I Got Sued for Malpractice. Here’s What Really Happens.

What REALLY happens when you’re named in a malpractice lawsuit?

In this eye-opening episode, Joe Rodriguez sits down with Paul Lefebvre, lead claims professional and risk advisor, and Andrew Clark, head of business development at Physicians Preferred Medical — an anesthesia-specific malpractice carrier — to pull back the curtain on malpractice litigation. From the first call after an adverse event to depositions, defense strategies, and courtroom realities, this conversation is packed with must-know insights for every CRNA, anesthesiologist, and anesthesia group leader.

We talk about why most anesthesia lawsuits are defensible, how to avoid career-derailing mistakes, the truth behind insurance carriers and legal strategy, and what separates providers who bounce back from those who don’t. This is not just about risk — it’s about resilience, smart choices, and protecting your future.

Keywords: Malpractice, Anesthesia, Risk Management, Litigation, Informed Consent 

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Transcript

Joseph Rodriguez (00:00)
Hey everybody, this is Joe Rodriguez. Here is the truth that most anesthesia providers don't know about being sued. Getting sued for malpractice doesn't mean that you're going to lose or that you did anything wrong. But the way you handle it and what happens after you're caught in litigation or you get served or you get sued, that's what can really make or break the outcome depending on who you're working with. So

Welcome back to Anesthesia Should Be Constructed. Today, we are talking about what really happens when a CRNA or an anesthesiologist is named in a lawsuit. From the first phone call to the depositions to what separates defensible cases from potentially career ending mistakes. Guests for today are Paul LeFerv, if I'm saying that correctly, he's an attorney. He's the lead claims professional and risk advisor, as well as Andrew Clark, the head of business development at

physicians preferred medical, a anesthesia specific malpractice carrier that's been in the trenches with providers for a long time. Just a disclaimer, this is not an advertisement for them, but the group I am part of does work with them directly. So we do have a relationship outside this podcast. We cover some of the most common mistakes that providers can make. Why most, not all, but most anesthesia lawsuits are defensible.

how to immediately lower your risk, right? And how your choice of carrier makes a bigger difference than you think. So if you're a CRNA or an MD or you're a group leader, this is one you should enjoy. Let's get into it. Hey everyone, real quick. If you're listening to this, you're probably the kind of anesthesia provider who wants to understand more than just how to push drugs. This podcast is about understanding what's really going on, whether it's legally,

clinically or financially and the often small but powerful ways you can protect and advance your career outside of the OR. Anesthesia Deconstructed is already one of the top podcasts, at least in anesthesia. Out there we get a few thousand listens per episode, but subscribing helps us keep that momentum and it helps us bring on more compelling guests that are commentary and the kind of insight that actually moves our careers forward.

Subscribing is free. helps us keep doing what we're trying to do and it means you'll stay sharp, connected and stay a step ahead. So please hit the subscribe button and enjoy the show.

Joseph Rodriguez (02:33)
we have Paul LaFave, who is the, let's see if I can get this right, the lead claims professional risk adjuster. Did I get it right, Paul?

Paul Lefebvre (02:40)
Close, lead claims professional and ⁓ risk advisor for prefer... You got it.

Joseph Rodriguez (02:44)
Advisor.

for yes for PP and physicians preferred medical. You manage the moderate and highest severity claim and litigation files for anesthesiologist, CRNAs, CAAs and anesthesia practices. And also complimenting him is Andrew Clark and you handle business development for PPM guys. Thank you so much for being on Anesthesia Deconstructed.

Andrew Clark (03:07)
Thank you for having us. Excited to be here.

Joseph Rodriguez (03:08)
Of course, of course.

Alright, so let's let's jump right in. ⁓ The one thing so you guys are obviously subject matter experts. OK, what is the one thing that CRNAs and anesthesiologists don't know but should know when they're being sued for malpractice? Let's start there and then we'll just operate organically after that.

Paul Lefebvre (03:30)
Well, each case is a little unique, but I do think that something that I think the community anesthesia community will serve to know is that the vast majority of the cases, the claims lawsuits that we defend are defensible on the medicine. So when a new claim or lawsuit comes in, obviously it's a scary time in a person's life. And I think that just based on 37 years of handling nothing, but anesthesia specific.

claims and lawsuits. ⁓ Our track record and our loss experience would suggest that most of these cases, say for a few areas that we can talk about a little bit later on, ⁓ areas of exposure potentially, but vast majority of cases are defensible on the medicine and we're going to get you through it to the other side.

Joseph Rodriguez (04:21)
So it sounds like I've been told and read that something around 90 % of malpractice cases are dismissed or settled with minimal impact to the provider. Paul, ⁓ would you say that's a fair characterization?

Paul Lefebvre (04:35)
Yeah, that's fair. I'd say for us, the settlements would usually between 10 and 20 % of the lawsuits that are filed result in an indemnity payment, claims and lawsuits, and vast majority are dismissed. And of the ones that proceed to trial, vast majority are defensible on the medicine and about 92 % in recent years, time when we...

go to trial result in defense verdict.

Joseph Rodriguez (05:07)
Okay, fair enough. And what about you, Andrew, the the sales or the business development side, something that CRNAs and anesthesiologists usually don't know, but they should know when they're dealing with malpractice issues or when they're sued.

Andrew Clark (05:21)
Yeah, I would say asking your current carrier ⁓ whether or not they ensure other parties that were in the OR at the time. ⁓ So, you know, something that's pretty common that we hear when we're discussing whether or not a prospect should join PPM is the shifting of liability. So if you are the anesthesia provider, let's say the surgeon's in the room, maybe there's ⁓ another anesthesiologist who comes in.

Everyone has a million dollars on the table if you're all insured with the same carrier. It doesn't really make sense from a financial perspective for that carrier to spend $400,000 in attorney fees to get you specifically out of the case just to shift the liability onto someone else who's in the OR at the time. Ultimately knowing that they could end up spending $400,000 on that person as well or paying out the policy limits. So it's important. Go ahead. Yeah.

Joseph Rodriguez (06:09)
Hmm.

So yeah, go ahead. Yeah, you know, go ahead.

Andrew Clark (06:20)
Yeah, it's just important to know who, when you're in the OR, ⁓ who is, which carrier they're with. ⁓ Make sure that everyone has the same limits, and parity of limits is something that we talk about a lot too, and I can elaborate on that a little bit later.

Joseph Rodriguez (06:35)
Okay, yeah, fair enough. that's a, maybe that's a good segue because I know I want to make sure to get the history of PP on record, so to speak. PP is anesthesia specific. You just mentioned about knowing effectively who is protecting who, whose interests are aligned and maybe only partially aligned. But could you speak to a little bit about the background of PPM? Cause I know it's anesthesia specific.

Andrew Clark (06:59)
Sure, yes, our company was founded by an anesthesiologist back in the late 80s, kind of under the premise that at the time, and this is still true to some extent to this day, there was quite a bit of subsidization occurring between specialties. there was an incongruency in the risk to premium ratios when you're looking at anesthesia versus OB, neuro, some of the higher risk specialties.

Joseph Rodriguez (07:05)
Mm-hmm.

Andrew Clark (07:26)
And so the losses that weren't occurring for anesthesia, the premiums from those policyholders were being used to subsidize the loss experience of some of the other specialties. And so there are really kind of three basic pillars on which the company was founded. There's the anesthesia specificity piece, you know, primarily kind of grounded in that subsidization that I'm talking about. We really focus on proactive anesthesia specific risk management. And so

Joseph Rodriguez (07:43)
Mm-hmm.

Andrew Clark (07:55)
100 % of Paul and his team's time has been on anesthesia claims, anesthesia risk management, focusing on your specialty and helping you to improve patient safety and avoid adverse events. And then the third pillar is aggressive defense. And so Paul kind of talked about that. A lot of the times these claims are defensible. And we believe that you...

Joseph Rodriguez (08:08)
Of course.

Andrew Clark (08:20)
need the opportunity to stand behind your good care and to defend yourself as an anesthesia provider.

Joseph Rodriguez (08:28)
Yeah, that makes a lot of sense. And because you mentioned being subsidized a number of times, so just to kind of zoom out on the economics of it. So effectively what you're saying, for those who are not familiar, anyone who's running an anesthesia practice, by the way, is very familiar with subsidies right now. And I'm talking to my counselor about this regularly, and my therapist says I can talk about it in public now because it's very painful. But I digress. That's an issue for another another episode. But as far as anesthesia subsidies, effectively what you are saying

is the premium dollars, the dollars coming out of the pockets of anesthesiologists of CRNAs is going from their pool of risk that's meant to defend them, right? And they're taking because that pool of dollars is getting sufficiently large because of a low claims and low payouts. Companies would take that money and put it into other specialties and use it to defend them. Is that a kind of a layman's understanding of it?

Andrew Clark (09:23)
Yeah, yeah, I think that's a good explanation. And a good analogy would be the LA fires that happened relatively recently. So, you know, lots of big million dollar homes, expensive cars that were torched in the flames. And, you know, the premiums from some of the other communities surrounding and nationwide, if you're looking at, the all states of the world are used to subsidize those losses.

Joseph Rodriguez (09:46)
Yes.

Yes, does and this is for the for the insurance nerds who are listening. Does PPM have their own actuaries who are effectively math professionals who are calculating the risk of anesthesia specific claims?

Andrew Clark (10:04)
Yeah, we have an actuary in-house who does exactly that. You know, he puts together some of our special programs like risk sharing programs for some of bigger groups. ⁓ And then also one of the things that he does that kind of sets us apart, he keeps his thumb to the pulse really, really well of filings. So anytime rate changes are filed nationwide, he puts them on a spreadsheet, presents them to the rest of the company.

Joseph Rodriguez (10:14)
Mm-hmm.

Andrew Clark (10:30)
know, gets that information in our hands so that we know exactly what's going on in the marketplace.

Joseph Rodriguez (10:35)
And when you say on the filings, you're talking about, because this is really interesting diving into the business end of it, I didn't anticipate it, but you're effectively saying your actuary is watching what people are paying for premiums or who's getting sued and settling. Those are two different buckets.

Andrew Clark (10:51)
Yeah, we're talking about premiums. So insurance is a regulated industry when you make changes to your filed rates that are above usually 5%, but it does vary based on the state. Then you have to publicly file them, provide an actuarial explanation of why you think they're justified. And so we have access to those and we use them in our decision making as well.

Joseph Rodriguez (10:53)
Okay.

Mm-hmm.

Okay, all right, that makes sense. you said PP started by an anesthesiologist. Great, and you're part of the world, out in the center of the country. Now you guys are insuring people nationwide, correct? You're insured, as we mentioned at the top of the introduction, all sorts of anesthesia professionals now. How long have you been insuring CRNAs? And just out of curiosity, what was the driver behind that? Besides expanding the market, right? I imagine there was some risk evaluation that went on there, right?

Andrew Clark (11:43)
Yeah, you know, we've been ensuring CRNAs is part of the care team model for basically our entire company's history. Now, we've really, within probably the last five to six years, deep dived into 1099 style CRNAs, you know, putting together risk management programs that really focus on what they have going on, you know, a lot of endoscopy and ASCs and that sort of thing. But, you know, as the market expands and

The advanced practitioners continue to expand their scope of practice. It just makes sense from a business perspective for us to ⁓ focus on them as well.

Joseph Rodriguez (12:21)
Okay, yeah, that makes sense. I want to kind of flip over to the clinical side a little bit. ⁓ So Paul, in your role, I imagine, how long have you been at PP now, Paul? 2018?

Paul Lefebvre (12:31)
I

joined PPM in 2018. So it'll be seven years here pretty soon.

Joseph Rodriguez (12:35)
Okay, got it.

Okay, and just for context, were you in the anesthesia malpractice business ⁓ before or industry before that? Or is this your first for and anesthesia world?

Paul Lefebvre (12:49)
It was the first foray into anesthesia world as well as insurance side. So before I joined PPM, was with the ⁓ Missouri Board of Registration for the Healing Arts. general counsel for the Medical Board of Missouri.

Joseph Rodriguez (12:56)
Okay. Okay.

Okay.

Okay. Duly noted. All right. That makes sense. So you've probably seen both at the medical board and certainly in your role now, I imagine you're overseeing hundreds of claims a lot. I don't know how to quantify it actually. ⁓ But is that a fair assumption? A lot of lawsuits that you've, you know, overseen or reviewed or been part of?

Paul Lefebvre (13:24)
Sure. So we're actively defending, you know, several hundred claims and lawsuits at any given time. We have about 500 adverse events reported to us between 350 and 500 on a given year. You know, obviously not all of those result in a claim or a lawsuit. think Andrew will talk about it a little later. We can visit about, you know, some of the misconceptions about reporting incidents and things like that. So we've got we've got five in-house attorneys that are

Joseph Rodriguez (13:30)
Mm-hmm.

Right, of course.

Mm-hmm.

Paul Lefebvre (13:55)
in our claims department. So we're all able to offer guidance to our insurers when they call in. And again, the vast majority of those, what we call an intake, come in through the phone. just policyholder or insured pick up the phone, give us a call after an adverse event or just looking for some guidance.

Joseph Rodriguez (14:13)
Yeah.

What is, in your view, Paul, what is the biggest mistake that CRNAs, anesthesiologists make during the lawsuit process? Right. And I realize there's many stages of a lawsuit, but generally speaking, perhaps early on, what's the big thing that people do that they shouldn't do?

Paul Lefebvre (14:35)
Sure, think that right out of the gate, we try to, ⁓ again, some of the things we touched upon earlier about the defensibility of the cases. And it's easy for me to say on the phone, I appreciate that. It's really hard on our insurers when there's a sentinel event or a significant complication that a patient experiences. Lots of times they don't anticipate that resulting in a lawsuit. Sometimes they might. ⁓ But I would say on the lines of the bigger mistakes that we see is we work with where

We're single specialty and we work with a handful of attorneys in each given state. So they've got lots of experience defending anesthesia professionals as well. ⁓ And probably some of the pitfalls or rakes that we want to avoid stepping on or maybe not following the guidance of counsel when they're about conversations or just ⁓ in preparation for depositions, things like that. think that a handful of defensible cases that can be.

complicated by a poor deposition maybe because they didn't listen to defense counsel.

Joseph Rodriguez (15:41)
Yeah, imagine when people don't listen to their defense counsel, either from PP or, know, or the barred individual in that state who's, you know, actually quote representing if I'm character, is it right? There's the right, right, right, right. When people do that, why do you think what's a generalization that I suppose people can learn from? Why do think people don't listen to their defense counsel?

Paul Lefebvre (15:53)
That's right. We're not representing the individual policyholders. We're overseeing the claim file.

Joseph Rodriguez (16:10)
Is it because they feel they can figure it out on their own? These are highly educated people that you're ensuring.

Paul Lefebvre (16:17)
Yep, I think that that's probably the biggest factor sometimes. ⁓ But the specialty that we ensure, we don't necessarily always have the huge personalities in the room. easier to, maybe these are few and far between. Maybe some other specialties experience that issue a little bit more often. But yeah, I think that that's, no, that was a shot at the surgeons. Yeah, no, they're good. ⁓

Joseph Rodriguez (16:22)
Mm-hmm.

Mm-hmm.

Are you saying that's why I don't fit in Paul? Are you saying I don't fit into this specialty? Yeah. Okay, I got it. All good. All good. I understand.

Paul Lefebvre (16:44)
So it's times where I've been in an operating room twice in my life for both my kids. ⁓ Both my kids were sections and that was my experience. So the first one was pre-PPM, the second one was post-joining PPM. So it was very different observations I was watching with the CRNA who was handling the anesthesia services for my wife was doing more on the second one just to see evaluating the informed consent process and all that kind of stuff that we do on a daily basis. But yeah.

Joseph Rodriguez (16:50)
Okay.

Yes. Yes. Hopefully they did. Hopefully they did well and, you

know, shared all the relevant risks.

Paul Lefebvre (17:15)
But it's an uncomfortable place to be. I'm outside my element. ⁓ They hand you your kid and there's 19 wires to trip over and got to go through three things. ⁓ Imagine it's similar for doctors and advanced practice clinicians who have never been in a courtroom before, never had their deposition taken. So I think that these are all experiences that we don't ⁓ anticipate, that we don't...

Joseph Rodriguez (17:35)
Hmm, very much so.

Paul Lefebvre (17:42)
It's not front of mind. We're not thinking about how we can be a good witness during a deposition before a lawsuit's filed. ⁓ And I think that sometimes there's some preconceived notions about the medical legal system in general and kind of outcomes are preordained and this is all just a formality, which really isn't the case at all. Every case is unique. Every defendant in a case is unique. Every situation is unique.

Joseph Rodriguez (18:08)
Yeah, I think for two observations there, or one observation and a question rather, I think to outside watchers, when you don't know about a high knowledge subject matter, everything looks somewhat similar, right? People look at anesthesia and they think white stuff, yellow stuff, right? You you're pushing propofol, you're spinning sivoflurine, you're putting a tube, and it's like there's so many areas where you can screw that up. And I imagine it's similar with legal proceedings. Is that it? Do you think that's fair, Paul? Is that my own?

Paul Lefebvre (18:36)
I do. Yeah,

Joseph Rodriguez (18:38)
Mm-hmm.

Paul Lefebvre (18:38)
I think that and part of the guidance that at our ⁓ local council that we ensure to represent the individual insureds, you know, they'll often tell them if you don't remember something, that's okay. You can rely on your medical record. You can rely on your custom and practice. Oftentimes, the doctor or CRNL give us a call and let me know they were served with a lawsuit and all one first questions I'll ask is do you remember this patient encounter and with maybe two or three years ago and

Joseph Rodriguez (18:48)
Mm-hmm.

Paul Lefebvre (19:05)
More frequently than not, they'll say, I don't have any recollection of this case. It was just, didn't know that there was this complication, did not anticipate this, don't have any recollection of this particular patient encounter. And that's usually a pretty good indication for me that this is the type of case that we can routinely defend. can, know, a plaintiff's attorney may identify something in a medical record or, you know, it might just be based on damages or an experienced plaintiff's attorney.

Joseph Rodriguez (19:34)
Hmm.

Paul Lefebvre (19:35)
that thinks that every case, if there's a complication or an adverse event that somebody is paying on the other end. so that's types of things that we'll navigate.

Joseph Rodriguez (19:45)
Okay, yeah, that makes sense. ⁓ You mentioned plaintiff attorneys and from your point of view, Paul, knowing and feel free either of you to answer this if either of you want to weigh in. Are plaintiffs attorneys financially motivated to file claims which in a way that could cloud their judgment on what's legitimate and not legitimate?

Paul Lefebvre (20:09)
Well, I don't want to make an overgeneralization, but I think that they're oftentimes focused on the damages side of the case. ⁓ Whether there was a departure from the standard of care, even a link on the causation element of a case is kind of secondary. We look at a case and I start there. Was there a departure from the standard of care? Don't move on to the next step. This is a case that can be defended on the medicine. Let's do it. Sometimes there's... ⁓

Joseph Rodriguez (20:13)
Mm-hmm.

Sure.

Mm-hmm.

Mm-hmm.

Paul Lefebvre (20:39)
causation issue where we can defend it as well. And if we get to those points where we've got concern, you know, our experts that we retain to work with us on the cases, identify some areas of potential exposures with regard to a departure from the standard of care and resulted in a patient injury, then we'll then we'll get into damages and we'll take a look at it. I think lots of times when plaintiff attorneys take these cases, they look at the damages first and foremost, the medicine is secondary and that's

Andrew Clark (20:43)
you

Joseph Rodriguez (20:43)
Mm-hmm.

Mm-hmm. Mm-hmm.

Are they, and this is just me being curious about the industry itself, are plaintiffs' attorneys typically paid in terms of a percentage of damages?

Paul Lefebvre (21:16)
Exactly. So they it's almost exclusively contingency fees across the board. So they'll get a percentage. Yeah.

Joseph Rodriguez (21:22)
Okay, right.

Right, so for those who don't know, right, effectively, you know, it's funny, because for most anesthesia professionals, ⁓ they are paid upfront, right? We get reimbursed, you know, many months later, and most of us don't have that ⁓ understanding of the rest of the industry, so to speak. But that effectively means plaintiffs' attorneys won't take anything upfront. They'll get paid only if they win, and then they'll get paid a percentage. Does that sound right?

Paul Lefebvre (21:50)
That's right. And they're also investing a significant amount of money into legal expenses throughout the course of that lawsuit as well. So which comes out of any award if there is one at the end or settlement that will come off first. So they've but they've could be tens or hundred thousand dollars in experts and deposition transcripts and all the other costs and fees that go into bringing a medical malpractice lawsuit.

Joseph Rodriguez (21:57)
Hmm.

Mm-hmm.

Okay, yeah, that's again just for clarity for the audience. This is not meant to and my question is not meant to criticize plaintiffs attorneys. There's certainly there's a you know, the system needs plaintiffs attorneys at times, but it is more to identify the general, know what how the industry actually works, right? Yeah, so yeah, just for.

Paul Lefebvre (22:39)
And it's good

for listeners to know that too, that just because they're named in a suit, it doesn't mean that they did something wrong. That's what we're here for is to, it's oftentimes not the pursuit of the truth. Plaintiff's attorneys may want to frame it that way, but might be pursuit of recovery of damages. ⁓ But if we have expert support in these cases and sometimes some of the cases that we'll get.

Joseph Rodriguez (22:43)
Mm-hmm.

Mm-hmm.

Paul Lefebvre (23:06)
Drug into, it's clear we're only there because we're another insurance policy. This is not an anesthesia related complication. This is clearly a surgical complication. And frankly, oftentimes the surgeon can defend those cases on the medicine without us as well. Some sophisticated plaintiff's attorneys might try to pull in a few different parties to see if they can induce some finger pointing. Again, that goes back to the lack of any preparation or direction from counsel during the course of litigation.

where those are really some of the bigger things that we want to avoid. Because it's not like, everybody hears the standard of care on the road, ⁓ short of a deer running out in the fog in the middle of the night, there'd be no accidents. Usually if there's an accident, somebody departed from the standard of care of operating motor vehicle on the road. But we're not immortal. There's complications. And sometimes it's a choose your own adventure. We've got three choices. We're going to have a robust informed consent discussion with the patient.

Joseph Rodriguez (23:44)
Mm-hmm.

Mm-hmm.

Paul Lefebvre (24:05)
and patient autonomy and they make a decision that the benefits outweigh the risks of the procedure and patient decides to undergo a procedure and they experience one of those complications. We don't know what would have happened had they chose something different. Hindsight's always 20-20, but the critiquing of the anesthesia plan and things like that, Monday morning quarterbacking, those are the types of issues we gotta navigate.

Joseph Rodriguez (24:22)
Mm-hmm.

Of course.

I always tell people you give me 30 minutes with your chart and a good lawyer and I will find something you did wrong. Right? Like anyone can go back, you know, and Monday morning quarterback those issues. You talked about, there's actually two parts there. So you mentioned deposition, right? This is a key part. It is part of the legal proceeding, right? It's not a warmup. It's an actual legal proceeding. I want you to critique the advice that I have given to other people through my experience and for context.

I have been involved in a few different as an expert witness. The case I was involved in personally, I got dismissed very early in the process. But effectively, you know, when that occurs, the first thing I do is tell them to call whoever their malpractice carrier is. Right. And as a disclaimer, obviously, we ensure with you guys and we think you guys do a great job. So in my specific case, I'd be referring them to you, Paul. But usually we have a conversation first.

And when these things come up, usually advise like a one-on-one, just a colleague to colleague conversation. I usually advise the following. And the first is it's really three things. The first is I tell them to tell the truth. Right. Obvious. This seems obvious, but I think for people who are at what they perceive to be a deleveraged position, they feel like they're extremely at risk. being scrutinized. So they become really worried.

about how they answer and how it can be misperceived and misconstrued and all that sort of thing, which leads to the second two points. And this is what I'm curious on your input on. I tried to tell them to say, hey, you need to look at the context of the question as in if someone asks you something like, wouldn't you say it was reasonable that this would have had a different outcome if you hadn't done X, Y, and Z, right? And obviously this is the

context of that is a very, it's a very leading question. And then I often will answer, I will tell them to answer only what they truly know. As in, I have no idea what the outcome would have been if those other things had occurred. What I can tell you is that, right, the standard of care was met. Here's why it was met. And effectively to stick to that main message, you know, answering the specific question, but also keeping in mind the broader context, which I find

is very difficult for people to do, especially as you said in this specialty, a lot of type A people, a lot of hyper detailed people, lot of people where they really are driving down on very specific details and they can be very hard on themselves. So, but I try to get them to see the broader picture as well. So tell the truth, know the context and only answer what you know, otherwise say, I don't know. Right, what do you think about that? Yeah.

Paul Lefebvre (27:15)
Yep. And listen to the question. Answer the question that's asked as

well. I think that that's a frequent pitfall sometimes we'll see during depositions is that you want to defend your case on question number two. And your attorney is going to have an opportunity to ask you some questions as well. This is something that we encounter, particularly at trial, where a plaintiff's attorney is on cross and able to lead, ask leading questions.

that require yes or no answers. And sometimes you may not want to give a yes or no answer because you know what he's doing, but having faith in your defense attorney is going to be able to come through and help ⁓ clean up some of those responses or questions or whatever the other side's trying to imply. And frankly, lots of times those strategies backfire because the jury is watching those things. And if they feel like...

one party is trying to trick the other one. You you ask the same question four times and you don't get it. Then you get it on the fifth time where they elicit the response that they wanted. And, know, that's all part of their closing argument. Of course, the jury sat there and listened to, you know, the defendant answer the question honestly four times in a row and you kept coming back to the well. So, yeah, listening to the question carefully, following the guidance of defense counsel during that deposition prep. And again,

Joseph Rodriguez (28:29)
Mmhmm. Mmhmm.

Paul Lefebvre (28:39)
And like we said, it's always okay if the answer is, don't recall, or I need to look at my record, to refresh my recollection of that. And that's easier for the specific clinical questions. It becomes a little bit more challenging when you present those types of hypotheticals that you were suggesting about the patient's outcome and things like that as well. But we'll be prepared.

Joseph Rodriguez (28:44)
Hmm.

Yeah, of course.

Yeah, indeed.

Makes sense. All right. ⁓ So Andrew, obviously what Paul is sharing, I think is part of the value proposition for PPM, PP specifically, right? Because could you, I want to answer two questions here. First of all, this type of advice from your standard malpractice brokerage, right? Is that available to what degree? And then more broadly speaking, with PP what

what's different about PPM than those other options, right? Than the Baxter's or whatever else is out there.

Andrew Clark (29:30)
Thank

Yeah, so I think when you think about anesthesia or anesthesia providers as a percentage of the overall pool of medical providers in the US, it represents about 6%. And so if you think about a ⁓ big multi specialty carrier out there with only 6 % of their book of business being anesthesia, I it really makes sense that they wouldn't be able to devote the time and resources, have the balls of the world out

Joseph Rodriguez (29:42)
Mm-hmm.

Andrew Clark (30:03)
there answering these very specific questions. You know, because it's just financially imprudent to spend that amount of resources on 6 % of your book. You know, another kind of piece of the puzzle that sets us apart that allows for this type of communication to occur, you know, that Paul's talking about with the managing the claims and managing the local defense counsel, we're a direct writer.

Joseph Rodriguez (30:14)
Mm-hmm.

Andrew Clark (30:31)
So we don't use agents or brokers. You mentioned Baxter. ⁓ So not only does it kind of create some rate stability for us where we don't have to pay commissions, there's no pressure on us by agents, but also it drives a lot more effective communication directly between our policyholders and our team of attorneys. So.

You know, you're not going to... So picture 1 a.m., you're in the O.R., something terrible occurs. The very last thing that you want to do is dial an 800 number, get pigeonholed into the phone tree that we all know and hate. You know, you spend five minutes selecting all the different options just to get a general voicemail that you're hoping someone's going to call you back on. It's the worst. Everybody's had that experience.

Joseph Rodriguez (31:11)
Mm-hmm.

Right, Yes. And

they check that voicemail four days after they got out of the office or got back from being out of the office. And yeah, you never get a reply. Meanwhile, the wheels of the issue are still spinning, right? Not to mention your internal emotional state.

Andrew Clark (31:32)
Yeah,

yes, yes. The emotional piece of it, I think, is kind of undersold. our team of attorneys is available 24-7-365. We have a phone system that rings between everyone's cell phones until someone answers. And so you can always get one of our attorneys that's included with your premiums. It's not like we charge extra for that or anything, the real-time advice. And so it just...

Joseph Rodriguez (31:37)
Hmm.

Andrew Clark (31:58)
It'll put people at ease and also it gives our attorneys the ability to really jump in quickly, you know, provide guidance, provide recommendations that help decrease the odds of an adverse event turning into a claim.

Joseph Rodriguez (32:11)
Sure, yeah, that makes sense, which I want to come back to that. ⁓ But you mentioned brokerages, right? And or agencies. don't think most like I have a vague understanding of what that means in terms of a service firm, right? Just kind of an organizing umbrella. But what are those things? And why don't you have them? They seem like they're useful. But yeah, please weigh in.

Andrew Clark (32:33)
Yeah, so the most common distribution channel for insurance in the US is agency distribution. you either

Joseph Rodriguez (32:37)
Mm hmm. Right, and

that's your state farm agent, right? Your local person with the little business card, right? OK, got it. That's the agent.

Andrew Clark (32:42)
Right. Yeah. their value proposition

is generally, I can take your insurance to market. I can have the carriers, you know, work against each other to get you the lowest price. You know, I can answer all of your questions that you have about insurance, you know, because it is, it's kind of nebulous. Nobody really likes to talk about insurance. There are a lot of questions out there, you know, is this covered special circumstances?

Joseph Rodriguez (32:56)
Mm-hmm.

sure. And there's a million different

types, right? There's a million different types of insurance, even I am just like, my gosh. So that's why I call you guys, right? It's just easier. And this is that and by the way, we receive no financial benefit for this pot. You're like, there's nothing funny going on here, right? This is just to have a good conversation. But ⁓ I do I do think you're I mean, effectively, what I hear you saying is, you don't have those agents, right? And you don't go ahead, please clarify.

Andrew Clark (33:11)
Right.

Exactly.

No discount.

Yeah,

90 % of our book of business is direct and I have my agent's license, but I work directly for the company so that I can answer the insurance specific questions that an agent normally would, but we don't have to deal with the rigmarole and ineffective communication and some of the things that come along with agency distribution.

Joseph Rodriguez (33:38)
Hmm. Okay? Mm-hmm.

Right, right. I think those are, I'm sure there's some upsides as well, just like I think in the service sector at large in the United States, there's always upsides and downsides, like in-house counsel versus outside counsel, right? There's always upsides and downsides. And obviously you guys effectively have both on the counsel side, but so effectively you're acting as the de facto agent if there was one, right? And you're not, you know, dealing with, I'm communicating with, you know, four or five, six different carriers and trying to.

Andrew Clark (34:16)
Exactly.

Joseph Rodriguez (34:23)
funnel that into a good option. sounds like what you're saying is you're identifying the decision points in the economic, the financial decision and trying to reduce the variability, reduce the costs, reduce the confusion, so on and so forth. Correct?

Andrew Clark (34:39)
Exactly. You know, a lot of our competitors really like agency distribution because it creates a lot of opportunity for scaling, you know, economies, scope and scale. If you can really get your business out there via agency, but we don't really have that desire since we're so specialized.

Joseph Rodriguez (34:55)
Okay, yeah, that makes sense. then the steps between agency and brokerage. Is Baxter a brokerage? I honestly don't know.

Andrew Clark (35:05)
I believe that they're an agent, not a brokerage, and really the difference is volume and ⁓ lines of business offered. So brokerages are larger and they offer more products.

Joseph Rodriguez (35:09)
Okay?

Okay, got it.

Okay, duly noted. So for instance, like ANA insurance services, would be an agency or a brokerage, one or the other? Correct. Okay, got it. And the actual carrier there is MedPro, whereas effectively you've streamlined that vertical into one company. Is that a fair understanding?

Andrew Clark (35:27)
Yeah, they're an agency.

Yeah, yeah, that's accurate.

Joseph Rodriguez (35:40)
Okay, okay, got it. makes sense. And then in your introduction, you said something that stuck out to me and in regard to who owns PP right? There's no private equity involvement, which is a big topic in healthcare right now. ⁓ I believe if I'm understanding it correctly, it is owned by its policyholders.

Andrew Clark (36:01)
That's correct. So we are a mutual owned by policyholders. Now it's kind of a complicated structure that we have. Ultimately control of the company does roll up to Pro Assurance, which is a publicly held company out of Alabama. They're a pretty large ⁓ MPL carrier. They offer a lot of lines and they are multi-specialty. So think of us as like the policyholder owned, niched out arm of Pro Assurance.

Joseph Rodriguez (36:10)
Mm-hmm.

Okay, Julie, I imagine that comes with some sort of financial backing, some resources, so on and so forth. That's why you're part of a parent company. ⁓ But you're the anesthesia specific niche company, correct?

Andrew Clark (36:42)
That's correct. And so we enjoy ⁓ quite a bit of autonomy. You know, we get to our own rates and choose where we want to focus as far as getting business, you know, who to hire and that sort of thing for internal employees. But we enjoy the financial backing of the parent company, specifically with reinsurance. So it's kind of complicated insurance nerd stuff, but yeah, just think layers of insurance on top of

Joseph Rodriguez (36:48)
Mm-hmm.

Yes, that sounds, reinsurance sounds complicated. Yes.

Andrew Clark (37:12)
layers of insurance.

Joseph Rodriguez (37:13)
Okay, Dually noted. Yeah, because insurance companies have to have insurance, right? In case their coffers run dry, so to speak. It's all about mitigating the risk, so to speak. Okay, I want to come back to some of the business stuff, but to flip back over to the practical side, Paul, as far as for your insureds, right? I'm thinking about things they can do effectively immediately, right? Right away. What are, what's one smart, proactive thing that I could do?

Andrew Clark (37:17)
Exactly.

Mm-hmm.

Joseph Rodriguez (37:43)
as an anesthesia provider this week or today to reduce my malpractice risk? What's practical and immediate that I could change in my practice to begin to reduce my risk?

Paul Lefebvre (37:58)
I'll try to, I might offer two, if that's okay. One more specific clinical and one maybe just an overarching general type of thing that we might see with our cases. think that ⁓ communication in the perioperative setting, starting both with the patient, patient's family, ⁓ colleagues that you're working with and just across the board, we do see those instances where ⁓ there could be an adverse event attributed to ⁓ lack of communication, ⁓ lack of...

Joseph Rodriguez (38:01)
Please.

Mm-hmm.

Mm-hmm

Paul Lefebvre (38:27)
understanding, so those types of things. It's such a unique relationship that anesthesia professional has with the patient. It's not like a physician-patient relationship like a surgeon might have with the patient or a primary care physician. You're meeting your anesthesia professional on the day of the procedure. They might be the first person you meet in the morning and they might be the last person you see when you leave, but they're not choosing you. ⁓ You might just be assigned to that OR that day. So,

Joseph Rodriguez (38:37)
Right. It's not long term.

Paul Lefebvre (38:54)
those opportunities to develop some rapport with the patient, answer questions. I know that there's oftentimes lots of questions about informed consent and things like that. And something we'll always mention is it's a process. It's not a signature on the form. ⁓ Every case is unique. Every situation is unique in what that process might look like. But I think those opportunities as well as effective communication amongst the clinical team as well.

Joseph Rodriguez (39:08)
Hmm.

Paul Lefebvre (39:22)
Certainly don't want there to be any misunderstandings or areas where you might invite exposure just because we're not, we know we're busy, but relaying some information could be helpful. Exactly. And then more along the lines of a specific patient safety issue that we're currently focused on, and always will be for the foreseeable future, I think is, is any listeners out there that want to evaluate their facilities medication safety?

Joseph Rodriguez (39:26)
Hmm.

And there's

Paul Lefebvre (39:50)
practices and things like that. So, you know, we continue to see medication errors. Those are the types of preventable outcomes that we try to do what we can. We work closely with the Anesthesia Patient Safety Foundation. That's among the priority group ⁓ for medication safety. You know, wrong route, wrong drug administration errors, know, overdoses in the context of the incorrect ⁓ dose being administered and also

Joseph Rodriguez (40:03)
Yep, love that.

Mm-hmm.

Paul Lefebvre (40:20)
known risk or known allergies. ⁓ Sometimes that might be an oversight in the medical record. Sometimes it might just be educating the patient about a pseudo allergy or, you know, this is a side effect of the medication. And while I understand that you've, you know, experienced a cough from this, or you had some nausea after I'm going to give you some medicine when we're done with the case. And ⁓ I do think that if this particular drug would be helpful for you in controlling your pain or make you, you know,

Joseph Rodriguez (40:29)
Mm-hmm.

Mm-hmm.

Paul Lefebvre (40:47)
is taking a couple of minutes to maybe educate the patients on some of those things would be helpful. And then, you know, if you have a perioperative pharmacy on site that can help with ready to administer products, we've seen an uptick in tranexamic acid, bupivacaine mix ups in recent years, unfortunately. think it was the Poyce study in 2021 as an orthopedic journal discussed, you know, kind of prophylactic administration of TXA for hips and

Joseph Rodriguez (40:56)
soon.

Hmm.

Paul Lefebvre (41:17)
needs major joint procedures. okay. Yeah, so, you know, some of our insureds work at facilities where those are coming, you know, premixed in infusion bags and being brought up. Maybe they've got a spinal kit where everything is kept separate the whole time, but certainly have a large share as well that are taking those drugs out of the tray or pre-preparing syringes in advance on their own. And those might end up in the same pocket.

Joseph Rodriguez (41:37)
Right?

Paul Lefebvre (41:44)
things like that. So they happen for a variety of reasons. Exactly. ⁓ Frankly, it's sometimes amazing. It doesn't happen more often, know, the multitasking and the directions that you guys are being pulled in every day. So I think that if there are opportunities to improve medication safety practices at your facilities, you know, it should be a team sport as well, you know, so coordinating with pharmacy, if there's, you know, administering medication for a surgeon, you know, maybe getting there, they're

Joseph Rodriguez (41:45)
Sure. Easy when you're moving quick. Yep.

Hmm.

Paul Lefebvre (42:14)
Help lobbying for a change too. There are pre-filled infusion bags for TXA that come readily available too if you don't have a pharmacy. Not working for a pharmaceutical company or anything like that. I don't even know who prepares them, but as a specialty, anesthesia is unique in how patient safety oriented they are. So there's lots of buy-in and other members of the clinical team look to anesthesia oftentimes for identifying.

Joseph Rodriguez (42:20)
Hmm

Hmm.

Paul Lefebvre (42:43)
these issues. So speaking up and identifying problems go a way.

Joseph Rodriguez (42:44)
Indeed.

Yeah, that that makes a lot of sense. And I love the work Anesthesia Patient Safety Foundation. You guys don't know this. But have you met Mark Warner before? Yeah, cool guy. So I was a lowly little chief CRNA out in, you know, effectively rural Arizona, small town Arizona. I wrote that guy an email during COVID and he wrote me back like with the very thorough I could tell he typed it himself answer. And I was like, that is a very cool thing. It's a very human thing to reach out to.

Paul Lefebvre (42:57)
I have.

Joseph Rodriguez (43:17)
A relative unknown because he didn't know who I was at all. So yeah, love. I appreciate that work. You said that consent is a process. Tell me more about that.

Paul Lefebvre (43:28)
So look at the informed consent process. It's not a signature on a form. It's the patient has autonomy to make a decision about their medical care. So that goes to the ethical side of medicine as well. It went away from the clinician centric to the patient centric. So, you know, it's not here, take this medicine. It's good for you. It's ⁓ here's, you know, the procedure we're going to perform today. And here's the anesthesia plan. If you

Joseph Rodriguez (43:43)
Mm-hmm.

Paul Lefebvre (43:57)
you know, have a, you know, ASA1 that's coming in for, you know, an ankle scope or something that, you know, minor procedure, you know, highlighting some of the potential risks that might be unique to that, tailoring it to the patient, taking a few minutes to highlight some of those risks. It doesn't mean that you have to scare the life out of them by going through the absolute worst case scenarios of things. But if they've got an opportunity to review.

Joseph Rodriguez (44:18)
Mm-hmm.

Paul Lefebvre (44:24)
We're certainly proponents of anesthesia specific informed consent form. ⁓ We've got examples on our website. ⁓ can ⁓ break it down by anesthesia plan, give the patient a few minutes to review the form, talk about it with their family if they want to, see if there's any questions. And then essentially the patient's saying, appreciate these are the risks of the procedure ⁓ and notwithstanding those, think the benefits of undergoing a surgical procedure are going to outweigh those risks.

Joseph Rodriguez (44:29)
Indeed, indeed.

Paul Lefebvre (44:54)
patient I'm choosing to proceed. So I think it's just, you know, being available to answer those questions. And again, it's another touch point to develop that report because that's a personal conversation oftentimes. It can be.

Joseph Rodriguez (45:01)
Mm-hmm.

Would you agree, okay, I sound like a plaintiff lawyer. Would you agree with the following statement? ⁓ But would you agree with the idea that, because you said you don't have to scare the patient. And I think that's the, when clinicians hear review and informed consent, they think of every possible detail. That's our brains are used to processing information. Because we don't want to miss anything, right? I often advise clinicians, providers, what have you to, it's your responsibility to

share the relevant risks, the most relevant risks to that anesthetic, not necessarily to the surgery, but to the surgery in how it relates to the anesthetic. And maybe even for the facility, right? If you're talking about the risks of a surgery center versus ⁓ a tertiary care hospital, rather than contrasting that to reviewing, you may die today. You may die from these five different things. And I'm gonna take 10 minutes.

you know, in the middle of this busy surgery center to review all the things you may die from in two minutes or two seconds, maybe, ⁓ you know, reviewing the most relevant or the most applicable or the most likely risks. Would you say it's a reasonable strategy with informed consent in that process?

Paul Lefebvre (46:19)
Yeah, I do. It sounds like you're tailoring it to the patient. You you've got a ruptured AAA or you might have a conversation with the patient and their family about, you know, prospects of there being a serious complication during the procedure. know, they say four or they say five and that might be a conversation that takes place. If it's contained on the informed consent form as well. And I think giving that to the patient in advance and giving them the time.

time to review it. I might want to review every risk that's on there. There might be another patient who, you know, couldn't sleep the night before the procedure and is already anxious. And we know that there's a correlation between, you know, anxiety pre-op and post-op recovery. ⁓ There's literature out there to suggest that's the case. you've got your North Star is the best interest of the patient. And if the best interests of the patient are just to highlight some of those specific risks that are maybe pertinent to them.

um, and that particular procedure and it might just be, you know, most likely risk that could occur here is, is you bite down on the endotracheal tube where you're grinding your teeth as you emerge. You've got, you know, a bridge or crowns that, you know, dental injuries are, are common complication of general anesthesia. Um, you know, having a conversation with the patient about that, that might be it, or it might be a, you know, for a regional block. Um, and we do see lots of, um, it can get a little

messy sometimes because you don't know whether it's the tourniquet time, the boot, the traction, the block. But oftentimes, yeah, when you find out about it for the first time, 90 days post-op, it's usually because of the block by then, you know, because the patients talk to the surgeon. They've been referred over to pain management doc, exactly. Right. So, you know, mention highlighting those risks just because again, I think that

Joseph Rodriguez (47:51)
Mm-hmm. All sorts of bad things. Mm-hmm.

Whatever you do mean. I've never experienced that before. Yeah. Yep.

Andrew Clark (48:08)
Thank

Paul Lefebvre (48:15)
there's literature out there to suggest that there are claims that are pursued legitimately by patients who just want to know what happened to them that they didn't know. And I think that that conversation taking place, it's a lot easier when the patient wakes up with a loose crown when you had the conversation before the procedure took place than either you're telling them about that being a risk for the first time when you're in the PACU.

Joseph Rodriguez (48:22)
course.

Yeah, that makes a lot of sense. Paul, one more question to you, and then I want to open something up for both of you. For those who have, because you're working with providers, right, professionals, clinicians who are going through that malpractice process, you mentioned effectively second victim syndrome, right? It can be very traumatic for them, very difficult for them. ⁓ Often, this really settles in with people. It can be a very devastating ⁓ experience, even if they win.

Even if they win, it can be stressful. So with that in mind, from your point of view, what separates those who go through these very difficult experiences and bounce back and get up to 30,000 feet and they're at fighting weight again, metaphorically speaking, and they're doing really good. They're back and providing great care to patients versus those who it really affects them long-term in a traumatic way. What do you think the difference between those two scenarios is?

Paul Lefebvre (49:33)
You know, I suspect and I can only speculate to be honest, because it's kind of a person, it be a personal thing and case by case basis. It could be support structure that they have around them, both within their professional groups, maybe at home, as well as feeling supported at the hospital. Reassurance that, you know, you didn't do anything wrong. There's nothing worse than sitting through a trial. know, again, we know that the case is entirely defensible on the medicine and we know we've got.

Joseph Rodriguez (49:42)
Hmm.

Hmm

Paul Lefebvre (50:02)
reputable experts and they found a professional plaintiff's expert who does it for a living and has made millions of dollars flying around the country testifying against anesthesiologists and CRNAs. If the jury is following the medicine and the judge's instruction, this is gonna be a defense verdict 99 out of 100 times. You can get unlucky with a jury, but this is those types of really defensible cases. But when we're talking about a wrongful death suit, we are in a room for

Joseph Rodriguez (50:14)
Mm-hmm.

Hmm.

Paul Lefebvre (50:32)
one, two, maybe even three weeks in front of strangers where you're being blamed for the death of another human being. I think sometimes that's not appreciated enough about how stressful that experience can be. I think that there's a weight that's lifted off your shoulders once the jury returns that verdict and involves you wrongdoing, which again, going through that process, it's the vast majority of the time when we get to that.

Joseph Rodriguez (50:43)
Yeah.

Paul Lefebvre (51:02)
point if that's the direction of the file based on our experience and handling those cases. ⁓ But I think that, you know, just having that support, support, you know, starts with us. I can only control what's what I can. And obviously, we want to provide all the support and resources that we can for those individuals. Never once sat in a meeting where someone said, well, why did you approve this expense? Or, you know, why are we defending this case? ⁓

Joseph Rodriguez (51:07)
Hmm.

Hmm.

This is me.

Paul Lefebvre (51:32)
come,

my dad's a physician, I come from a family of c conversations at the din up kind of thing. So, folks at home. Um, but it' had that cost of defense, we settle this case for ex. be defended, doesn't mat injury or wrongful death

Joseph Rodriguez (51:41)
Mm-hmm.

Paul Lefebvre (52:01)
that wants to defend their care. then that's the file strategy, which makes my job easier. And that it's a binary choice instead of some nebulous, you know, what are we talking about at the meeting today kind of thing.

Joseph Rodriguez (52:11)
Mm-hmm.

Right, right. No, that makes a lot of sense. ⁓ I have one more. I actually have a follow up question from what you said for you, Andrew. With PPM, where do you fall in terms of, and you may not know from an evidentiary point of view or evidence point of view, but where do you think PPM falls in terms of the size of other insurance malpractice companies?

Andrew Clark (52:37)
So insurance is not immune to all of the consolidation that's occurred within many of the industries around the US over the last probably 20 years. you know, our market share does vary significantly from state to state. you know, there are some jurisdictions that are just not as attractive to us. So we, yes, we, you know, try to stay out of there. You know, we, ⁓

Joseph Rodriguez (53:00)
Of course. Yeah.

New Jersey, New Jersey, is that what you're saying? You're picking them? No, I'm

just kidding. We love New Jersey. Yes, yes. Bruce Springsteen and all those things. But yes, I just like that. I'm from Philadelphia, so I like to pick on New Jersey. anyway, please, and feel no pressure to answer in terms of specifics, but maybe even like, you know, this is the biggest, this is the smallest, and you know, there's four or five levels in where we fall. I don't want to put pressure on you to answer with specific industry data or anything like that.

Andrew Clark (53:07)
You know what, Jersey's actually pretty good. You'd be surprised. ⁓

No, that's fine. If you look at it in terms of our parent company, ProAssurance is the third largest MPL carrier in the nation. ⁓ So that falls behind the doctor's company and medical protective. And ⁓ as a company, ensure ⁓ roughly, know, PPM specifically, ensure roughly 20 % of the ⁓ physician population.

Joseph Rodriguez (53:35)
Mm-hmm.

Andrew Clark (53:55)
CRNAs, you know, it's a little bit more nebulous. yeah.

Joseph Rodriguez (54:00)
Right, because you're ensuring practices, right? And then

then it may be get harder to quantify in the data and then you have your independence as well, right? So on and so forth.

Andrew Clark (54:09)
Exactly. you know, I'd say that our number one competitor right now is not a TTC or medical protective. It's hospital employment. You know, there's a lot of pressure on these groups to join hospitals. And I would if you'd asked me that five years ago, I probably would have said private equity and you know, all the consolidation that occurred there. But that's that's kind of slowed. We've seen some non renewal of contracts and things that kind of hint that we're headed the opposite direction.

But hospital employment is our number one competitor. We've actually not lost an insured group to a competitor in over nine years. So we have solid record that we're proud of there.

Joseph Rodriguez (54:46)
Okay, very nice.

That's impressive. And yeah, I think ⁓ we're going to talk about hospital consolidation on another episode, but it's interesting to me from a service sector dynamic. I always tell people, if hospitals, if I can, if I can fix my own plumbing without calling a plumber, I definitely will. Right. But when these problems become more and more complex, I'm not sure hospitals will get the, what they're looking for. They'll probably gain on control, but lose on cost. I digress.

That's that is definitely a subject for another time. I deal with that quite a bit. ⁓ Just keep my eye on the time here. I want to close out with this question for both of you. So Andrew, obviously you're on the business side, right? You've got the business degree, the MBA, so on and so forth. Paul, you're on the legal side. What is the if you could dispel wisdom to the 120,000 or so anesthesiologists and CRNAs out there, what's the one thing you wish you could tell every new CRNA or anesthesiologist?

when they're choosing their malpractice carrier, realizing that obviously not all lawyers are the same, right? And not all malpractice companies or malpractice policies are the same, even though from a generic point of view, they might seem interchangeable, but both from a business point of view or maybe the features point of view, and then from the legal point of view, what's one thing you could share with all of those individuals before choosing their malpractice carrier?

Andrew Clark (56:15)
So I'll go ahead and answer first. On the business side, I would say you ask them, well, it's kind of a two-parter, but basically I would ask them, who do I contact in the case of an adverse event? And we're thinking about the carrier, not the agent. So kind of keep that in mind, because the agency piece can kind of convolute who to talk to about what.

Joseph Rodriguez (56:39)
Right,

definitely. agent might be trusted and friendly and so on and so forth, but at end of the day, it'll be the carrier and the policies that you've signed on to making the decisions. Yeah.

Andrew Clark (56:47)
Yeah, and make sure that you're not reporting those incidents to the agents. You know, there can be some legal complications from that, you know, from depo perspective. But, ⁓ you know, so you ask them that question and just kind of assess their response, you know, am I sending these in via email? Am I calling? You know, does it have to be in writing? There are some carriers out there that have really specific rules about whether or not coverage is triggered. you know,

Who do I report to? How do I report? What information needs to be included? And what's the process look like thereafter? So you met Tracy Diochovich last weekend at the AZA &H, so everyone knows for the listeners. She was asked a question at the end of her presentation about reporting. There's a myth, kind of a misconception out there that over-reporting, or what you perceive to be over-reporting,

Joseph Rodriguez (57:29)
Mm-hmm.

Andrew Clark (57:42)
can have a negative impact on you as an insurer, specifically your premium. So I think that, at least specifically with PPM, that couldn't be further from the truth, and I hope that that's inaccurate with our competitors as well, specifically looking at it through that patient safety lens. Not only does it help the carrier triage right out the gate as far as risk management goes, but also it helps us keep our thumb on the pulse of exactly what's going on with claims trends.

Joseph Rodriguez (57:54)
Mm-hmm.

you

Andrew Clark (58:11)
You know, so if there's some sort of trend within like a specific facility type or jurisdiction, we need to know about it. And if you're afraid of reporting to us, it's just going to move us further away from those goals.

Joseph Rodriguez (58:27)
Makes sense. And what about you, Paul? If you could dispel knowledge into the minds of all 120,000 anesthesia ⁓ providers out there, what's the one thing they should know before choosing their malpractice option?

Paul Lefebvre (58:29)
you

You know, I think kind of to piggyback a little bit, but I want to ⁓ go a little earlier on in the process before there is a claim or an adverse event. I think that, you know, we offer risk management resources, patient safety resources. I really want to look at our relationship as a partnership with our groups and our insurers as far as advancing patient safety. so we spend quite a bit of time on what we call special services, things like that.

Joseph Rodriguez (59:02)
Hmm.

Paul Lefebvre (59:10)
our risk management program. We do 30 anesthesia specific risk management seminars or more each year between my colleagues and I. We contribute to a number of publications, including our own internal risk management newsletter and as well as the APSF newsletter. Not a week goes by that we don't get a phone call or an email. I was talking to an anesthesiologist in upstate New York about an hour before we sat down for this

Joseph Rodriguez (59:27)
Mm-hmm.

Paul Lefebvre (59:40)
this discussion today and he had a question about Department of Health coming by and they had a meeting about their informed consent process and some issues on the form or some changes and just looking for some general guidance or, you know, we had questions about student trainees and paramedic students intubating patients, you know, all kinds of questions about potential liability exposure associated with this or how can we advance, you know, I was talking a little bit earlier about

Joseph Rodriguez (59:51)
Hmm

Paul Lefebvre (1:00:10)
Now medication safety practices, just kind of a real time conversation about strategies for that individual facility, that individual practice environment to try to advance patient safety. And that's a common goal that we share. If we could get to a point where we dedicated 95 % of our time to that and 5 % to the claims and lawsuits, that would be ideal. And if we ever got to 100, I'm confident I'd be able to find something else to do anyway.

Joseph Rodriguez (1:00:21)
Hmm.

Hmm.

Indeed, indeed.

Paul Lefebvre (1:00:38)
that'd be a place that I'd start to, is what types of resources do we have to keep me out of the frying pan in the first place.

Joseph Rodriguez (1:00:46)
Yeah, indeed. Those are those are great services guys. Thank you so much for being on this is there's so many different ways we could take this but and I'm known for my verbosity but I want to distill this down into something useful so we're gonna we're gonna leave it right there. Thank you so much for being on.

Paul Lefebvre (1:01:02)
Thank you.

Andrew Clark (1:01:03)
Thank you for having us, Joe. It was a good time.