From: Name Withheld
I took a 27 year old female to surgery and performed a tarsal tunnel release. She was slightly overweight with no co-morbidities. She was not a smoker nor on birth control. There was no family history of blood disorders. Following surgery, she was ambulating in a CAM walker. About two weeks after surgery, I was contacted on vacation by her mother who was a nurse. She informed me of swelling in the surgical leg. I instructed her to take the patient to the ED, which she did. Her mother and I were both concerned about a possible DVT, and the mother informed the ED of such. She stated it was six hours in the ED before she was finally scanned positive for DVT.
Subsequently, she developed a PE and was intubated as non-responsive. I communicated with the mother on a daily basis and visited the patient in the hospital out of respect. About a month later, the decision to pull the intubation was made and she passed away. This was their only child and it hurt me deeply. I’ve always been vigilant about DVT and prophylaxis but don’t think I would change my position with the exact same case. Anticoagulation in a patient with no apparent concerns for DVT has its own risks. I must say, had a lawsuit been made, I would have settled regardless and not put that family through anything further.
Name Withheld
04/01/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE)
From: Ivar E. Roth, DPM, MPH
I had a patient who had a moderate bunion but was elderly and widowed with questionable circulation and a history of a P.E. She begged me to do surgery on her bunion and I told her that she had to live with it as it was not so bad, and she was at great risk. She ignored my advice and went to a local foot orthopod. She called me and asked if I would assist. I told her that I would speak to the orthopod first, but if he did the surgery, I would assist.
I called the orthopod and told him my opinion and that he should not do surgery on her, but if he did, he should put her on heparin, etc. When I arrived at the OR to be the assistant, I asked him if he anti-coagulated her. He told me that he thought it was unnecessary. He successfully did the Austin bunionectomy. The next day, she developed a P.E. and died at the hospital. The Ortho told her daughter that she was old and it was her time, and that was the end of that. He avoided discussing what happened and took no direct responsibility for his actions.
Ivar E. Roth, DPM, MPH, Newport Beach, CA
03/31/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1B
From: Paul Kesselman, DPM
Dr. Jacobs once again has hit the nail on the head. As for Dr. Chaskin, it’s readily apparent that his posting is not in touch with reality. A case in Queens county where Dr. Chaskin practices, supports the fact that even though a particular pathology may be out of your scope of practice, you still have a due diligence to do something basic. Pick up the phone and make a call to someone with the expertise to treat that condition.
DPMs have been screaming about becoming part of the mainstream healthcare team, yet Dr. Chaskin seems to want to hide behind an archaic wall, based solely on the NY licensure system. It seems he supports shirking from a duty to care even when we are faced with something which may be beyond our skills or is out of our state scope of practice. When was picking up the phone to call a colleague of another specialty or the ER not...
Editor's note: Dr. Kesselman's extended-length letter can be read here.
03/31/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1A
From: Elliot Udell, DPM
Dr. Jacobs writes, "DVT and pulmonary embolism are concerns for any patient immobilized or non-weight-bearing regardless of whether or not surgery was performed."
A patient presented to my office with severe pain in the back of his right leg. There was no history of surgery or immobilization. When I palpated the gastrocnemius muscles, the patient nearly "hit the ceiling" with pain. I sent him right to the emergency room where they did Doppler studies and confirmed that it was a DVT. They placed him on IV heparin and kept him for well over a week. The patient thanked me for saving his life.
Elliot Udell, DPM, Hicksville, NY
03/31/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE)
RE: Lessons Learned from DVT/PE Malpractice Cases
From: Allen M. Jacobs, DPM
I wanted to share some examples from my experience as an expert witness in DVT/PE cases in which there was a substantial risk of breach of duty and harm caused directly by that breach. In one case, the patient was scheduled for a tarsal tunnel surgery. The patient informed the podiatrist of her history of a Factor V Leiden mutation. The primary physician evaluating the patient prior to surgery recommended prophylaxis for 10 days. No prophylaxis was administered. The result was a massive PE with residual pulmonary compromise. Tough to defend. The case settled.
In another case, a patient was scheduled for flatfoot surgery (TAL, calcaneal osteotomy, repair of PT tendon) with cast immobilization. The patient record indicated that the podiatrist was informed, "My brother died of a blood clot. My father died of a blood clot." There was no documented specific clotting disorder documented. Nevertheless, surgery and immobilization followed with no...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
03/20/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1B
From: Jay S. Grife, DPM, JD, MA
Dr. Jacobs is 1,000% correct in his discussion. As podiatrists, you can rest assured that if a patient suffers a post-operative DVT episode, you, as captain of the ship, will be a named Defendant should a lawsuit ensue. It is also likely the clearing physician will be a Defendant but not a certainty by any means because the clearing physician will claim exactly what Dr. Jacobs suggested.
An example is a client who had an obvious Factor V Leiden mutation which had been previously diagnosed, and the podiatrist performed her own H & P but simply did not realize what Factor V Leiden mutation entailed. End of story and case. It behooves all podiatrists to follow Dr. Jacobs’ suggestions as to management of potential DVT issues.
Jay S. Grife, DPM, JD, MA, Jacksonville, FL
03/20/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1A
From: Rod Tomczak, DPM, MD, EdD
I think the "pre-op clearance" is to "stratisfy" (sic) the patient, similar to the ASA classification of patients and to satisfy the internist or GP when surgery was done in earlier times when the family doctor knew the patient and the podiatrist was not able to act like an independent contractor and take over the patient's care without notifying the family doc.
Historically, and by that I mean everyone before you and I, and most podiatrists before the 3-year residency programs who do not recognize a subtly sick patient and the pre-op anesthesia visit was not much more than a discussion of a golf handicap or how the grandkids were doing. I was perfectly happy knowing that my conversations and examinations of patients revealed a sick patient. I was pleased to know I could call the family doctor and talk physician speak explaining my...
Editor's note: Dr. Tomczak's extended-length letter can be read here.
03/18/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1B
From: Steven Kravitz, DPM
The on-going dispute by a small number of podiatrists seeking the ability to perform their own medical clearance for surgical intervention in hospitals has always baffled me. I fully support increasing education and increasing the diagnostic ability of our graduates to diagnose systemic diseases affecting the lower extremity and having knowledge as to how to manage them as well. But at the end of the day, treating these medical conditions is out of our scope of practice... and by all means should be. We do not have the medical education that an allopathic physician has.
Until that day arrives, we should not be performing medical clearance for conditions we are not licensed to treat. Additionally, there is a concern with the business aspect of providing medical clearance for our surgical patients, as this increases our malpractice risk and raises the cost for all of us trying to provide good quality medicine in the challenging business environment. We certainly do not need increased cost in this regard.
At the end of the day, it is best for the patient and best for our practice to have medical clearance provided by allopathic physicians who are licensed to treat and manage these problems when they arise. It is for that reason that they also assume the medical liability in providing this clearance for our patients--and we should be thankful for them for doing this.
Steven Kravitz, DPM, Winston-Salem, NC area
03/18/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE) - PART 1A
From: Allen M. Jacobs, DPM
The question of who is responsible for thromboembolic episodes in the podiatry patient is an important one, with reference to patient safety and secondarily malpractice allegations. DVT and pulmonary embolism are a major cause for alleged medical negligence against podiatric physicians. Dr. Chaskin posits, and Dr. Udell comments, on the suggestion that the physician who "cleared the patient" is responsible for the thromboembolism. I believe the problem is a bit more complex.
Many physicians maintain the position that they do not "clear" a patient for surgery, but rather "risk stratify" the patient, as the need for surgery and the decision to proceed with surgery are generally that of the surgeon. Under certain circumstances, in theory, an argument could be advanced that the "clearing physician" may be partially to totally liable for an episode of DVT/pulmonary embolism. As a hypothetical, you might refer a patient with known Factor V Leiden mutation or...
Editor's note: Dr. Jacobs' extended-length letter can be read here.
03/17/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE)
From: Elliot Udell, DPM
Dr. Chaskin’s point that the clearing physician should be the one who is held responsible if a patient develops a pulmonary embolism brings us back to the long hashed discussions on PM News. Those discussions germinated from those of us who took courses in general physical examinations, who wanted to do their own medical clearances.
The counter argument was that most orthopedic surgeons, ophthalmologists, and other medical surgical subspecialists would always defer to an internist or family practitioner to do his or her pre-op examinations. So why should podiatrists not follow this? The answer lies in Dr. Chaskin's reasoning that if the patient should have a post-op medical complication, only the clearing MD or DO should be held accountable, not the podiatrist.
Elliot Udell, DPM, Hicksville, NY
03/11/2025
RESPONSES/COMMENTS (MEDICAL MALPRACTICE)
RE: "Nuclear" Malpractice Awards
From: Allen M. Jacobs, DPM
So-called "nuclear" malpractice awards may be outliers, but statistical protection is not absolute protection. As podiatrists do more and more surgery, engage in more complex surgeries, treat more patients with diabetes, manage more ulcerations, and treat more patients who have multiple co-morbidities, the potential for poor outcomes and large malpractice judgment would be expected to increase. I was a defense expert in a recent case in which the plaintiff asked for $76,000,000. The jury came back with a $4,000,000 verdict.
According to AI-generated data, in 2023 there were 57 malpractice verdicts greater than $10,000,000. According to the international reassurance company TransRe, mega malpractice awards are increasing in number. According to author Alicia Gallegos, 2023 "blew away every record previously set among high malpractice verdicts." Although Florida, New York,...
Editor's note: Dr. Jacobs' extended-length letter can be read here
