Improving the way malpractice is handled

My response to Pauline W. Chen MD’s Well Blog of Dec. 15 in the New York Times in which she described some of the ways physicians are negatively impacted by malpractice suits.

Clearly, physicians are negatively impacted when undergoing malpractice suits. Some experience depression and thoughts of suicide, others emotional depletion and burnout.

It is not surprising that surgeons who have weathered the strain of a suit ended up ordering unnecessary tests or refusing to take on patients with complicated problems. Neither is it surprising that some surgeons may be become so mentally traumatized by a lawsuit that they may be prone to further errors and more malpractice suits.

This sad state of affairs adds to the already confused and complicated doctor-patient relationship in a unique way. Why? Because many patient safety groups recommend that patients contemplating surgery should ask their physicians how many similar operations they have performed as a way of ascertaining their experience and expertise. In itself this is not a bad thing. And, even though surgeons are well-trained by the time they begin practice, it gives some patients more confidence going into surgery knowing that their doctor has performed a large number of the procedure that they are scheduled to have.

One cannot help but wonder that if the strain of a malpractice suit can make some surgeons more prone to error then maybe patients should also ask their surgeons if they are involved in any malpractice litigation.

The point is that better ways are needed to address malpractice suits. For many good surgeons are sued without merit and forced to undergo unnecessarily the strain of litigation. And if that strain makes them more liable to error, then patients and surgeons will both benefit from changing the malpractice system. The system now is too adversarial. It pits doctors against patients and plaintiff lawyers against defense lawyers. About one-half of the money in lawsuits goes to pay for court costs and the fees of both the plaintiff and the defense attorneys.

Health courts are one way of making the system more efficient and less costly. These are special courts presided over by judges with special malpractice training. The idea is to reach a quick settlement eliminate unnecessary haggling between both sides.

Another method would be to create pre-trial screening panels in which groups of doctors would review alleged malpractice cases and offer an opinion as to whether negligence had occurred. This would give the insurance companies and the doctors involved as well as the defense and the plaintiff attorneys a reference point from which to decide whether to defend or to settle a case.

As medicine advances, its procedures and medications have great potential to alleviate suffering and pain, but they can carry risk. It’s a fact that many of the malpractice cases that occur involve procedures that weren’t even possible years ago. Internal organs can be nicked doing needle biopsies or contrast studies, and medications have side-effects than can be harmful.

Thus finding ways to handle malpractice cases such as health courts or pre-trial screening panels that minimize the hostilities and wrangling that prolong the settlement of cases are worth the attention of our lawmakers.

Edward J. Volpintesta MD

Ensuring the future of Primary Care

Letter published in Academic Medicine




Academic Medicine:

December 2011 - Volume 86 - Issue 12 - p 1484

Letters to the Editor

Ensuring the Future of Primary Care


Volpintesta, Edward Joseph MD


To the Editor:

Shortening the duration of training for primary care physicians, as suggested by Dorsey and colleagues,1 is an idea whose time has come. But there are many who will dispute changing the traditional pathway.

In 2009, I commented on reshaping the primary care curriculum by shortening the training period from 11 to about 8 years and by tailoring the basic science courses to more accurately reflect what primary care doctors actually need.2 My suggestions were summarily and sharply repudiated because my colleagues in primary care believed that my approach would lead to inferiorly trained physicians.3

Unfortunately, many of our leaders in medicine have failed to understand how greatly the role of the primary care physician has changed over the past few decades. The coordinating function of primary care physicians has become almost as great as its medical care function. Because of the time spent on coordinating patients' health care needs, primary care doctors are spending less time treating their sicker patients, referring them, instead, to specialists for care.

Thus, capable primary care doctors in their “new” role could be trained without the intense exposure to the basic sciences and hospital medicine that exist today. To some, this may seem not only heretical but naïve. But the daily routines of many primary care doctors, if studied, will show that less science and more social and coordinating skills will be needed if primary care is to survive.

Edward Joseph Volpintesta, MD


References


1 Dorsey ER, Nicholson S, Frist WH. Commentary: Improving the supply and distribution of primary care physicians. Acad Med. 2011;86:541–543. http://journals.lww.com/academicmedicine/Fulltext/2011/05000/Commentary__Improving_the_Supply_and_Distribution.6.aspx. Accessed July 22, 2011.

Cited Here...


2 Volpintesta EJ. An immodest proposal to solve the primary-care physician shortage. Conn Med. 2009;73:56–64.

Cited Here...


3 Mueller K, Gates PJ, Viereg K. Re: An immodest proposal to solve the primary-care physician shortage. Conn Med. 2009;73:477–478

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Questioning the Validity, Cost, and Effectiveness of Recredentialling: It's About Time

Letter sent to Connecticut Medicine.


December 5, 2011
Connecticut Medicine
Letter to the Editor

Questioning the Validity, Methodology, Cost, and Effectiveness of ReCredentialling: It’s About Time

One of the several actions taken by the Connecticut State Medical Society’s (CSMS) delegates at the annual meeting of the AMA held in Chicago in June 2011, was requesting the AMA to further study the “validity, methodology, cost, and effectiveness” of the American Board of Medical Specialties’ (ABMS) recredentialing system. 1

The CSMS and its AMA delegates deserve commendation for their courage and persistence in keeping this very contentious issue alive. Some members may not know it but this issue had its origin on the floor of the CSMS House of Delegates in 2008.
It was then brought to the New England Delegation to the AMA where it was further discussed and following it approval there, the decision was made to present it at the Organized Medical Staff Section of the AMA’s annual meeting in 2008

Discussion on the resolution was overwhelmingly favorable and it was referred for further study. The Young Physicians’ Section at that time also presented a resolution that questioned the methods of the ABMS. Their concerns added both political and moral strength to the resolution that emerged from the floor of the CSMS House of Delegates.

Criticizing the methods of the ABMS may seem naïve or overly-ambitious or even quixotic to some. Some may even be insulted, but, increasingly physicians are making known their unhappiness over the boards’ methods; and the inordinate power they possess over physicians’ reputations and their professional lives.
In a recent New York Times article 2 the author an internist complained about the time spent on preparation and the impracticality of the recertification test itself.

The internist mentioned how in the real world, cases were discussed with colleagues and that extensive data bases exist where information can be readily retrieved; and that caring for patients “rarely comes down to a single right answer that can be checked off in a blissful isolation”. Most of the blog responses to the article were critical of the boards’ philosophy.

It is interesting that the move to making recertification mandatory occurred in 2000, the same year that Institute of Medicine (IOM) published its To Err is Human report. That report announced that hospital errors were causing as many as 100,000 deaths yearly. Although a follow-up study published in the Journal of the American Medical Association challenged the conclusions of the report, attempts at damage control were futile. For patient advocacy groups quickly used the “100,000 deaths by medical errors” as their mantra in pushing for physician accountability and it was used by many groups whose interests were opposed to those of organized medicine. This included above all, the malpractice lawyers.

Whether the launching of mandatory recredentialing and the appearance of the IOM report was coincidence or related in some way, only the leadership of the two organizations can answer. But it is tempting to speculate that the ABMS saw the IOM report as a once-in- a lifetime opportunity to extend its monopolistic control over the credentialing business and control over the way physicians practice; not to mention a public-spirited way of increasing the revenues of the ABMS..
Correcting the defects in the boards is important because they plan to make physicians’ certification status public. 3

The boards’ claim that certification goes above and beyond basic medical licensure is a subtle way of casting suspicion on physicians who are not certified or who have not recertified and coercing them to recertify . This is wrong because the boards started as voluntary exams.

I think that the intentions of the ABMS to provide a voluntary testing service to physicians by which they can assess the knowledge they need in their individual practices are commendable.
But there are several defects that cannot be overlooked. Here are some of the most troublesome:
(1) The pass/fail method is punitive and unnecessary for physicians who have already been certified. Ideally the boards should uncover areas of weakness and recommend remedial study. “De-certifying” a physician is demeaning and unprofessional. It should be rare for physicians to be de-certified. It should occur only if a physician has repeatedly demonstrated an inability to provide good care and if so, has failed to improve with remedial study.
(2) The boards were intended to be voluntary and never meant to infringe on physicians’ abilities to make a living.
(3) There are many qualities that good physicians have and which can never be identified on a computer-based exam. Compassion, empathy, connecting with patients and colleagues, working as a team member, and participating in medical affairs are just a few of the traits that contribute to a physician’s complete professionalism.
(4) Physicians should only be tested in knowledge that they actually use.
The ABMS’s influence extends into every specialty and into every physician’s life in one way or another, for better or worse. Such wide-ranging power gives it a privilege unsurpassed among our medical organizations. Unchecked, such power can lead to exploitation of the very profession that it should be serving.
It is difficult to convince large organizations to change. We need look no further than the many organizations on Wall Street that in recent years lost their way and succumbed to the lust for power and prestige and ultimately caused much grief to those who had placed their trust in them.
For this reason it is good that the CSMS has continued to ask the AMA to study the “validity, methodology, cost, and effectiveness”, of its recredentialing system. It’s about time.
Edward J. Volpintesta MD
Bethel


1. Summary of Proceedings: CSMS House of Delegates—Annual Meeting, Mystic Marriott Hotel &Spa, Groton, September 16-17, 2011. Conn Med 2011; 75(10):647-651.
2. Ofri D. Being a med student. New York Times [well.blogs.nytimes.com.] accessed 11/5/2011.
3. Krupa C. ABMS to make physician maintenance-of-certification status public [amednews.com] accessed 11/14/2011.

Barriers to physicians' communication

Letter sent to Connecticut State Medical Society regarding the need for physicians communicate with each other, the public, their medical leaders, and legislators.

CSMS president Michael Krinsky, MD made several good points in his president’s address at the CSMS of House of Delegates Annual Meeting, September 16&17, 2011.1
Of particular importance was his appeal to physicians to “communicate, communicate, communicate”. With so many means at our disposal to communicate, however, we seem to do it less and to do it less effectively than ever.

Why is this? Here are some personal observations.

(1) We don’t always stay focused. This refers to those of us who can’t keep our thoughts restricted to the issue at hand. Whether orally or in written speech it is too easy to let our minds wander, with the result that instead of focusing and remaining focused, we get sidetracked and go off in all directions. Maybe some of us are garrulous by nature or become so when speaking in a group. But even experienced leaders who are accustomed to “communicating” sometimes are unclear or speak too long. Perhaps they fear that being pith and precise may be misinterpreted as indicating lack preparation or lack of interest.

(2) The communicator doesn’t think out his/her thoughts before expressing them. People often just shoot (or write) from the hip without having any good supporting evidence to give them credibility. An opinion takes on more credibility if accompanies by supporting evidence or good logical thought.

(3)Fear of being perceived as too far out of the mainstream. For most of us, expressing ourselves honestly can be distressing. It’s almost a truism that the opinions that we freely share privately we rarely express in group situations with our peers. I imagine that by the time we finish college and medical school our youthful idealism has succumbed to the years of conservative indoctrination and submission to authority that accompanies our training.

(4) Sometimes the listener or reader is too lazy to respond to what they have listened to or read. This is bad because communication, ideally, is a two-way affair. It is dialogue. Without hearing from others what we have said, how can we know if we are on the right track? A response may increase our convictions on a subject. And if it shows us that we were wrong or even only partly so we will have benefitted. For those who enjoy communicating, not receiving a response can give one self-doubt and dissuade one from continuing. Responses do not and should not always support what is being discussed, but they should be cordial and positive and constructive.

(5) Time is a big limiting factor in communicating. It is less so when one is on the keyboard of one’s computer than when one is participating in a group situation. Because we are all so busy with professional duties and personal responsibilities, the time we allow ourselves for communicating has become less and less. There is pressure on the person running the meeting to keep on schedule and finish on time. This can lead to the absurd conclusion that even though a meeting has not taken a few steps forward in solving a problem or clarified some point or other, since it has finished on time, the person presiding has done a good job!

(6) Some issues are emotionally charged and elicit zealous and even vehement feelings. Although the usual response is to enjoin the person speaking to calm down, I think that a short outburst if it is not scurrilous or prejudicial should be permitted. It clears the air, and sometimes it is the only way to make one’s point.

(7) Some of us take offense when we are contradicted in oral discussions. This can poison communication. I have seen it result in loss of collegiality. Confrontation is good and without it little is accomplished.

(8) Finally, communication needs to be spiced with occasional humor. Too much of it makes physicians forget what they have convened for. But too little humor, which is more often the case, stifles free and open discussion.

1. Krinsky M. Address of the new president: CSMS house of delegates, annual meeting, September 16&17, 2011. Conn Med 2011; 75:637-639.

Edward J. Volpintesta MD

the bedside evaluation

Re: a recent article in the Annals of Internal Medicine discussing the value of the bedside evaluation:
November 3, 2011

The Annals of Internal Medicine


In an era that has fetishized imaging and laboratory testing, the authors’ espousal of the importance of the bedside evaluation has particular importance. (1)
Even if one is not adept in the diagnostic skills that good bedside examination requires, there is much to be learned just by sitting down and talking to the patient and encouraging him/her to describe their symptoms and their personal histories. Talking and listening establishes a connection with patients that is a two-way affair. First, of course the doctors gets knowledge of when a symptom started, how long it has lasted, and any other accompanying information that along with the physical exam will help to establish a diagnosis.
But, connecting with a patient also gives the doctor an added sense of respect for the patient that may encourage closer attention to the patient’s overall hospital and post-hospital care.

Today it is not unusual for patients to be discharged while still in the early stages of convalescence. Having diagnosed a patient’s pneumonia and started proper antibiotic therapy, it is too easy for a resident to rationalize that he/she has done everything necessary for the patient. Because hospitals are penalized for not discharging patients within prescribed time frames, there is a danger that they are conniving at premature discharging of patients and even proud their “through put” prowess.

Planting the seeds of “through-put” in the minds of residents can stifle their humanitarian instincts.

Thus residents should use the bedside evaluation not only for sharpening their clinical skills and for controlling the urge to resort to extensive imaging and laboratory testing, but also as a constant reminder of the intrinsically human character of medicine and the need to protect it.

1.Verghese A ,Brady E, Kapur C, Horwitz RI. The bedside evaluation: ritual and reason. Ann Int Med. 2011:155:553.

Edward J. Volpintesta MD

Flaws in the recertification process

Recertification creates a false dichotomy among physicians. Yet leaders in medicine are quiet.
November 14, 2011
Amednews
To the Editor,

Regarding “ABMS to make physicians’ maintenance- of- certification status public”
(amednews, posted Nov. 14, 2011) :

In its self-appointed role, the ABMS has insinuated itself as the arbiter of physician competence, competing with the authority of the states’ departments of public health. It is never mentioned that the boards were established as a voluntary testing service for interested physicians to demonstrate an above average knowledge in their specialty. Not as a surrogate for state licensing boards.

But there is an ethical problem here as well. The word “certified” implies that certified physicians are competent and those who are not certified are not. Most physicians would agree that this sends a misleading message to the public. It gives the ABMS undue influence over physicians’ reputations and their ability to make a living. And by so doing it eliminates the original voluntary basis of the ABMS, making it a coercive one instead. For clearly, most physicians will admit that they take the boards out of fear for being seen as uncertified or decertified.

Thus the ABMS should refer to those who are boarded as “diplomates”. This eliminates the prejudice against those physicians who under the present classification are not certified. And it still accords those who are the recognition that they worked for.

Edward J. Volpintesta MD

Physician Advocacy as a requirement of their education?

An article in Academic Medicine questioned the need for physician advocacy as a requirement of their education. My response follows:
November 6, 2011
Academic Medicine
To the Editor

It should be a source of embarrassment to all physicians that the question of whether physician advocacy (1) should be a requirement of their education has even been raised.

Unlike all the other things that physicians have to learn in medical school and residency, advocacy has to do with unquantifiable personal qualities like honor and courage, and a sense of protectorship. With advocacy there are no guidelines and no certification exams. Although advocacy is important most medical students are too busy to give it much thought. Getting good grades, finding a good residency, and passing the boards make time spent discussing advocacy seem to most like a waste of time.

Nevertheless, one would think that physicians’ responsibilities to safeguard the ideals of their profession would be discussed with medical students throughout their training even if not formally in the classroom. I like the idea of making advocacy education mandatory, but the value of advocacy will not take root easily, except in the few who are naturally inclined to see its value and are willing to embrace it.

Thus, even if not mandated there are ways for educators to impart to students the value of advocacy. It could take the form of an afterthought on hospital rounds or even a pithy interjection during a classroom discussion.

Of course, for this to occur, teachers themselves have to believe that advocacy is important. It would help if they had some personal experiences to relate, perhaps a letter they wrote in response to a newspaper article about malpractice or the rising costs of health care. Or a recent medical society meeting that they attended in which they spoke out on an issue such as how insurers’ intrusions are transforming medicine into a business.

1.Kanter SL. On physician Advocacy. Acad Med. 2011;86:1059-1060.
Edward J. Volpintesta MD