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August 1996
Volume 60 |
Number 8
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| Letters to the
Editor |
Draft Standards From the Spectrum of Practice Patterns
The articles by Robert A. Caplan, M.D., Frederick W. Cheney,
M.D., and Karen B. Domino, M.D., in the June edition of the ASA
NEWSLETTER referring to the impact of the Closed Claims Project
on professional liability are well-thought and well-presented.
In this respect, we practicing anesthesiologists applaud their
commendable effort.
As the Closed Claims Project indicates, it was able to collect
and analyze about 3,500 adverse outcome cases from 14,500 practicing
anesthesiologists. These cases were the main source of reference
upon which "standards of practice" and "guidelines"
were drafted. Assuming that each of the 3,500 adverse outcome
cases originated individually from a pool of 14,500 anesthesiologists
leaves a second pool of 11,000 individual anesthesiologists practicing
without incidence.
While we all can learn from adverse outcomes, we should not disregard
the learning potential from the majority of our colleagues (11,000
strong) who practiced and/or practice anesthesia with sound clinical
judgment and individual standards high enough to keep them out
of trouble and out of the statistics of the Closed Claims file.
I do not think they are either that lucky or capable in avoiding
intense scrutiny and effectively conceal adverse outcomes.
As studies like the Closed Claims Project draw their conclusions
from 3,500 adverse outcomes, they should study with equal effort
the practice patterns of the 11,000 anesthesiologists who, by
adhering to some self-defined high standards, were able to avoid
adverse outcomes. By studying a broad spectrum of practice patterns,
one can segregate all contributory elements of safe and high standard
practice. Combining the findings of both adverse outcome and high-standard
safe practice studies, one can draft "standards and guidelines"
that do not stifle individuals' efforts to excel in the safe practice
of anesthesia. Otherwise, we may have to lower the quality of
high-standard practice patterns for the sake of raising low-quality
practices to somewhat higher yet mediocre standards.
A similar example is the situation that exists today with the
public education in this country. By legislative fiat, high-quality
public education has been lowered to somewhat mediocre levels
with the hope that low-quality education will gradually move to
somewhat higher but still mediocre levels.
You cannot learn to bake a pie from those who always burn it.
Istrati Kupeli, M.D.
Wellesley Hills, Massachusetts
ASA Closed Claims Project's Response
Dr. Kupeli's remarks provide an opportunity to review some important
limitations of closed claims data. First, we do not know the overall
number of anesthetics (the "denominator") from which
claims arise in the ASA Closed Claims Project database. Thus,
the findings cannot be used to generate incidence data. Second,
cases in the Closed Claims Project database contain no identifying
information, so we do not know whether each claim arises from
a different practitioner or whether some practitioners account
for multiple claims. Third, the database is not an exclusive
collection of mistakes or clinical errors: in approximately 40
percent of cases, reviewers judged that the practitioners met
the applicable standard of care. This means that the presence
of a claim in the database does not necessarily indicate that
a practitioner engaged in unsafe or low-quality practice. Fourth,
malpractice claims are filed by only a small fraction of patients
who sustain medically induced injuries.1,2 Thus, it
is difficult to attach any useful meaning to the isolated finding
that a practitioner has (or has not) been involved in a malpractice
lawsuit.
From our perspective, the limitations of closed claims data do
not permit the type of arithmetic arguments offered by Dr. Kupeli.
However, we heartily agree with the spirit of his letter. The
analysis of adverse outcomes is only one of many avenues for innovation
and improvement in medical care. As Dr. Kupeli suggests, there
may be much to gain from the rigorous and systematic study of
practitioners with long-standing records of clinical excellence.
Robert A. Caplan, M.D.
Frederick W. Cheney, M.D.
Karen B. Domino, M.D.
Karen L. Posner, Ph.D.
ASA Closed Claims Project
Seattle, Washington
References:
1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse
events and negligence in hospitalized patients. Results of the
Harvard Medical Practice Study I. N Engl J Med. 1991; 324:3700-3706.
2. Hiatt HH, Barnes BA, Brennan TA, et al. A study of medical
injury and medical malpractice. An overview. N Engl J Med.
1989; 321:480-484.
'Preventive' Measures
My comments are in regards to the June issue of the ASA NEWSLETTER.
I have noticed on two occasions the word preventative.
The first occurred in Dr. Frederick W. Cheney's article on adverse
events, on page 13, and the second time, on page 20, where it
is in the heading Preventative Measures. While this word
is correctly spelled, I have a personal dislike of the spelling.
I believe that the preferred spelling is preventive. For
as long as I can remember, this word has been spelled preventive,
until recently, when I see more and more people using the less
common spelling. I classify this in the same league as the word
orient. Often, people say orientate.
I am particularly bothered by this spelling as a physician, because
we have had the specialty of preventive medicine for many
years. I will continue to fight this gradual trend toward the
less acceptable spelling until the specialty changes its spelling
to preventative medicine. I do not think that is going
to happen.
Thank you for taking the time to read this. I am very pleased
with the monthly NEWSLETTERs. They have greatly improved
in content and style in recent years.
Roger A. Williams, M.D.
Greenwood Village, Colorado
Correction, Please!
After "A Touch of History" appeared on page 34 of the
February 1996 ASA NEWSLETTER, Theodore W. Fox, M.D., of
Fair Haven, New Jersey, supplied the answer to the question "What
was the make of Dr. Paul Wood's diminutive automobile?"
According to Dr. Fox, it was neither a Volkswagen nor an Austin,
as I had conjectured, but a Crosley.
Curtis W. Caine, M.D.
Jackson, Mississippi
Public Relations From a Different Viewpoint
I interviewed an anesthesiologist. I know this person because
he is my daddy. I chose to interview him because he helps people
every day.
My dad makes people go to sleep. Then the surgery will not hurt
the person. He thought about this in college because his friend
was an anesthesiologist. He went to medical school and five years
of residency. It took 10 years after college.
My dad takes away pain with medicine. He also takes away pain
by kissing people in my family to make them feel better.
Tamara Murphy, age 7
Eagan, Minnesota
[daughter of Stephen M. Murphy, M.D.]
The views and opinions expressed
in the "Letters to the Editor" are those of the authors
and do not necessarily reflect the views of ASA or the NEWSLETTER
Editorial Board. The Editor has the authority to accept or
reject any letter submitted for publication. Letters must be signed
(although name may be withheld on request) and are subject to
editing and abridgment.
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