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PubMed2004

Human resources: a common-sense discipline.

Being able to hire the right team members, keeping them engaged ina professional and productive environment, and avoiding litigation help keep the team functioning and meeting the everyday goals of providing quality patient care. Although these topics may seem complex, medical providers and professionals have resources available to them, such as the Human Resources department, the Medical Director, senior management,and legal counsel. Hiring the right people, creating a positive work environment, and avoiding litigation are all common sense principals that are relevant regardless of profession, industry, or company. Understanding how to apply the principles and concepts of Human Resources and personnel management can seem overwhelming: however, asking for help from the resources mentioned previously and applying the common sense information found in this article will help one to be a successful leader and practitioner.

Attitude of Health Personnel↗

PubMed2001

State gun control advocacy tactics and resources.

CONTEXT: Enacting state laws to regulate firearm use, availability, or manufacture is one plausible strategy for preventing firearm-related injuries. Organizations that use a wide range of advocacy tactics may be successful in promoting gun control policies. OBJECTIVES: To describe tactics commonly used by groups that advocate for state gun control laws and to assess whether financial resources were associated with groups' use of these advocacy tactics. DESIGN/PARTICIPANTS: We identified 679 local and state organizations potentially active on state-level gun control issues in 1998 and mailed a 153-item questionnaire to the groups' leaders. MAIN OUTCOMES: Organizations' use of 35 gun control advocacy tactics. RESULTS: Seventy-nine percent (n=538) of groups responded to our survey, and, of those eligible, eighty-one percent (n=207) completed questionnaires. Organizations commonly used public education, media, and legislative lobbying tactics, and fewer engaged in electioneering and litigation. Except for lobbying, no associations were found between groups' use of advocacy tactics and their level of financial resources. CONCLUSIONS: Organizations advocating for state gun control laws have a varied tactical repertoire, with fewer using electioneering and litigation than other approaches. Financial resources do not appear to be the determining factor in the advocacy methods employed.

Chi-Square Distribution↗

PubMed2004

The public's misconception about traumatic brain injury: a follow up survey.

Two prior surveys from rural Louisiana, Canada, and New York [Arch. Clin. Neuropsychol. 3 (1988) 331; Arch. Clin. Neuropsychol. 8 (1993) 461] revealed that a high portion of the population endorses misconceptions about the sequelae of traumatic brain injury (TBI). The purpose of this study was to assess the public's perceptions of head trauma in an urban setting in the Northeast region of the country and to compare those results with surveys from other geographical areas conducted 8 and 13 years ago. This study also examined the prevalence of perceptions about TBI that may be relevant to personal injury litigation with TBI plaintiffs. Data were collected at an office of the Department of Motor Vehicles from persons conducting business there. Participants (n = 179) voluntarily completed a 19-item survey covering several facets of brain injury. This sample endorsed misconceptions at a level consistent with previous studies, indicating a comparable lack of knowledge about moderate to severe TBI. With regard to mild TBI, however, our sample generally endorsed fewer misconceptions than previous samples. The public also holds perceptions of TBI that may be relevant to personal injury litigation involving TBI plaintiffs.

Adult↗

PubMed2003

ASA closed claims in obstetrics: lessons learned.

What have we learned so far from the Closed Claims database? For the most part, analysis of the claims made supports the generally held beliefs about the medico-legal risk of obstetrical anesthesia. However, the obstetric files do reveal a risk profile that differs significantly from the nonobstetric files. One of the most surprising observations was the large proportion of relatively "minor" injuries in the obstetric files in contrast to the nonobstetric files. These claims may simply be the result of an increased incidence of such problems in obstetric patients. However, careful review of statements made in the files revealed that a substantial number of patients were unhappy with the care provided and felt themselves ignored and mistreated. Meyers has suggested that malpractice litigation serves the purpose not only of reparation of injury for substandard care but also one of emotional vindication [19]. Not unexpectedly, anesthesiologists are frequently named in claims involving bad fetal outcomes. Most of these claims, for whatever reason, do not result in payments to the litigant. Problems involving airway management, focusing on difficult intubation and pulmonary aspiration, are unfortunately well represented in the obstetrical files. There is no clear indication that this is changing. One of the principle causes of major adverse outcomes with regional anesthesia is local anesthetic toxicity. There is evidence that the frequency of these claims is on the decline. Nerve injury as a result of direct neural trauma continues to appear at regular intervals in the claims files. It is clear from review of the ASA Closed Claim database that there are many unrecognized factors, separate from major injuries, that must be important motivating factors in patients who bring claims against anesthesiologists. A lawsuit does not necessarily signify injury. It has been suggested that the number of patients harmed by negligent care who actually file a claim may be less than 2% [12]. In contrast, lawsuits are usually not filed unless people perceive that they or a family member have been wronged by the system. Anesthesia care providers should give attention to conducting themselves in such a manner that patients will not be motivated to bring suit for an unexpected outcome [20]. Therefore, merely focusing one's attention on reducing the potential for major injuries may have little effect on solving the medico-legal dilemma in obstetrical anesthesia. The uniqueness of the ASA Closed Claims database is that it reflects the consumer's perspective. This point can not be emphasized enough because one of the best measures of quality of care comes from the patient's perspective. What can help? Careful personal conduct Establish good rapport Involvement in prenatal education Early pre-anesthetic evaluation Provide realistic expectation Regularly review potential major and minor risks.

Anesthesia, Obstetrical↗

PubMed2002

John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington Veterans Affairs Medical Center.

BACKGROUND: After the Veterans Affairs Medical Center (VAMC) in Lexington, Kentucky, lost two major malpractice cases in the mid-1980s, leaders started taking a more proactive approach to identifying and investigating incidents that could result in litigation. An informal risk management team met regularly to discuss litigation-prone incidents. During one in-depth review, the team learned that a medication error had caused the patient's death. Although the family would probably never have found out, the team decided to honestly inform the family of exactly what had happened and assist in filing for any financial settlement that might be appropriate. This decision evolved into an organization wide full disclosure policy and procedure. DISCLOSURE POLICY AND PROCEDURE: The Lexington VAMC's policy on full disclosure includes informing patients and/or their families of adverse events known to have caused harm or injury to the patient as a result of medical error or negligence. The disclosure includes discussions of liability and also includes apology and discussion of remedy and compensation. RESULTS: Full disclosure is the right thing to do and the moral and ethical thing to do. Moreover, doing the right thing actually seems to have mitigated the financial repercussions of inevitable adverse events that result in injury to patients. As reported in 1999, Lexington VAMC was in the top quarter of medical centers for number of tort claims filed but was in the lowest quarter for malpractice payouts resulting from these torts.

Awards and Prizes↗

PubMed2003

Colored pain drawings: preliminary observations in a neurosurgical practice.

BACKGROUND: Black and white pain drawings were introduced as a proposed means to identify patients, presenting with low back pain, who demonstrated functional overlay upon neurological testing. The use of color may enhance the usefulness of such pain drawings, but has not been described for adult patients. AIMS: To retrospectively explore the use of colored pain drawings in patients with neck, low back, or radicular pain. METHODS: Patients with neck, low back, or radicular pain referred to a community-based neurosurgical practice for evaluation during 1 year (n=359) depicted their pain on anatomical drawings using colored pencils representing different pain characteristics. Patients with abnormal (n=55) and normal (n=54) pain drawings were selected for this study. Use of medications, findings on physical examination, radiographic findings, activity levels, Waddell signs, and pending litigation were recorded and compared between patients with normal and abnormal pain drawings, as assessed according to the Ransford penalty point system. RESULTS: Patients whose colored pain drawings were abnormal, demonstrated a greater use of medications, more non-focal clinical findings, Waddell signs, impaired activity levels, involvement in pending litigation, and significantly fewer pathological radiographic findings than patients with normal pain drawings. CONCLUSIONS: Our findings agree with previous observations using black and white pain drawings, indicating that colored pain drawings are no less useful than the black and white approach. Further research is necessary to examine the psychometric properties and clinical usefulness of colored pain drawings to predict outcomes and/or determine treatment.

Adult↗

PubMed1998

Medical malpractice in twentieth century United States. The interaction of technology, law and culture.

Although medical malpractice litigation in the United States has generated extensive professional and scholarly attention, few analyses of the issue have explored its underlying causes. This essay develops and employs an historical framework to explain the late 20th century phenomenon and concludes that widespread medical malpractice suits are the result of a combination of short-term topical causes and long-term cultural changes that are ignored or left untouched by most reform efforts. Most importantly, however, the development and proliferation of new and improved medical technologies has played a pivotal role throughout the entire history of the litigation, an effect that has become most prominent and important in the last third of the 20th century.

Culture↗

PubMed2005

Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis.

There continues to be debate about the long-term neuropsychological impact of mild traumatic brain injury (MTBI). A meta-analysis of the relevant literature was conducted to determine the impact of MTBI across nine cognitive domains. The analysis was based on 39 studies involving 1463 cases of MTBI and 1191 control cases. The overall effect of MTBI on neuropsychological functioning was moderate (d = .54). However, findings were moderated by cognitive domain, time since injury, patient characteristics, and sampling methods. Acute effects (less than 3 months postinjury) of MTBI were greatest for delayed memory and fluency (d = 1.03 and .89, respectively). In unselected or prospective samples, the overall analysis revealed no residual neuropsychological impairment by 3 months postinjury (d = .04). In contrast, clinic-based samples and samples including participants in litigation were associated with greater cognitive sequelae of MTBI (d = .74 and .78, respectively at 3 months or greater). Indeed, litigation was associated with stable or worsening of cognitive functioning over time. The implications and limitations of these findings are discussed.

Brain Injuries↗

PubMed2000

Medical malpractice among physicians: who will be sued and who will pay?

This paper examines whether a physician's future claims of medical malpractice are predictable from information on the physician's recent claims history, training credentials, practice characteristics, and demographics. Data on the medical malpractice experience of 8,733 Michigan physicians between 1980 and 1989 is analyzed. We find strong evidence of repetition over time regarding who was sued and who paid claims. The worse a physician's malpractice litigation record during 1980-1984, the worse was his record during 1985-1989. Training credentials were also highly predictive of future malpractice experience. Physicians trained at lower ranked medical schools or who went through lower-ranked residency programs faced higher odds of developing adverse malpractice records, even after controlling for their previous litigation record. Growing internet access to information on these characteristics will help inform prospective patients if they wish to avoid physicians likely to be sued and likely to make payments in the future for malpractice.

Adult↗

PubMed2005

[Learning from the experiences of an arbitration unit for medical liability questions].

While other countries', e.g. the United States', experience with alternative dispute resolution (ADR) in medical malpractice has been disappointing, German physicians have instituted extrajudicial claims resolution as an alternative to civil litigation: Established by the Arztekammern (corporate bodies of professional self-governance) in the mid-1970s, the Schlichtungsstellen (SchlSt--claims resolution panels) offer patients and doctors, on a voluntary basis, proceedings directed toward achieving a settlement. The number of cases submitted to these panels has been constantly growing since. In 90% of cases decided upon by the panel, civil litigation was avoided. Doctors can, as exemplified by the operation of the SchlSt, tackle difficult and complex problems and solve them--without being funded or directed by outside agencies. What can be learnt from being, as a physician member, associated with a SchlSt for several years? (1) Physicians--as Eddy has pointed out--must make decisions about complex problems under difficult conditions on the basis of inadequate information. Expert testimony suffers from similar uncertainties. Decisions on individual cases cannot be improved by external and necessarily generalized ruling (disease management programs, other directives). (2) Errors and adverse events in medical care have to be accepted as principally unavoidable. Most claims heard by the panel have to do with operations and--in the non-surgical specialties--with invasive procedures. Medical tasks of high complexity, as many operative and invasive procedures indeed are, seem to have an inherent accident-proneness. Therefore decisions as to operations and invasive procedures should be weighed with utmost care. More is not always better (3) 25% of the patients filing claims with the SchlSt complain of deficient doctor-patient-communication. Failure of doctors and staff to communicate adequately with the patients and with their professional contacts plays an important role as risk factor for negligence and injury and even as cause of disputes and claims. (4) The GP, the generalist in a profession characterized by specialization, has to treat a wide spectrum of diseases, wider than any specialist. As far as can be seen, he does his job well. He needs adequate--if possible personal--contact with and support by his colleagues involved in the treatment of the same patient.

Germany↗

PubMed2006

Medicolegal aspects of neoplastic dermatology.

Medical malpractice litigation is rising at an explosive rate in the US and, to a lesser extent, in Canada. The impact of medical malpractice litigation on health care costs and the cost of insurance is dramatic. Certain specialist categories are becoming uninsurable in some parts of the US, while in others, clinicians are retiring early, restricting or changing practice or changing states of residence in consequence of medical malpractice claims and of the cost and availability of insurance. This, in turn, has had the real effect of denying care to patients in some communities in the US. Some 13% of all medical malpractice claims relate to one area of neoplastic dermatopathology, specifically, melanocytic neoplasia. Certain steps can be taken by pathology laboratories to reduce, but never completely eliminate, the risk of medical malpractice claims. In this review, attention is paid to the source of medical malpractice claims and an abbreviated approach to specific strategies for risk management is presented.

Dermatology↗

PubMed2004

Success in crown and bridge work.

All practitioners wish for success in their restorative work mainly due to their desire to do the best for their patients, but increasingly the achievement of success, ie the avoidance of failure, is felt to be necessary to avoid the spectre of litigation. The number of patient-led litigation cases is on the increase and the majority involve crown and bridge work.

Crowns↗

PubMed1999

Clinical risk management: principles of consent and patient information.

Clinical Risk Management and its integral elements form part of the foundation of 'Clinical Governance'. An important principle within Clinical Risk Management is that of consent and patient information which, in a changing climate of complaint and litigation, means that it is essential that clinicians have a sound understanding of its importance. This paper provides a structured understanding of the background and practice of consent and patient information. With such knowledge clinicians can help patients achieve a better understanding of what they are undertaking, and so reduce the risk of complaint and litigation. This paper discusses the topics of: current indemnification, ethics, law, the information content required for consent, duration of consent, who should take consent, capacity to give consent, mental incapacity, and details of how to perform risk assessment. However, areas applicable to the Mental Health Act have been excluded.

Advance Directives↗

PubMed2002

Does the conscious exaggeration scale detect deception within patients with chronic pain alleged to have secondary gain?

OBJECTIVES: The illness behavior questionnaire (IBQ) is a test battery developed by Pilowsky to detect what he has termed abnormal illness behavior, which includes malingering. The IBQ has been widely utilized in patients with chronic pain (PWCP). Clayer developed a 21-item scale out of the IBQ, which he termed the conscious exaggeration (CE) scale. He proposed that the CE scale could detect conscious deception, i.e., malingering. The purpose of the present study is to test the CE scale in PWCP alleged to have secondary gain and thereby at greater risk for poor pain treatment outcome. It was postulated that the CE scale should generate scores in these groups significantly different from a comparison group and should predict treatment outcome in the secondary gain groups. DESIGN: A total of 96 PWCP completed the CE scale at admission and after completion of a 1-month pain facility treatment regimen. Other relevant pain variables, such as pain, depression, and anxiety, were measured and the data collected at admission and treatment completion. Work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. PWCP secondary gain subgroups (Workers' Compensation patients, patients in litigation, patients having a lawyer) were compared to the comparison group (no secondary gain factors) for treatment CE scale change scores. In order to control for the effects of pain, an analysis of covariance with pain level statistically removed was performed on admission and discharge CE scores utilizing the above patient subgroups. Pearson product correlations were utilized to determine the relationships between CE scores and psychological variables. Stepwise regression analyses were utilized to predict return to work with the CE scale score as a potential predictor. SETTING: Pain facility. PATIENTS: PWCP treated for 1 month in a pain facility. RESULTS: Overall, the analyses did not support the main hypothesis. For example, CE scale scores did not predict return to work. There was a significant degree of correlation between the variables of pain, depression, anxiety, and CE scale scores. CONCLUSIONS: PWCP characterized by the alleged secondary gain variables of Workers' compensation status, litigation, and having a lawyer did not differentially respond to the CE scale versus the comparison group. The CE scale, therefore, does not appear to be a valid instrument for identifying exaggeration in PWCP.

Journal Article↗

PubMed1999

The occurrence and impact of generalized pain.

A major problem with estimating the impact of chronic generalized pain is that the term remains undefined. It appears to encompass several distinct clinical entities, including rheumatoid arthritis and fibromyalgia, which can exist alone or together in a given individual. Nonetheless, chronic generalized pain appears to have a sizable impact on both the individual and society. Although little is known about causal relationships, demographic risk factors for chronic generalized pain are female sex, age in the forties and fifties, lower income, lower education, and being divorced or separated. Chronic generalized pain affects the individual in several ways, including physical and psychological distress, losses of function, quality of life, employment and income, and prolonged litigation for many. Its impact on society includes increased utilization of health care resources, loss of work productivity, disability and insurance costs, costs of litigation and social policy. Future research into the impact of chronic generalized pain must begin by defining this term in a way that is both valid in construct and convenient to use. Research is also warranted to develop and validate diagnostic tools that may better distinguish various subsets of chronic generalized pain, both to better understand the pathological processes involved and to allow for estimates of the relative contribution of each subset to societal costs.

Chronic Disease↗

PubMed2002

Medical, social, and legal implications of treating nausea and vomiting of pregnancy.

This article will deal with medical, social, and legal implications of treating nausea and vomiting of pregnancy (NVP). Clinical problems occur when the symptoms become exaggerated and result in debilitation, dehydration, and hospitalization. The treatment of NVP in its early stages has the implication that it will prevent the more serious complications, including hospitalization. Therapeutic modalities discussed in this conference that have been used or are being tested are primarily symptomatic treatments (antihistamines, Bendectin (Merrell Dow; Cincinatti, Ohio), phenothiazines, hypnosis, accupressure, relaxation behavioral modification, audiogenic feedback training, newer medications, diet, and nutritional support). Bendectin is probably the most studied medication with regard to its reproductive effects, and the studies clearly demonstrate that therapeutic doses of Bendectin have no measurable reproductive risks to the mother or the fetus. In spite of Bendectin's record of safety, numerous nonmeritorious congenital malformation lawsuits were filed and went to trial, and that junk science was presented at these trials. The Bendectin era focused our attention on the area of nonmeritorious litigation and junk science, which could have an effect on any new or less well-studied therapies, because such a high percentage of women are treated for NVP. Because 3% of the offspring will be affected with birth defects, the potential for litigation is immense. The solutions are (1) for legal problems, the medical community should focus their attention on junk scientists and their junk science, over which physicians should have some authority, and (2) for the treatment problem, it would seem most logical that a major research effort should be directed toward brain receptors that are involved in these physiologic effects. Furthermore, it would be imperative to study the array of molecules, both natural and manufactured, that can interact with these receptors for the amelioration of nausea. Until we understand the mechanism and specific therapy for NVP, it would appear that the reintroduction of Bendectin is the logical intermediate course to follow. We should also accompany the introduction of Bendectin with an educational campaign with regard to the lack of reproductive risks for this medication. The Food and Drug Administration has set the stage for the reintroduction of Bendectin by republishing their conclusion that Bendectin does not represent an increase in reproductive risks to the fetuses of pregnant women.

Abnormalities, Drug-Induced↗

PubMed2002

Detecting exaggeration and malingering with the trail making test.

The purpose of this study was to examine whether unusual performance on the Trail Making Test could be indicative of deliberate exaggeration. Participants were 571 patients seen as part of a hospital trauma service who had acute traumatic brain injuries, and 228 patients involved in head injury litigation. As expected, the hospital patients with more severe traumatic brain injuries performed more poorly than the patients with less severe brain injuries on Trails A and Trails B. Cutoff score tables were developed for the patients with acute traumatic brain injuries for the total sample and by injury severity groups. Scores falling at or below the 5th percentile were considered suspicious for possible exaggeration. The performances of the head injury litigants who exaggerated on at least one well-validated symptom validity test were compared to these cutoffs. Very high positive predictive values for individuals with very mild head injuries on Trails A and B were identified (i.e., both 100%); lower positive predictive values were obtained for individuals with more severe head injuries (55.6-60%). The negative predictive values were only moderate (range=66.4-78.2%), and the sensitivity was very low (range = 7.1-18.5%) for all groups. Scores that fall in the range of possible biased responding should be considered "red flags" for the clinician because they likely do not make biological or psychometric sense. However, the sensitivity of the test for deliberate exaggeration is very low, so clinicians who rely on this test in isolation to identify deliberately poor performance will fail to identify the vast majority of cases.

Adult↗

PubMedDate not supplied

Do duration of exposure, proximity to electronic manufacturing plants, and involvement in a lawsuit affect chlorinated solvent toxicity?

The author examined the effects of duration of residence, proximity to microchip plants, and being a party in litigation involving neurobehavioral functioning in individuals who had been chronically exposed to trichloroethylene-associated solvents from the environment. The author compared duration of exposure for the 236 residents, all of whom were located in 3 proximity zones in Phoenix, Arizona; some of the individuals had been in the process of solvent-related litigation for fewer than 10 yr, whereas some had been involved for more than 10 yr. The 236 residents were compared with 58 nonclaimants in 3 residential areas within the exposure zones. Neurobehavioral function testing was described in the study that appears prior to this study in this issue. Prior to comparisons, test scores were adjusted for age, sex, education level, and other significant factors. Individuals who had been exposed for fewer than 10 yr were not different from individuals who had been exposed for longer periods. Proximity to microchip plants produced no statistically significant effects. Among the 169 exposed subjects (i.e., exposure for 15 yr to trichloroethylene-associated solvents), of whom some were parties in lawsuits, those who lived in the near west area (Zone A) of Phoenix did not differ with respect to results of the 14 neurobehavioral tests that were administered. However, Zone B subjects, located to the north of the plant, differed with respect to 2 of the tests; and Zone C subjects, located beyond Zone A, Phoenix, differed with respect to 3 of the tests. In conclusion, duration of residence, proximity to microchip plants, and being a party to a lawsuit had no significant effects on neurobehavioral functioning, but, in this study, parties in the lawsuit were subjects who experienced more frequent symptoms.

Adolescent↗