Transcript: Legal Questions from Nurse Practitioners Answered

​Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP, and you're watching NP Practice Made Simple, the weekly videos to help save you time, frustration, and help you learn faster, so you can take the best care of your patients. So in this week's video, it is an interview with my personal lawyer, Irnise Williams, and we had such an amazing conversation. So we gathered the questions from the Real World NP community, of questions that you'd like to ask a lawyer, and really went through piece by piece, and we got to a lot of things. But a lot of big questions that people have, "Should I have my own malpractice insurance?" "What are the most common reasons to be sued?" "How to document things appropriately?" And a whole bunch of other big questions, that people really worry about as nurse practitioners, newer and experienced.

So I really hope you enjoy this episode of NP Practice Made Simple, and you can find Your Nurse Lawyer on Instagram, @yournurselawyer, and if you haven't signed up for The Ultimate Resource Guide for the New NP, be sure to do so at realworldnp.com/guide. You'll get these videos sent straight to your inbox every week with notes from me, patient stories, and bonus content that I really just don't share anywhere else, including the opportunity to submit your questions for future upcoming interviews. Without further ado though, I'm going to share my interview with Irnise. Thank you so much for being here. I'm so excited.

Irnise Williams:
Me too, [inaudible 00:01:23].

Liz Rohr:
So do you want to introduce yourself?

Irnise Williams:
Yes, I'm Irnise. I am a nurse and a lawyer. I've been a nurse for 12 years, and an attorney for six years, and I work with healthcare providers and healthcare entrepreneurs who have their own practices, or their own businesses, to ensure that they understand their risk and liabilities. I do some community education as well. I'm a mom, I'm a wife, and I'm a current New Yorker and travel nurse currently after the COVID crisis.

Liz Rohr:
Nice. That is so cool. Thank you so much for being here. I cannot wait to answer all of these questions. So I asked the Real World NP community what their legal questions were, and we broke it down into the categories of the general most common things. And do you have any disclaimers you want to add?

Irnise Williams:
Yes, I will add that none of the advice that I give here, medical or legal, qualifies as attorney-client privilege, or establishes any relationship of attorney-client. It is general advice that I would give in any type of public setting. And if there are any specific questions, or scenarios, I would definitely tell you to consult with an attorney in your area.

Liz Rohr:
Totally, and you have such great resources to direct people too.

Irnise Williams:
[Inaudible 00:02:49]

Liz Rohr:
Absolutely. So I think we broke down the major questions that people had. So the first one is about the general topic of documentation. I think that people are so worried about what to chart, what not to chart. What are your thoughts about that?

Irnise Williams:
Yeah, documentation is a conversation I think for all nurses and nurse practitioners, even some providers, who are just unsure about what is enough, and what is acceptable. I always lead with, "If you have to take this into court, you want to be able to back yourself up," because when someone sues a provider or an organization, the only thing you have is your chart. I think sometimes people think they will have their memory, but it could be years. It could be five years. It could be 10 years, depending on what the situation is. And so the only thing that you will have, is what's in that chart, and you want to be able to cover yourself with the information that's in the chart, because that's all you're going to be able to bring into court.

There are some instances where there will be some external information that could potentially be provided. But in healthcare cases, all we have is the documentation of the conversations that we have with our patients, the treatments that we've provided, their refusals, or if they agree to go forward with that. All of those decisions need to be in the chart.

I know as new providers, they struggle with time management, because you're trying to see a lot of patients. The expectations on you are extremely high. Even if you have three, six months, nine months worth of training, the expectations are high, and the pressure is there. And so you may not have all of the time to document right there on the spot, but I think there are some tools and resources that are out there, depending on what EMR system you use, to pre-chart some items, to do some shortcuts, to do some short notes, and to figure out ways to help you centralize some of the very important and critical information, and then maybe go back and review and edit later.

I think that's the key thing. I think when there are situations where you are asking, or advising your patient to do something that they're not agreeing to, those are the things you want to put in the chart as well. So if you're telling the patient they need to see a specialist, and they're saying, "I'm not going to see a specialist, I don't think that is important." Those exact words should probably go in the chart, [inaudible 00:05:11]-

Liz Rohr:
That happens all the time.

Irnise Williams:
Definitely, and then we'll be like, "Okay, fine, whatever. We'll talk about it later." And adding that as well, saying, "Patient said, 'I'm not going to see a specialist,' and then I understood what they said. I validated that that was an okay option for now, and that we would follow back up on it later." Right?

Liz Rohr:
Mm-hmm.

Irnise Williams:
So not that you're even allowing that to pass and just say, "Fine, we'll just leave it at that." But you'll say, "Okay, I want to give the patient autonomy, but I also want to reiterate to them the importance of going to do whatever I'm advising them to do." So that is a type of documentation, I think that becomes critical when patients say, "Oh, there's a delayed diagnosis." Or, "I didn't know that I had this disease. No one ever told me that."

And that comes up. Someone will say they don't know they have diabetes, but they're taking medication for their diabetes. And I'm like, "You know. You picked up the medication. Someone had to have told you along the way." But if there's no information in the chart that said, "I educated the patient." Or, "I referred the patient to speak with the diabetes specialist, or with someone on the team to have a specific conversation about this," Then that's where providers get caught up, basically, when there's no actual documentation on what steps they took to ensure that the patient knew, understood, verbalized understanding, and then they were in a position to take the next steps.

So I think sometimes where providers struggle as well, is you'll advise a patient to do something, and not ensure that they're able to do it. So if you tell someone, "I need you to go see the specialist." And they say, "Okay." They take the referral, but they never go. And then they come back, and you say, "Hey, you didn't go to the specialist. Here's another referral." No one ever asked them why they didn't go. It could be because the copay is $50. It could be because it's outside of an area that they can get to easily. It could be that their hours are limited, or that they couldn't get an appointment.

Liz Rohr:
Oh, wow.

Irnise Williams:
Those conversations have to be documented, and those questions need to be asked. There are a lot of assumptions that go into having these conversations with patients where, "Oh, a patient is just not compliant." Never say a patient is not compliant in the chart, right?

Liz Rohr:
Yeah.

Irnise Williams:
You do want to speak to the reasons like, "A patient is undomiciled, so picking up medication may not be something that they can do at the time." Sending medication to a specific pharmacy may be difficult for them, because if they're moving from shelter to shelter, they may not have access to that pharmacy in another month, or in another few weeks. Or they may not have access to money in another few months, or another few weeks, even if you give them a 60 or a 90-day supply, right? And so [inaudible 00:07:59]-

Liz Rohr:
And so providers are liable in those situations?

Irnise Williams:
Not necessarily liable or not, but if it's not documented, and if something happens to that patient, you could be brought to court in a case where a family member may say, "Well, they didn't take care of family member because they were homeless, or they didn't take care of my family member, because of X, Y, and Z." You want to be able to say, "I offered the patient a 90-day supply, let them know that if they ran out and weren't able to go to the pharmacy, to come back, and we would give them another 90 days." So you want to have those very specific conversations documented. I think when I read a lot of charts with a lot of general information. Yes, putting in the H&P is important, but the H&P is in a whole bunch of other places. So yes, that is of course an easy information that you can add to the chart, but some of the specifics of the conversations that you're having with the patient have to be there to show that there is a progression in the care that you're providing.

You don't want a patient to continue to come to see you week after week, month after month, and nothing is getting better, and there's no information in the chart as to why. So in a job that I worked before, we had a patient who was a diabetic, everything was under control. She switched insurances, and they began to deny the medication she needed. The provider began to document every single time the patient came, how much work was put into trying to get that patient help. The patient ended up dying because the insurance denied their medications, and if the provider and the diabetes coordinator and all these people didn't document the reason why this patient no longer had access to the medications that they needed, it could have looked like we were neglectful in that situation. But they went above and beyond, and ensured that they documented every phone call to the insurance company, every letter, every outreach to an organization to attempt to help this patient to get access to that, to try to change her insurance.

All of those specifics were put in the chart. So once she was literally on her deathbed, and the family told the provider, "We knew exactly why this happened, and it was not the provider's fault, it was not the organization's fault." It really spoke to the struggles and the failures of the insurance company. But if you work in a federally qualified healthcare center, there are times when you get audited by the federal government. And when they see those types of things, they're going to dig deep. They're going to want to know why this happened, especially if they're getting a bill for weeks to weeks of care in an intensive care unit for someone who you're managing, and who you're caring for. They'll want to know how did this patient go from being well-managed, never being hospitalized for five years, and then all of a sudden being in an ICU for six months.

Liz Rohr:
That's horrifying. That is so enraging and horrifying.

Irnise Williams:
[Inaudible 00:10:43], it was one of the hardest situations. I think, we all, the provider was so heartbroken. The family was heartbroken. I mean, every person involved, because they really had worked so hard to get this person to that point of being well-controlled and that little simple decision to change her insurance, because she thought it would be a better option, literally led to hit death.

Liz Rohr:
[Inaudible 00:11:02].

Irnise Williams:
And so it's tragic. There's so many tragedies that happen, and I think as providers, we make assumptions that everyone knows why. We make assumptions that, even during COVID, if you're sending someone a referral for the longest, radiology centers had closed, and they weren't seeing anyone, they didn't care, COVID negative, how severe, that needed to be documented, right? So there has been so many delays in care this year, and if your patient had a disease process that needed to see a specialist, or see a radiologist, or get an MRI, or something that could not be done, you need to speak to that. Because 10 years from now, COVID's is going to seem like it never really happened as much as-

Liz Rohr:
Oh, you're so right.

Irnise Williams:
... it is a very intense situation now, and it is all our life revolves around, in 10 years it's going to be a figment of our imagination. We're going to forget how hard we labored through that, just like having a baby. Like, "Oh my God, that was so terrible." And then two years, you're like, "Oh my goodness, I think I can have another baby," after you complained about how hard it was.

Liz Rohr:
It's so true. And I think about that when I'm doing my documentation now, and the boundaries where I feel like we're pushing, because people don't want to be seen in person. We're trying to keep them on a telemedicine visit because they don't want to expose themselves. And I'm just documenting like, "This is in the COVID pandemic, patient declines," but it makes me nervous thinking about that future thing, that future backdating. I think what would be really helpful, if we can keep with the documentation, but incorporate ...

Because I think that, I'm obsessed with the lived experience of the new nurse practitioner, and I can already hear the panic. I'm getting a little bit of panic too. But in terms of, so the documentation thing, the time management thing is so hard. But I think if we work backwards, what are the most common things that people get sued for? And I think that, because obviously we want to give that maximal optimal care at all times. But if we're talking about the frame of documentation, what do you feel, in your perception, in your experience, the most common things are? Sounds like delay in care is one, neglect is another. If you can lay that out, the most common reasons that people get sued, and how to avoid them, I think that would be super helpful to tie into that documentation conversation?

Irnise Williams:
So most family practitioners, providers get sued in federally qualified healthcare centers. Those groups of people who treat patients on a daily basis, mostly get sued for delay in diagnosis.

Liz Rohr:
Most get what?

Irnise Williams:
Get sued for delay in diagnosis. That is the biggest one. That one costs the most, and goes to court. So if someone is diagnosed with breast cancer, you feel a lump, they go to radiology, or whatever you guys call them, to go get further care. And you don't follow up to make sure that they follow through with the entire process, and then six months later they went from stage one to stage three, and now they're having a mastectomy, and now all these other things are happening. That is a lot of what usually happens, and it's usually cancer. Cancer is usually the one that causes people to sue the most.

I feel like there have been very few lawsuits about the chronic illnesses. So I think some people assume that those people who have chronic illnesses may come back and sue, but I think chronic illnesses, it looks so different in every single person, and it's just a long process, that it's very rare that someone has a chronic illness necessarily. And they come back and sue because they had a chronic illness that eventually led to either an amputation, or someone's death. That's really rare, because we know that it's so much that goes into a chronic illness and managing a chronic illness that it's usually not the provider's fault, and it's something that's very hard to prove.

The other big one that I think people sue about, is treatment, how they're treated, so discrimination. So, "They discriminated against me, because I was homeless, or because I was Black, Hispanic, transgender." Those are big, because people feel like they're not being treated appropriate, or given the appropriate care, and because of that, it led to whatever outcome has happened. So that's the other big one. And family practitioner [inaudible 00:15:45]. For any nurse practitioners that work in the hospital, a lot has to do with prescriptions and things. I mean, I guess, providers, family nurse practitioners provide prescriptions as well, appropriate prescription. So not necessarily for the patient, but the federal government will come after people who aren't writing appropriate prescriptions. So your DEA license, you do want to protect it, of course, and you want to make sure that there aren't pads laying around, that it's not easy access to print prescriptions illegally. Someone may have access to the office, or to the documents, things like that. And not necessarily people being held.

I think people assume that if you get sued that people automatically are guilty. That's not true. It's a process, and it's a very long process. So in an instance where someone brings a case against a provider because of something they did or didn't do, there's an initial investigation that goes into that. And then if there's a substantial evidence that really can be decided by a judge basically, then that's when it goes to court. But people can call, and make a claim, and call the board on you, and do all those different things, but that doesn't mean it'll always goes somewhere. But I think the anxiety that people have, is understandable, because it's your life, your livelihood, your license, and you do want to do everything to protect it.

But in that, they practice defensive documentation. So defensive documentation is where you are basically saying, "The patient didn't do this, the patient didn't do ..." It's very spastic, and it's not showing what it is that you're doing as a provider. It's putting all the onus on the patient. So you're saying, "I told the patient to do these things and the patient didn't do any of these things," you're not really talking about the relationship and the education, the support, the resources. You're focused more on the outcome. And so it's like, "I told the patient to do this. The patient didn't do this, and now this is what's happening." But in reality, healthcare and is a continuous conversation. So if you're educating the patient today, you still may need to re-educate next month, and then the month after that. It's a continual process. I think we can't just assume, or count people out, just because they're not agreeable to something, because I am a very difficult patient.

Liz Rohr:
I think all nurses are.

Irnise Williams:
And it may take me two or three visits to really accept what it is that you're saying. I talked about this when I was talking a little bit about diabetes, and I had gestational diabetes, and I was like, "I am not checking my blood sugar." And she was like, "No, you have to." I was like, "I'm not doing that. I work, I'm busy." And she was just like, "Okay." But the next time I came back, she was like, "Have you been checking your blood sugar?" I was like, "Girl, I told you I was not doing that."

And so it's like you have to not just say, "Patient said no, we left it at that." Just say, "I reeducated the patient, and made them understand how important it was. And then I followed back up on the next visit." That's how you document. You don't document all of the negative things that are happening in the conversation, the negative relationship that the patient may have with their disease process, or with you, or with healthcare, but you have to document what you're doing to get them on the right track. Even if they never get there.

Liz Rohr:
Totally.

Irnise Williams:
Yeah, so you-

Liz Rohr:
I guess one of the things that I was thinking is, because I've struggled with this, especially with patients if they don't want to do things, they have their full right to. I guess I'm finding myself a little bit surprised by, like if you're telling somebody to go get imaging, or advising them to get imaging, they agree to it, but then they don't go, I guess in my mind always thought that if they're an adult, if they're a consenting adult, they have their cognition intact, that, that is enough. But it sounds like it's not. It sounds like you ... I'm curious about that, because I think that, well, this could open up a can of worms, but I feel like there's a lot of conversations that I have about empowering patients, having conversations with them, and encouraging their own responsibility. Versus that, what is that word, the, I don't know, patriarchal, patronizing? I don't know, whatever that term is of you telling them what to do. So that's interesting that it's a lot more.

Irnise Williams:
Yeah, I think that's what saves people. And so that's why when I ask people, "Do you know how to have difficult conversations with people," is because sometimes you think you're saying something, and you're relaying a concept to a patient, and they understand. And they may just be like, "Okay, I hear you," and they don't really understand. And I give you an example of recently, where a patient was dying. We knew the patient was dying, and we're doing just ridiculous things. And everyone was afraid to tell the family that the patient was dying. And so we're on a phone call with the family, the doctor, the attending, the other nurses, and I finally was like, "Ma'am, I don't know you and I don't know this patient, but I'm telling you what the outcome is going to be if we don't stop what we're doing, and take care of where she is right now."

And then the daughter finally sat back and was like, "Okay, I hear what you're saying." Because everyone was just skirting around the issue, and assuming that she knew that her mother was going to die. I'm like, "Did you tell her that her mother is going to die, that her mother is dying, and that the state that mother is in means that this can be a very quick death that leaves no closure." And so I think there is this assumption that we're saying things clearly, and sometimes you have to say things just different ways, or someone has to hear someone else's voice.

You want the nurse to come back and follow up. Or sometimes it's the medical office assistant who has a great relationship with the patient who can go in and say, "You really need to listen to what the doctor's telling you," [inaudible 00:21:46]. I think we can never discredit anyone's value in educating their patient. It starts from the minute they walk into the building to the minute that they leave. And empowering everyone to be able to build that relationship with the patients allows the provider more room to be the provider, and not to have all of these extra things. Because the more time you spend trying to convince someone to do something, the less you're really able to actually do the work that you're there to do.

Liz Rohr:
Yeah, totally. And I wonder, and speaking of difficult conversations, we can go in any direction you want, but I think it just ties really nicely into how to tell a patient when you've made a mistake. That's like a general question, we don't have to go into that if you don't want to. And we can-

Irnise Williams:
No, I mean, I think that's real. I've been there, when I gave the wrong vaccine to someone's child, and they're like, "Oh, you wanted this vaccine and not that one?" It happened.

Liz Rohr:
I told them the community about a mistake I made recently about a, I guess, I can say it here too. I had a woman who was pregnant who had a UTI, and I just didn't order the repeat UTI, repeat culture a week later, because I just was moving fast and I wasn't thinking. It was the end of the day, it was a really long day. And she really wanted to get out. And then it's having that conversation of, luckily nothing bad happened, but that was uncomfortable. I was like, "Ooh, that does not feel good." But yeah, any thoughts you have about?

Irnise Williams:
Yeah, so the last [inaudible 00:23:18], we've made a lot of mistakes. So we had a lot of these conversations, and I think the first thing is to be gentle with yourself. I think we put so much pressure on ourselves as if we have to be perfect, as if the patient expects us to be perfect, as if we're not human. And the anxiety that you feel when you make a mistake is not necessarily that the mistake was made, or what the outcome may be for the patient, it's how they're going to make you feel, and how you feel about yourself. So all that energy that is the hotness, the sweats, the anxiety that you feel is more about what are they going to say, or how they're going to respond. So I think if you go in and take a deep breath, and really relax and say, "Okay," to yourself, "I made a mistake."

And really stuff like how this happened, because it's never usually intentional. It's usually because we're busy, or we're moving too fast, we have too many patients. Someone called your name in the middle of you doing something that you're meant to do, then you just went to the left instead of the right. It happens. And to explain to people, to be honest. I think for me when I've made a mistake, or in a situation where someone else has made a mistake, and I have to call the patient myself, I always start with saying, who I am and how long I've been working in healthcare, why I work in healthcare, why it's important to me to take care of you appropriately. And then to admit the mistake I made and say, "I so sincerely apologize for that, and this is how we're working to make sure that never happens to any other patient."

Liz Rohr:
I feel like if you told me you made a mistake, I want to cry right now, because of like, yeah, it's just so beautiful to say it that way, because clearly you are a very caring person, and so you would never want to intentionally hurt somebody. So I feel like as a patient receiving that, I'd be like, "Oh yeah."

Irnise Williams:
And so I always was the one who was put on the spot, like, "Can you call this patient and tell them we took the wrong blood?" And I was just like, "Hey, we've been working to improve the clinic for the last two years, and we have made a lot of strides in doing so, but yesterday, we took your blood with a tube that was expired." Yeah, it has happened. The only time that I think I exploded, was we drew the wrong labs on someone three times. It was absolutely insane. And I literally had just had that conversation. So then I just started screaming. I was a manager, but I was like, "[Inaudible 00:25:50], the patient's hate me. The doctor's going to kill me." I was acting so crazy. The staff were just looking at me, and then I got called by my boss and I was just crying, "I can't believe they keep doing this to me." Those instances where you keep making the same mistake over and over, it's just no excuse for it.

Liz Rohr:
Yeah, that's [inaudible 00:26:10].

Irnise Williams:
Seriously, you;ve got to figure out a better way. And then that's where the risk management compliance team comes in, because if three or four people are making the same mistake over and over, something is missed. Something is happening, let's figure out why. So I think it's easy sometimes to say people are making this mistake and there's something wrong with them. But sometimes you have to look at it from a systemic level-

Liz Rohr:
Totally.

Irnise Williams:
... and say, "Okay, this mistake is happening continuously. What can we do to either fix it, or put enough a red flag in place, that makes people double check? Or figure out why this is happening over and over?" And then you fix the system, and then hopefully people don't make the same mistake.

Liz Rohr:
Yeah, totally. I guess the question I have about that, is do you have any thoughts about the documentation around it? It doesn't sound like that's a huge malpractice risk, of you making a mistake, in terms of the volume of lawsuits, but do you have any thoughts about documentation of mistakes?

Irnise Williams:
Yeah, so never go back and delete what you originally did.

Liz Rohr:
Totally.

Irnise Williams:
Go in and of course write an addendum to what it is that you're making. And I will never say, when you document, you don't have to say, "I made a mistake." I would document, "Order was not placed, followed up with the patient," and then say, "Patient came in, did the order." No one can tie that was a mistake. And I always try to tell people when I look at charts as an attorney or consultant with other attorneys, I look for wording that's like, yes, I'm going to read through 500 pages of documents, but I'm really looking for things that stick out to me. So if you wrote, "Order was not placed, followed up with the patient, informed them that the order should have been placed, it's two days delayed, patient came back, returned, this happened," whatever happened, and the outcome, what am I going to say to that?

That's healthcare, and I think we assume that healthcare is a perfect situation. Healthcare is extremely imperfect, because it's run by people. It's not run by a machine. So there are going to be outcomes where it's not perfect, but that doesn't necessarily mean you're going to get sued. I also try to explain that the most time, when people usually sue, it's not normally just because they had a bad outcome, it's because of how they were treated. So if I had a delayed diagnosis, but you treated me so well, when we finally got to the point of giving me care and treatment, you made sure that everything was expedited, that I got all of the best care, and got the best surgeons, and the best, like, "Who am I going to come back and sue? It happens. Life happens." People are understanding of that.

It's when people are dismissive, disrespectful and demeaning to patients when they come back, or they're completely silent about the mistake or the issue, and they don't say anything. And no one expects you to go say, "I'm sorry," and to grovel and to ask for forgiveness. We're not asking, patients don't ask for that. Patients usually just ask for some type of transparency. They want to know that someone knew that it was a mistake, realized the mistake, and self-corrected, that they weren't telling you, as a patient, how to take care of them.

Liz Rohr:
Totally.

Irnise Williams:
And so I think that's really the disconnect. And so healthcare providers feel like people sue too much, but healthcare care providers forget that people sue because you disrespected them, and made them feel less of a person. So I've been in situations where people have made mistakes, and I've been like, "Huh, it ain't a big deal. It happens." And then I've been in situations where people have done things where I'm like, "I am going to drag you, and you have just angered me." So that's when people sue, is when you take them to that point, where you're not giving them the level of respect that they deserve [inaudible 00:30:13].

And so that's the disconnect. So I think a lot of good providers who have all of this anxiety aren't usually the people who get sued. It's the arrogant, the cocky, that, "I'm better than you. I make no mistakes." So surgeons get sued a lot, because they have this air of, "I don't make mistakes. There is no way that I did this wrong.

Liz Rohr:
[Inaudible 00:30:36].

Irnise Williams:
If this was done wrong, it was because ..." You know?

Liz Rohr:
Yeah.

Irnise Williams:
And that's why the operating room is a very dangerous place for egos, emotions, and outcomes, because of those types of attitudes. So I think a lot of family providers feel like they, I'm like, "It's not a lot of lawsuits that can go wrong in family health, because it's just only but so much you can do and they're so many players involved. It's never just the provider. It's so many other things."

So many other layers, insurance, red tape, social workers trying to get, it's a lot. It's never just usually one person. But in healthcare settings where it's usually the mistake of one person, those are very rare. And people will come to the hospital and say, "I just want to know what happened to my family member." And the hospital will be like, "We can't give you any information." And now you have to sue, because that's the only way you're going to be able to get the chart.

Liz Rohr:
That's sad.

Irnise Williams:
The only way you'll be able to figure out what happens. The only way that you'll get some type of closure for someone who either had some type of life-changing damage done or who passed away.

Liz Rohr:
Yes, and it's like, I just keep coming back to, and this comes up a lot I think with new nurse practitioners, is that, and I had this myself when I was new. I was so focused on the medical and the doing, and I was still of course thinking about the emotional aspects. But I remember as a new grad being like, "I don't want to hear about the fluffy stuff. I just want to be able to learn how to do my job." But this is so inherent. It's just wild. That emotional connection, closure, validation, all of that stuff that is integral. The outcomes are important too. But those are the foundations.

Irnise Williams:
Yeah.

Liz Rohr:
As of this recording, the last week's video I talked about trauma-informed care where it's basically like, I don't know, some people I feel like could write it off as this touchy-feely thing, but it's honestly, this is the foundations. If you're sensitive to people's needs and rapport and relationship, yeah.

Irnise Williams:
That is it. And I think we would put a lot of lawyers out of business if we tapped into that more.

Liz Rohr:
Yeah.

Irnise Williams:
I think there is this conversation that's happening now in the birth world, where they're starting to understand trauma-informed care. Because they have the hardest outcomes. You do have to have a happy ending for people to feel good about it. But there's so much trauma that goes on in the care from conception all the way to birth that people bring to the table, that then if the outcome isn't perfect, that becomes someone's fault, right? And if that isn't treated in the beginning, or dealt with in the beginning, that negative outcome is then related to all of the trauma that has happened to that patient.

Liz Rohr:
Totally.

Irnise Williams:
I think if healthcare providers can understand that people bring to you whatever experiences they have had with providers ... When I go to the dentist, I'm always like, "I have had terrible experiences with the dentist." And they're just like, "But not with us?" And I'm like, "It doesn't matter.

Liz Rohr:
It doesn't matter.

Irnise Williams:
Take good care of me, be gentle." And the dentist has to take that into consideration and be gentle with you.

Liz Rohr:
Right?

Irnise Williams:
And so if we put that into a healthcare setting and say, "People who come to see you could have experienced so many different types of trauma, whether it be healthcare-related or personal. We have to take that into consideration." We do have to take a second and step back and say, "How are you?" And yes, sometimes people will go on and on, but you have to be bold enough to say, "You know what? I am so glad to hear that you're doing well, but let's get to your visit and why you're today. I don't want to waste your time. I know you're busy."

So being able to give that relationship-building aspect of your care, definitely leads to people feeling like, "Oh, I love my provider. They're the best in the world." And when you make the mistake, they're like, "Oh, don't worry about it. I know you didn't mean to." And that happens where you make the mistake and people are just like, "Oh, it wasn't intentional. I knew you were busy." Because you took that second to really see who they are as a person, and not just who they are as a patient.

Liz Rohr:
Yeah, and I think that so many new grads, and I work with some mentees one-on-one, and they all have that experience of their patients love them because they give them the time, they give them their heart, all that stuff. So yeah, because I think so many other new NPs, in this context specifically, beat themselves up about not knowing all the things. And they worry about all the missing things, and documenting things wrong. And there's always things to worry about. But if we have the foundations of relationship, then we definitely have a strong hold to put on. We have so many questions. We don't have to address all of them, but I want to address some of the other ones, so what about ... I'm going to pause here, and we can edit this out. How are we doing with time for you? And where do you think you want to ...

Irnise Williams:
Oh, I'm all good with time. I think we can go into the medical malpractice insurance, and personal legal representation.

Liz Rohr:
Cool.

Irnise Williams:
I think those two, because we touched on a couple of the other things [inaudible 00:35:48]-

Liz Rohr:
Yeah, I think we did. Okay. So back to recording. So with medical malpractice insurance, this question comes up all the time, and I'm sure you get this question a million times a day too, of malpractice insurance. When do you need it? Do I need it because of my employer? What are the flavors of that conversation of separate medical malpractice insurance, or medical malpractice insurance in general?

Irnise Williams:
So this is such a common topic that I don't understand how nurse practitioner schools and programs and nursing programs aren't having this conversation the week before graduation, or the month before graduation. It's a huge issue, and [inaudible 00:36:30], and if you don't know anything about it, you would just like, "Oh, I'm just going to get it just in case." So if you work for a healthcare organization that provides medical malpractice insurance, and that's all you do, your full-time job is with this organization that is insured and covered, then you're fine. You don't need anything extra, or different. And the reason is that if you have it, and someone sues either your organization, or decides to try to sue you, and they find out, you have to disclose it that you have it, they're going to keep you in the case, instead of kicking you out, because that's more money to them. So their healthcare organization has whatever millions of dollar policy, and if you have a $1 million policy, that's one more million that client could potentially get.

Liz Rohr:
Oh my God, this is blowing my mind.

Irnise Williams:
So you don't, and the way that hospitals negotiate to get people's names off of cases, is by saying, "They don't have anything to offer. If you take this from them, they don't have any insurance. We're going to pay you whatever it is that you want to get. But if you take our providers off, if you take our nurses off, if you take our radiologist off, then we can get to the conversation," which is basically the money.

Liz Rohr:
Like settling with the-

Irnise Williams:
Exactly, either settling or even if they go to court, then negotiation doesn't, they don't go anywhere unless they say, "Take these people's names off."

Liz Rohr:
[Inaudible 00:38:00].

Irnise Williams:
And so nurses in the hospital who document defensively, and I have those conversations with a couple of different nursing groups sometimes, it's like, "Don't. You don't have a reason to, the legal team is going to get you out. One, they don't want you in a seat, answering questions, because they know you know how bad it is. So they don't want a nurse involved at all, because your interest is self, and is not protecting the organization." The doctor, if they have to keep the doctor, the doctor is going to defend themselves and they're also going to defend the hospital, because that's who pays them. So that's who protects them. And it's a lot harder to get a job as a doctor than it is as a nurse, whereas a nurse will be like, "Oh, I'm about to throw everybody under the bus, and I'll just going to get another job."

And so they do not want nurses on these cases at all. They don't want them deposed, they don't want them testifying. They don't want them near an attorney, because so much more could happen. Whereas the patient, or the client can be coming for one issue, and the nurse is like, "And then they forgot to draw labs. And then ..." That's just how nurses are. Nurses are so, I don't understand why nurses are like this. I don't know.

Liz Rohr:
[Inaudible 00:39:11].

Irnise Williams:
They're so intense when it comes to documentation and protecting themselves. And I'm like, "Trust me, honey, the attorney at the hospital does not want you on their team. They don't see you as an ally at all." So-

Liz Rohr:
Oh God.

Irnise Williams:
... if you're a nurse practitioner, you don't want to have that extra coverage. If you're doing something outside of that, if you're doing per diem work for a company, if you have your own business, if you are doing Suboxone treatments in a separate clinic, or flu clinics. Things like that, that may not be fully insured, yes, you should have some type of coverage.

I wouldn't go have a million dollar coverage. I would maybe have a $100,000, or maybe half a million dollars, if you're doing some very intensive work. But if you're doing a flu clinic, you don't need a million dollar coverage.

Liz Rohr:
That's nice to know.

Irnise Williams:
You just need something small, just in case something happens, someone has a negative outcome, and they just may bring something to the table. Because malpractice insurance just isn't about the money. They also provide other resources to you under your coverage. So it's just like home insurance. So home insurance isn't just about covering just the outside of the house. They may cover different aspects of your home, or if you have a fire, they may put you up in a hotel. Those different tenets of it. So in medical malpractice insurance, they provide other things-coverage as well. So if they provide malpractice insurance, like sometimes if you work in a Suboxone clinic, if there's a flood and everything is damaged and you can't work, they may give you money to help cover that, or repair the costs of those things.

So there are little things that they cover outside of just someone coming to sue you, or try to [inaudible 00:40:53] you. They do provide resources to risk managers. So if you are working with a medical malpractice insurance, they'll give you a number to call if you're running into an issue, to be able to ask questions because you don't have a risk manager that works for you. So they'll give you resources and access to those people, so that you can ask those questions as you may be having an issue when you're out in the field, if that makes sense?

Liz Rohr:
I understand.

Irnise Williams:
So that's really the only time you need it. And then when you talk about having an attorney at your side, as a new nurse practitioner, I think a lot of people see a contract, hopefully you read every word of the contract. Because [inaudible 00:41:31]-

Liz Rohr:
Some people don't have contracts, actually. It's, yeah, this is like a little wild west. I feel like I learned about contracts. I was interviewed for a job, and they gave me a contract, and I was like, "Oh, okay. I didn't know there was a contract to sign." I read through it. It seems fine, but some people don't even have contracts. So any thought, I love welcome all of the thoughts?

Irnise Williams:
Yeah, so I think as if you're in a situation where you are going to be held responsible for a certain amount of patients, for a certain outcomes for either income, some providers have to bring in a certain amount, see a certain amount of patients, and reach a certain amount of money, like, "You have to see this amount of patience and then bring in this amount of money by doing X, Y, and Z." If you have those type of responsibilities, you need to have a contract, because you want someone to say, "What happens if that doesn't happen?" There are no protections for you.

There's no and, or buts, there's no really detailed explanation. And I think that's what happens when a lot of providers are going through a situation, and be like, "Oh, I didn't know that I had to see that many patients," or, "I didn't know that I had to commit to that many hours of following up on my referrals." So other aspects of the job that isn't just doing patient care. There may be other responsibilities that you have, if it's teaching, if it's precepting, whatever the case may be, you would those things to be detailed out. You also would like to know when you're going to get a raise, how is this structured? Because if you don't have a contract, they don't have to give you a raise.

Liz Rohr:
Yeah.

Irnise Williams:
So if you work for me and I say, "You come and make $150,000," when do you get a raise? When do you get a performance evaluation? When do we look at your load and see if we need to provide more office hours for you to be able to do different types of work? Or to split your time between telemedicine and in person, when do we discuss that? If you as a new practitioner are going to come to me and say, "Hey, I've been working here for two years. I think I need a raise?" I'm going to look at you like you're crazy.

And so of course I think any new provider is not going to say, "I need a contract." But I think as a provider, if someone's not offering a contract, then you should be asking some detailed questions of, "When would my performance evaluation occur? How do raises work? How are payment structured?" I know recently an organization I worked for, it was like everyone was paid, across the board, a salary and now it's tied to how many patients you see. And then it was tied to your patient outcomes, the numbers, the patient [inaudible 00:44:17]-

Liz Rohr:
Quality measures?

Irnise Williams:
Yeah, your quality measures. You want that detail. Because if it's not, then they can automatically, and it could be arbitrary on like, "Oh, you didn't do this, or you didn't do that." So you know that stuff. But you have nothing to bring to an attorney to say, "Hey, I lost my job. This was our contract. What should I do?" If you don't have a contract, no attorney's going to talk to you.

Liz Rohr:
Yeah. So quality measures being things like percentage of patients with diabetes, "A1C less than 9%," and colon cancer screening may be, and depends, I think, what the measures are that they're looking for. Like, what percentage of those metrics, generally speaking.

Irnise Williams:
So if your pay is tied to those metrics, you want that to [inaudible 00:44:59] out-

Liz Rohr:
Yeah, documented?

Irnise Williams:
... to protect yourself in case of someone who tries to say that you're not doing what it is that you're doing, you can say, "Well, this was a contract that I had, and this is what we agree to." And it also, things change. People will get you into a job and tell you that you'll be doing one thing, and then you get there and all of a sudden you're doing another. And if you don't have anything to protect you, or to say, "This is what we originally agreed to," you're stuck doing whatever it is that they tell you to do.

Liz Rohr:
Yeah. And I think a couple of people had asked about hiring a contract lawyer and they found it to be a little cost-prohibitive. So I don't know. It depends, I think the rates are different. And what is your perspective? Do you think that that should be requisite? Because I feel like I had no idea what a contract lawyer was. I had no idea, I was clueless, when I had a brand new job, as an NP.

Irnise Williams:
So I think one of the things I think is hard, and why I try to have more conversations about healthcare in the legal world, and why that connects, is it's very secretive and a mystery. Unless you are an attorney, and you know attorneys, or you have attorneys in your family, you really don't know what goes on. You don't know what is a good rate, or what is not a good rate, if it's inflated. You don't know what you're going to get for $750, if that's what someone's asking, right?

So some attorneys are charging $350 an hour up to a $1,000 an hour, depending on how big of a law firm that they work for. So no, a nurse practitioner should not necessarily go and work for, go find an attorney at a law firm, because they're going to bill you and it's going to be something that you just can't afford, and it's very discouraging. Then there are a lot of solo practitioners or providers, attorneys who have their own practices, who just don't advertise well enough. So you just don't know where to look, or where to start, or who to trust with it. We've had that conversation about working with attorneys who just don't understand what it's that you do.

And so we, as attorneys, can sometimes struggle with trying to find other resources of other attorneys. There are so many attorneys in this country, but yet when you're looking for something very specific, all of a sudden you can't find anyone. But I do feel like, yes, a lot of people use things like LegalZoom, and these different apps and websites to create contracts, or to use their services. And not to say that they're bad, but sometimes they don't have your best interest in mind. So they don't understand healthcare. They're just a lawyer who's contracted to work with LegalZoom, and they're just going to do whatever they feel is okay, and they don't really have any health legal experience.

So if you're in a position where you need an attorney, you don't have resources, you can reach out to law schools, surprisingly, a lot of law schools have clinics, and that is right up their alley. If you call a law school and the students are in clinic, usually during the school year and sometimes in the summer, and say, "Hey, is there anyone available to review my contract?" So it would be maybe a student reviewing your contract [inaudible 00:48:04], who's probably going to be more detailed than a regular attorney, because they don't have anything else to do, they will be supervised by a licensed attorney.

Liz Rohr:
That's awesome.

Irnise Williams:
So it's not necessarily outside of, it's not just a student doing the work for you. It's actually two attorneys, or a future attorney and an actual licensed attorney doing that work.

Liz Rohr:
That sounds great.

Irnise Williams:
But that's a good place to start-

Liz Rohr:
[Inaudible 00:48:24].

Irnise Williams:
... position. Or they can refer you it. A lot of times, like I went to Howard Law, which is in DC, if it was something that we couldn't do, they would make it their business to connect you with a lawyer who could help.

Liz Rohr:
That's [inaudible 00:48:38].

Irnise Williams:
... and get you the resources that you need. So that's a good place to start, is to find a law school in your area, in your city, or in your state, to find some resources to help you. Even though people aren't in the office, they're still connected via email, even sometimes via phone, to make sure that people are getting what it is, what they need.

And there also are Legal Aid offices. You may not feel like you qualify for legal aid, but you also don't want to pay somebody a 1,000 an hour to look at a contract that may take them five hours, to them. That's not acceptable. But legal aid is a great resource. So Legal Aid, yes, are for people who cannot afford a lawyer. But if you call them and say, "Hey, I'm looking for a lawyer who does X, Y, and Z," they have a list of lawyers who either does inexpensive work, or who does pro bono work. But a lot of times those lawyers who sign up to do pro bono work is what they do voluntarily, but they also work as regular lawyers. So those are usually the ones who have lower rates, and you can have access to provide you whatever resources that you need.

Liz Rohr:
Totally.

Irnise Williams:
So I would say yes, if you can read your own contract, you can take the risk to do it. But there are times I've read a contract for nurse practitioners specifically, and I'm like, "What happens when that, what would you do if that happened?" They didn't mention anything about pay, or they didn't mention anything about that. Let's talk about the structure? Or the requirements are so high. I'm like, "You're really going to see a 100 patients in a month?" How is that going to work, that volume? What does that look like?

Liz Rohr:
I know.

Irnise Williams:
What support do you have? Those kind of things. And then they're able to go back to the table and say, "What support do I have?

Liz Rohr:
Nice.

Irnise Williams:
How am I supposed to get that done? How many hours am I supposed to commit to that?" Or people are now given unlimited PTO, that may be a little bit rare in healthcare, but in certain situations, if you're getting unlimited PTO, how do I request that? Do I get paid? There are just other questions that you have to ask, that you wouldn't-

Liz Rohr:
Totally.

Irnise Williams:
... think about as a normal person, because you're so excited about the opportunity, and that excitement sometimes puts a block in front of me. It doesn't allow you to necessarily ask the appropriate questions.

Liz Rohr:
Totally. So a couple other things we wanted to cover. Scope of practice, do you want to talk about scope of practice?

Irnise Williams:
Yeah, I think nurse practitioners are just, to me, the best care providers.

Liz Rohr:
Oh.

Irnise Williams:
I love nurse providers.

Liz Rohr:
... that's so nice. I love them.

Irnise Williams:
No, they're just so detailed and so good. And they just have a heart. Because some providers are just like, "You don't have a heart, you don't care about me." And I think of course it's state-based, it depends what your state allows. Like I am a Maryland-bar attorney, so Maryland is a full practice, state where nurse practitioners can work independently. So they have the autonomy to do a lot of different things, whereas certain states have not passed those rules. So you have to look at the scope that is laid out by the Board Of Nursing, or whoever governs you in your state as to what it is that you can do. If you're in a situation where a provider's asking you to do something that you feel like may be out of your scope, if you work in a setting where you have a risk manager or compliance officer, or an attorney on the team, you should reach out to them, because they're the ones who write the policies. And they're going to say, "Oh no, that's not okay. I'll talk to them. I'll make sure you're protected."

If you're in a situation where you don't have that, you can always call the board and ask, or email the board and say, "Is this within my scope? Can I do that?" And they're not going to penalize you for asking questions even if you already did it. No one's going to say, you didn't know. And that's why you're asking the questions. So making sure that you're comfortable with your scope, I think is what is really some of the challenges I feel like nurse practitioners have. It's like, "This is all you can do. Make sure you're comfortable in those things."

So if they're asking you to do, we didn't really talk about specifically, but FMLA paperwork, that is within your scope. How do you do that effectively and efficiently? It's not up to someone to explain to you, that's up to you as a provider to learn the best tips, the tools, how to protect yourself, how to make sure that everything that is true, is documented. And what is not true that the patient may be asking you to write down, is not documented, those kind of things. So there is also some responsibility on the nurse practitioner to get educated, to find the resources that they need to.

That's what CE credits are for, when you're going to sign a contract and hopefully they're giving you thousands of dollars to use those CE credits, to use them for things that you know that you're struggling with. But those areas where you have lots of questions, use that money to dig deeper, because there are so many resources out there. And I say to be careful, I think social media is an amazing tool, but in the recent weeks I'm realizing that people are taking that as, the information that is shared on social media, as gold. And it's not, [inaudible 00:53:45]-

Liz Rohr:
I mean my stuff is gold.

Irnise Williams:
Of course, but it's not just social media. You're actually providing curriculum that is well-rounded, and nuanced, and information that provides people an opportunity to ask more questions. But there's some resources that are out there, that is just spewing information that is not necessarily nuanced, and it's not allowing people to ask questions. So I feel like more people are asking about medical malpractice insurance because people are saying, "You need medical malpractice insurance." They're hearing that from somewhere. I never thought about having medical malpractice insurance 12 years ago. Why would I? I worked for an organization.

Liz Rohr:
Totally.

Irnise Williams:
And so it's like someone is saying that somewhere, that information is being spewed somewhere, saying that, "You need to protect yourself, you need this." Why? And then there's no opportunity to ask the question why, which then leads people to make decisions that may not be appropriate for them.

Liz Rohr:
Yeah, no, totally. And the question with scope, I think there were a couple of example questions. We weren't trying to do two specific stuff, but if you have a family nurse practitioner. And you're working in a psych setting, a psychiatric mental illness, mental wellness, health setting. Versus if, I don't know, there's so many branches off of examples, but I think you're, it really just sounds like it comes down from to state to state, and the Board Of Nursing and hopefully-

Irnise Williams:
Yeah, it comes down to the support. So if a provider's asked you to do something independently and never checking back up, and never giving you the training that you need, and you don't have anybody to partner with to make these types of very crucial decisions that you don't feel like you're trained on, scope or no scope, don't do it. That's not appropriate. But if they're giving you extensive amount of training, they are giving you access to someone who has extensive experience working with that patient population, and you're doing the care as a nurse practitioner, that's within your scope, I don't think that's wrong. I think that you have the resources that you need to ask questions when you run into a situation that you're not comfortable with, that you received extensive amounts of training, that should make you more comfortable with the patient population that you'll be taking care of, that's okay.

As long as that's within your state, within your scope. That may be a new environment, but that doesn't necessarily mean it's outside of your scope. So that's like a nurse practitioner who's done med surg now they're being put in a critical critical care unit, but all of a sudden, you've gotten three months of training, and you have a provider who can answer every single one of your questions, or who will, that's okay. It's not easy. It may be tough. We've seen it happen in the hospitals, people being thrown all over the place. We get it. It's not ideal, but if you have the resources and the support, then it doesn't mean that it's outside of your space.

Liz Rohr:
Absolutely. Well I think what is one more question we can tackle? What do you think, grab bag?

Irnise Williams:
Yeah, so I think there are a couple things we wanted to highlight. Things we said we would talk about at the beginning, but we forgot. Someone asked something about estate planning, and protecting your assets.

Liz Rohr:
Oh yes. Yep.

Irnise Williams:
You were in a situation where someone attempted to sue you. How do you do that? You have to talk to an estate planning lawyer. I do not do estate planning at all. There are some amazing resources out there. The Just In Case-lawyer is someone who I follow, who does estate planning. She's in Texas though, but she [inaudible 00:57:23]-

Liz Rohr:
Is she right?

Irnise Williams:
Yeah.

Liz Rohr:
Yeah, she's great. I know, I think she was going to ask that if it was state-based, I think [inaudible 00:57:29]-

Irnise Williams:
Yeah, it's definitely state based but she would at least be able to point you to the right resources.

Liz Rohr:
Yeah, totally.

Irnise Williams:
Because she's an estate planning lawyer and they have their own communities, and things like that. So yes, there are some things I think that you should do, but that's very specific, and you have to meet with an estate planning lawyer to figure out what you have, and what should be protected, and what's not, what can be left out, or what can be put in. So that's a very specific question, but I think meeting with a estate planning lawyer is crucial on that point. And usually estate planning lawyer are aren't as expensive as people think. I think we assume all attorneys are really expensive, but estate planning lawyers, the value of estate planning is so valuable, and that when you treat people well, they're going to continue to come back.

So estate planning lawyers usually don't charge crazy amounts of money, because you have to come back and update your paperwork every year, every few years. You may have more kids, or you may have bought a house. So if someone's paying $30,000 for an estate plan, they're not ever going to come back to update. And that doesn't help the estate planning lawyer. So I feel like don't ever assume that someone's more expensive than they may be just because it may be something that you're not familiar with. And you can always shop around and say, "What are your rates?" And then you can always compare to them to other people as well.

Liz Rohr:
Totally. It is such a valuable thing that it's a grown-up thing that I've been putting off.

Irnise Williams:
Me too. I mean, I'm a bad lawyer, and I'm also a bad [inaudible 00:59:01] I move so much. I'm like, "I don't want to do an estate here. I may move on." And then I've been in New York for three years. I should have had an estate.

Liz Rohr:
It's so valuable, it's so important. It's hard to see sometimes that there's the work and the effort and the money, and how much it pays off eventually.

Irnise Williams:
[Inaudible 00:59:19].

Liz Rohr:
But did you want to touch on the FMLA pre-op COVID work letter question? Or not?

Irnise Williams:
Yeah, I mean I think in more detail, when you're talking about, it's a little bit of documentation and FMLA paperwork pre-op planning. So I think with FMLA paperwork, you just have to be very specific and honest about the symptoms that the patient is having. Where I used to work, people would just be so vague, and then the patient would have to come back, and come back, and come back, [inaudible 00:59:49]. What the job or the employer is looking for, is can they come back to work? So if you're saying, "Patient is having difficulty walking," that does not mean anything to the employer because they may be at a job that they're seated. So, "Okay, it may take you a while to walk in here, but if you can get in here and get to a chair, you can work."

So you need to be detailed and speak enough to if that patient can sit in a chair for eight hours. Ask the patient what type of work environment that they work in, and what it is that they do, and what their job is asking them to do. If they're on light duty, some people can go back to work on light duty. That makes sense. But for some people that's not even an option.

So when it's not an option, you have to speak specifically to what that person can do. They cannot walk more than 500 feet without having severe pain, it should be that specific. They cannot sit in a chair for more than two hours without having crippling pain. So they may need to be at home, in a bed, lay down, in their house.

Liz Rohr:
[Inaudible 01:01:00].

Irnise Williams:
Because it just doesn't make sense. You need to be able to speak specifically to what it is that their job description is, and what their job is asking them to do, and then whatever symptoms, or issues that they may be having medically, and how that's impossible for them to be able to manage their health while at work.

Liz Rohr:
Totally.

Irnise Williams:
Because that's what the job, the job doesn't want to be responsible at work for someone who comes in and has a stroke or heart attack because they can't manage their care. But they also want to know, they also don't want to put someone out who may not need to be put out of work, because that is costly for them. So I think those specifics I think would be more helpful on FMLA paperwork. And pre-op clearances, I see crazy things with those too. But the surgeon wants to know that they're not going to get in trouble for taking care of a patient who is not really medically ready. So it is important that we're doing the hemoglobin A1C and the blood sugars, and whatever other pre-testing that needs to be done, the EKGs, and all of those things, and ensuring that they're accurate and correct, or it done in a timely manner, so that the surgeon's not put at risk.

Liz Rohr:
Totally.

Irnise Williams:
Because I think what people don't understand about a pre-op clearance, it really gives a surgeon an idea, and the anesthesiologist, an idea of what protections they need to put in place to protect themselves to make sure that the patient doesn't die on the table, and now they're being sued. It feels like we have to think of these documents as a team effort, it's not just you protecting yourself, it's not you just protecting the patient, you're also protecting the next provider when it comes to the pre-op clearance. So it does need to be detailed, all the sections should be filled out. You shouldn't just see ... Sometimes you can say, "See attachments," or things like that when it's too wordy, but you want to make sure that you're referring them back to something, that you're not just leaving things blank, and then asking them to assume that hasn't been done.

Liz Rohr:
I think the understanding that I've pulled, and correct me if I'm wrong, I think there's two things. One is making sure that it's documenting their current clinical status appropriately, doing the testing that they've requested, which is actually a side conversation. I think Curbsiders has a podcast about the evidence around how much testing we actually need to do, versus what makes us feel better. Whatever. I just go based on what they need from me. And then the other thing, is you can say, "No contraindications for surgery," but not to say, "Clearance." And correct me if I'm wrong, I don't know if you have any thoughts about the verbiage to say, because if you say, "Clearance," then that you're more on the hook or something. I don't know. It may be totally false.

Irnise Williams:
Yeah, I don't think that's true. I wouldn't say, "No contraindications," because there may be a contraindication of why they may not need the surgery, but the benefit analysis may be that it's more important that they get the surgery, even though it maybe a risk that they may die. So I wouldn't say, "No contraindications, because a lot of times patients do have contraindications of why they shouldn't go to surgery.

Liz Rohr:
Right.

Irnise Williams:
And [inaudible 01:04:08]-

Liz Rohr:
But it's more like a risks-benefit discussion it sounds like, just documenting that?

Irnise Williams:
Yeah, definitely. That is really up to the surgeon to have. So I definitely wouldn't write, "No contraindications." And I don't think, "Clearance," or anything, that those specifics make you more on the hook or not.

Liz Rohr:
More liable?

Irnise Williams:
Because all you're doing, I think the pre-op clearance really is what the surgeon is asking for, the surgical team may be asking for. It's not asking you to say, "This patient is not going to die if they get to the surgery." That's not their expectation. Their expectation is that, "You just do whatever it is that we ask you to do to make sure that we're protected, and we have a good idea." And I think sometimes people underestimate the power of those documents, because the anesthesiologist really is the person who takes into consideration some of that information for themselves on how they're going to manage the patient. So if you don't put that the patient has sleep apnea-

Liz Rohr:
Oh yeah

Irnise Williams:
... that they are not on their machine, and they're not taking it seriously, and they're not, that's a huge-

Liz Rohr:
Yeah, that's important, really important.

Irnise Williams:
... very important for an anesthesiologist, or a nurse anesthetist-

Liz Rohr:
Totally.

Irnise Williams:
... to taking into consideration when they're putting someone to sleep. So that's what it really is. It's making sure you're putting enough information for the next provider to be able to protect themself.

Liz Rohr:
Totally. And then I think the clinical, because I can hear the questions of the clinical questions, your decision ... That is a separate topic I think for NPs to dig into is having the conversations about the risk benefits, and deciding if it's appropriate. That's a separate conversation. We're mostly talking about, once you've had that conversation, what your documenting and all that stuff.

Irnise Williams:
Yeah, but I don't think it's really up to even the primary provider to decide if it's appropriate. It's up to the surgeon. Because surgeries-

Liz Rohr:
Yeah, it's both.

Irnise Williams:
... are risky. And then, "Yeah, you've had five open heart surgeries, and you have all these stents, and you have a high risk of getting a blood clot, but if we don't fix your aneurysm, you're going to die tomorrow." And you as a provider may say, "Ooh, this patient may not be ready to be cleared." But the surgeon may say, may have reasons as to why they want to move forward. So yeah, definitely both. But I don't think that you guys should take on so much pressure.

Liz Rohr:
Yeah, you're right.

Irnise Williams:
Because the risk that comes out of it, I feel like there's very rarely been instances where the pre-op clearance is why someone gets sued.

Liz Rohr:
Yeah.

Irnise Williams:
They never really go back to that. Even the surgeons that I-

Liz Rohr:
If there's a problem?

Irnise Williams:
Yeah, the surgeons that I've seen have paid really big payouts, or a really big cases, it never really boils down to the pre-op, or to the primary provider. Because it usually is what the surgical team did or didn't do, and never what they took into consideration, usually has to do with the outcome. So was the surgeon actually capable, well-trained, or had the resources, or whatever, to do the surgery that they did? And was the outcome a part of the risks that were explained to the patient?

Liz Rohr:
Right, that's right.

Irnise Williams:
And so I think that that is usually what happens, when I've seen the ugliest cases. It's usually the surgeon did something egregious, pre-op cleared or not, it was not the primary care provider's problem. And I think it's hard to go that far back for an attorney. I think people think that people are looking for people to sue. No. I know so many attorneys who will turn down a case in a second. They're like, "I'm not doing that. It's too ..." Because it's a costly to try to go after and find out the right information to review the [inaudible 01:07:41], it's expensive for the attorney. Because you don't get paid unless they get paid.

So unless it's a straight shot, it's very rare that an attorney's going to invest the time and the money to go after a primary provider in a situation where the surgeon, who has more coverage, who has more malpractice insurance, who's covered by a hospital, we're not going to the primary care provider.

Liz Rohr:
[Inaudible 01:08:02].

Irnise Williams:
So I think when you think about it like that, not to say you should completely relax about it. But I think you should take into consideration that people aren't going to backtrack that far, and try to put some type of blame on you, because then it's going to be like, "Okay, I said that they were cleared, that had [inaudible 01:08:20]-"

Liz Rohr:
It doesn't really work like that. Yeah.

Irnise Williams:
Yeah, it rarely ever worked if it goes that far back.

Liz Rohr:
Totally. Well, should we wrap up?

Irnise Williams:
Yeah. Oh, I think someone was asking a little bit about fraud.

Liz Rohr:
Oh yes, go for it.

Irnise Williams:
If people want to talk about fraud, I do some things on Instagram, talking about fraud, but the Office of the Inspector General puts out a report every day, pretty much. But you can go to the Office of the Inspector General, which is the feds, basically, and look at the cases that they're going, the people who they're either indicting, or sending to jail, or [inaudible 01:08:56]-

Liz Rohr:
I'm like so nosy, that's like a murder-crime series.

Irnise Williams:
They're so good, and so funny. People are ridiculous.

Liz Rohr:
I've seen some of your posts, you're like ...

Irnise Williams:
"Girl, how did you think you were going to get a kickback? Oh, come on." A hot mess. They're goofy and fun. But it literally, it's the same thing happening over and over. People are doing crazy things, and someone is now looking for the money, and trying to account for that, and now all of a sudden their whole plan is exposed. So when you have questions about fraud, that's a good place to start, because the feds are way more aggressive than the states when it comes to fraud. But the feds are aggressive, so even-

Liz Rohr:
Yeah, they do not play.

Irnise Williams:
They don't play. If they review a 100 charts and two charts show that they over-billed, they're going to take that, whatever that percentage is, and times it times all of your patients.

Liz Rohr:
Oh my-

Irnise Williams:
.. for the past year, and you're going to pay them that money back.

Liz Rohr:
Oh my-

Irnise Williams:
Oh, yeah.

Liz Rohr:
So this applies to me too?

Irnise Williams:
Oh, definitely applies. It definitely applies about over, billing, we can have a whole conversation about billing-

Liz Rohr:
Oh yes.

Irnise Williams:
... and all that. Usually in the hospitals, that's what really happens. Then in this conversation, we talked a little bit about decreasing liability and mitigating risk. But I'm working on something to really educate people on how to do that. Because I think that, it's what we're talking about today. And people want to know, "How can I prevent this from happening?" And I think that most people are doing the right things. I think most providers are doing the right things. I think in six years, maybe 6,000 nurses to nurse practitioners have lost their license, and there are thousands and thousands. And usually the reasons why people lose their license, it's because they did something really egregious, like kill somebody, or drunk driving. It's never usually like, "I forgot to document," it is never that small.

It is usually a pattern of bad behavior, or people thinking that they're getting away with something and they're not. So I do hope that this conversation gives people an ability to relax a little bit, and be the provider that you dreamed of. I think if you get back to that. Like, "When I became a nurse practitioner, I wanted to be this person," be that person. And then all of the other issues, and the things that you have, and the skills that you're learning as a new nurse practitioner, even as an experienced nurse practitioner, because things change every single day, and you're always learning something new, will come with time. And you'll become better at it and more proficient at it. If you take the pressure off of yourself, I think you can really become a better provider, because you can see people for who they are, and not just the disease that they have.

Liz Rohr:
Totally. Thank you so much for being here. This is just so wonderful. Do you want to tell people where they can find you?

Irnise Williams:
Oh.

Liz Rohr:
Yeah?

Irnise Williams:
On Instagram, Facebook, Twitter, LinkedIn, Pinterest. Don't go on Pinterest, because I'm a little [inaudible 01:12:05], but I'm Your Nurse Lawyer on everywhere.

Liz Rohr:
Awesome.

Irnise Williams:
You can reach out to me on Instagram if you have any other questions following up with this, if you listen to the podcast. I can of course always send people resources and things like other referrals. I help people find other attorneys that [inaudible 01:12:25] specifically, so you can reach out to me, and I definitely will get back to you. And then on my Instagram page, all my contact information is there. But yes, I'm Your Nurse Lawyer, and I hope to really build a better healthcare system for healthcare providers, where they have a little bit more information, and they know about these legal aspects. So that they can be more comfortable with doing what it is that they do best.

Liz Rohr:
Totally. I'm so, so excited for everything you have coming up, and all of that education coming.

Irnise Williams:
Thanks.

Liz Rohr:
I can't wait. So thank you so much again.

Irnise Williams:
Thank you.

Liz Rohr:
I so appreciate it.