The ontological basis of strong artificial life

In 1973, the United States Congress enacted legislation requiring physicians to initiate Peer Review Organizations to monitor utilization and quality of hospital and physician services in the federally funded Medicare program. A hardly noticed provision of the statute intimated the desirability of formulating guidelines for medical treatment. What was originally intended to simplify and universalize general standards by which quality of care could be objectively measured has more recently escalated into formalized projects, subsidized by government, to create "practice parameters". The impetus to define clinical conditions and methods of treatment for specific medical conditions (practice parameters) and standards of practice to avoid or defend malpractice claims (risk management protocols) are part of the movement in the United States for tort reform. If the vague "reasonable man" standard of care in negligence law can be supplanted by a scientifically developed, particularized medical practice standard, it is anticipated that spurious claims and defensive medical practice will be discouraged, quality improved, iatrogenic injury and malpractice litigation diminished. Many U.S. states undertook tort reform in the last decade. A few have embarked on medical-legal reform. One state is conducting a five-year medical liability project that calls for the development of practice parameters and risk management protocols in four medical specialties. The parameters will have the effect of law and may be introduced as evidence in medical malpractice trials. How the parameters are established, their effect on the strategies of litigation, the resultant trial problems in the introduction of evidence and in the burden of proof and their potential for acceptance by a significant number of jurisdictions-are the issues to be explored in this paper.     

The Impact Factor--a reliable scientific parameter?

Informed consent is currently an ethical, medical and legal requirement. An increase in public discussion of real or supposed malpractice has led to critical attitude in patients and increased demands on informed consent by the courts. Unfortunately, the legal requirements of informed consent have developed from atypical situations involving dissatisfied and injured patients rather than from the more usual occurrences of physicians helping patients with subsequent patient satisfaction. In addition, laws have not set forth clear guidelines for physicians to follow. We review the elements of informed consent based on current Austrian and German jurisdiction in the particular field of anesthesiology and summarize the legal and medical realities in order to point out specific criteria for decision making.     

Serum growth hormone-binding protein is decreased in prepubertal children with idiopathic short stature

Every activity of a medical practitioner may be subjected to court control. This creates not only uncertainty gut also anger amongst most physicians. However, it is clear that no court judgement against a physician will be made without the competent support of independent medical experts. On the basis of the relevant legal literature and judgments, the present article is an attempt to consider medical errors in the administration of contrast media, to describe the required medical informed consent before such measures, and to discuss the ever increasing importance of adequate documentation in the light of malpractice proceedings. importance of adequate documentation in the light of malpractice proceedings. This is followed by a discussion of the very important medical necessity to inform the patient about recommended behaviour after injections of such contrast media, the responsibility question in both civil and criminal terms in case of an incident, and various tips for steps to be taken in the case of a liability action.     

The functional outcome of lower-extremity fractures with vascular injury

Salvage of lower-extremity Gustilo type IIIC fractures is difficult, time-consuming for the patients and physicians, and not universally successful because of poor functional outcomes. Even if successful with limb salvage, the functional result may be unsatisfactory because of mutilating injuries to muscle and nerve, bone loss, and the presence of chronic infection. From July 1991 until July 1994, revascularizations of open IIIC fractures were attempted for wounds with Mangled Extremity Severity Score (MESS) < or = 10. The functional results were evaluated at 2 years after injury. Thirty-six lower-extremity revascularizations were performed on 34 patients, including 1 patient with bilateral distal tibial IIIC fractures and a child with IIIC femoral fracture accompanied by ipsilateral distal tibial amputation. Excluded were patients with below-ankle IIIC fractures as well as patients who underwent immediate amputation at admission. After the revascularization, seven patients with IIIC fractures (7 of 36, 19.4%) underwent secondary amputation within 1 week. At the 2-year follow-up, the overall secondary amputation rate was 25% (9 of 36) and the salvage rate was 75% (27 of 36). Those were no deaths. Of the 29 salvaged limbs among these 27 patients, 23 limbs (23 of 29, 79.3%) required secondary coverage procedures that included 12 free flap transfers (12 of 29, 41.4%). Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, MESS was able to predict the secondary amputation rate and the functional result. Sixteen of the 17 limb-salvaged patients with MESS < or = 7 were able to achieve minimal functional requirements, whereas 3 of the 10 patients with MESS = 8 to 10 failed to achieve minimal functional requirements at the 2-year follow-up. Using statistical analysis, we found that the salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. Using our protocol for treatment for IIIC fractures, the threshold for immediate amputation can be raised from MESS = 7 to MESS = 9. Our conclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.     

Perceptual errors and negligence

Radiologic errors continue to be made at a rate that has changed little over the past 50 years, despite a variety of methods that have been proposed to reduce such errors. Many of these methods, as well as other steps that can be taken to decrease errors, are described elsewhere [6, 31, 32]. However, the question of whether a missed radiographic diagnosis constitutes malpractice has confounded radiologists, patients, referring physicians, attorneys, jurors, and judges for decades, and it is not likely that the question will be resolved to the satisfaction of any of these parties in the foreseeable future. Against this backdrop, radiologists continue to be subjected to malpractice litigation more for missing radiographic diagnoses than for any other reason. Moreover, radiologists who are sued for missing diagnoses are likely to have more indemnification paid on their behalf to satisfy a settlement or adverse jury verdict than for any other malpractice allegation. Assuredly, it is difficult to defend a radiologist who has failed to perceive a radiographic abnormality that in retrospect can be readily perceived by medical and nonmedical observers alike. Nonetheless, solid defense-supporting data are available that, at times, can be presented to a jury successfully to achieve vindication for a defendant radiologist. These data include statistics regarding the frequency of errors committed by radiologists and other physicians during the course of ordinary everyday practice, the factors that cause varying conspicuity of radiographic densities, the limitations of normal human visual perception, and evidence that the process by which the radiologist originally rendered the interpretation was free of deficiency.     

Liability in breast cancer screening

The U.S. breast cancer mortality rate has risen over the past 29 years in women 50 years of age and older. This is surprising in light of the fact that the disease is curable when detected early through mammography together with clinical breast examinations (CBE). One major problem is that many women are not being screened. Only about one-third of women 50 years of age and older are receiving yearly screening mammograms, despite published guidelines. Regarding CBE, more women are receiving them, but there is room for improvement. The main reasons given by women for not having a mammogram are: 1) their physicians did not recommend it; 2) they did not know they needed one; or 3) they did not have any breast problems. These responses reflect a lack of awareness of breast cancer screening recommendations and indicate that women are not being given adequate information about breast cancer from their physicians. This paper will explore the medical malpractice literature in order to discuss the question of whether physicians should be liable for failing to inform their female patients.     

Interactions between criminal justice and other areas of law from the viewpoint of the civil rights judge

More than in the past, patients are consulting lawyers to check medical treatment for malpractice. One of 10,000 city-inhabitants institutes proceedings for compensations. In the past, a charge was brought at the same time to achieve examination of patients records and to obtain an expert opinion at government expenses. Due to recent jurisdiction, the patient got the right to examine treatment records without the necessity to specify his reasons. Settlement institutions of the society of physicians of Germany facilitate an examination of a treatment procedure for mistakes without costs. Therefore, there is no more incentive for a charge to achieve compensations. The continuation of civil proceedings may not depend on the result of the investigation proceedings due to the different kind of evidence. The special duties of civil courts working with medical liability and expert opinions seem to show that civil proceedings are suited the best to clarify a dispute between physicians and patients. This also avoids to pillories the physician.     

Beyond tort reform

Organized medicine has spent a great deal of time, energy, and money attempting to revise the legal tort system. Yet, change, if any, has been incredibly slow. There are many reasons for this. Tort law has been a part of American jurisprudence for hundreds of years. In addition, most state legislatures are populated with large numbers of attorneys. This paper explores the economic factors that underlie the litigation process in medical negligence/malpractice cases. It suggests that the current tort system is not as antimedicine as physicians commonly believe, rather, it is physician-friendly. Presented here is a more efficient and cost-effective method of addressing medical negligence/malpractice cases. An exclusive relationship between the liability insurance carrier and a defense law firm is proposed. Rather than using the old billable hours system to charge for its services, the defense law firm negotiates a yearly retainer based upon a percentage of the annual liability insurance premiums paid. How this relationship would result in a more efficient and cost-effective approach to the present tort system is examined.     

The effects of malpractice on Mississippi physicians

Medical malpractice and its effects on physicians in Mississippi is reviewed to assess its effects upon decisions in practice, patient care, and the physical and emotional toll on physicians. Through a random survey of 500 physicians in Mississippi across all areas of medicine it was determined that 47.3% of the respondents had been involved in malpractice litigation, a higher percentage than the United States average in 1989. The predominant emotional response to litigation was anger. Most physicians did not seek outside help as an aid in coping.     

Boron neutron capture therapy: re-irradiation response of the rat spinal cord

PURPOSE: To examine factors that influenced, positively or negatively, the specialty career choices of physicians trained at Yale-New Haven Hospital (YNHH) from 1929 to 1994. METHOD: The authors sent questionnaires to 4,888 physicians who had trained or were training in YNHH-sponsored residency programs. The physicians rated 36 factors posited to be influenced in career choice on a seven-point Likert scale from very negative to very positive. The authors compared the means of each factor's ratings by decade of medical school graduation. RESULTS: The most positively rated influences were similar in each decade from the 1920s to the 1990s. These influences shared characteristics of intellectual curiosity ("intellectual content of the specialty" and "challenging diagnostic problems"), altruism ("interest in helping people" and "opportunity to make differences in people's lives"), and personal identity ("consistent with personality" and "possess the required skill or ability"). Negative factors, such as "demands on time and effort," "stress in the field," and "malpractice costs," were also consistently rated throughout the decades. CONCLUSION: The reasons that physicians choose certain specialty careers have not changed significantly over the past 65 years despite all the changes that have occurred in medicine. Physicians continue to seek professional opportunities that are viewed as intellectually challenging and of benefit to others.     

Stress and medical malpractice: Organizational risk assessment and intervention.

Four studies were conducted to examine both the relation between stress and medical malpractice and the impact of stress management programs in reducing malpractice risk. Sixty-seven hospitals and more than 12,000 individuals participated. In Study 1, hospital departments with a current record of malpractice reported higher levels of on-the-job stress than did matched, low-risk departments. In Study 2, workplace stress levels of 61 hospitals correlated significantly with frequency of malpractice claims. In Study 3, a longitudinal investigation was conducted to evaluate the impact of an organization-wide stress management program on the frequency of reported medication errors. Results suggest a significant drop in average monthly medication errors as a result of the program. Study 4 was a 2-year longitudinal investigation that compared the frequency of medical malpractice claims. Hospitals (n?=?22) that implemented an organization-wide stress management program had significantly fewer claims as compared with a matched sample of hospitals (n?=?22) that did not participate. Implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of the Physician Insurers Association of America database as a surveillance tool for diabetes-related malpractice claims in the U.S

OBJECTIVE: To examine the available national surveillance data on malpractice claims associated with diabetes and to determine the medical specialties having the highest number of claims and the classes and costs of filed claims relating to diabetes. RESEARCH DESIGN AND METHODS: Data was abstracted from the Data Sharing Reports (DSRs) of the Physicians Insurers Association of America (PIAA), as well as a search of the PIAA's computerized database for the period spanning 1 January 1985 to 31 December 1996. Data on numbers of claims, medical causes of loss, indemnity paid, demographics of claimants and physicians, severity, and medical specialties with diabetes-related claims were available. RESULTS: A total of 906 diabetes claims were reported to PIAA, and the total indemnity paid was $26,892,848. A significant downward trend (P = 0.004) was noted for the period between 1993 and 1996. Diabetes claimants were older and predominantly male, relative to all claimants. Ophthalmology, internal medicine, and general and family practice had the highest rates of reported claims at 16.5, 13.6, and 13.4 diabetes claims per 1,000 claims, respectively. Of the diabetes-related injuries, 44% occurred in the practitioners office, as compared with 27% for all claims. A greater proportion of diabetes claims were associated with the highest level of severity of injury with respect to all claims compiled by the PIAA. CONCLUSIONS: The database of the PIAA can be a useful resource to monitor trends in diabetes-related malpractice. Further study into whether claims result from lack of adherence to practice guidelines is needed. Prevention programs designed to reduce the liability among high-risk specialties may also lead to improved care for the patient with diabetes.     

Medical care as physical injury from the viewpoint of the surgeon

The current criminal law regarding medical malpractice is based on the over 100 years old principle of personal injury, as defined in Section 223 of the criminal code. Attempts to revise this legislation have failed repeatedly in the past. The surgeon's duty of disclosure has gained pivotal importance, often being a handicap for differential surgical treatment. The lack of a specific criminal law regarding medical malpractice in combination with the theoretical construct of a surgical intervention as an authorized personal injury is disadvantageous for both patient and surgeon, since the surgeon is led to deny malpractice and therefore compensation by the liability insurance is not guaranteed. The threat with criminal penal for the surgeon which acted wrong but not gross negligent should be diminished by a definition of a specific criminal law on medical and surgical malpractice.     

Stroke and malpractice claims

We describe 15 malpractice claims that were filed after the patients had strokes. Both embolic and thrombotic, sterile and infected strokes led to claims. Ten of the claims alleged physician failure to protect the patient, two alleged physician failure to react as called for by symptoms, and three were related to medication. We conclude that physicians should advise patients of the possibility of stroke when circumstances warrant it, as well as documenting their judgment and suggested preventive practices. These cases further suggest that treatment decisions supported by documented second opinions may reduce the number of malpractice claims for strokes.     

Malpractice claims experiences of psychologists: Policy issues, cost comparisons with psychiatrists, and prescription privilege implications.

Psychiatrists often argue that psychologists are not competent to diagnose mental disorders or formulate treatment plans and that patients will be harmed if psychologists provide psychotherapy without supervision by psychiatrists. However, a review of 13 years of psychology's nationally available professional liability (malpractice) insurance has shown that there has never been a court award about any insured psychologist practitioner for failure to refer to a physician when needed, failure to identify a medical problem, or failure to provide appropriate psychological care for a patient with medical complications. Psychiatric malpractice insurance costs are 3-24 times more than psychological malpractice coverage, depending on the state. The implications for public policy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The local community as a life environment for the elderly--on the future role of the community in supporting the elderly

Current and recent internal medicine residents were surveyed on their level of confidence in practicing operational medicine, satisfaction with graduate medical education, the impact of TRICARE, the military managed care plan, on their patients and education, and intentions on remaining in uniformed service. Their sentiments were recorded on a five-point Likert scale (1 = strongly agree, 3 = neutral, 5 = strongly disagree). Two hundred twenty-one of the 294 surveys were returned (75.2%). Most physicians felt unprepared to perform duties in a nuclear, biological, or chemical warfare environment, or handle administrative aspects of operational medicine (mean scores, 3.2-3.7). A majority of respondents felt satisfied with the quality of their residency experience (mean score, 1.9). Although more than half of those surveyed (53.6%) listed the opportunity to teach residents as a top factor influencing their retention decision, most felt skeptical that graduate medical education would remain important in the future (mean score, 3.6). Most physicians agreed that restriction of TRICARE to patients less than 65 years old may degrade the quality of military internal medicine residencies (mean score, 1.6). Previous service, Reserve Officer Training Corps experience, and graduation from the Uniformed Services University of the Health Sciences were factors associated with increased physician intention to remain beyond their obligated service. The most common factors inducing physicians to leave the military included frequent deployments, relocations, and financial compensation. Factors cited most frequently as influencing physicians to stay on active duty included high-quality colleagues, opportunities for teaching residents, and freedom from malpractice and office management details.     

Physicians disciplined by a state medical board

CONTEXT: State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group. OBJECTIVE: To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians. DESIGN: Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale. SUBJECTS: All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997. MAIN OUTCOME MEASURES: Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline. RESULTS: A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92). CONCLUSIONS: A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.     

Medicolegal errors in the ED related to the involuntary confinement of psychiatric patients

To determine the effectiveness of emergency department (ED) physicians properly and correctly completing documents required for emergency confinement of psychiatric patients, 1,000 Physician Emergency Certificates filed by ED physicians in the Shreveport, Louisiana, region were reviewed for appropriateness and for correctness of completion based on the applicable state law. Of the Physician Emergency Certificates reviewed 4.2% were incomplete or inappropriate. The most significant sources of error involved incomplete documentation of the mental status examination and not documenting the specific reason (dangerous to self, dangerous to others, or gravely disabled) for the patient meeting requirements for involuntary confinement. Other errors included confinement for reasons not appropriate for a psychiatric unit. This study suggests that ED physicians should be more cautious and thorough in completing the documents required for emergency confinement of psychiatric patients, so that the physician is less likely to be sued for malpractice or charged with the false imprisonment of such patients, and the patient's civil liberties are protected.     

Solo versus group practice in the medical profession: the influence of malpractice risk

While Partnerships are a significant form of business organization in many sectors of the economy, relatively little is known about the incentives which lead to their formation. This paper explores the formation of partnerships among office based physicians when facing some risk of malpractice litigation. Theoretical results indicate that malpractice exposure can increase the incentives to shirk within a partnership, and so exert a significant influence on the decision to form a partnership. Empirical results find that malpractice risk has the expected negative effect on some partnership formation.     

Relation between negligent adverse events and the outcomes of medical-malpractice litigation

BACKGROUND: We have previously shown that in New York State the initiation of malpractice suits correlates poorly with the actual occurrence of adverse events (injuries resulting from medical treatment) and negligence. There is little information on the outcome of such lawsuits, however. To assess the ability of malpractice litigation to make accurate determinations, we studied 51 malpractice suits to identify factors that predict payment to plaintiffs. METHODS: Among malpractice claims that we reviewed independently in an earlier study, we identified 51 litigated claims and followed them over a 10-year period to determine whether the malpractice insurer had closed the case. We obtained detailed summaries of the cases from the insurers and reviewed the litigation files if the outcome of a case differed from the outcome predicted in our original review. RESULTS: Of the 51 malpractice cases, 46 had been closed as of December 31, 1995. Among these cases, 10 of 24 that we originally identified as involving no adverse event were settled for the plaintiffs (mean payment, $28,760), as were 6 of 13 cases classified as involving adverse events but no negligence (mean payment, $98,192) and 5 of 9 cases in which adverse events due to negligence were found in our assessment (mean payment, $66,944). Seven of eight claims involving permanent disability were settled for the plaintiffs (mean payment, $201,250). In a multivariate analysis, disability (permanent vs. temporary or none) was the only significant predictor of payment (P=0.03). There was no association between the occurrence of an adverse event due to negligence (P = 0.32) or an adverse event of any type (P=0.79) and payment. CONCLUSIONS: Among the malpractice claims we studied, the severity of the patient's disability, not the occurrence of an adverse event or an adverse event due to negligence, was predictive of payment to the plaintiff.