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Monday, April 3, 2017

BY JACKIE LAM

The American College of Emergency Physicians' public censure of Peter Rosen, MD, shed light on how expert witness testimonies are especially problematic for EPs. Emergency Medicine News spoke with David Sklar, MD, a distinguished professor emeritus of emergency medicine at the University of New Mexico and an author of the paper, The Expert Witness in Emergency Medicine, about the reasons behind that and the need for an alternative system to address medical errors. (Ann Emerg Med 2014;63[6]:731.)

Unlike other medical specialties, emergency physicians often have to treat based on incomplete information, with patients they don't know, and whose conditions are not always clear. "In many cases, what you're dealing with are probabilities. For example, someone has chest pain," Dr. Sklar said. "They may have a five percent probability of a heart attack, so now you have to make a decision. Is five percent a high enough number that I need to admit this person to the hospital, knowing that 95 percent of the time they are not going to be having a heart attack?"

These probabilities could lead different physicians to manage a patient differently. This gray area of uncertainty and lack of consensus open up room for expert witnesses to give widely different opinions in the courtroom. "An expert could come in and say, 'In my experience, I would never send someone home when we have a one percent chance of a heart attack.' And now you have the jury sitting there thinking, 'Gee, I don't know. Is one percent high or low? The expert just said he would never do it,'" Dr. Sklar said. "Then you have another expert saying, 'One percent is low. We send them all home all the time.' Then they'll try to look at what the guideline is saying, and the guidelines may not be absolutely clear either."

Given the conditions under which EPs are pressured to make decisions, Dr. Sklar said it's inevitable that they will make some mistakes. "You can always in retrospect see something and say, 'Obviously, he made a mistake, the person died,'" Dr. Sklar said. "But when you are the person practicing, you don't know what is going to happen."

Many different factors, individual and systemic, contribute to medical errors. Most medical injuries are the result of the inherent risk in the practice of medicine or system errors, not negligence. (Int J Gen Med 2013;6:49.) "For example, is information from radiology getting back to the emergency physician accurately and quickly?" Dr. Sklar asked. "Did the nurse and the doctor communicate the right directions to the patient before discharge? To deal with all of those, we have to be able to talk about errors and identify them."

The current medical malpractice system, however, not only zeroes in on care providers to blame but also discourages physicians from addressing their medical errors and preventing future ones. The most commonly cited barrier to disclosure and apology by physicians is fear of legal liability. (Clin Orthop Relat Res 2009;467[2]:376.) Most medical errors are also the result of unavoidable human error, which can only be reduced through system changes. (To Err is Human: Building a Safer Health System. Washington: National Academy Press; 2000.) Punishment for errors will not reduce future errors. It might, however, incentivize workers to hide rather than report these errors.

There is, therefore, a need to replace the existing medical malpractice system with one that would address errors in a constructive way. "It's a human thing to make errors, but it doesn't necessarily mean if you make an error, the person has to suffer," Dr. Sklar said. "We need to change the malpractice system so that it's not emphasizing blame. When you're trying to find an individual to blame, you're essentially saying that it was this person's fault. But most errors are not like that. Most of them are what they call a Swiss cheese model where there are multiple things that happen."

Dr. Sklar said EPs need a good mechanism to deal with medical errors, a support system to talk to when they happen, and a way to move past them so they can continue to practice. He encourages his students to talk about their mistakes and support each other when a medical error happens. He holds a weekly morbidity and mortality conference to talk about medical errors, including surprises and bad outcomes. Having seen many of his colleagues go through medical malpractice suits and quit the profession, Dr. Sklar said that it's key to retaining people in emergency medicine. "We spend so many years training folks. We can't lose them after they have an error," he said.​

Read "Rosen, Censured by ACEP, Disputes Claims as 'Unjust,'" at http://bit.ly/2oCGhrQ​


Wednesday, March 29, 2017

Eight major emergency medicine organizations have formed the Coalition to Oppose Medical Merit Badges, pledging to eliminate hospital requirements that board-certified emergency physicians obtain certification in advanced resuscitation, trauma care, stroke care, cardiovascular care, or pediatric care needed for medical staff privileges.

The organizations also said mandat
ory continuing medical education requirements "do not offer any meaningful value for the public or for the emergency physician who has achieved and maintained board certification," saying those conditions are often promulgated by others who "incompletely understand the foundation of knowledge and skills" acquired by successfully completing an emergency medicine residency program approved by the Accreditation Council for Graduate Medical Education.

These merit badges, the news release stated, add no additional value for board-certified emergency physicians and devalue the board certification process by failing to recognize the rigor of ABEM's Maintenance of Certification program. "In essence, medical merit badges set a lower bar than a diplomate's education, training, and ongoing learning," the coalition said.

T
he eight groups acknowledged that changing the requirements for medical merit badges will be "a long and challenging struggle," but promised to develop a long-term strategy to create success and a pathway to recognize clinical excellence.

The members of the coalition are:

  • American Academy of Emergency Medicine (AAEM)
  • American Academy of Emergency Medicine/Resident and Student Association (AAEM/RSA)
  • American Board of Emergency Medicine (ABEM)
  • American College of Emergency Physicians (ACEP)
  • Association of Academic Chairs of Emergency Medicine (AACEM)
  • Council of Emergency Medicine Residency Directors (CORD)
  • Emergency Medicine Residents' Association (EMRA)
  • Society for Academic Emergency Medicine (SAEM)

Friday, February 10, 2017

UPDATE, March 29, 2017: SummaHealth lost its ACGME appeal, and its emergency medicine residency will close July 1


The emergency medicine residency program at Summa Health in Ohio lost its accreditation and was placed on probation by the Accreditation Council on Graduate Medical Education, according to the Akron Beacon Journal. (http://bit.ly/2ku7ryw.)

ACGME said it will withdraw the accreditation on July 1, though Summa said it would appeal the decision within the 30 days ACGME allotted for that process.

Other emergency medicine residency programs in Ohio have offered to help Summa's first- and second-year residents find new slots to finish their training, but nothing official has been announced.

The SUMMA emergency medicine residency program was started in 1980 by Summa Emergency Associates (SEA), the physician group that staffed Summa's five emergency departments for 40 years but that lost its contract on Jan. 1 to US Acute Care Solutions.

​Read the EMN article about that below.


Thursday, February 2, 2017

BY RUTH SORELLE, MPH

The lightning-swift switch in emergency department physician staffing at Summa Health System in Akron, OH, turned out to be the final straw for the hospital's board of directors. What started with the emergency physician group being replaced on Jan. 1 ended only 25 days later with the Summa board of directors accepting the resignation of Thomas Malone, MD, the controversial president and CEO whose actions sparked the turmoil.

summa hospital.jpg

Those involved in the dispute between the Summa Health System and the emergency medicine group, Summa Emergency Associates (SEA) that staffed its emergency departments for 40 years, agreed on one thing: At midnight on New Year's Eve, the system's contract with SEA ended and one hastily written and approved with US Acute Care Solutions (USACS) was activated.

"The night of the transition, they [physicians from USACS] came in an hour early," said Jeffrey Wright, MD, the president of SEA. "We had all the patients taken care of, and we did an appropriate checkout. They took over the new patients at 11:15 p.m. We checked out, and our doctors left at midnight. Dr. Malone walked us out."

Prior to Dr. Malone's resignation, nearly 250 doctors had voted no confidence in the administration as had the 230 residents in its well-respected residency programs.

Letters from the American College of Emergency Physicians, the American Academy of Emergency Medicine, the Society of Academic Emergency Medicine, and the Emergency Medicine Residents Association all pointed to the need for careful consideration in selecting a leader of the residency program and its faculty. "USACS must also commit itself to the preservation of the academic missions, including the Emergency Medicine residency program, at the Summa Health System Hospitals," SAEM wrote in its statement. "High-stakes negotiations take time, effort, and ultimately, compromise. All stakeholders, including the public, payers, health care administrators, and physicians, must recognize the danger this failed negotiation represents to Emergency Medicine, and ultimately, to the care of critically ill and injured patients. SAEM fully stands with and supports those who have dedicated their academic careers to our specialty as well as the residents and fellows who have trusted Summa Health to provide them with the high-quality training they expected."

There is no question that negotiations between Dr. Malone and Dr. Wright began late. The three-year contract that Summa Health and Summa Emergency Associates operated under until Dec. 31 came about as a request for proposal issued in 2013, said Dr. Wright. To win the contract, his group had to agree to staff emergency departments at the Akron and Barberton campuses, and at Wadsworth-Rittman, Summa Health Green, and Summa Health Medina. Negotiations began in the summer, he said. Only the first two emergency departments were profitable for the group, and SEA told the administration that the hospital had to subsidize operations at the other three facilities for the physician group to avoid a huge financial loss.

Dr. Wright said Dr. Malone put him off when he asked about the contract renewal before late November. "We were offered the first contract in this negotiation on Nov. 28," he said. He said he discussed it briefly with Valerie Gibson, RN, the system's chief operating officer. "That first contract cut GME funding by 20 percent, which took it from 10 core faculty down to five," Dr. Wright said.


summa malone.jpg
 Dr Thomas Malone

That would not meet the requirements of the Accreditation Council for Graduate Medical Education, he said, because the program's 30 residents required 10 faculty members. His rewrite contained a request for a 15-year contract.

"I didn't expect to see it. However, the first contract did not address the low patient volume at the low-performing hospitals," Dr. Wright said. "One hospital sees 21 patients per day. Eighty percent of the patients are urgent care. Another hospital see 31 patients a day. Both have low acuity and volume."

That contract revision also contained a raise for the core faculty and suggested taking them out of two of the poorly performing emergency departments. He suggested making those facilities urgent care, closing them, or finding someone else to staff them. Dr. Wright said he was concerned because the contract suggested by the Summa Health leadership was worse than the one they had received three years before. During these contract negotiations, he said, Vivian von Gruenigen, MD, a senior vice president and the chief medical officer for Summa, took part in the negotiations, a fact that concerned him because she is the wife of Dominic Bagnoli, MD, the chief executive officer of USACS. "That's a major conflict of interest," said Dr. Wright.

Marty Richmond, the director of corporate communications for USACS, which is based in Canton, OH, said his understanding was that "she was peripherally involved in the negotiations with SEA. When it became obvious they would have to look for alternatives, she recused herself."

Mr. Richmond said Summa contacted USACS for the first time on Dec. 24 because he was told negotiations with SEA had stalled. "On the 27th, we were asked for a proposal," he said. "We submitted on the 29th, and by the evening of the 29th, we were told we would begin staffing [all five emergency rooms] at midnight on the first."

Mr. Richmond said USACS has a bank of Ohio physicians from which they could draw to staff the Summa EDs. "The residents were not there when we showed up" on Dec. 31, he said. "They had been sent home for the month of January." USACS officials met with the residents on Jan. 3, and the residents returned that afternoon. Scott Felten, MD, was named interim program director, and Mr. Richmond said Dr. Felten is interviewing faculty replacements. "The door is still open for the former physicians," he said. "The quickest way to continuity for the residency program is through the SEA physicians."

​Sharhabeel Jwayyed, MD, the former director of the residency program, said the loss of the contract and his job "was like an ambush." He said Drs. Wright and Malone talked several times, meeting face-to-face for the first time on Dec. 26. On the 27th, he said, Dr. Malone said SEA was done.

The USACS physicians were given emergency credentials on New Year's Eve and New Year's Day. Kevin Rodgers, MD, the president of the American Academy of Emergency Medicine, said that was a red flag. He said a reasonable search for a residency director and 10 core faculty cannot be done in the five days that USACS had to fill those academic spots. The Accreditation Council for Graduate Medical Education is currently evaluating the program.

Dr. Rodgers said USACS is no longer a strictly physician-owned practice because a hedge fund is involved. USACS was established in May 2015 by Dr. Bagnoli's group, Emergency Medicine Physicians (EMP), and the investment firm of Welsh, Carson, Anderson & Stowe. "AAEM doesn't endorse that," he said.

"What is the bottom line here?" he said. "What about patients, residents and medical staff?" Dr. Rodgers asked. SEA was offered a contract extension, but Dr. Wright said he saw no advantage in that, and Dr. Rodgers agreed. "Jeff Wright looked at the offer for an extension and decided what was good for them. The contract was a bad choice and an extension would put them in a bad place," he said. He acknowledged that opinions on that differ, and said Dr. Wright and the SEA leadership were a bit complacent because of their track record with the hospital group. "There's no one not at fault here," he said.


Monday, January 9, 2017

This article will appear in the February issue of EMN.

​BY RUTH SORELLE, MPH 

A New York emergency physician who has lectured and written extensively on evidence-based medicine and the doctor-patient relationship admitted in a New York court on Dec. 16 to five counts of sexually assaulting four female patients in the emergency department at Mount Sinai Hospital.

A source close to the proceedings said on background that 45-year-old David Newman, MD, pled guilty to all counts of the indictment against him, and was promised by Judge Michael Obus of the Supreme Court a sentence of two years in prison and three years of post-release supervision. Prosecutors had sought four years in prison with 10 years of post-release supervision. Dr. Newman was scheduled for sentencing on Jan. 23, and remained free on $50,000 bond at press time. Neither he nor his attorney returned calls from Emergency Medicine News about the case.

Dr. Newman was suspended immediately after the allegations came to light, said a spokesperson for Mount Sinai and is no longer employed at the hospital, where he had been the director of clinical emergency research. "We believe that with this guilty plea today, justice is served," said the spokesperson. "Mount Sinai took prompt and effective steps to aid in this investigation, fully cooperating with authorities to ensure swift action."

In a civil action filed against him, the hospital, and other emergency department personnel, the woman claimed that she was drugged when she sought treatment for shoulder pain at the Mount Sinai ED Jan. 11, 2016. After triage, according to the suit, she received Toradol and Flexeril. A physician and a physician assistant assessed her condition, and the physician introduced her to Dr. Newman, who became her treating physician, the suit said. While she was waiting for an x-ray, she thought the physician gave her morphine through an IV, she said in the suit. (Dr. Newman said it was propofol.)

As she awaited the test results in an exam room, Dr. Newman entered the room and began to fondle her breasts, according to the civil suit. She said in the suit that he told her she needed more pain medication and despite the fact that she demurred and tried to pull her hand away, he gave her another shot of what she believed was morphine. "The effects of the drugs rendered [her] legally incapable of consenting to sexual conduct," the suit said. "While [she] laid on the examination table, [she] heard sounds and saw movement that led her to believe — a belief that was later confirmed by the lab results — that [Dr. Newman] was masturbating. [Dr. Newman] touched [her] breasts and [she] felt an object on her face and mouth. Soon thereafter, [he] ejaculated on [her] face and breasts," according to the suit.

Records indicated that nurses entered the room afterwards and appeared alarmed by her condition, the suit noted. The patient said in the court filing that she asked that Dr. Newman not enter the room again, and told the physician assistant what had happened. He asked if she wanted the police called, and when she said she did and asked to speak to his supervisor, he said Dr. Newman was his supervisor. He advised her to go home and sleep on it before calling the police, according to the suit.

While the plaintiff asked again to be discharged, Dr. Newman suggested she stay. The effects of the drugs resulted in her being too dizzy to leave the hospital and she stayed in the treatment room for about four hours, the suit noted. Eventually, although still feeling the effects of the drugs, she left the hospital and walked home. Once there, she contacted the police, who took her to Harlem Hospital for examination. Swabs taken from her face tested positive for semen, and the DNA was eventually found to match Dr. Newman's, the suit noted.

​Medical Discipline
More than a year will have passed before Dr. Newman faces sentencing for his actions and the actions themselves. Yet in many cases, physicians who sexually abuse patients face no medical discipline at all, according to a report in PLOS One. (Feb. 3, 2016; http://bit.ly/2hCrjSI.) The study by the Public Citizen Health Research Groups spanned nearly a decade (2003 to 2013) and found that 1,039 physicians had one or more report related to sexual misconduct. Most of the malpractice reports involved women or girls and said the misconduct caused "emotional injury," according to the National Practitioner Data Bank. Most had only licensure reports.

Physicians who had been reported for sexual misconduct were more likely to receive serious licensure actions and revocation of clinical privileges than those reported for other activities, but 70 percent were not disciplined by medical boards at all, according to the research report.

The study's lead author, Azza AbuDagga, PhD, called the findings of the report disturbing, despite the limitations of the National Practitioner Data Bank. "[That] more than two-thirds of the physicians with sexual-misconducted-related clinical privileges and malpractice-payment reports were not disciplined by any state medical board for such conduct is concerning because the NPDB" (National Practitioner Data Bank) gives medical boards access to such reports from each of the states, the report said. Dr. AbuDagga noted that the rate of reporting for such abuse is lower than would be expected. Patients often do not report such incidents, she said. Often there is no physical evidence and attorneys are reluctant to take cases when financial rewards are not expected to be huge.

While medical boards are charged with protecting the public from such physicians, there is often no legislative oversight. Dr. AbuDagga said states should look at a law passed in Illinois in 2011 that permanently and immediately revokes the license of a person convicted of a sex crime. "Within a few months [of that law's passage], the state revoked the licenses of 12 professionals who had been convicted of sexual crimes," she said.

"At the end of day, it is all with reporting," said Dr. AbuDagga. "The authorities need to take sexual misconduct and give it the weight it deserves. The damage to these patients is for life."

Preventing such actions starts with the patient, she said. "Patients should ask for a chaperone, especially if they are seeking care that involves an intimate exam," Dr. AbuDagga explained, adding that hospitals should be required by law to query the data bank for every physician they hire or to whom they give clinical privileges. A continuous query that notifies them automatically when a report is sent to the data bank would be the safest, she said.

Patients do not have access to the National Practitioner Data Bank, she said, but they can look up their physician's record through the Federation of State Medical Boards' website. (https://www.fsmb.org/.)

A recent report from the Atlanta-Journal Constitution found that more than 2,400 doctors in the United States have been sanctioned for sexually abusing patients, but the state medical boards allowed more than half of them to keep their licenses. (Dr. Newman's license was suspended soon after the allegations were made, and Mount Sinai forbade him from practicing in the hospital.)

Dr. Newman referred in his book, Hippocrates' Shadow, to a 2005 perspective piece in The New England Journal of Medicine about the lack of professional standards for patient modesty and discretion in the physical examination of patients. "For instance, should there be same-sex chaperones present for examinations of a potentially private body area? And which areas — the waistline, the groin, the buttocks? ... There's no policy, no approved or disseminated guidelines, no ethical writ and no accepted convention."