Dr. Christopher M. Conley - Surviving the (Law) Suits; Recognizing and Supporting the Second Victim

I think Renekton. Good. Welcome to our Combined Grand Rounds for the Departments of Anesthesia and Surgery. It is my great pleasure to introduce our guest speaker this morning, Dr. Chris Connelly, who I'm sure is a very familiar face to many of you. Dr. Connelly is currently a clinical associate professor of Anesthesiology and Pediatrics at the Boston University School of Medicine. And Anesthesia attending at the Department of Anesthesiology at Boston Medical Center. He earned his undergraduate degree from Amherst College and Medical Degree from Columbia before completing a residency in Anesthesia at Bergaman Women's Hospital and a fellowship in Pediatric Anesthesia here at Boston Children's Hospital. After completing his training, he had dual appointments and practiced both here and at Boston Medical Center. And in 2015, he left our staff to be at Boston Medical Center full time. He has served as their Associate Program Director for their Anesthesia Residency Program since 2013 and has been the Director of Pediatric Anesthesia there since 2014. He is also the Founder and Medical Director of the Boston Medical Center's Virtual Pediatric Period Parade of Home, which is a consortium of Pediatric subspecialist who triage and medically optimized children pre-op in absence of a pre-op clinic. Today, Dr. Connelly is going to present an actual case from the operating room here at Boston Children's Hospital that ended in a bad outcome. And it's a case that some of our audience members may have been involved with. And we just want to mention upfront and recognize for those individuals that may have been involved that may be difficult to hear about again. And that we are fortunate to have a plethora of peer support resources available, if need be, from the Office of Clinician Support. We have a DOCS program. We have our very own Anesthesia Peer Support Group. Anyway, with that, I just want to thank you so much, Chris, for taking the time to speak to us today and sharing your experience and helping us learn from it. And I will turn things over to you. Thank you very much, Dr. Ray. Thank you all for having me this morning. It's not every day you have the opportunity to speak at the number one children's hospital in the country. And I'm deeply indebted to many of you in this audience for your teachings and mentoring both in my residency, my fellowship and as an attending. I'm also profoundly grateful to so many of you who supported me during the case I'm going to describe and it's aftermath. While the case was ongoing, I was advised by my attorneys to not discuss it with anyone. At the time, all I wanted to do was hug and express gratitude to every attending fellow resident and CRNA at Boston Children's who ran into that room to try to help. I am forever thankful and humbled by each of you. I understand if this talk hits too close to home, if some of you choose to tune out, that's okay too. I have two big goals for us today. On the one hand, I hope to expand our understanding of the medical legal process from the perspective of a caregiver. On the other, I'd like to delve into the emotional and psychological impact of being involved in a catastrophic case. By sharing my own experience, I hope to show how an understanding of one may help us endure and survive the other. I have no relevant financial disclosures. I do however have a personal stake in this. I'm hoping that in hearing this talk, perhaps someone in this audience will feel a little less alone and helpless, should they find themselves in the crosshairs of the medical legal system. Finally, I have a license to practice medicine, but I am not a lawyer. While I may describe my experience and paint some of the steps of illegal proceeding with broad strokes, this is a moral support and wellness talk, and in no ways intended to be legal advice. Let's rip the bandaid off at the start. You're probably going to be sued. In a 2017 AMA study across all specialties, 34% of all physician surveyed have been sued, and 16.8% have been sued two or more times. The longer you practice, the higher your chances. By this time, we're 65, 75% of physicians in low risk specialties, and 99% of those in high risk specialties will have been sued. So where do we fall? This is from an August 2011 New England Journal issue. Neurosurgery wins or loses, depending on your perspective, for the highest incidence of lawsuits. In the second figure, you see that juror sympathy impacts size of awards, as mean payout for pediatrics lawsuits to offset of all other specialties. Cases that prompt lawsuits often surround unexpected catastrophic outcomes, especially in neonatal, pediatric and obstetric complications, patient dissatisfaction with care or patient disability after an event are also causative. Position factors may have the best place to channel our efforts, as we may be able to reduce, but not eliminate our chances of becoming a defendant. A 1992 study in JAMA surveyed plaintiffs who've been pursued lawsuits in perinatal injury. 44% of respondents initiated their lawsuit either to needing information or suspicion of a cover-up surrounding their child's injury. The recurring theme here is that the perception of poor or dishonest communication with families can stimulate the pursuit of medical malpractice litigation. Established longstanding patient relationships were one of the few protective traits that seems to decrease patients' tendency to file suit. Physicians with less total or zero face time with patients or lack of repeat customers, including anesthesiologists, radiologists and pathologists, are likely at a distinct disadvantage here. While that signature on your informed consent listing the myriad of possible complications may seem to be a legal release, it truly isn't. For the most part, consent seems to have its impact in retrospect. If you discuss the possibility, it may aid, but cannot act alone in your defense. However, the absence of a consent discussion and signature may be a fast track to payouts for the plaintiffs. Medical malpractice is a business. You, the physician or other insured provider are an account holder, your malpractice coverage. The case you were part of represents an opportunity for the malpractice attorneys to transfer those funds into their own accounts. Their take is usually one-third of the settlement or jury award. For them, it is not personal. At best, you and your confidence, your family life, and emotional life, are collateral damage. We are bombarded by commercial malpractice groups on television, the internet, even billboards of block away from our medical center. This is a targeted advertising to normalize the process of suing doctors. Patients and families are made to feel that they have little or nothing to lose by pursuing malpractice litigation. Most plaintiffs attorneys charge nothing unless they win, and there is no burden of proof to initiate a malpractice lawsuit. Additionally, compared to other areas of law, counter-soups against patients and families by defendants of medical malpractice cases are largely discouraged. Remember, this is not a criminal proceeding. Although it has potential to complicate licensure and credentialing, the medical malpractice suit is not a formal complaint to a medical or licensure board. Law suits are not a criminal. Law suits are not initiated to make you a better doctor or to write a wrong. Medical malpractice suits have but one goal to get money. According to a 2016 New England Journal review, among cases that were settled or found in favor of the plaintiff, the average payout for malpractice lawsuits was $371,000. The lawyers take on that is a little over 120,000. Understanding that getting sued is a part of being a physician in the US health care system is an important part of enduring and surviving the process. Despite the emotional tollless process will surely take on you, some things are in your favor sitting in the defendant's side of a medical malpractice suit. While it takes little to no evidence to file a malpractice claim against a physician in the US, winning the case as a plaintiff is an entirely different story. The plaintiff must prove beyond a reasonable doubt that the physician acted negligently diverting from the standard of care that the patient sustained harm and that there was a causative link between the negligence and the outcome. Any break in this chain is enough for the plaintiff to lose the case. The physician or defendant usually wins. I put that in quotes because even if you're exonerated or removed from the list of defendants, it is always an ordeal costing you time, heartache, and more. But from a money perspective, the majority of malpractice claims are dropped by the plaintiff dismissed by court or settled before trial for an amount less than your malpractice policy limits. The few outright victories from malpractice plaintiffs' attorneys offset their frequent losses. In the rare event that a malpractice case makes it through trial to a jury, they overwhelmingly favor the physicians. Only 2% of anesthesia malpractice cases that go through trial result in a judgment for the plaintiff. But when you're the defendant, all the reassuring statistics in the world won't prepare you for what's coming. This is my story, my N equals one. I remember that day in fragments, losing the airway on induction, the code, the failed trake, then hours later holding my own toddler while sobbing on the kitchen floor. Robbie was an extremely anxious 19-year-old patient with contractures, scleroderma, and graft versus host disease, which were all complications from a bone marrow transplant. He had developed cataracts, further limiting his independence, but was petrified of having them removed while awake. Mac was not an option he was willing to entertain. Those who know me can relate that I live on the over cautious end of the anesthesiologist spectrum. Having not cared for many teenagers presenting with restrictive lung disease and scleroderma, I discussed the case with a couple of the groups most senior pediatric anesthesiologists. We reviewed the previous laryngoscopy from a couple of years before, which was a Mac 3 grade one view, while acknowledging the interval progression of his graft versus host disease. Everybody suggested that I induce channel anesthesia and intubate. I returned to Robbie's bedside and pretty out to take one last look at him before going back to the OR. Before leaving, seeing the nervousness in his family's faces, I stopped, put a hand on the dad's shoulder and said, look, I've got a little boy at home too. I'm gonna watch over your son like he's my own. We pre-oxygenated for what seemed like forever, reviewed our plan for video laryngoscopy due to his impaired neck extension that he developed after the last surgery and proceeded to induce anesthesia. My resident put the McGrath video luringoscope in and times stood still. Down the center of the pharynx, completely including the view, was something that looked like a grafted tendon. The view didn't improve when I grabbed the luringoscope. The pathologist at Boston Children's would later describe never having seen anything like it. Even before the desaturation and brated cardian suit, I called an anesthesia stat for extra help and moved down the difficult airway algorithm to no avail. Neither mask nor oral airway nor LMA were able to generate much in the way of ventilation. ENT responded for a surgical airway, couldn't rigid bronch and failed on the first trache attempt. Airway was reestablished on the second attempt with Rosk following shortly after, but the damage was done. As soon as the situation was stable, I went with the surgeon to update the family. I spent a good part of that night in the next several evenings in the family lounge of the ICU with his parents. The first conversations were infused with hope, he's a fighter. Robbie stepped out as seeing how distraught I was, came up and hugged me and I let him. We both cried as he told me he believed I did everything I could. When the sedation was weaned, the disappointing brain imagery and intractable seizures followed. Robbie was put on comfort measures and died shortly after. This event and the legal proceedings that followed were the single greatest challenge I faced in my career as a physician. While I hope that none of you ever encounters this experience over the next several slides, I hope to share with you some of the lessons I learned while living. After a bad outcome, once the situation and hopefully the patient is stabilized, as soon as you can be safely relieved from clinical duty, you need to prioritize speaking with the patient's family or loved ones. This is often very difficult. Take a moment to gather yourself, clean yourself up, change your scrubs if they're soiled. The conversation that follows will be etched into the minds of that family for a long time. Activate your hospital's patient relations team early. They are immensely helpful at these difficult moments, aiding and finding an appropriate quiet, con-for-fruim to talk as well as providing resources, both big and small for families. Bring a senior, more experienced colleague if you can. They can help feel the more difficult questions and assist you if you stumble or are overwhelmed during the conversation. Facts, not guesses, are very important here. You may describe the circumstances of the event and your best assessment of the patient's status, but accuracy and honesty are paramount. We don't yet know is a powerful valid statement in the immediate aftermath of an emergency. Families latch on to hope, be tempered in your optimism. Share the plan moving forward. Reassure the family that the team continues to provide vigilant, compassionate care to the patient, which enabled you to step away from the bedside to come and keep them informed. Answer any questions they have in the moment to the best of your ability and set up an outline of the next steps in the process of care. This should include when they might expect the next contact from the team regarding progress and when the family can go and see and touch the patient. Again, patient relations can be a huge help with coordinating this. Expressing sorrow for what happened is not an admission of guilt. It's okay to care and to cry with your patients and their families, but remember that in this moment, the family's experience and not our own needs to be center stage. After a traumatic event, certain key stakeholders must be informed right away. You're going to need help, support, and guidance and chances are you're not in the best state of mind after an event like this. In addition to notifying patient relations, your first few calls should be to your supervisor or chairman and your hospital's risk management team. Certainly, when this happens, the last thing you're going to be excited to do is to journal about it, but for better or for worse, this could be one of the most important things you write in your professional lifetime. As soon as you're done informing the family and the need to know group, your biggest priority must be to document the event as completely and accurately as possible. Ensure that your record is accurate and complete, including administered medications, airway documentation, and communications, including calls for help and stats. In these instances, often multiple teams, physician and nursing will be documenting the same incident, including code records. Whenever possible, confirm that timelines and interventions are in agreement. In a sociologist, you may find the character limits of the electronic anesthesia record make it difficult to fit your description of the event. I recommend writing a separate narrative of the incident in the form of an event note. EMR's track and archive changes, and you may be called away while writing the note, so it helps to draft it on a separate sheet of paper or in the word document before saving it to the chart. Running your note by a senior colleague or risk management professional can help you recall critical steps that you took, but forgot to write down. When you are writing your description of the event, state the facts. You may describe your thought process and why you chose your specific course of action, but never guess and do not editorialize. While it may be tempting to distance yourself from fault and to shift blame families and their lawyers pick up on this disunity within the team, the chart is not a chat room, it is a legal document. In these moments, departments need to circle the wagons and support their family and their faculty. As soon as they can safely transition away from the bedside, the providers involved in the event should be excused from clinical assignment, cases that were to follow should be postponed or assumed by a separate team. As soon as you're done writing about the event, that's when you really start feeling it. In the hours, days, weeks and months that followed, I was a mess. I experienced what Susan Scott calls intrusive reflections, including anxiety, flashbacks, nightmares, insomnia, a deep depression and a crisis of confidence in myself as a physician. I imagined every conversation that occurred as I walked by colleagues at work was an indictment of my professional judgment. I felt my breathing tightened up just pulling into the hospital parking lot. And for the first time in as long as I could remember, I did not enjoy my work. I began to view every patient as a potential plaintiff. It was them versus me. I seriously considered leaving medicine altogether. I would later find out the dis constellation of symptoms has a name. Dr. Albert Wu first described the phenomenon of the second victim in 2000. The associated shame, self-doubt, and guilt can be devastating and debilitating the healthcare professionals. If left unchecked, it can lead to depression and healthcare workers suicide. In that last slide, I mentioned Susan Scott. Her pioneering work describes the second victim phenomenon as in six stages. The process begins with the experience of a devastating outcome and ends when we move forward and move on. So far on this map, we've covered stages one and two. There's a little bit of healing in the third stage, restoring personal integrity, which involves reaching out to trusted colleagues, friends, and family as you link back into clinical work. But don't get too comfortable. The inquisitions are coming. The necessary fact finding and damage control process that follows with risk management and M&Ms may quickly undo whatever healing has become. Protected conferences is a relative term, as you may not feel very insulated when the peer review meetings dissect your traumatic experience through the critical lens of retrospect. Being on the receiving end of this process has made me more sensitive to how I conduct myself and bring up suggestions when my colleagues are in that hot seat. Unfortunately, for some of us, stage four also includes the medical legal proceedings that sometimes follow. A letter arrives with an unfamiliar legal office as letterhead. Inquisition is an app description here when a family or patient elects to pursue legal action against you. Each state has its own laws as to how long after an event occurs the medical malpractice suit can be filed. Typically, it's between two to six years after the incident. Opening that envelope, you may find yourself right back in the intrusive reflection stage of things. The language in these letters is often highly stylized, implying that you delivered incompetent negligent callous care. What's worse, your legal team quickly reminds you of the can't confide culture wherein other than a few exceptions, lawyers and spouses, you can't discuss the case with anyone. You are now a doctor who has been sued, a member of that not so simple to re-credential club. How is this going to affect your professional reputation, your job security, and your family's financial well-being? What if they win big and it exceeds my malpractice coverage limits? Now, history is on your side here. It's exquisitely rare that jury's award damages over and above the individual limits of physician's malpractice policies, which is part of the reason that medical malpractice plaintiffs' attorneys are incentivized to name all healthcare workers in the room when filing suit. While being named in a lawsuit maybe out of your control, the choices you make next can define the outcome. What not to do if you get named? Do not go on a venting spree about the case. You need to be very careful who you talk to after being named in a lawsuit. There is a natural, strong, and initial temptation to tell your side to anyone who can listen. At the outset, only your lawyer and your partner or spouse are safe places to discuss the details of the case outside of peer-reviewed conferences. Otherwise, you're permitted to discuss the emotions you're experiencing but nothing specific about the case. The problem is, as anesthesiologists and surgeons, I'm really guessing that all of medicine specialties fall victim into this. It's impossible to separate the emotions we have about the case from the details of it. We need people to know what our thought process was, how we were trying to make the right choices from a place of reason, a thoughtful plan that addressed the patient's safety and comfort. Our emotions are deeply intertwined with what we did and why we did it. As the details of the case emerge, and the plaintiffs complain that certs facts or concerns about the patient's disease state or the science of your case, it may be tempting to further your expertise on the topic, collecting papers and evidence to defend the choices and decisions you made during the event. Please resist this temptation. Do not go on a research spree. Your case will not be stronger if you bone up on the pathology encountered on the day of the event. Your notes and your understanding of the situation at the time of the event is what matters. Your defense team will independently secure experts of their own who will present evidence in your favor at the time of trial. Most importantly, at this point you should not access any of the plaintiffs' medical record via the electronic medical record, as you are no longer their healthcare provider, making chart access a hip avialation. Your legal team and not you will obtain the medical records and all the notes surrounding the case that you'll need to agree examin' when you're looking at the event to mount your defense. So what should you do if you're named in a lawsuit? Contact your malpractice and sure. Get contact info for phone numbers, emails, every way that you need to easily reach your legal team. Tell your department chairman you've been named in a suit. You're going to need time off for meetings, depositions, and other things that you can't yet anticipate. Finally, breathe. Look, as anesthesiologist breathing has a special place in our hearts as it relates to patient outcomes, but this is about a different kind of survival. From the moment you're informed of involvement in a malpractice case, even if the case is dismissed or settled prior to going to trial, there will be a lengthy emotional marathon ahead. Your malpractice insurer will supply you a legal advocate, but you need to be your greatest wellness advocate. Self-care is essential, both as it pertains to your physical health and your emotional and behavioral health. So get help early. Find safe spaces, non-discoverable opportunities to vent. Conversations with your spouse are protected from legal discovery. Yet even the best of life partners often don't have the training or the bandwidth to be your only co-pilot on this very emotional journey. It is never too early to seek professional counseling following a devastating patient event. Conversations during psychotherapy sessions are protected thanks to physician patient privilege. In recent years, most hospitals and healthcare systems have expanded their internal resources in behavioral medicine through low cost, accessible employee health programs. Other helpful supports may include private conversations with your clergy or religious leaders, which are also safe from subpoena and legal discovery. After being named in a suit, you enter the discovery phase of the trial. Both teams will secure medical experts to support their side of the case. The plaintiffs team will next send over interrogatories, a series of questions about you, the case, and your participation in the event. In a way, this is the essay question portion of your lawsuit. The questions are going to be framed to make you look bad, callous, and careless. They may also include topics like your experience with the patient's disease state, standards of care for the treatment of your patient's condition, and your consideration of alternative management of the event. You, your lawyers, and your team's legal experts are going to come together on your answers. The process of combing through and responding to the interrogatories may cause you to re-experience the trauma of the event. Sometime after the interrogatories, the deposition occurs. This is a completely separate event and may occur years in advance of the trial. You will likely speak far more during the deposition than you will at the actual trial. This is arguably the most important and most stressful portion of the trial for you as a defendant. For the first time, you'll be sitting across from the plaintiffs' attorneys, and they're going to take this opportunity to trap you into a misstep that strengthens their case against you and weakens your defense. They're going to try to get under your skin to wear you down. It's best to take an approach very similar to preparation for the oral boards. Prepare, answer questions to simply and truthfully, and don't guess. For even the shortest simplest of questions, pause, think, then respond. There is strategy and gamesmanship at play here. Depositions are always transcribed in real time with a court reporter. Some are also audio and video recorded. After your deposition, you will need to review the transcript, both for accuracy, sometimes the scribe gets it wrong, and for consistency. You may and probably will make some mistakes in your deposition. It is critical to review your answers with your legal team between the deposition and your time of trial, where some of your responses will be revisited by plaintiffs' attorneys. When you are asked similar questions or confronted with inconsistencies in your response, you don't want to be caught off-guarded. Trials, injuries are unpredictable. So even as late as the 11th hour, your case is very likely to settle. Depending on your malpractice insurance, you may not get to choose whether to fight the case. Even in cases where physicians have the right to reject a settlement, you may be subject to what's called a hammer clause. This means that if you lose, any rewards to the plaintiff beyond a proposed settlement would come out of your personal assets. Advantage of settling in advance of a jury verdict include a more reasonable top end for the payout, protecting you from any unprecedented or extreme jury award. Unfortunately, any settlement needs to be reported to the National Practitioner Data Bank and will come up every time you re-credential, apply for new jobs, or renew your medical license for the next 10 years. To review, the vast majority of medical malpractice cases never make it to trial, as the cases are either dropped or settled before you have your day in court. If your case makes it to trial, although anxiety provoking, this is typically good news for physicians who win the overwhelming majority of malpractice cases that go to the end of the trial. Trials typically last two to four weeks, rarely they can go longer. In most cases, your team will want you to be there every day as a sign of your personal and emotional investment that the jury can see. Over the course of the trial, if it appears your side might not win, your legal team may still enter into a settlement agreement with the plaintiff. This often includes so-called high-low agreements, which create both the basement and the ceiling for what the payout will be to the plaintiff. For the plaintiff, this guarantees they get some minimum payout, even in the event that the jury eventually sides with your team or dismisses the case. On your side, this protects you from the jury delivering a way over the top or statement verdict that exceeds the limits of your malpractice coverage. While challenging and disruptive to your personal and professional life, however the trial ends, it means the end of the inquisition. One way or the other, you'll be moving on. Nearly six years after our initial event, we were set to go to trial. The autopsy report described an epiglottis that had been fused over the top of the larynx, making him physically impossible to intubate from above. One of the world's experts on graft versus host disease was prepared to testify that this complication was unexpected and had never been described in the graft versus host disease literature. In June of 2020, I was going to have my day where I spoke with the jury and explained all the steps I'd taken to the best of my ability and knowledge to compassionately care for a very sick kid. Then COVID happened. All trials were postponed. In January of 2021, I received an email that the company that had purchased my malpractice carrier in the meantime had unilaterally decided to settle the case after the plaintiff's team accepted their lowball offer of $190,000, which is what they guessed the paperwork for the trial was going to cost. They told me it was a business decision. Nothing personal. They wanted to move on. It was over. I was numb. Now, Scott suggests there are three directions to go when you get to the other side of this second victim process. I'm not sure that these paths are mutually exclusive. Each of us named in a lawsuit to some degree ponders each path before choosing our final trajectories. Option one, dropping out may manifest in a number of ways. At its worst, it may mean succumbing to depression, suicide or falling into the trap of self-medication with alcohol and substance dependence. Milder, but also unfortunate departures may involve leaving medicine entirely. In the middle is surviving. On this path, you go from loving what you do to dreading going to work. The thrill is gone and the anxiety is ever present. You get through the day, rinse and repeat. I walked this path for a while. The survival approach in mindset is a loss for both the providers and their patients. When you're in surviving mode, you're not far from veering off into that dropping out group. Every patient is a potential plaintiff, bad outcome or both. Leaving is the best part of your day. The path to thriving takes time and effort to arrive at. I have to actively choose this path each day or it won't happen. When I do commit to thriving, I love my job and am humbled at the faith that my patients and my colleagues place in me each day as an anesthesiologist. Having access to a comprehensive support system is the reason I am still here and gives us our best chance of getting to the other side of this without losing our passion for this amazing field. For those still paying attention, I admit I purposefully skipped a stage, emotional first aid. I appreciate what Susan Scott did when she built this framework for the stages of the second victim experience. But the way I experienced was less of a linear progression and more of a sine wave with emotional values in each stage of the legal process that were only offset by a commitment to my own emotional first aid. This was my experience of it. Emotional first aid encompasses all the systems and supports needed to navigate the aftermath of a catastrophic patient care event. It includes having strong family and home support. Your whole family, your spouse, your kids, your pets, go through this hurting and healing process with you. Choose your family wisely. As a man of faith, I found prayer very helpful every morning on my drive into work. The prayer or meditation, giving yourself the time and opportunity to quiet your mind and work through this myriad of emotions is invaluable. My colleagues, both at Boston Medical Center and especially at Boston Children's, saved me. There were times, especially in the immediate aftermath where I was tempestuous, angry and feeling totally lost. Your support through condolences, a squeeze of the shoulder and reassurances in your faith in me as a person and as a physician was sometimes the only thing that kept me going. As important, however, was getting connected into a professional counselor. I was fortunate to have a colleague who had endured a similar experience and referred me to Dr. Ken Stetell. Dr. Stetell is a psychiatrist who specializes in physician litigation support. Having a seasoned pro to help me move through the emotions of the case and then through the complex emotional gauntlet of litigation gave me the tools I needed to rebuild my confidence and rediscover my love. I was at least once in my career. Don't go it alone. Seek support, find the safe spaces and circumstances to talk about it and don't let this break you. Departments in hospitals, let's fix what is broken. Every time a peer reference, repredential inform asks us of our awareness of a colleague's involvement in a lawsuit, we reinforce the stigma, shaming and isolation that tears us down. Don't let this break our greatest asset, our people. Build support and reinforce crisis response teams mandate breaks and non-clinical periods following catastrophic outcomes both to grieve and to digest the event. Burnout related to the second victim phenomenon has emotional costs to individuals and real fiscal costs to hospitals in the form of personal loss and attrition. Value your people. Give the time and space for healthcare workers to heal and your providers and your patients will be better for it. Let's work to expand peer review protected sessions to include and examine the emotional state and coping of those involved in the crisis response. Thank you all so much for this opportunity and I'm happy to answer any questions. Chris, this is Amy Vincent. I just want to thank you for sharing this. It's not easy to go through a story like this, especially so publicly. And I know that your story probably is reaching people who are feeling very isolated about this pass of emotions that you go on. So that's the first thing I just really want to thank you for your honesty and your vulnerability today. It's a really powerful thing to do. And I also want to applaud you for meeting head on the concern about speaking to people when there's concern for litigation. This is something that I've talked to people about. Malpractice attorneys on both sides and you know, there's so much fear built up around it, but I don't know of an instance where a peer supporter was ever called to the stand because no malpractice attorneys ever going to pull someone up to the stand to humanize the defendant. And you know, you just showed us why. And I kind of honestly, so thank you for setting such a good example and for being so open and honest about this. I really appreciate it. Amy, I can't thank you enough and it's funny. I've given this talk across the country and I've never been so nervous as I was the night before tonight, have a for today. Because you folks are my family. You raised me from a pup in the world of anesthesia. You opened my eyes to how to become compassionate, meticulous physicians. And I am so sorry for all of you who were a part of this, but I am even more grateful to have you as colleagues and friends. So, Christus is Charlie. Hey, how are you? I'm all right. Good. So, what Christus didn't say is that I was the only person left on this case being sued with him until the very end. And my comment here is not so much to that, but to the fact that Christ and all of us are going to end up with patients that we don't see preoperatively. In this case, it was the fact that this person was seen in pre-optionic and everyone said red flags, red flags, red flags. And Christus was the guy that pulled the short straw at the end and ended up with this case. And it's really hard at the last minute to go against everything all your colleagues said and say, stop. I got to do something. Maybe not do this case. And I don't think people really appreciate the decisions made prior to the patient coming up to the operating room have a direct effect on what we do and how we do it. And sometimes leads us down the golden path toward disaster outcome. So, Christ, I'm sorry this happened to you, but you survived it. So, good luck. Charlie, I appreciate you. You were my airway Yoda. And I have to tell you in the midst of the horror of this, when you came in to try to help, I thought if anybody could get a view. And the hardest part of this was not reaching out to all the people who I knew had been in my corner and had come in and I was instructed not to. And I just, I cannot thank you all enough and I'm so sorry. I feel like I should have just thrown my hands up in the air and just done what I wanted to do, which was to go back and hug each of you for trying to help. Chris, I just want to thank you as well. This is incredibly powerful and I think really helpful for a lot of people. Just from a technical standpoint, a lot of people get concerned about being reported to the national database or data bank medical liability. When in this particular case, when this was settled by the company, did you have any ability to input as to whether or not your name went forward or how that particular thing is. No, so and I thank you, Dr. Cravero and I know that, you know, before coming over to children's, you know, I know that you had extensive work in quality as well at Dartmouth. And so certainly, you know, I'm sure you've been there for a lot of providers in tough cases. So you, one of the jarring things is how little control you have as a physician. The only thing that you really have control over when it comes to documentation is when you do the credentialing process, you can craft the reasoning that the settlement was reported. And the other part that I was advised by my team is when when they look closer at the verdict or sort of particularly with the settlement and they see that for example, in my case, it was a loss of life case. And they paid off basically was everyone immediately related to the child had actually passed on his mom had passed on since and this been about six years, but the father who was never in the child's life showed up conveniently at the end looking for a payout. And so he took the the case and they paid him a patents at $190,000, which was against the seven figure initial ask. So I have been, I don't know, you know, how accurate it is, but I have been informed by a number of defense experts that when when hospitals and groups and credentialing offices take a look at the small payouts, they assume it was just a convenience payout. Yeah. Thanks, that's fantastic. Chris, it's the fish good to you. I think you can see in the chat a lot of emotional thanks to you, and I want to extend it as well. You know, we've all been in many discussions, grand rounds, GME sessions, etc. where we have lawyers and risk managers talk to us. It's a little dispassionate for them. They're in the process. They see the grieving, they see the stress, but it is very, very rare for someone to do what you have just done. And it's different and it means a lot. And thank you for that. And I know you're, I know you're doing it to help those who are going through or have been through or will go through what you've been through. So, so thank you. I'm a bit of everybody. And you want to address a little bit of what would you and Joe just talked about as chiefs, we have to, we have to sign off on a lot of credentialing forms. And I see them. I can assure you that many people on the screen have been through such experiences. And I can tell you that a chief and then the credentials committee have to, and then eventually the board trustees have to sign off on having read and acknowledged what the actions against any particular physician have been. And at that stage is at least it's Boston Children's. I can't speak for any decisions. That is not in the position. The chiefs, the credential committee, the board recognize exactly what you just presented and the facts. Even if you have a big, and there are people who have had big settlements. So, to reduce a tiny bit of the anxiety, it would be exceedingly rare for somebody to lose their privileges of Boston Children's or to not get privilege of just coming through somebody else, from someplace else because of having had a settlement or even a jury verdict against them. Yes, it is, it is horrifying every time you have to fill out a reference form for your colleagues. Are you aware of this person ever having been even named in a suit and you should answer that truthfully. But when it gets the review stage, my experience at the administrative level is that there is more than humanity, it's almost dismissed as administrative. If somebody had a large number of repetitive large settlements, that would obviously be a red flag. But it is not an acquisition at the chief level, at the credential level. There is tremendous respect for the faculty. And I think we all have tremendous respect for you and what you just did. I encourage everybody who is going through or will go through what Chris just described to him to heed his advice as wisdom. I am 100% in agreement that we have supportive departments and forgive me when I use the word inquisition, which was actually I'm coining Susan Scott's term. I'm kind of describing the experience of it versus I know that the folks in those those chair seats are looking to watch out for their people. I am totally unable to keep up with the chat, but there was a specific question that I did want to address in sort of my resin advocacy role. I have a question about if and this from Sean Jackson, I appreciate you. I was wondering if you may speak a bit about how things went with the trainee. Do you have any advice on supporting them regardless of whether they were named in the suit. So this whole process has been eye opening for me and has really been a call to action about the person in physician I am and the type of colleague that I want to be. And part of that was getting involved on leadership committees within our peer connect system here at Boston Medical Center. The really hard part of this when you're the attending for a case once it gets linked into litigation is they are keenly against you speaking with trainees who get stuck in the litigation as well. So the lawyer teams on the defendant side are going to talk together, but they don't want you having any interactions. And that was spectacularly hard for me because I had a phenomenal resin in this. And in the immediate aftermath before the legal part came, I talked to her on multiple occasions. And it's hard to do because you're also in a very weird head space yourself and you're thinking back about all the ways you would have done different. But I think it is extremely important to be sensitive to others in the room, including trainees, including medical students. I mean, people who just hear about these things can be deeply affected by by them. And certainly we have to watch out for our own and have systems that actively circle back. You know, we do these debriefs in certain areas of the hospital, certainly on OB and after certain big, big complications. But I would say that anesthesia kind of lags in this. At least in my experience in departments, you know, certainly our nursing colleagues are sort of mourning the culture of debrief. I see you have really taken the lead in doing more debrief work, but but making that time in that space. I recommend doing it in the context of some kind of peer review conference and devoting about half of it to the emotion of the event so that you can speak freely and support each other in a way that couldn't be disposed. Wait, are there any other questions for Dr. Conley? I just want to echo the sentiment from the chat. It was an incredible presentation and thank you so much for opening up about all of this so that we can all learn. And I'm sure many of us relate to you in some respect. We've all been, you know, involved in something in a case with some type of bad outcome, whether or not it went to litigation or not. But it's incredibly relatable and very helpful to so many of us to hear about this. If there are any other questions, I think we may close things out today. Thank you, Chris. Thank you, Chris. Have a great day, everyone. I appreciate you all. Thank you so much. Thank you, Chris.