In keeping with the mindset of most Americans today, the answer to the question posed in the title of this post is, “the doctor.”

American Medical News reports that “Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physicians.” And these problems are increasing with more hand-offs and more people being involved with the “team” taking care of the patient.

The article began with an anecdote about a patient who needed a cardiac catheterization but wanted to think about it. He went home and died. The family sued and said the doctor did not “tell them how critical it was for him to have the procedure.”

The doctor did not document the conversation about the need for the procedure in the chart and lost the case.

Failure to make sure that appropriate follow-up was done and failure to contact patients about missed appointments are among the most frequent deficiencies cited as big legal risks for physicians.

Get this. “A common claim in lawsuits that involve missed appointments is lack of informed refusal. The allegation arises when patients admit they declined or ignored treatment recommendations, but allege they were not adequately educated about the medical risks of their decision.”

Lack of informed refusal. That’s a new one for me.

The article says that adequate documentation by the doctor will support his version of events.

What is to prevent any patient, who is explained any plan or procedure and declines, from simply saying, “I didn’t realize how serious this was”?

And where does this end? Should a doctor call all her patients every day to ask if they took their medications?

“Hello, Mrs. Balotelli. Did you take your Placebolol today?
“No, I didn’t think it was important.”
“Mrs. Balotelli, I wouldn’t have prescribed it for you if I didn’t think you needed it. I told you that you have to take  it to prevent you from having a stroke.”
“Well, doctor, I didn’t understand that a stroke might be a bad thing. And I don’t think my blood pressure is that high today anyway.”

Whatever happened to personal responsibility?

I guess it’s always someone else’s fault when anything goes wrong.

The article ends with a list of 16 things that a doctor and her staff should do for every patient to try to counter this disturbing trend.

Here are a few of them:

Maintain a current list with dates of problem identification, reviews, and resolutions.
Use the patient’s own words when documenting.
Indicate in writing or electronically that all results of tests, consultants, and referrals were reviewed.
Document all after-hours patient calls.
Document all advice in the patient’s record.
Detail the patient’s level of understanding during the informed consent process. [What is the doctor supposed to do if she doesn’t think the patient’s level of understanding is 100%?]

I’m sure these tasks won’t take much time or effort. And some lawyer will probably say that what the doctor wrote on the chart is not what the patient remembers him saying.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at and tweeting as @SkepticScalpel. His blog averages over 1000 page views per day, and he has over 6700 followers on Twitter.