian Guidelines for Forensic Psychiatry Assessment and Report Writing is a step to reduce the risk of such evaluations.

Booth BD, Waldman JC, Fortier JH, Garber G, Hardy K, Lemay K, Liu R, Tomita TM, Ramshaw LAL. Assessing adverse outcomes and learning needs in Canadian psychiatric independent medical examinations. The Journal of the American Academy of Psychiatry and the Law [Internet]. 2024 Mar 1;52(1). doi:10.29158/JAAPL.230116-23

Objectives: There is little known about the medico-legal risk for infectious disease specialists in Canada. The objective of this study was to identify the causes of these medico-legal risks with the goal of improving patient safety and outcomes.

Methods: A 10-year retrospective analysis of Canadian Medical Protective Association (CMPA) closed medico-legal cases from 2012 to 2021 was performed. Peer expert criticism was used to identify factors that contributed to the medico-legal cases at the provider, team or system level, and were contrasted with the patient complaint.

Results: During the study period there were 571 infectious disease physician members of the CMPA. There were 96 patient medico-legal cases: 45 College complaints, 40 civil legal matters and 11 hospital complaints. Ten cases were associated with severe patient harm or death. Patients were most likely to complain about perceived deficient assessments (54%), diagnostic errors (53%), inadequate monitoring or follow up (20%) and unprofessional manner (20%). In contrast, peer experts were most critical of the areas of diagnostic assessment (20%), deficient assessment (10%), failure to perform test/intervention (8%) and failure to refer (6%).

Conclusions: While infectious disease physicians tend to have lower medico-legal risks compared to other healthcare providers, these risks still do exist. This descriptive study provides insights into the types of cases, presenting conditions, and patient allegations associated with their practice.

Pacheco K, Ji J, Barbosa K, Lemay K, Fortier JH, Garber G. Medico-legal risk of infectious disease physicians in Canada: A retrospective review. Journal of the Association of Medical Microbiology and Infectious Disease Canada [Online] 8, 4 pp. 319-327 (December 2023). doi: 10.3138/jammi-2023-0022

Background: During the COVID-19 pandemic, family physicians faced challenges including travel restrictions for patients, lockdowns, diagnostic testing delays, and changing public health guidelines. Given that 95% of Canadian physicians are members of the Canadian Medical Protective Association (CMPA), the CMPA’s telephone helpline — which offers peer-to-peer support — provides valuable insights into family physicians’ experiences during the pandemic.

Methods: We used a content analysis approach to identify and understand family physicians’ questions and concerns related to the COVID-19 pandemic expressed during calls to the Canadian Medical Protective Association (CMPA) telephone helpline. Calls were classified with preliminary codes and subsequently organized into themes. We collected aggregated data on calls, including province, call date, and whether the physician self-identified having hospital-based activities as part of their practice. Findings from the analysis were explored alongside family physician calls per month (call volume).

Results: Between 01 and 2020 and 31 December 2021, 2,272 family physician calls related to the pandemic were included for content analysis. We identified six major themes across these calls: challenging patient interactions; COVID-related care; the impact of the pandemic on the healthcare system; virtual care; physician obligations and rights; and public health matters. COVID-related call volumes were highest early in the pandemic especially among physicians without major hospital affiliation when family physicians practiced with little guidance on how to balance patient care and scarce resources in the face of a novel pandemic.

Conclusions: This research provides unique insight on the effects the COVID-19 pandemic had on family medicine in Canada. These results provide insights on the needs and information gaps of family physicians in a public health crisis and can inform preparedness efforts by public health agencies, professional organizations, educators, and practitioners.

MacDougall A, Fortier JH, Zhang C, Ehrat C, Best K, Blois H, Garber G. Family physicians’ questions about the COVID-19 pandemic: a content analysis of 2,272 helpline calls. BMC Primary Care 24, 192 (2023). doi: 10.1186/s12875-023-02147-w

Seely JM, Payant L, Zhang C, Aslanova R, Chothia S, MacIntyre A, Trop I, Yang Q, Garber G, Patlas M. Medico-legal cases in breast imaging in Canada: A trend analysis. Canadian Association of Radiologists Journal [Internet]. 2023 August 5 [cited 2023 Aug 22];0(0). doi:10.1177/08465371231193366

MacLean E, Garber G, Barbosa K, Liu R, Verge A, Mukhida K. Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management. Canadian Journal of Anesthesia. 2023 Jul 31;70,1504-1515. https://doi.org/10.1007/s12630-023-02531-1

Calder LA, Neilson HK, Whyte EM, Ji J, Bhatia RS. Medico-legal cases involving cardiologists and cardiac test underuse or overuse. CJC Open. 2020 Dec 1;3(4):434-441. doi: 10.1016/j.cjco.2020.11.018

Crosby ET, Duggan L, Finestone P, Liu R, De Gorter R, Calder LA. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anesth/J Can Anesth [Internet]. 2020 Nov 16 [cited 2020 Dec 9]. Available from: https://doi.org/10.1007/s12630-020-01846-7