No Sympathy for the Devil
In response to the “Washington Report” column
“Professional
Association Boycotts: Primer for a Frustrated Member”
in the December 2002 NEWSLETTER, let me offer
the following observations. Physicians/anesthesiologists
do have a legitimate alternative [to a physician boycott].
They can control their hours. This they have not done.
They have continued to increase volumes as individual
payments have decreased. At what point does the anesthesiologist
or group begin to value time over money? If the rate
of reimbursement for a case done at the margin falls
below that value, then limit the hours of service, go
home and enjoy family or some recreational pursuit.
If it is favorable to the hospital to extend the hours
of service, let them negotiate their prices with third-party
payers and prices with the anesthesiologists for extended
hours. Alternatively, find another group of anesthesia
providers. The latter is, of course, a significant risk.
In addition, you could not choose between third-party
payers, but you do have a choice.
However, there is another danger. The government does
not restrain or seek to restrain health costs. It tries
to limit its costs. The fact that we cost-shift to the
private sector is seemingly of very little concern to
them. The only issue for the politicians is not to appear
to be rationing health care to their major constituency:
the elderly. Remember, most of Medicare goes to the
geriatric population. In fact, I would submit that by
continuing to ratchet back on payments to physicians,
they force us to consider the limitation of services,
making doctors responsible for the rationing of care.
My colleagues in Europe do exactly that. What is worse
in some socialized systems is that they become the budget
holders for the government; a most unfortunate and unenviable
position to be in as a physician providing patient care.
These doctors are no doubt in a very difficult situation,
but so are we. It is the usual consequence when you
make a pact with the devil.
Timothy W. Rutter, M.D.
Ann Arbor, Michigan
Hired Guns in the Crosshairs
I applaud the efforts of the American Association
of Neurological Surgeons (AANS) with regard to implementing
a policy that can lead to disciplining their members
who provide dubious expert witness testimony.1
Their professional conduct program not only was affirmed
by an appellate court, whose ruling made for fascinating
and rather entertaining reading,2
but also has the support of the American Medical Association,
which has gone on record supporting the concept that
“providing expert testimony constitutes the
practice of medicine and that that practice needs
to be subject to peer review.”3
AANS’ accomplishment is likely to bring about
virtually instant tort reform for neurosurgeons since
“hired guns” and other neurosurgeons whose
expert witness testimony fails subsequent peer review,
if challenged, will likely experience an adverse action
to their association membership, which is reportable
to the National Practitioner Data Bank. Two results
would likely be that these discredited neurosurgeons
will see the end of their expert witness careers and
neurosurgeons would think extremely carefully about
the professional and economic consequences of their
expert witness testimony. This program should reduce
and eventually eliminate not only frivolous lawsuits
against neurosurgeons but also minimize the cadre
of “hired guns” and other itinerant neurosurgeons
whose inclination has been to stretch the truth or
blatantly lie for a fee.
I similarly applaud Mark J. Lema, M.D., Ph.D.,4
and Roger W. Litwiller, M.D.,5
who share this vision and are publicizing and spearheading
a significant effort by ASA to adopt a similar program.
I for one would gladly agree to an increase of my
annual ASA membership dues if it meant significantly
less concern that a mercenary anesthesiologist might
be tempted to stretch the truth or blatantly lie should
I ever be named in a medical malpractice lawsuit.
Effectively managing the current professional liability
calamity is truly “Anesthesiology’s Next
Assignment.”6
Here is a sound and just mechanism for rapid, proactive
fair tort reform, without the competing and procrastinating
machinations by the plaintiffs’ bar, insurance
industry, their highly paid lobbyists, the justice
department, state legislatures, etc., that has widespread
support and has survived multiple court challenges.
David Breznick, M.D.
Iron Mountain, Michigan
ASA Needs to Bite the Bullet
on Hired Gun Issue
The call for reform in expert testimony by President-Elect
Roger W. Litwiller, M.D., in the February
2003 NEWSLETTER is overdue
and urgent. Although medicine has failed to police itself
against incompetent practitioners in the past, medical
boards and specialty societies have made progress in
improving oversight, and the sanctioning or expulsion
of members who give “unacceptable” expert
testimony is a step in the right direction.
Plaintiffs’ lawyers have long recognized egotistical
“hired gun” physicians tongue-lashing their
colleagues in front of medically ignorant juries as
the cornerstone of their lucrative practice. Although
trying malpractice cases in front of a jury of our peers,
i.e., physicians, seems a distant reality, our professional
society should provide a panel of experts for case review
testimony, as is the case in arbitration boards of other
professions.
A recent case I reviewed as an expert for the defense
illustrated the importance of having more than one individual
in peer review. A high-risk, ASA 3E patient suffered
a bad outcome, in my view attributed to pre-existing
conditions superimposed on an acute disease process.
I was amazed and disheartened to discover that a prominent
member of our academic community was the plaintiff’s
expert witness. I will assume his motivation was weeding
out “bad apples” from our specialty. However,
I am convinced that a panel of similarly qualified and
respected clinicians may not have shared his conclusions.
This individual is probably also unaware that the defendant
settled the case, but because of the enormity of the
claim, the community hospital was subsequently sued
and faces a catastrophic insurance claim with its ability
to continue operations in doubt.
So the moral of this story is that playing with the
“expert” matches can burn down the hospital.
I sincerely hope ASA can move swiftly and decisively
to enact a case review process that is balanced and
effective, whatever the cost.
Frank J. Overkyk, M.D.
Johns Island, South Carolina
We’re Needed From Preop
to Postop
Amen, Brother! I read with great joy the letter from
Jay H. Epstein, M.D.,
“We’re Our
Own Worst Enemy,” in the February
2003 issue of the NEWSLETTER. His words were especially
poignant to me since the anesthesia care team model
is the dominant practice in the Midwest where I live
and practice anesthesia.
While I do believe that the anesthesia care team is
a safe and effective means of providing anesthesia care,
it is evident that patients, surgeons and operating
room staff hold varying opinions as to whether an anesthesiologist
is necessary or even helpful as a perioperative physician.
These opinions are validated daily by our lack of presence
in the operating suite, preoperative holding area and
on the wards.
The simplest solution to this problem is for the anesthesiologist
(and only the anesthesiologist) to complete the preoperative
evaluation and perform the postoperative visit. As Dr.
Epstein stated, this allows an excellent opportunity
to develop rapport with patients and family members
in addition to letting them know that there is another
highly trained physician in the operating room.
John J. Breth, M.D.
Shawnee Mission, Kansas |