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BRIEF COMMUNICATIONS: Thomas H. Glick Malpractice claims: Outcome evidence to guide neurologic education? Neurology 2001; 56: 1099-1100 [Abstract] [Full text] [PDF]

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Reply to Michael I. Weintraub

Thomas H Glick   (26 June 2001)

Malpractice claims: Outcome evidence to guide neurologic education?

Michael I Weintraub   (26 June 2001)

Reply to Michael I. Weintraub 26 June 2001
Thomas H Glick Cambridge Hospital Cambridge, MA Send Correspondence to journal: Re: Reply to Michael I. Weintraub thomas_glick{at}hms.harvard.edu Thomas H Glick	My article attempted to stimulate further interest in neurologic adverse events, and Dr. Weintraub has responded, citing other work that is “more informative,” to his concerns. Indeed, other work is more relevant to issues of negligence, the tort system, expert witnesses, indemnification, and overall risk management, which I did not address, although these do challenge the neurologic profession. I intended, rather, to contribute to a process of establishing an epidemiology of neurologic errors and adverse outcomes which should help to inform educational objectives and priorities. The nub of the issue is the present limitations, which I emphasized, of malpractice claims data bases and whether we can extract some useful information on neurologic, as opposed to legal outcomes. I advocated further prospective research and analysis that might better separate the “wheat” of true adverse events from the “chaff” of litigation and judicial determination, and I do not believe that this process need wait for reform of the tort system or of standards for expert witnesses. There is a large amount of useful, but unused data that could be accessed. I appreciate Dr. Weintraub’s suggestion that medicolegal education should be enhanced at the residency level. An even more fundamental goal, however, would be to heighten awareness of the sources of patient harm caused by error and strengthen commitments to participating in systematic prevention.
Malpractice claims: Outcome evidence to guide neurologic education? 26 June 2001
Michael I Weintraub, Clinical Professor of Neurology New York Medical College Send Correspondence to journal: Re: Malpractice claims: Outcome evidence to guide neurologic education? sandi_moriarity{at}urmc.rochester.edu Michael I Weintraub	The recent article by Glick [1] and the accompanying cautionary editorial [2] are quite interesting and provocative and are a timely reminder that the neurologist is not immune from lawsuits. Currently there are a total of 18 million lawsuits per year in the United States and tort reform is just an illusion. Malpractice claims and settlements are indeed complex and thus, the information provided, may be erroneous if used as a surveillance tool. For example, some of the largest awards in medical litigation have been made for neurologic impairment in children. Sympathetic awards seem to be based on the degree of plaintiff disability rather than evidence of negligence or culpable acts. Recent years have seen changes in our understanding of birth asphyxia and the epidemiology of cerebral palsy (CP) and most cases of CP are not due to birth asphyxia. In addition, no intervention including Caesarean section has ever been shown to prevent CP. [3] Thus, the presence of CP does not establish substandard medical care or that birth hypoxia occurred. Yet, undaunted by these facts, a handful of the same neurologic and obstetrical experts are not deterred from testifying alleging negligence. Glick cites the Massachusetts malpractice experience (1989-1999), yet Safran and coworkers'[4] prior review from 1980-1989 was more informative. They found that expert witness testimony for plaintiffs was by out-of- state neurologists whereas defense experts were all from Massachusetts. Additionally, a panel review of plaintiff experts' opinions were found to be inaccurate in 56%!!! Similar experiences in other large states have identified traveling expert witnesses, with good credentials, making marginal or pseudo-scientific association which ultimately leads to junk justice.[5] What can be done to lessen the effect of this thriving cottage industry who have several individuals advertising their credentials in various law journals? Thus, flawed expert testimony is a major problem that often leads to erroneous verdicts and needs to be addressed more vigorously by the AAN and other specialty organizations. In January of 1998, the American Medical Association (AMA) passed Resolutions 121 and 216 indicating that expert witness testimony should be considered the practice of medicine subject to peer review and disciplinary sanctions. Thus, malpractice databases are not sensitive nor specific in detection of medical errors as long as flawed expert testimony exists. While there is a perception of fairness to this adversarial system, the reality is many plaintiff attorneys know who to call for a specific opinion. A review of more than 150,000 closed claims (January 1985-December 1996)[6] reveals that neurologists have the highest indemnity paid per file of all specialties ($216,724 vs $149,658). This alarming statistic, when critically analyzed, reveals that failure to diagnose, lack of informed consent, poor documentation and poor doctor-patient relationships are major issues. There is often a fine line between negligent medicine and poor quality of care or inherent risks of disease. Malpractice database information is complex and often flawed. Neurologists should pause to consider that a physician's behavior in developing strong doctor-patient relationships, as well as, giving proper informed consent (especially with use of anti-epileptic drugs, corticosteroids) and documentation will reduce the chances of claims for negligence. Medical-legal information should be part of the education of residents and practitioners. Perhaps the time is right for the AAN to develop an instructional video, in conjunction with medical malpractice carriers to be used in every residency program. This would be a useful first step in educating physicians about medical-legal problems. References 1. Glick TH: Malpractice Claims: Outcome Evidence. Neurology 2001. 2. Holloway RG, Panzer RJ: Lawyers, Litigation and Liability. Can they make patients safer? Neurology 2001; Pages 991-993. 3. Nelson KB: The Neurologically Impaired Child and Alleged Malpractice at Birth. Neurologic Clinics 1999; 17:283-293 (In Medical- Legal Issues Facing Neurologists: Editor, Weintraub MI, W.B. Saunders). 4. Safran A, Skydell B, Ropper S: Expert Witness Testimony in Neurology: Massachusetts Experience 1980-1990, Neurology Chronicle 1992; 2:1-6. 5. Huber T: Galileo's Revenge: Junk Science in the Court Room. Basic Books 1991. 6. Medical Liability Mutual Insurance Company (MLMIC), Specialty Bulletin Dec.1997.