COPIC Podcast: Within Normal Limits

COPIC Podcast: Within Normal Limits

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COPIC's Podcast—Within Normal Limits: Navigating Medical Risks

Within Normal Limits is a podcast produced by COPIC that focuses on a wide variety of risk management, patient safety, and professional liability issues. Hosted by Eric Zacharias, MD, an internal medicine doctor and physician risk manager with COPIC.

Within Normal Limits provides physicians and medical professionals with unfiltered insights that focus on pitfalls to avoid in medicine and best practices to improve patient care. The podcast centers around open conversations between physicians and medical experts. Each episode is around 20 minutes and dives into topics including practical guidance, detailed analysis, current issues, and case study reviews. Within Normal Limits is an opportunity to learn from others’ experience and gain knowledge that may help you be a better medical provider and deliver the best patient care possible.

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Episode 73: Just Culture—A Framework that Promotes Patient Safety
In this episode, we talk with Carrie Beth Roddy, a COPIC Patient Safety and Risk Manager, who joins Dr. Zacharias for a conversation on Just Culture. Carrie starts with defining the concept of Just Culture, explaining how it is being integrated into traditional medical culture, and the importance of using it to create opportunities to prevent future medical errors. We dig into the difference between human and system errors, factors that contribute to Just Culture’s success, how it facilitates more open discussions among providers while ensuring the highest level of safe treatment for patients, and ways that it supports meaningful interactions in the healthcare workplace.

Episode 72: Ensuring Patients Make Informed Decisions Through Informed Consent
Anna Barr, a nurse risk manager with COPIC, joins us for this episode to talk about the benefits of using informed consent in your medical practice. Anna highlights how informed consent is a process (not just a form), the goals of shared decision making that guide this, and how it can be a tool to foster trust and understanding with patients. In addition, we look at what situations require informed consent and key considerations in how you approach the process. Anna also explains what informed refusal is, how this differs from “against medical advice,” and provides examples of when you may want to utilize it.

Episode 71: Documentation—Telling the Story of Patient Care
This episode features COPIC Patient Safety and Risk Manager, Amanda Heinrichs, who discusses the importance of documentation—from sharing patient information with other medical team members to supporting care decisions. Amanda covers a wide breadth of documentation issues, such as limiting documentation to only facts about the case, moving past finger-pointing in the event of an undesirable outcome, and timely documentation to ensure quality of care. Furthermore, she talks about insights from attorneys, the pros and cons of using scribes, and conducting assessments to evaluate what is going on with patients to support your documentation.
Episode 70: Retaining and Maintaining Medical Records
COPIC Patient Safety and Risk Manager Cindy Walsh is our guest to set the record straight on medical records retention—giving us insight into ethical obligations, key considerations when referring patients or closing a practice, and the importance of having a clear records maintenance/retention policy. Furthermore, Cindy outlines how regular record audits and attention to state mandates now can prevent retention headaches in the future.
Episode 69: Semaglutide Medications: Liability Issues to Consider
Dr. Susan Sgambati, a colorectal surgeon and medical director with COPIC, is our guest on this episode that looks at the increased use of semaglutide medications driven by the popularity of Ozempic being used for weight loss. The discussion focuses on liability and risk issues, including recently issued FDA warning letters surrounding the use of compounded forms of the medication. Dr. Sgambati talks about how the medication works, side effects, how to assess patients who are interested in these medications, and other considerations as part of your evaluation.
Episode 68: Preventing Falls in the Healthcare Setting
Pamela Johnson—a nurse and Senior Manager of Practice Quality and Facilities Risk Management at COPIC—joins us for a discussion about data around patient falls in health care facilities. Pamela highlights the top three areas where falls occur in these settings and talks about top risk factors that contribute to these incidents. She also points to adjustments that can make an immediate preventative impact, such as proper lighting and pathways, the importance of environmental rounds, and dispels major myths about falls and healthcare.
Episode 67: Ensuring Patients Make Informed Decisions Through Informed Consent
Anna Barr, a nurse risk manager with COPIC, joins us for this episode to talk about the benefits of using informed consent in your medical practice. Anna highlights how informed consent is a process (not just a form), the goals of shared decision making that guide this, and how it can be a tool to foster trust and understanding with patients. In addition, we look at what situations require informed consent and key considerations in how you approach the process. Anna also explains what informed refusal is, how this differs from “against medical advice,” and provides examples of when you may want to utilize it.

Episode 66: COPIC Medical Foundation Grant Recipient: Children's Hospital Colorado
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes back Jennifer Disabato, DNP, and William Anderson, MD, who are co-directors for the ImPACT Program and Navigation Hub, which focuses on care coordination for complex pediatric patients as they transition to adult care. Jennifer and Dr. Anderson talk about the progress made in building skilled teams to support patients going through these transitions. In addition, they discuss the other key focus of the program—coaching medical clinics on these transitions through trainings, evidenced-based templates, and resources to address EHR communication challenges and other related issues.

Episode 65: COPIC Medical Foundation Grant Recipient: West Mountain Regional Health Alliance
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes two staff members from West Mountain Regional Health Alliance—Christina Gair, Executive Director, and Namrata Shrestha, Assistant Director. Grant funding went toward a care coordination effort to support individuals experiencing homelessness with coordination by hospitals, health and behavioral health providers, community organizations and government agencies. The discussion looks at the challenges of coordination across multiple organizations and different workflows, consideration of factors such as social needs (e.g., food, housing, transportation) and behavioral health, and the importance of creating a useful tool that helps “connect the dots” for care teams.

Episode 64: COPIC Medical Foundation Grant Recipient: Providence Portland Medical Foundation
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes Dr. Matthew Gonzales and Dr. Deborah Unger who are affiliated with a grant provided to the Providence Portland Medical Foundation. Grant funding supported Providence and the Oregon Physician Orders for Life Sustaining Treatment (POLST) Registry for a partnership to build a bi-directional interface which integrates Providence's Epic electronic health record with the Registry. Dr. Gonzales and Dr. Unger discuss about how POLST is designed to respect people’s wishes around care/treatment inside and outside of health care settings. They also talk about how POLST is utilizing digital technology to inform others across different systems, the challenge of state-by-state legislation, and the insight gained through the project so far.

Episode 63: COPIC Medical Foundation Grant Recipient: Minnesota Medical Association Foundation
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes Tori Bahr, MD and Katie Stangl who are affiliated with a grant provided to the Minnesota Medical Association Foundation. Grant funding supported Project ECHO, which focuses on the challenge of transitioning youth with medical complexity to adult care in Minnesota. The discussion explains the different conditions that fall under “childhood onset medical complexity” and how the ECHO hub-and-spoke model leverages virtual collaboration to expand expertise and knowledge, and connects providers across different settings to address patient care issues.

Episode 62: Documentation: How Much is Enough?
Documentation in medicine is no one’s favorite topic. In this episode, host Dr. Eric Zacharias aims to simplify guidance surrounding “what” and “how much” is needed for patient safety and risk management purposes. What follows is not “hard” science, but rather a discussion of basic criteria—and what's realistic and reasonable outside of policy rules and guidelines.

Episode 61: Burnout, Exhaustion, and Leaving the Practice of Medicine
In this episode, we are joined by David Weill, MD, a transplant doctor and author of Exhale: Hope, Healing, and a Life in Transplant. Dr. Weill shares openly about losing and saving patients, dysfunctional teams and systems, and burnout in transplant medicine. Through the lens of his own emotional and physical exhaustion, he explores the underbelly of hospital systems and the clinical, administrative, and financial issues plaguing the specialty. He is an advocate of shifting the blame of burnout away from the individual and placing it on the macro problems that contribute to physician dissatisfaction.

Episode 60: AI’s Impact on Medicine (Part Two)
We continue the conversation about artificial intelligence (AI) in this second episode of a two-part series. Our guest is Dr. Michael Victoroff, a family medicine physician, patient safety and risk management specialist, and clinical informatics expert. Dr. Victoroff uses image interpretation in radiology as an example of AI because it sees things humans miss and humans see things AI misses. We look at other AI applications—support for diagnosing and creating a treatment plan, concerns with visit notes (e.g., inaccuracies, information designed for billing purposes versus information for patient care, bias that can emerge, etc.), and the knowledge medical providers will need to acquire about AI’s role in medicine. In addition, Dr. Victoroff highlights key risk considerations such as cyber risks, AI impersonation of other medical professionals and facilities, and how this technology may extend into our personal lives.

Episode 59: AI’s Impact on Medicine
In this two-part series, we look at the rise of artificial intelligence (AI) and examine the potential ways it may impact medicine. Our guest is Dr. Michael Victoroff, a family medicine physician, patient safety and risk management specialist, and clinical informatics expert who has gone down the rabbit hole of trying to understand the good, the bad, and the ugly of AI. Dr. Victoroff explains the fundamental technology behind AI applications, such as ChatGPT, and its interactive structure designed to generate human-like language and conversation. He talks about the concept of machine learning, how the “garbage in, garbage out” theory applies, and the “black box” dilemma of not knowing exactly how this technology got to its answers and what sources or information were used. We then look at the potential roles of AI in health care related to replacing scribes and documentation, voice recognition and language translation capabilities, and the ever-present concerns over accuracy and inadvertent errors that may arise.

Episode 58: Addressing the Issue of Maternity Care Deserts
In this episode, we look at a major challenge in obstetrics (OB) care with our guest, Lori Adams, who is a nurse, COPIC risk manager, and OB expert. Lori talks about her experience in a rural hospital and educating providers. The discussion focuses on “maternity care deserts” where access to OB services is limited or not available. Lori highlights how these deserts contribute to maternal death rates, the disparities we are seeing in certain geographic and demographic areas, and how emergency care units are dealing with OB situations. She also points to the training and education that is being implemented to address this issue and how state-level perinatal collaboratives are working to improve maternal health.

Episode 57: Increasing Racial and Ethnic Diversity in Medical Education
In this episode, we are joined by Dr. Shanta Zimmer, associate dean for diversity and inclusion at the University of Colorado School of Medicine. Dr. Zimmer talks about how the COVID-19 pandemic highlighted racial disparities and health care inequities in severity of illness and the role the health care system ultimately plays in systemically-addressing social determinants of health. She also speaks on how the university is working toward inclusive excellence and removing barriers that prevent the best and brightest from entering medical education. COPIC has supported diversity, equity and inclusion (DEI) scholarships for medical students and purchased simulation equipment for medical education, including a set of diverse mannequins to better represent patients and students.

Episode 56: How You Drive May Affect Patient Care
In this episode, we’re joined by surgeon and COPIC risk manager, Dr. Jeff Varnell. Starting with the premise that, like driving, the practice of medicine is governed by systemic rules and dependent on individual responsibility, Dr. Varnell uses metaphors and general understandings we hold about driving to illustrate how adverse events in medicine are often avoidable and preventable, like many of our road-based accidents. He invites listeners to examine through a lens of personal accountability the human factors that lead to errors in communication and cognitive bias, including "reckless" versus "risky" behavior.

Episode 55: Hope, Help, and Possibilities for People at Risk for Limb Loss
With 28 million Americans at risk for limb loss due to trauma, tumors, or infections, the nonprofit Limb Preservation Foundation is enhancing the quality of life of people in the Rocky Mountain region. Executive Director Marcy Rubik joins us to talk about how health care professionals from all backgrounds have joined this effort to offset financial stressors, provide education, and advance research.

Episode 54: The Nuanced Role Physicians Play with Advanced Practice Providers
Understanding the regulatory environment is key to managing risks associated with working with advanced practice providers (APPs), Dr. Alan Lembitz, COPIC's Chief Medical Officer says. But he cautions providers to understand this isn’t always simple. He reminds providers that it’s on them to ensure they are following the regulatory rules, which vary based on state and provider type. COPIC has seen cases of plaintiff attorneys alleging APPs practicing outside of the scope of licensure and inadequate supervision. In this episode, Dr. Lembitz breaks down high-risk areas, as well as what physicians and APPs need to know about managing risks in all practice settings.

Episode 53: A Conversation on Risk in Urology, Including the Pandemic’s Impact on Patient Care
The guest for this episode is Stephen Siegel, MD, a urologist in a multi-specialty group and a medical school classmate of our host. The former classmates discuss the impact of COVID-19 on surgical intervention, delay of diagnosis, and routine screening. They also discuss general risk areas in urology, including transitions of care, telehealth, and risks associated with PSA-level management across a patient’s lifetime.

Episode 52: Fulfilling Opioid Education Training Requirements
This episode features Dr. Alan Lembitz, Chief Medical Officer for COPIC, and focuses on uncertainty around federal and state opioid education requirements for medical providers. The conversation examines common questions from “what do I need to do to fulfill my licensure requirements?” to “how do I prove that I am in compliance with these requirements?” Dr. Lembitz also looks at details with the new DEA requirement of eight hours of training around substance use disorders, concerns if providers don’t fulfill these requirements, and highlights of COPIC resources that are available to help meet these requirements.

Episode 51: Physician Health Programs—Caring for Caregivers
This episode’s guest is Scott Humphreys, MD, forensic psychologist and medical director of the Colorado Physician Health Program (CPHP). This nonprofit independent peer assistance program provides licensed professionals with confidential, individualized evaluation and treatment referrals for health problems such as psychiatric illness and substance abuse. Dr. Humphreys discusses the stigma associated with physicians transitioning into the role of patient and the approach CPHP takes to ensure they can ultimately have a healthy practice and healthy life.

Episode 50: Dealing with Potentially Violent Patients
Dr. Michael Victoroff, a family medicine physician and COPIC consultant with expertise in clinical informatics, is our guest for this episode that focuses on situations where patients may become violent. The discussion examines emotional states in patients, such as frustration or unhappiness, that can escalate into physical conflict and why we have seen a substantial increase in these types of encounters. Dr. Victoroff talks about de-escalation and conflict management skills, our innate flight-or-fight reactions, and the importance of appropriate training for the health care setting. In addition, the conversation explores ethical and legal considerations along with the moral dilemma of protecting yourself while trying to protect others.


Episode 49: What I Wished I Knew When I Started Out in Medicine
In this episode, Dr. Jeffrey Varnell, a former surgeon and risk management consultant, reflects back on things physicians wished they would have learned during their medical residencies and when they first started their practice. In particular, he talks about effectively utilizing professional review, onboarding and managing expectations around a practice’s policies and procedures (from billing to EHRs), the importance of peer support and mentorship, and the benefits of creating a “toolkit” to help new physicians integrate into the practice setting.

Episode 48: Educating Providers About Health Care Disparities and Patients with Disabilities
The episode’s guest is Chanda Hinton, the founder and executive director of the Chanda Plan Foundation, who also helps run the Chanda Center for Health, an organization that helps people living with long-term disabilities through integrative health care. The discussion focuses on looking at health care through a lens of disability and disparity, and how medical providers can help address this. Chanda talks about her organization’s belief that “people living with long-term physical disabilities have the right to create their own healthcare path, live independently, and be active members in community” and the various ways they support this ideal. She also highlights an online, CME-accredited course that was created to educate medical providers about patients with disabilities and the major challenges they face as well as overcoming systematic barriers to serve this patient population.

Episode 47: COPIC Medical Foundation Grant Recipient: Children’s Health Fund
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes Arturo Brito, MD, MPH, the President and CEO of Children’s Health Fund. Dr. Brito highlights how the grant was used to support the review, update, and dissemination of the successful Referral Management Initiative to incorporate new technologies that enhance care coordination procedures for pediatric populations living in under-resourced communities. They talk about health equity, innovation with mobile clinic programs, concern over COVID-19’s long-term impact on pediatric patients, addressing the challenges of navigating a complex health care system, and how “continuous improvement” serves as a guide for the organization’s efforts.

Episode 46: COPIC Medical Foundation Grant Recipient: Children’s Hospital Colorado Foundation
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes two guests from the Children’s Hospital Colorado: Jennifer Disabato, a pediatric nurse practitioner, and William Anderson, MD, an Associate Program Director. Ms. Disabato and Dr. Anderson highlight how the grant was used to support the ImPACT Navigation Hub—a centralized resource hub to coordinate the transition of young adult patients with pediatric onset conditions to adult care. They talk about some of the key challenges this patient segment faces in navigating health care systems, the importance of educating providers about this issue, and the broader application of their program and what they have learned from it.

Episode 45: COPIC Medical Foundation Grant Recipient: Mile High Health Alliance
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes two guests from the Mile High Health Alliance: Dede de Percin, Executive Director, and Vicente Cardona, Program Manager. Dede and Vicente highlight how the grant was used to support the “Orange Flag” Project—an initiative that uses historic, predictive, and real-time data to inform emergency department personnel of a patient’s high utilization of emergency services to aid in care coordination. They talk about approaching the issue from a grassroots and systems level, the importance of collaboration with other organizations, what data tells us about high utilizers of ERs, and how they are working with medical providers to initiate protocols to improve outcomes.

Episode 44: COPIC Medical Foundation Grant Recipient: Children’s National
This episode is part of a special series that focuses on organizations that received grant funding from the COPIC Medical Foundation for initiatives that address the issue of reducing fragmentation across care settings. Dr. Zacharias welcomes Olivia Soutullo, a psychologist and Director of Parent-Child Interaction Therapy Services at Children’s National (Washington, D.C.). Olivia highlights how grant funding from the Foundation was used to support a program aimed at improving coordination of pediatric mental care after psychiatric hospitalization. She talks about some of the key challenges faced in these situations, the importance of connecting with the families involved and helping them navigate mental health resources, and how they are evaluating outcomes to determine success as well as gathering insight to guide long-term efforts in this area. 

Episode 43: Treating Family, Friends, and Staff
Dr. Dennis Boyle, a COPIC physician consultant and rheumatologist, is the guest on this episode which looks at the issue of treating friends, family, and staff as patients. The discussion looks at the ethical, legal, and other considerations in these types of situations using some case studies and highlighting the American Medical Association’s guidance. In particular, there is the issue of how your professional judgement may be impacted when you have a close, personal relationship with a patient. Dr. Boyle also highlights other concerns that include confidentiality, sensitive examinations, and dealing with the urge to provide medical advice to people you care about.

Episode 42: The Ongoing Challenge of Chest Pain in Patients
This episode examines patients who present with chest pain and how this can run the full spectrum of being a minor irritation to a more serious condition that requires immediate attention. Dr. Zacharias draws upon his experience in internal medicine to talk about using clinical judgment to work through an assessment. He delves into using a differential diagnosis approach, addressing emergency situations, and evaluating considerations based on a patient’s medical history. In addition, Dr. Zacharias looks at how mental health conditions can influence chest pain and tests to rule in (and rule out) certain conditions.

Episode 41: Navigating Conversations with Patients About Guns
Due to recent active shooter situations and a renewed focus on the safety of health care providers, COPIC is re-releasing this past episode. Some providers may draw a strict boundary about discussing guns with their patients (or not think about it). But research has shown there are situations when access to firearms is a potential risk factor and raising this issue can be not only appropriate but necessary. Dr. Michael Victoroff, who is a firearms safety expert, addresses some scenarios associated with guns that can arise in the clinical setting. These range from imminent danger (e.g., suicide risk) to general considerations that vary from household to household (e.g., storage methods). Dr. Victoroff offers guidance on how to approach this topic with non-confrontational questions and suggestions for credible resources for healthcare providers.

Episode 40: Helping Kids Cope with Anxieties Around Medical Care and Pain Management
This episode’s guest is Jody Thomas, PhD, Founder/Chief Executive Officer of The Meg Foundation, a nonprofit whose mission is to empower families with the pain management strategies, skills, and support they need to prevent and reduce pain. The discussion examines how “fear of needles” and health care avoidance can develop in early childhood, and what strategies can be implemented—by parents and medical providers—to prevent negative associations with medical care. Thomas highlights some best practices for pain management with children, such as over-the-counter numbing creams and comforting techniques, and talks about resources they have developed in partnership with health care organizations to support physicians. In addition, she talks about how her organization has used its experience to address vaccine hesitancy, the role anxiety plays in this, and how they have shared insight to help overcome these barriers.

Episode 39: Diagnosing Stevens-Johnson Syndrome
Our guest for this episode is Dr. Dan Rosenquist, a family medicine physician in Nebraska and risk manager for COPIC. The focus is on Stevens-Johnson syndrome and toxic epidermal necrolysis, which are commonly caused by medications or infections and typically present as skin reactions. Dr. Rosenquist walks through the causes and symptoms to be aware of, the role of certain medications in this condition, and discussing the issue with patients. The conversation also touches on having a high index of suspicion, particularly early in its presentation, as the findings may be subtle or confused with more common conditions.
Episode 38: A Return to Discussing Spinal Epidural Abscess
Dr. Zacharias reexamines the issues that lead to spinal epidural abscess, a rare condition that can result in severe adverse outcomes and allegations of negligent care. We start with a clear definition of spinal epidural abscess, why it occurs, and some notable contributing factors. From there, Dr. Zacharias examines risk factors with patients and some suggestions on being highly vigilant about certain signs that should increase your index of suspicion. He also walks through some examples of symptoms that patients commonly present with as well as key considerations when evaluating and treating patients with these symptoms.

Episode 37: A Discussion with Dr. MeiLan Han—A Leading Pulmonologist and Author
This special episode features Dr. MeiLan Han, a Professor of Medicine and Chief of Pulmonary and Critical Care at the University of Michigan and author of the book Breathing Lessons: A Doctor’s Guide to Lung Health. Dr. Han shares her perspective on the impact of COVID-related respiratory issues and how this emphasized the importance of healthy lungs and the vital role they play. She talks about her background in pulmonary care and why her desire to better educate patients (and other physicians) on lung health led to writing Breathing Lessons. The discussion also touches on research data insights, measuring lung function as people age, the use of spirometry testing, and advocating for improved public policy on lung health. In addition, Dr. Han highlights the importance of expanding patient conversations beyond just addressing complaints to also focusing on awareness of environmental and socioeconomic factors that contribute to lung disease as well as practical, preventative steps patients can take to reduce risks.

Episode 36: Can You Really “Clear a Patient for Surgery”?
This episode features Dr. Jeff Varnell, a surgeon and COPIC physician risk manager, who offers some insight about the phrase of “clearing a patient for surgery,” and how this has evolved over time. The discussion starts on the idea of evaluating patients prior to surgery with a focus on maximizing their condition and ability to get through surgery safely, and how this informs the post-surgery recovery plan. Dr. Varnell then talks about preoperative screening processes, from nutritional screening to pain management, and the importance of using a team/systematic approach to improve outcomes and reduce risk.

Episode 35: Managing Patients Who Bring in Wearable Device Data
Dr. Zacharias tackles the subject of managing patients who come armed with data from wearable devices (e.g., Fitbits, Apple Watches) believing that this information is valuable for their medical care. He uses the case study of a patient who is a trail runner and has concerns about elevated heart rates (as indicated by device data) and how this may connect with a family history of early heart disease. In responding to this type of situation, Dr. Zacharias highlights the importance of differentiating consumer-grade devices from approved medical diagnostic devices, explains how the data may inform a careful evaluation focused on the patient’s concerns, and how to handle documentation of this data in the medical record.

Episode 34: Using Ketamine to Treat Depression
This episode’s guest is Dr. Will Van Derveer, a recognized leader in integrative psychiatry, who shares his insight about using ketamine to treat depression and the different schools of thought about how it should be used. He provides some background about the origins of ketamine use in medicine and research studies that demonstrated positive results for patients with depression. The discussion touches on the concerns with ketamine (diversion and addiction), the duration of benefit, “rule outs” to consider, and the influence of Michael Pollan’s book, How to Change Your Mind, on the renewed interest in psychedelics as therapeutic tools. Based on his experience, Dr. Van Derveer also talks about creating the optimal setting and preparing patients for this type of treatment as well as taking an integrative approach that looks at underlying issues, such as diet and lifestyle habits, that contribute to depression.

Episode 33: Preventing Surgical Fires and Injuries Related to Electrical Surgical Units
Dr. Rebecca Vogel, a general surgeon and COPIC board member, is the guest for this episode that explores key areas of risk management associated with certain surgical injuries. Dr. Vogel talks about her involvement with surgical residency programs and integrating a focus on “maintaining your passion and humanism” throughout your career in medicine. Using a case study about a surgical fire, we look at key factors that contribute to these types of incidents—from the risk of a laser igniting oxygen to miscommunication between a surgeon and an anesthesiologist. Dr. Vogel then highlights the importance of “putting the patient first,” assessing the situational risks, and understanding the safety protocols relevant to the procedure you are performing. She also reinforces the value of training that covers the basic physics associated with electrical surgical units such as cut mode settings and how this awareness can impact patient safety.

Episode 32: Reducing the Risk of Bile Duct Injuries During Laparoscopic Cholecystectomy Procedures
Dr. Sue Sgambati, COPIC’s Medical Director and a colorectal surgeon, returns to the podcast to discuss risks and guidelines associated with laparoscopic cholecystectomy. Dr. Sgambati talks about the background behind utilizing this approach and how a reduced recovery time led to improved patient and provider satisfaction. However, one of the concerns that has emerged is the risk of bile duct injuries (BDIs). Dr. Sgambati focuses on guidelines developed from a multi-society consensus that identify optimal strategies for the prevention of BDIs. In particular, she highlights five key guidelines to consider, provides some real-life context from her experience as a surgeon, and reinforces the importance of documenting your thought process with any type of medical procedure.

Episode 31: The Delicate Process of Terminating a Patient
Dr. Zacharias is joined by Dr. Sue Sgambati, COPIC’s Medical Director, to discuss situations where a physician is thinking about terminating a patient from their practice. Common issues that we see include multiple missed appointments, rude behavior, or non-compliance with medication. The conversation focuses on considerations from a physician’s perspective (disclaimer: consult an attorney for legal advice in these situations) starting with a thoughtful analysis of “why do you want to terminate a patient? what is the core issue?” We look at assessing the timing of a termination, how to draft a formal letter that is brief and objective (without letting emotions seep in), and other aspects that include transferring medical records and referrals to other providers. BONUS CONTENT: Dr. Zacharias highlights the news around using monoclonal antibodies in the treatment of COVID.

Episode 30: Getting to the Heart of Health Care: Perspectives from an Esteemed Cardiologist
This episode’s guest is Dr. Nelson Trujillo, a cardiologist out of Boulder, Colorado, who also has a background in biomedical engineering and nuclear medicine. Dr. Trujillo shares his personal journey, the influence of prominent mentors, why he gravitated toward the prevention of cardiovascular disease, and the notable paradigm shifts he has observed during his career. He shares some insights about “triple rule out,” diagnosing acute coronary syndrome, and considerations when evaluating major risk factors. Dr. Trujillo also talks about prevention and intervention strategies—from adopting a Mediterranean diet to the threshold between benefits and risks with exercise, and the ongoing debate about the impact of alcohol. In addition, he highlights some of the promising research and ideas that may change how we predict coronary disease and improve outcomes.

Episode 29: Handling Unsolicited Diagnostic Tests
This episode focuses on the issue of what medical practices should do when they receive clinical information (often test results) about an individual who is not a recognized patient, or which did not originate from an order or request from the practice. This situation increases as patients have more options to self-refer for tests, and more ways to deliver results to providers. Examples include health fair reports, results of self-authorized tests, or records from external providers. Such information, once received, can present an information management dilemma and potential liability exposure. We walk through considerations such as evaluating if there is an existing provider-patient relationship, was the information sent in error, how clinically urgent the information is, and documentation steps to take.

Episode 28: Forum Panel Discussion: A Candid Conversation on the Risks We See and What You Need to Know
Taped live at the annual Patient Safety & Risk Management Forum, this episode features a panel discussion with Dr. Zacharias, Dr. Alan Lembitz, COPIC’s Chief Medical Officer, and Dr. Sue Sgambati, COPIC’s Medical Director. Using a series of real case studies, the panel highlights key patient safety and risk management principles based on where we consistently see medical liability issues. The cases cover topics such as “normalized deviance” that occurs with system workarounds; empowering medical staff to voice concerns; common diagnostic errors associated with heads, hearts, bellies, bugs, and cancer; the importance of checking vital signs; subtle symptoms that can turn into severe issues; paying attention to pain out of proportion; and more. In addition, the physicians talk about the art of disclosure along with burnout prevention and wellness strategies.

Episode 27: When a Patient Disagrees with Your Care Recommendations: Using Informed Refusal as a Tool
Dr. Alan Lembitz, COPIC’s Chief Medical Officer, joins us to talk about managing situations where patients make decisions about their care that you don’t believe is in their best interest. Using a case study review, we analyze a scenario that illustrates the importance of using an informed refusal form to document a patient’s choice that goes against your recommended care. This presents a challenge in balancing the concerns of protecting your patient while protecting yourself from a medical liability lawsuit. In addition, we look at factors such as patient competency, reasons why patients may refuse care (including financial concerns), documentation guidelines, the difference of informed refusal versus “against medical advice,” and navigating the process of shared decision-making.

Special Episode: Requirements for Nebraska Physicians Who Prescribe Opioids/Controlled Substances
This episode focuses on Nebraska legislation that outlines rules for prescribing and continuing education around opioids and controlled substances. The legislation was passed in 2018, but its implementation was delayed because of COVID. However, these requirements are now in effect starting in October 2021. Among the requirements are that prescribers must obtain 3.0 hours of CME regarding prescribing opioids on a biennial basis (0.5 hours of which MUST cover Nebraska’s Prescription Drug Monitoring Program or PDMP). Dr. Zacharias outlines the details of meeting these requirements, including accessing a half-hour PDMP training video on the Nebraska Department of Health and Human Services’ website and upcoming online COPIC seminars that fulfill 2.0 hours of CME. There are two different COPIC seminars (each one is an hour) that provide risk management guidance around opioids, including the risks of addiction and overdose. The seminars are no-cost to attend, open to all Nebraska prescribers, and will be held on 9/28, 9/30, 10/12, and 10/14.

Episode 26: Talking with Patients Who Are Hesitant About the Vaccine
It’s an issue that many physicians are facing and something that continues to be a focus in public discourse—people who don’t want to take the COVID vaccine. The conversations providers are having on this topic can be emotionally charged, full of confusion and disinformation, and difficult to navigate. This episode’s guest, Dr. Dennis Boyle, is an expert on communication and shares some insight on how to approach these situations such as the idea of “developing a therapeutic alliance” as a framing point, inquisitive inquiries, and seeking first to understand why a patient is hesitant. In addition, the discussion touches on the benefit of highlighting the extensive research work done to develop mRNA vaccines and thoughts on what to say to younger patients who are anti-vaccine.


Episode 25: Medication Errors: The Potential Side Effects and Risks of Prescribing
Dr. Dennis Boyle, COPIC physician risk manager, joins the podcast again to talk with Dr. Zacharias about ongoing issues we see with medication errors. These include drug-to-drug interactions, medications that are most prevalent in medical liability lawsuits (antibiotics, pain medicine, and anticoagulants), and awareness about black box warnings. Dr. Boyle walks through some case studies to illustrate why errors occur and highlights steps physicians can take to proactively address these situations. The conversation also covers the importance of documenting your thought process when prescribing, the use of “read backs,” the “five rights” of medication use (right patient, right drug, right time, right dose, and right route), the challenges of drug monitoring.

Episode 24: Nonverbal Communication: How Your Body Talks and What Patients Hear
Dr. Zacharias is joined by Dr. Dennis Boyle, a COPIC physician risk manager, to talk about key elements of nonverbal communication that occur during physician-patient interactions such as touch, facial expressions, posture as well as the speed and tone of your voice. Dr. Boyle talks about nonverbal cues in both how we sent messages to patients and how “micro expressions” from patients can provide valuable insight into how our messages are being received and the patient’s state of mind. He also mentions the “golden minute” of when you first encounter a patient and have an opportunity to form a connection, how nonverbal communication may influence the likelihood of being sued, and the importance of nonverbal communication from other medical staff in a patient’s overall experience.

Episode 23: A Conversation with the Colorado Medical Society’s President—Dr. Sami Dia‪b‬
In this episode, we are proud to have Dr. Sami Diab, the president of the Colorado Medical Society (CMS). Dr. Diab describes his journey into medicine, from growing up in Syria to finding his calling as an oncologist to joining the leadership team at CMS. He talks about how his medical background is applied in his current role when dealing with public policy and state legislative issues, and how he approaches his work by thinking about the ways broader decisions may impact medical providers, patients, and the overall health care system. Other topics on his mind include managing the challenges of physician burnout, the value of talking to peer physicians, and access to care and affordability. In addition, Dr. Diab emphasizes the importance of energizing other physicians about their role within health care and how to sustain joy in your medical practice while cultivating resilience.

Episode 22: With Power Comes Responsibility—Ethical and Legal Issues That Physicians Fac‪e‬
Dr. Michael Victoroff joins the podcast again to talk about administrative or conduct issues that can create legal concerns for physicians. Many of these relate to the authority a medical license grants and the power of a physician’s signature (i.e., prescribing medications, signing off on medical charts, etc.). Dr. Victoroff makes the distinction between willful misconduct and inadvertent actions that can lead to accusations of billing fraud, disciplinary proceedings, and governmental investigations. He also highlights common situations where these issues occur such as supervising other medical staff, serving as a medical director, or providing patient coverage for other physicians. Dr. Victoroff notes that well-intentioned favors and a desire to help can sometimes place good physicians in bad situations, and he provides some guidance that includes staying within your scope of practice—things you do on a regular basis. In addition, the discussion turns to EHRs, the challenges of automated templates, and being aware that your notes accurately reflect the care you provided.

Episode 21: Considerations with Opioids and Pain Management—A Surgeon’s Perspectiv‪e
Dr. Sue Sgambati, COPIC’s medical director and a colorectal surgeon, joins Dr. Zacharias to talk about her personal experience in balancing the professional responsibility to treat pain with concerns over opioid addiction. Dr. Sgambati reviews the historical background of key factors that contributed to the overprescribing of opioids and what she saw and learned in her own practice. She then talks about the value of using tools such as a state’s prescription drug monitoring program, opioid risk assessment tools, and guidelines published by organizations such as the CDC. Dr. Sgambati also addresses alternatives to opioids that are being used, the challenges of having conversations with patients about opioids and how to document these, and the availability of naloxone to counter overdoses.

Episode 20: Telehealth: The Evolving World of Remote Car‪e
Dr. Zacharias welcomes Dr. Michael Victoroff, a COPIC consultant and health information technology expert, to talk about the increased use of telehealth driven by COVID-19 and how this has become a more permanent shift in health care. They discuss the applicable regulations and practical guidelines that are defining the telehealth environment and what physicians should know to effectively navigate these interactions. Dr. Victoroff shares his thoughts about how the perspectives of providers, patients, and regulatory agencies have changed, the importance of reimbursement, and why “telehealth is one of the best things to happen to medicine.” In addition, he highlights considerations with technical platforms, privacy and security standards, documentation elements unique to telehealth, and concerns with providing telehealth care to patients in other states.

Episode 19: Cultivating a Culture of Safet‪y
Dr. Benjamin Keidan, Boulder Community Health's Chief Medical Officer, joins us to share his thoughts on how to implement and reinforce a culture of safety. Dr. Keidan talks about his personal journey and how an MBA gave him a better understanding of the financial, human resources, and legal perspectives that impact health care. He highlights the importance of creating a system that values collaboration among all medical team members and a shared commitment to clearly defined patient safety goals. The conversation then focuses on the benefits of shifting away from a culture of blame to one that encourages reporting, continuous learning, and prevention. Dr. Keidan also talks about his experience with using a “systems perspective” to identify areas for improvement, making “the right thing the easiest to do” for staff, and ensuring that medical providers understand how to report incidents and that there is consistent follow up to explain how concerns are being addressed.

Episode 18: An Inside Look at How the Colorado Medical Board Responds to Complaint‪s
Dr. Zacharias is joined by Dr. Dennis Boyle, a COPIC physician risk manager, and Dr. Donald J. Lefkowits, the current president of the Colorado Medical Board. Dr. Lefkowits talks about his journey from working in emergency medicine to becoming part of the Board’s leadership. He then walks through the types of complaints the Board receives and how they manage the process of addressing these. This includes recommendations for physicians who receive complaints, from using an attorney to help draft a response (a no-cost service available with COPIC’s coverage) to using a factual, non-emotional tone in your response to adhering to the 30-day timeframe. Dr. Lefkowits also talks about the issue of physician wellness and the assistance programs available to support providers dealing with challenges.

Episode 17: COVID-19 and Its Potential Impact on Medical Liability Issue‪s
Dr. Zacharias welcomes Dr. Alan Lembitz, COPIC’s chief medical officer, to talk about what we are seeing in terms of the medical liability issues that may come in the wake of COVID-19. Dr. Lembitz highlights what initial claims data and trends is telling us, and how, due to the “long-tail” of incident reporting, the full impact of COVID-19 will take some time to emerge and understand. The discussion also looks at public perception of the challenges medical providers faced during the pandemic, concerns over patients with non-COVID-19 conditions that held off on treatment because of fears of the virus, and the benefits and limitations of telehealth. In addition, Dr. Lembitz mentions the importance of documenting shared decision making with patients during this time to detail the factors that may have impacted patient care.

Episode 16: Using Simulation Technology to Teach the Next Generation of Medical Professional‪s‬
In this episode, we look at medical education with two representatives from Pikes Peak Community College (PPCC)—Lisa James, Executive Director of PPCC’s Foundation, and Amber Lippincott, Associate Dean of Nursing. Their discussion explores health care trends that are influencing student programs in nursing and other allied health professional fields. In particular, they highlight simulation technology to teach students evidence-based practices, and the benefits of using an advanced birthing simulation mannequins funded by a grant from the COPIC Medical Foundation. This allows students to develop essential clinical skills and practice labor/delivery scenarios in an environment that allows them to learn from their mistakes and develop teamwork, communication, and decision-making skills.

Episode 15: Colorectal Cancer Screenings: A Shift in Guideline‪s‬
Dr. Sue Sgambati, a colorectal surgeon and COPIC’s medical director, discusses the recent recommendation from the U.S Preventive Services Task Force that colorectal cancer screening routinely begin at age 45, instead of age 50. This recommendation is in response to the sharp rise in the number of colorectal cancers in young adults. Dr. Sgambati draws upon her own experience to talk about considerations when evaluating symptoms and whether or not to include a colonoscopy as part of a workup. She also highlights her perspective on colonoscopies versus additional tests for patients that can identify signs of cancer based on stool samples.

Episode 14: A View from the Inside: Dr. Alan Lembitz, Chief Medical Officer at COPI‪C‬
Dr. Alan Lembitz joins us on this episode to talk about some of his key lessons learned over the years as COPIC’s chief medical officer. In particular, the conversation focuses on how and why COPIC developed its Practice Quality Reviews that help identify potential areas of risk. Dr. Lembitz discusses how claims data is distilled down to develop Level One Guidelines (best practices) about common areas where we see issues occur such as documentation, patient communication, and medication safety. He also highlights the importance of vital signs when care is reviewed and how physicians should view the terms “negligence” and “standard of care” from a medical liability perspective.

Episode 13: Addressing Adverse Outcomes Part II: A Deeper Dive Into Cando‪r‬
What is Candor? How does it benefit patients and providers? Dr. Zacharias is joined by Dr. Sue Sgambati, the medical director at COPIC, to answer these questions and provide some insight. In this context, Candor refers to a framework that emerged out of efforts by the Agency for Healthcare Research and Quality (AHRQ) to encourage an environment that supports open, honest conversations with patients after adverse outcomes occur. It is also designed to investigate and learn from what happened, to address the patients’ needs alongside providers’ needs, and to disseminate any lessons learned in order to improve future outcomes. Dr. Sgambati talks about how COPIC guides providers through Candor, especially In Colorado and Iowa where there is legislation that formalizes this process, and some of the key lessons learned from managing these types of cases.

Episode 12: Addressing Adverse Outcomes Part I: COPIC’s 3Rs and CANDOR Programs
Dr. Jeff Varnell, a surgeon and COPIC physician risk manager, is the guest for this episode that focuses on addressing adverse outcomes through COPIC’s 3Rs and CANDOR Programs. Dr. Varnell has managed the 3Rs (Recognize, Respond, and Resolve) process and highlights its origins and goals of maintaining the physician-patient relationship and improving the quality of medical care. He also talks about how 3Rs and CANDOR try to move away from an adversarial approach to one that guides physicians through managing difficult patient conversations and using best practices for disclosure that includes open and honest conversations. In addition, Dr. Varnell points to the positive results that have emerged from 3Rs and how these benefit both patients and physicians.

Episode 11: Physician Leaders: A Pediatrician’s Perspective on Care Integration and Improving Patient Safety
Dr. Zacharias welcomes Dr. Sophia Meharena, a pediatrician and member of COPIC’s Board of Directors, to talk about her personal journey into medicine and the transformative experience of doing her residency at Children’s Hospital Colorado. She also discusses her current role at a safety net clinic and highlights the value of integration that occurs with other specialists, health care navigators, and social services; along with her concerns about the pandemic’s impact on pediatric patients (i.e., social isolation, dietary health, financial constraints, etc.). In addition, Dr. Meharena talks about her involvement with the COPIC Medical Foundation and how its grant funding seeks to improve patient safety in measurable and meaningful ways such as support for simulation technology used for training medical providers.

Episode 10: A Brotherly Discussion on Cognitive Issues and Alzheimer's
Dr. Zacharias’s brother, Alan, is our guest, not just because he is related to our host, but because he is a neurologist and expert in cognitive impairment. The two discuss having patient conversations about memory issues associated with “normal aging” and differentiating these from possible early indicators of Alzheimer's disease. Alan then does a deep dive into diagnosing Alzheimer’s; the role of diet, physical activity, social engagement to improve functionality; and available treatments as well as potential new therapeutics on the horizon. Lastly, Eric finally learns the truth regarding his often used conjecture that there are no Grandmaster chess players over the age of 60.

Episode 9: Using the Mediterranean Diet as a Patient Wellness Tool
Coming off the holidays, this episode taps into Dr. Zacharias’s knowledge as a published author on the benefits of the Mediterranean diet. In a conversation with Dr. Sue Sgambati, COPIC’s Medical Director, Dr. Zacharias talks about how a six-month sabbatical traveling across countries such as France, Italy, and Spain, enabled him to research how dietary habits can reduce coronary heart disease and optimize your health. The discussion focuses on the eight principle areas of the Mediterranean diet and how physicians can incorporate these into recommendations for patients that encourage healthy habits and still allow them to enjoy the “pleasure of eating.”

Episode 8: The Senior Surgeon: Assessing Skills as We Age
As we get older, there is value in the wisdom and experience we gain. However, there is also a well-documented risk for cognitive and physical decline that accompanies aging. In this episode, Dr. Zacharias looks at the issue of assessing the skills of aging physicians with his guest, Dr, Jeffrey Varnell, a surgeon and COPIC physician risk manager. It’s a topic filled with gray areas (pun intended) that include evaluation through voluntary testing, mandatory retirement ages, and patient safety considerations. There is also a discussion of the fulfillment and identity that comes with being a physician and how this can influence when people finally decide to hang their white coats up.

Special Episode: A Good Outcome from a Patient's Perspective
In this episode, we hear from one of Dr. Zacharias’ patients who is doing well due to early recognition of an often-missed condition—epidural spinal lesion. The patient initially presented with symptoms that included back pain and mild saddle anesthesia. The episode provides an insightful perspective from the patient’s point-of-view and reinforces the importance of remaining hypervigilant to subtle signs that can escalate quickly.  

Episode 7: Navigating Conversations with Patients About Guns
Some providers may draw a strict boundary about discussing guns with their patients (or not think about it). But research has shown there are situations when access to firearms is a potential risk factor and raising this issue can be not only appropriate but necessary. Dr. Michael Victoroff, who is a firearms safety expert, addresses some scenarios associated with guns that can arise in the clinical setting. These range from imminent danger (e.g., suicide risk) to general considerations that vary from household to household (e.g., storage methods). Dr. Victoroff offers guidance on how to approach this topic with non-confrontational questions and suggestions for credible resources for healthcare providers.

Episode 6: Burnout from COVID-19: Moving Forward with Resilience
While burnout is a long-standing issue in health care, the compounded impact of COVID-19 has heightened its prevalence and the importance of efforts to address the well-being of medical providers. In this episode, Dr. Zacharias talks to one of COPIC’s experts on physician burnout, Dr. Dennis Boyle. They dissect the root causes of burnout and three key diameters to consider—depersonalization, emotional exhaustion, and feelings of low accomplishment. They also look at other influential factors such as EHRs, workplace culture, and personality traits as well as the omnipresence of grief in health care. In addition, they talk about how the trend of prescribing “simple mindfulness” can be a challenging practice to put into action, and what steps can be taken to effectively approach this.

Episode 5: A Frontline Doctor’s Perspective on COVID-19
Dr. Zacharias talks with Dr. Connor Graham, a frontline hospitalist at a critical care access hospital, about his direct experience in dealing with COVID-19. Dr. Graham discusses how patient cases have changed since March, the risk of exposure and the emotional strain medical providers face, and the ways treatment options have evolved. In addition, he addresses the challenging logistics of prolonged hospitalizations, from the delicate balance of staffing needs to the coordination that occurs between different facilities to managing patients with urgent, non-COVID-19 conditions. The two doctors also share insight on how they handle the personal stress and their cautious, yet optimistic view on how vaccines will be a game changer.

Episode 4: Informed Consent—The Joy (and Pain) of Shared Decisions
Informed consent shouldn’t be viewed as just an obligation to get a signed form, but rather, an opportunity to engage patients in shared decision-making. Dr. Jeffrey Varnell, a surgeon and COPIC physician risk manager, joins Dr. Zacharias to talk about the process of disclosing essential information during the informed consent process so that patients understand the recommended treatment and indications, risks, benefits, alternatives, and risks of not proceeding. In addition, they review the importance of not delegating this process to those who aren’t performing the procedure and assessing a patient’s understanding.

Episode 3: Sepsis—A Bad Infection That Can Get Worse
Sepsis is a common syndrome, and although our knowledge of how to treat it has improved significantly, this bacterial infection can be very lethal if not caught early. Dr. Susan Sgambati, a colorectal surgeon and COPIC’s medical director, joins Dr. Zacharias to review some sepsis case studies and discuss why early recognition is critical, the value of clinical judgement and vital signs, and how pain out of proportion to what you are seeing can be a key indicator.
BONUS CONTENT: COVID-19 Considerations During the Holidays
The latest developments in the COVID-19 saga include some good news (promising results from COVID-19 vaccines) and some not-so-good news (a spike in cases across the country). Dr. Zacharias offers an honest assessment about the risks in a clinical setting, the risks at home, realistic precautions to take, and why Clorox wipes may be the best Christmas present (if you can find them).

Episode 2: Spinal Epidural Abscess—A Difficult Diagnosis
Dr. Zacharias switches places with his peer, Dr. Boyle, who asks questions about a classic case study that involves…you guessed it—spinal epidural abscess. The conversation gets deep into the clinical aspects surrounding a patient who visits the emergency room several times in an eight-day period with complaints of a subjective fever and severe back pain. As Dr. Zacharias notes, this is a difficult case and “the standard of care is to miss it.” Using a step-by-step analysis, the two doctors offer guidance on where things can go wrong and the factors that should be examined to avoid a bad outcome.

Episode 1: Med Mal 101—Heads, Hearts, Bellies, and Bugs
Our first episode draws upon decades of medical liability experience to distill down the key areas where we consistently see malpractice lawsuits—heads (neurologic), hearts (chest pain), bellies (abdominal pain), and bugs (infections). We examine why physicians sometimes misdiagnose symptoms that seem obvious in hindsight, but in actual practice, are not so simple. Our guest is Dr. Dennis Boyle, a rheumatologist who also teaches at University of Colorado School of Medicine and is a physician risk manager with COPIC. Dr. Boyle and Dr. Zacharias walk through some sample scenarios and offer guidance on how to avoid common risks while enhancing patient safety. 
BONUS CONTENT: Dr. Zacharias talks about how medical residents are named in up to 30% of medical liability lawsuits, what types of lawsuits these are, and the long-term impact these can have on residents. He also highlights COPIC’s Resident Rotation Program that helps the next generation of physicians prepare for issues they will likely face during their careers.