Patient
Insurance
In the “Letters to the Editor” section of
the October
2002 NEWSLETTER, Rogerio
L.R. Videira, M.D., described the institution of patient
insurance existing in Sweden. I would like to complete
his description of the health care system in Sweden
by mentioning one of its benefits to patients and health
care providers — the absence of expensive legal
lawsuits. My comments follow.
Sweden counts 8.8 million inhabitants, and all inhabitants
receive health care through public health care institutions.
There are very few private health care providers. Complaints
regarding medical malpractice can be made to the National
Board of Health and Welfare.
According to the Patient Injury Act, a patient suffering
injury in the course of medical treatment can file a
claim for compensation to the Patient Insurance Claims
(PIC). The insurance was initially financed through
a voluntary consortium of public health care institutions,
but since 1997, the economical participation is obligatory
for all health care providers. Since 1975, more than
120,000 complaints have been made. In recent years,
the number of complaints amount to 9,000 per year.
The PIC does not address the question of fault when
considering a claim, but if the damage sustained is
deemed to have been ”avoidable,” compensation
can be offered. The definition of avoidable damage is
often difficult to explain to patients: Life-saving
hysterectomy following obstetric hemorrhage will not
be compensated if this was a consequence of otherwise
correctly performed medical care. An infection caused
by a surgical drape accidentally left in the abdomen
during the same surgical procedure will cause compensation
to be made as this accident is considered avoidable
by scrupulous intraoperative control measures.
The size of the economical compensation will seem ridiculous
according to standards in the United States. Only health
care expenses and loss of earnings exceeding
costs and losses expected by the scheduled treatment
will be compensated. No compensation for suffering is
usually made. I have, however, learned that in recent
years, postdural puncture headache following spinal
or epidural anaesthesia, although deemed as ”unavoidable,”
will be compensated with the equivalent of $500.
The risk of any health care provider to be sued for
enormous amounts of money is practically nonexistent.
One reason could be that the social security system,
of which the PIC is only a minor component, always guarantees
a decent minimum of economical standards to the country’s
inhabitants.
Vibeke Moen, M.D.
Kalmar, Sweden
Batting for Our Colleagues
and Our Patients
It is rare that I disagree with our esteemed Editor.
In reading the “Ventilations” titled “Aliens
Among Us” in the December
2002 ASA NEWSLETTER,
I can agree that the “hired guns” of the
plaintiff’s bar should be identified and admonished,
but I strongly disagree with the sweeping statement
that “... as a rule, defense work is good, and
plaintiff’s work is bad.” Such a generalization
would suggest that plaintiff’s work is wrong.
If that is the Editor’s intent, I beg to differ.
Have we not forgotten our proud pronouncements to
be patient advocates? Are we not honest and objective
about peer review — for better or for worse?
Does the Editor’s attitude give credence to
the attorneys’ claim of the “conspiracy
of silence?”
I would have preferred that the Editor applaud those
anesthesiologists who not only have been willing to
defend their colleagues in a court of law but also
have been willing to provide expert witness testimony
when patients are unnecessarily harmed. In the medical
staff peer review process, we have embraced an obligation
to defend those physicians who are unfairly accused
as well as to validate (and correct) those instances
where substandard care has contributed to unsatisfactory
outcomes. Just as effective and legitimate peer review
at the medical staff level requires us to speak out
against bad practices, likewise, we have a similar
obligation to participate in the medical malpractice
arena as a service to the community, to patients and
to our specialty. ASA’s “Guidelines for
Expert Witness Qualifications and Testimony”
and “Guidelines for the Ethical Practice of
Anesthesiology” support such unbiased participation
in civil litigation. Only those anesthesiologists
who consult on both sides of the bar (the “switch
hitters”) have any credibility.
If you have to play the game, make sure a switch hitter
is in your lineup!
R. Lawrence Sullivan, Jr., M.D.
Palo Alto, California
Editor’s Reply: My comment
was taken out of context. The next sentence praises
those who testify in behalf of patient care and against
a colleague. However, I think that most physicians
have some trepidation when asked to testify against
another ASA member.
— M.J.L.
Confessions of a ‘Switch
Hitter’
I am a board-certified anesthesiologist retired from
active practice who, for many years, has been available
to both plaintiffs and the defense bar for medical malpractice
consultation
(see “Ventilations,”
December 2002).
During a consult, I am paid for only one thing, the
time that I spend to review the matter and to develop
a truthful opinion. This opinion is based on almost
30 years of intense clinical and administrative experience.
The major goal for me is to maintain intellectual honesty.
The work is extremely interesting.
To restrict my efforts to defense or plaintiff’s
work would require a simplistic view of the litigation
process, which would damage my carefully built reputation
and honest appraisal. I am strongly in favor of proposed
guidelines for ethical testimony. Well-developed standards
would go a long way in preventing obviously biased and
scientifically unsupported testimony. Perhaps the development
of a cadre of registered expert witnesses would be of
value to the Society.
Whatever course we take, the legal process must be addressed.
It will not go away. Accurate and truthful testimony
is at present the best method available for dealing
with this unpleasant problem.
W. Sterrett Foster, M.D.
Louisville, Kentucky
Our Specialty by Another Name
Would Smell Sweeter
The questions asked about the future of our specialty
by Ronald D. Miller, M.D., in the “What’s
New In…” section of the December
2002 NEWSLETTER are not
trivial and certainly do need long-range thinking. Here
is a suggestion for the very first step into that uncertain
future: The name currently used to describe what we
do, “anesthesiology,” should be discarded.
It should be changed to “perioperative medicine.”
This term is embedded in Dr. Miller’s article,
and he fears that we will withdraw entirely from the
many activities and opportunities it implies. We should
ask to be called “perioperativists.” Such
a change would open up a range of possibilities that,
as he suggests, we should explore and discuss. If someone
had told us 40 years ago that there would be specialists
called “hospitalists,” we would have laughed.
Now, not only do we know what the word means, we know
what these doctors do.
In the list of American academic departments published
together by the Society of Academic Anesthesiology Chairs
(SAAC) and the Association of Anesthesiology Program
Directors (AAPD), there are 135 departments of anesthesiology
and four departments of anesthesia. One of the latter
is Dr. Miller’s very own.
If this proposed name change is thought of as the nectar
that will nourish our future, there are 10 additional
departments who have taken a sip from the chalice without
gulping down the whole draught. There are three departments
of anesthesiology and critical care medicine, one department
of anesthesiology and pain management, three departments
of anesthesiology and critical care and one each of
the following: department of perioperative and pain
medicine, department of anesthesiology and pain medicine
and a department of anesthesiology and pain management.
It seems that these 10 found “anesthesiology”
or “anesthesia,” on their own, inadequate
to describe what they do.
I have not been able to find a comparable list of the
names of the hundreds of private practice departments,
but it would be interesting to know if a similar movement
is starting in community practice — and perhaps
even to find out why.
Gerald L. Zeitlin, M.D.
Newton, Massachusetts
Informed Consent Controversy
Karin Bierstein’s otherwise helpful article, “Informed
Consent Is More Than a Signature,” in the December
2002 NEWSLETTER was marred
by the discussion of what information adequately constitutes
appropriate informed consent. The side effects and complications
of anesthesia are well known to us all, yet I suspect
each of us presents anesthesia risk very differently.
Is it enough to say, “You might be a little nauseated”
or is it necessary to say, “There is a miniscule
chance you will die,” to a healthy 30-year-old
woman having a laparoscopy?
Today when we barely have enough time to learn about
the patient and establish some rapport, just how much
of the truth should we tell and how should we tell it?
On one hand, patients should be treated as ends, not
means, and be fully informed so that they can make autonomous
decisions; on the other hand, protecting them from hearing
the worst might arguably be kinder. This ethical dilemma
is compounded by the practical concern of administrators
and surgeons that we not frighten off the customers.
While the “reasonable patient” standard
may be enough for lawyers, why should practicing anesthesiologists
settle for such confusing metaphysical angst? I believe
the time has come for ASA to establish specific “reasonable
anesthesiologist” informed consent guidelines
that go beyond the article’s vague noncommittal
discussion. Such a policy would serve to put all the
involved parties on the same page in an ethical and
compassionate fashion. It would also be consistent with
the historically proactive approach of ASA and, if publicized
in the lay press, further demonstrate the honesty and
courage of our profession.
Steven S. Kron, M.D.
New Britain, Connecticut
Response from Karin Bierstein:
Dr. Kron and I are on the same spectrum, albeit at different
points. Anesthesiologists and their legal advisors all
struggle with striking a balance between the dictates
of clinical experience, judgment, ethics and efficiency
on the one hand, and the time, effort and counter-intuitiveness
of the measures anesthesiologists must take in order
to obtain maximum legal protection on the other. The
simple graphbelow applies equally to informed consent,
Medicare billing rules, Health Insurance Portability
and Accountability Act privacy and security requirements
and other areas in which physicians may run the risk
of noncompliance with the law.
The best action in terms of clinical practice is not
necessarily at odds with a high level of legal protection,
but compliance — and its documentation —
can certainly encumber and slow things down. In the
case of informed consent, the “reasonable anesthesiologist”
may know that the healthy 30-year-old patient in the
holding area is not going to benefit in the slightest
from hearing that 1 in 13,000 anesthesia patients may
die (if one uses Dr. Lagasse’s recent study*).
If the unthinkable were to happen, however, the jury
might feel that a “reasonable patient” would
have wanted to know about the remote possibility of
death, and it is the jury’s (or judge’s)
“reasonable patient” standard that would
decide the malpractice case.
When lawyers tell doctors that “you must”
or “you should” do something that seems
unnecessary or impractical, the subtext is “in
order to minimize the chances that this will cost you
legal damages or fines.” It is up to the reasonable
anesthesiologist to decide where on the spectrum to
place him or herself.
Karin Bierstein, J.D., M.P.H.
Assistant Director of Governmental Affairs (Regulatory)
*Lagasse RS. Anesthesia safety: Model
or myth? A review of the published literature and analysis
of current original data. Anesthesiology. 2002;
97(6):1609-1617.
Here’s the Rub on Clean
Hands
With great interest I read the article by Jonathan D.
Katz, M.D., in the January
2003 NEWSLETTER regarding
the endorsement of alcohol-based hand rubs by the Centers
for Disease Control and Prevention.1
As an anesthesiologist trained in Germany, where alcohol-based
hand rubs utilizing 70 percent alcohol are considered
to be standard of care for more than 20 years now, I
can understand the concerns about skin and contact dermatitis.
However, the data from the occupational health organizations
(Berufsgenossenschaften) in Germany do not support claims
of increased incidence of dermatitis compared to other
forms of hand hygiene (personal communication BG Gesundheitsdienst
und Wohlfahrtspflege Hamburg).
In contrast, Boyce recently demonstrated that alcohol-based
hand rubs reduce the incidence of this complication
compared to soap and water2
and that the higher concentration versions are probably
more reliable.3 The
net effect in time reduction using alcohol-based hand
rubs has also been shown.4
In addition, I would like to stress the importance of
easy access to a alcohol-based hand rub for the anesthesiologist
and intensivist, which can be mounted, for example,
on the anesthesia cart or at the door of an intensive
care unit to increase the compliance with this truly
livesaving and simple procedure that prevents nosocomial
infections. An institutional skin care protocol and
sufficient supply with skin care products for health
care workers as mandated by the German Occupational
Health Law (Arbeitsstättenverordnung) can help
to further reduce the danger of skin problems.
In addition, the implementation of a structured program
for infection control in anesthesia might help to increase
awareness not only about hand hygiene but other important
infection control issues such as use of multidose vials,
correct preparation and use of propofol syringes, maximal
barrier precautions for central line placement or isolation
protocols for patients with methicillin-resistant Staphylococcus
aureus or vancomycin-resistant enterococci
infections or colonization.
Because the operating room is not only the profit center
of the hospital but also the marketplace to transmit
infection due to its invasive nature and high patient
turnover, those issues should be in the mindset of every
anesthesiologist.
Sebastian Schulz-Stübner, M.D., Ph.D.
Iowa City, Iowa
| References: |
| 1. Boyce JM, Pittet D. Guideline for Hand Hygiene
in Health Care Settings. Recommendations of the
Health Care Infection Control Practices Advisory
Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. Society for Healthcare Epidemiology
of America/Association for Professionals in Infection
Control/Infectious Diseases Society of America.
MMWR Recomm Rep 2002; 51: 1-45, quiz
CE1-4. |
| 2. Boyce JM, Kelliher S, Vallande N. Skin irritation
and dryness associated with two hand-hygiene regimens:
Soap-and-water hand washing versus hand antisepsis
with an alcoholic hand gel. Infect Control
Hosp Epidemiol. 2000; 21: 442-448. |
| 3. Boyce JM, Larson EL, Weinstein RA. Alcohol-based
hand gels and hand hygiene in hospitals. Lancet.
2002; 360:1509-1510,1511 |
| 4. Pittet D. Compliance with hand disinfection
and its impact on hospital-acquired infections.
J Hosp Infect. 2001; 48(suppl A):S40-6. |
A Bolivian Vacation With a Mission
As the medical coordinator of a surgical mission to
the country of Bolivia, I would like to invite interested
physicians to consider joining our team on one of our
trips. We go in the spring and fall, with our next mission
on April 26 until May 9, 2003. You can come for one
or two weeks. We have a great need for your skills and
expertise.
Our participants find the experience very enriching
and satisfying. We are sponsored by an independent Catholic
nonprofit organization and welcome persons of other
faiths or no faith at all. Please contact me by telephone
at (630) 588-0409 or pager at (708) 999-2599 for more
information, or visit our Web site at <www.solidaritybridge.org>.
Enrique Via-Reque, M.D.
Wheaton, Illinois
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