Thursday, March 25, 2010

Go Gators! An interesting use of "sovereign immunity" in Florida's medical malpractice reform

It's been an awful week or two for medical malpractice reform with state supreme courts in Georgia and Illinois striking down award caps on the vague category of "pain and suffering". (Missouri's supreme court reaffirmed that state's caps this same week ~ Rob)Such caps have been one of the most effective ways of discouraging frivolous or borderline lawsuits as it disincentives such proceedings unless the cases are truly egregious.

Florida has a bill being considered in it's legislature that would extend the concept of "sovereign immunity" to providers in the Emergency Room. Such status makes providers de facto ``agents of the state'', and consequently immune from medical malpractice lawsuits. In that setting the state would administer any successful claim, which would be subject to the sovereign immunity cap of $200,000. To recover more, victims would need to file a claims bill in the Florida Legislature. This turns the malpractice system into more of a no-fault worker's comp type of arrangement.

You can't help but think that would be a more efficient and fair way to administer such claims. Of course, trial lawyers are screaming bloody murder, but keeping them happy is low on society's to-do list (unless you are a Democrat politician accepting their bribes err... campaign contributions). If physicians are going to be involuntarily obligated by hospital credential committees or federal and state licensing issues to provide emergency services, they should at least enjoy some protection from these high risk (for malpractice exposure) duties. Kudos to Florida for experimenting with some real world solutions to tort reform!

Read more at the Miami Herald about this interesting idea.


Tuesday, March 23, 2010

New conflict of interest (COI) rules could decimate academic plastic surgery

The potential of conflicts (COI) for physicians who accept stipends or consulting fees has led some medical schools to formally prohibit their clinical faculty from accepting such compensation. This movement led to the resignation of a number of distinguished doctors who participate in industry sponsored research, consulting arrangements, and educational events. While not universal among medical schools at this point, this trend is likely to keep some of the best and brightest out of academics. Some consultants and speaks make tens or hundreds of thousands of dollars annually to supplement their clinical practice. As academic overhead tends to run high, this opportunity to make alternative income allowed some people to stay in academic surgery who might otherwise leave for pure private practice setups.

Stanford University has now (read here) taken the dramatic step of restricting even volunteer clinical or "adjunct" faculty from this as well. This type of restriction could have a potentially devastating effect on Plastic Surgery training as a number of the most prominent programs in plastic surgery (NYU, University of Texas-Southwestern, Emory, Johns Hopkins, Georgetown, Michigan, etc...) feature many active and adjunct surgeons whom recieve industry support or give educational seminars. The loss of access to these surgeons for training for real (or imagined) COI would be a big blow to the field. In January, the issue was highlighted in a when Boston doctor and well known Allergist-Immunologist, Dr. Lawrence DuBuske, resigned his Harvard medical school position rather than give up his speaking engagements. DuBuske got almost $99,000 from pharmaceutical giant GlaxoSmithKline in three months last year, more than any other doctor in the country.

While most speakers don't score that much in fees, it can add up to a substantial supplement to someone's clinical practice. COI have been managed in recent years by more stringent required disclosures by speakers at meetings and in our medical journals. The FDA has made efforts to remove panel members from hearings with any potential COI from drug and medical device hearings, including the hearings over silicone gel breast implants earlier this decade. The loggerheads with that idea is that many of the experts in these specialized fields inevitably have some COI from funding, speaking fees, stock holdings, or even intellectual property (shared or owned patents). Scott Spears (chief of plastic surgery at Georgetown University) is one of the world's experts on breast implants, but his testimony before the FDA during the hearings on silicone breast implants was attacked by activists trying to prevent the reintroduction of those devices by any means necessary because he is involved with dozens of companies in R&D, educational endeavours, and speaking sessions.

IMO, as long as clear disclosure by physicians is made these COI issues are manageable as long we always maintain some skepticism about what we are told and review data critically.


Sunday, March 21, 2010

Plastic Surgery 101's "Mythbusters" on the health care debate

As a physician, I have a vested interest in following the debate on reinventing the American health care system. Listening to these discussions, I find there is a distinct lack of candor about where the costs are in the system and little insight into where true potential savings are.

  • MYTH: Electronic medical records (EMR) will save money

FACT: No one can plausibly explain how any money will be saved. EMR does offer portablility of records, but does nothing to control cost in and of itself. The costs for physicans and hospitals to purchase equipment and pay ongoing subscription and IT costs will be a HUGE burden.
WINNERS: EMR vendors, IT companies, database miners and researchers
LOSERS: productivity of an office
OFF THE RECORD: Why should I be expected to subsidize a national EMR system through my office overhead when it's uncompensated and will surely be used down the road to squeeze providers?

  • MYTH: Primary Care Providers (PCP) are the sacred cow in reform and hold the key to holding costs down

FACT: The PCP workforce is under and ill-equiped to treat a mass influx of patients into the system. It will take years to retool the training infrastructure to handle the volume of patients. Massachusetts experiment in universal care for it's citizens has been crippled by an insufficent number of participating PCP MD's.
WINNERS: PCP will be getting a small increase in fees for routine office visits per the federal government at the expense of some specialists (Cardiologists, Radioloists, & GI docs mostly)
LOSERS: specialists physicians
OFF THE RECORD: Medical students will continue to avoid primary care because they percieve it tedious and they realize that nurse practictioners can do 85%+ of what they do for 50 cents on the dollar. It's also intuitive that specialists who work more and have trained 2-3x as long would be expected to earn a good deal more then PCP's.

  • MYTH: It's hard to find savings in healthcare!

FACT: There are some big savings in proceduras that could clearly be achieved with little affect on quality of care. Rigidly restricting (thru evidence based indications) the use of knee/shoulder arthroscopy and joint replacement surgery by orthopedists, upper/lower endoscopy by Gastroentreologists, coronary catheterization and stents by Cardiologists, lumbar spine surgery by Neurosurgeons, and the overuse of CT/MRI scans by all of us are the low hanging fruit in cost containment.
WINNERS: whoever's paying the bill (the feds or insurers)
LOSERS: whichever doctor's procedures are restricted and the idea (endorsed by my mother, wife, and many non-thoughtful doctors) that procedure or study "x" should be done "Just to be safe."
OFF THE RECORD: There's no way to make the numbers work without doing these kinds of restrictions. BTW I would not want to be a radiologist who expects to make big bucks in the next few years as they're about to get scalped.

One thing that makes me shake my head is the disconnect in the popular press when they talk about how individual doctor's practices are coping or planning to cope with whatever's coming. My favorite is the young PCP who is featured just out of residency boldly proclaiming things about how they're going to reinvent the doctor patient relationship by their use of technology.


Monday, March 01, 2010

Breast Implant bombs - Can you weaponize an implant? Unfortunately yes.

I saw a story today which touched on something I'd been thinking about for years. Apparently Islamic terrorists have been working on a way of turning a breast implant into a way to smuggle explosive liquids onto airliners. While that may sound like a joke headline from The Onion, it's really a scarry idea.

From relatively simple and innocuous ingredients, a highly explosive liquid can be produced.

This link to a BBC story demonstrates the devastating effect on a plane fuselage that such a liquid explosive could have:

I'm not exactly sure how you would trigger it, but presumable you could stab into the implant with a wire or pin and wire it to a celphone or battery (this type of liquid material can be ingnited with an electic charge)