October 2002
Volume 66 |
Number 10 |
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| Letters
to the Editor |
Lawsuits a Swede Deal in Northern Europe
First of all, Dr. Lema, thank you for your editorials and
the articles published in the ASA NEWSLETTER that
provide "food for thought" even (or especially)
for us who are geographically and culturally far away from
the United States.
Your editorial "America the Suable" (June 2002)
was very important and stimulating because it called for
a review of an entire system of attorneys and insurance
companies that was built on physicians' shoulders.
I would just like us to remember that some very well-developed
countries such as those in northern Europe minimized this
problem by creating a National Patient Insurance Institute.
In these countries, if a patient suffers an iatrogenic mishap,
he/she shall first request a reimbursement through this
Institute instead of filing a lawsuit. I think that an expert
from Sweden, Finland or Denmark should be invited to write
about it. Intuitively, the creation of this type of Institute
seems logical. I would like to hear what you or others have
to say.
Rogerio L. R. Videira, M.D. Saġ Paulo, Brazil
Reference
1. Moen V, Irestedt L, Raf L. Review of claims from the
Patient Insurance: Spinal anesthesia is not completely without
risks. Lakartidningen. 2000; 97(49):5769-5774. (Article
in Swedish).
Junk Testimony Contributes to Our Malpractice Crisis
In the June 2002 NEWSLETTER, Edward C. Mills, M.D.,
presents an informative overview of why our medical liability
insurance rates are increasing. One of the factors he lists
is the escalating cost of defending lawsuits; this is particularly
noteworthy considering that the majority of lawsuits filed
against physicians are resolved without any money paid to
the plaintiff. (One major Texas medical liability insurer
concludes 85 percent of its cases are in favor of the defendant.)
In Texas, we are seeing too many lawsuits where there is
clearly no fault on the part of the physician, yet an expert
has testified otherwise. And too often these experts' opinions
are not consistent with current scientific knowledge or
practice. These unreliable witnesses provide junk testimony
for a handsome fee.
One such expert has testified in a Texas case that an 8.0
endotracheal tube was too large for a 6-foot, 180 pound
man and that a precordial Doppler monitor should have been
used as well as an initial mildly hypertensive blood pressure
maintained during anesthesia for a total shoulder reconstruction.
This out-of-state expert is listed on a Web directory of
expert witnesses. His own Web site proclaims his Ivy League
training, his M.D. and Ph.D. degrees and his willingness
to arrange fast turnaround in reviewing cases. He also advertises
in two legal journals. He works for plaintiffs' attorneys.
Another expert in a different Texas case testified that
protamine should never be given faster than 5 mg per minute
to reverse heparin. This expert supported his assertions
by mentioning his appointed positions in ASA along with
his experience as an examiner for the American Board of
Anesthesiology. This is an abuse of his positions.
Part of the problem is us.
Joseph P. Annis, M.D.
Austin, Texas
Article Helps Stop Flying Metal Objects
I read with great interest the June 2002 article written
by Lawrence Litt, Ph.D., M.D., and Charles B. Cauldwell,
M.D., regarding safety measures when providing anesthesia
in the MRI suite. At our hospital, we have changed to aluminum
gas tanks to minimize the opportunity for human error. However,
other metal objects sometimes slip by as we enter the MRI
suite. The best solution, I feel, is to have a metal detector
similar to those in airports. This would eliminate flying
metal objects possibly injuring patients, and this would
be especially useful during stat calls to the suite. Apparently
some hospitals have already installed them, but I think
this should be mandatory for every MRI suite. Certainly,
with the much-publicized case in New York of the 6-year-old
boy, it seems that we should do everything we can to prevent
this from happening again.
One of the challenges we are facing since we have been
involved in providing anesthesia for our patients is keeping
neonates and infants warm. The room has to be at a certain
temperature for the equipment. We have no MRI-friendly temperature
probes available in the market that I am aware of, and somehow
wrapping them with blankets is not always enough. I firmly
believe that any site outside of the operating room in which
we are involved in providing anesthesia must be equal to,
in every aspect, to the set up we have in the operating
room.
This article was very informative and timely not only as
a refresher but also as a reminder that we all have similar
problems, and we must never accept the status quo if improvement
is possible. It was uplifting to read that common sense
prevails and that safety must always come first regardless
of outside pressures.
Laurette M. Ellis, M.D.
Miami, Florida
FDA's Black Box Is Empty
Since the Food and Drug Administration (FDA) droperidol
debacle is still of current interest in the newsletter,
may I take the opportunity of replying in print?
Dr. McCormick's explanation for the FDA's black box reaction
to droperidol is fuzzy math at its fuzziest.1 It is unclear
what the FDA's understanding is of clinical anesthesia and
the management and prophylaxis of postoperative nausea and
vomiting (PONV).
However, what is clear is that the FDA has apparently disregarded
the slew of randomized prospective studies in the anesthesia
literature of the efficacy (and lack of side effects) of
droperidol as prophylaxis for PONV. In addition, the FDA
also may not have noticed that there are reports of QT prolongation
with many of our induction agents. With the publication
of a recent case of propofol-induced QT prolongation,2 perhaps
the FDA should jump in with both feet (an interesting concept
with one already in mouth) and apply a black box warning
to one of the most ubiquitous induction agents that we have:
after all, there is now a case report of QT prolongation,
so the incidence must be about 0.00001 percent or something
similar to that caused by the dangerous droperidol!
Evan G. Pivalizza, M.B.
Houston, Texas
References:
1. McCormick CG. FDA Divison Director: Droperidol needs
more study. ASA Newsl. 2002: 66(7)37-38.
2. Sakabe M, Fujiki A, Inoue H. Propofol-induced marked
prolongation of QT interval in a patient with acute myocardial
infarction. Anesthesiology. 2002; 97:265-266.
Response to 'An Easy Day's Night for Hospital Administrators'
As an anesthesiologist who has become a hospital CEO two
years ago, I resent the statement by Robert F. LaPorta,
M.D., in his letter to the editor (July 2002) that "in
most hospitals, anyone from administration has left before
5 p.m." Any dedicated CEO who is running a successful
hospital works long, hard hours. There are many meetings
that occur outside of the hospital on nights and weekends.
We represent your hospital in numerous community activities.
We have countless meetings to plan and implement strategic
plans and do so in off hours so board members can attend.
We cultivate donors so that new buildings can be built and
new equipment can be bought.
I have practiced anesthesiology for 23 years and still
do one day a week. I can tell you, I spend less time at
home now than when I practiced full time. I drag my poor,
understanding husband to many community, political and hospital
fund-raising events. I love my job because I believe I am
leading a hospital that is providing first-class patient
care by providing physicians and employees the facility,
equipment and environment they need to practice their skills.
I believe I am using my M.D. and anesthesiology training
to help more patients than I ever could in full-time anesthesiology
practice.
One should never make generalizations about the job of
another until one walks in the other's shoes.
Kathleen C. Hittner, M.D.
President and CEO
Clinical Professor, Brown University
Providence, Rhode Island
Close Inspection Not Needed to Spot This Problem
Thomas H. Cromwell, M.D., wrote an excellent article (July
2002) outlining the regulatory ordeal to which he and his
institution were subjected. It was enlightening and, since
misery does love company, something of a relief as well.
I practice at a large hospital just south of San Francisco
where practice standards are also generally pretty high.
Over the past several months, we have been inspected, re-inspected,
surveyed and mock-surveyed by various entities, with our
treasured Medicare status also being threatened. Our "leadership,"
scared witless, seems locked in a desperate competition
to see who can most slavishly follow the most irrational,
annoying, costly and occasionally even unsafe recommendations
of the poorly qualified inspectors. Physicians who question
the process (aloud) are naturally considered enemies of
the state or worse, "not team players."
So my question for Dr. Cromwell, when he says we must "stand
up and be counted," is: where do we stand and who's
going to count us? And will we be counted or just shot down?
Hoping for help or even a bit of sympathy from the hospital
administrative structure is clearly delusional. If, indeed,
various arms of organized medicine have made extensive efforts
to "inject rationality" into this process in the
past, are they continuing now? I would suggest, and I suspect
Dr. Cromwell would agree, that however difficult such efforts
may be – and regardless of past failures – organized
medicine must ceaselessly battle against these regulatory
abuses and absurdities.
Are there committees within ASA and the American Medical
Association whose aim is to establish liaisons with regulators
in order to influence the process? Are our lobbyists educating
legislators about the counterproductive nature of the current
regulatory process, which contributes mightily to increased
medical costs and may in many cases actually worsen patient
care and safety? I'd like to hear more from our leaders
about what they are actually planning to do about this worsening
situation.
Name withheld upon request
Reader Not Glad He Met Aetna Article
As a 15-year member of ASA, I am appalled at the diatribe
launched at your membership by printing the "Practice
Management" column by Karin Bierstein regarding Aetna
(August 2002). We have been working tirelessly to keep our
financial feet above water from sharks like Aetna, and the
NEWSLETTER issues an article that abuses any trust
I had in the Society.
Will you write a letter like this for every insurer that
reports record profits and premiums and then attempts to
reduce our fees and tie us to Medicare billing? We are trying
our best to at least maintain our rates or get slight increases
from insurers that have kept our payments stagnant for years.
Editorials such as hers do not in any way help our cause.
We are willing to work with anyone as long as the playing
field is fair, but do not expect me to feel pity for those
who would undermine our specialty.
Melvin J. Bush, M.D.
Louisville, Kentucky
Editor's Note: Please see additional information on page
27.
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