Managing Your Practice

At press time, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices was expected to release recommendations for immunizing target populations against the novel 2009 H1N1 (pandemic) virus and for setting priorities in the likely event of a limited initial vaccine supply. Even with that guidance, though, I'm sure a lot of questions will remain about how this is really going to work.

Rolling out the pandemic influenza vaccine to appropriate high-risk groups, while also keeping up with seasonal influenza immunizations, is going to be highly challenging and complex.

For starters, if the virus continues to be less virulent than expected for a pandemic, it may be difficult to convince even high-risk populations to get vaccinated. And should the virus mutate and become more virulent, how can we get people to stick to the priorities advised by ACIP, especially when the vaccine is likely to be administered in a variety of settings outside of physician offices? And, as additional vaccine supply becomes available, how can we quickly alter the public health message to match the epidemiology of the pandemic and encourage the right people to get their shots?

The only thing that seems clear at this point is that the future of the 2009 H1N1 pandemic virus is unpredictable. The fact that it has persisted through the summer is in itself unusual, and we should be prepared for infection rates to increase this fall when school is back in session.

So what can primary care physicians do right now to prepare their offices?

Make sure that you and your staff are vaccinated, as soon as vaccine is available, against both seasonal and pandemic influenza. The immunization of health care providers should be considered high priority, so set up a system for following up with your staff to make sure that everyone receives vaccine against both seasonal and pandemic flu. Remember that the pandemic vaccine will probably require two doses. Don't assume that everyone is immunized. Data show that up to one-half of health care providers are not immunized against the seasonal flu.

Chemoprevention strategies will change depending on the resistance pattern and availability of antiviral medications. Offices could stock oseltamivir (Tamiflu) or zanamivir (Relenza) to use as chemoprevention for staff until they are fully immunized, but that would be an expensive strategy and the added value over rigorous infection control practices is unknown.

It's probably wise to call your local pharmacy and ask if there is likely to be a problem getting the amount of antiviral medication you would need to treat yourself and your staff, should that become recommended.

Chemoprevention of health care staff might be recommended if the virus becomes more virulent as health care workers are waiting to finish a two-dose schedule of vaccine. Make a few calls now to see where supplies could be located should you need chemoprevention drugs quickly.

If patient volume has tapered during the summer months, use the time to do some in-service training on hand washing (wash-in, wash-out practices) for all staff with patient contact. Proper hand washing or sanitizing reduces the risk of infection and needs to be performed correctly and consistently. Teach your staff members by showing them what you want them to do. While the public health message on hand washing has been stressed, the reality is that many clinical settings have become somewhat lackadaisical about enforcing infection control practices.

Also take the time now to check on the supply of personal protective gear such as gloves, masks, and eye protection and review with your staff appropriate use of protective gear for all routine procedures that can lead to exposure to the virus. This includes collecting oropharyngeal and nasopharyngeal specimens for the laboratory.

Stock up on tissues and hand sanitizer and delegate the job of keeping those items in plentiful supply in the patient waiting area and exam rooms. Put up signs instructing patients to use respiratory hygiene in the clinic and instruct staff to politely point out to patients when they are not covering their coughs and sneezes.

Take some time now to do some strategic thinking about how you could maximize your office space to triage and separate potentially infectious patients should the pandemic hit your local region particularly hard. Consider rearranging the appointment schedule so that patients with infectious conditions are seen toward the end of the day.

Finally, delegate someone on your staff to check the local health department Web site regularly, as well as the site of the Centers for Disease Control and Prevention (www.cdc.gov/h1n1flu/

 

▸ Who should receive the vaccine in order of priority.

▸ Who should be treated with antivirals if ill (and what antivirals to use).

▸ Who should receive antivirals prophylactically (and what antivirals to use).

At press time, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices was expected to release recommendations for immunizing target populations against the novel 2009 H1N1 (pandemic) virus and for setting priorities in the likely event of a limited initial vaccine supply. Even with that guidance, though, I'm sure a lot of questions will remain about how this is really going to work.

Rolling out the pandemic influenza vaccine to appropriate high-risk groups, while also keeping up with seasonal influenza immunizations, is going to be highly challenging and complex.

For starters, if the virus continues to be less virulent than expected for a pandemic, it may be difficult to convince even high-risk populations to get vaccinated. And should the virus mutate and become more virulent, how can we get people to stick to the priorities advised by ACIP, especially when the vaccine is likely to be administered in a variety of settings outside of physician offices? And, as additional vaccine supply becomes available, how can we quickly alter the public health message to match the epidemiology of the pandemic and encourage the right people to get their shots?

The only thing that seems clear at this point is that the future of the 2009 H1N1 pandemic virus is unpredictable. The fact that it has persisted through the summer is in itself unusual, and we should be prepared for infection rates to increase this fall when school is back in session.

So what can primary care physicians do right now to prepare their offices?

Make sure that you and your staff are vaccinated, as soon as vaccine is available, against both seasonal and pandemic influenza. The immunization of health care providers should be considered high priority, so set up a system for following up with your staff to make sure that everyone receives vaccine against both seasonal and pandemic flu. Remember that the pandemic vaccine will probably require two doses. Don't assume that everyone is immunized. Data show that up to one-half of health care providers are not immunized against the seasonal flu.

Chemoprevention strategies will change depending on the resistance pattern and availability of antiviral medications. Offices could stock oseltamivir (Tamiflu) or zanamivir (Relenza) to use as chemoprevention for staff until they are fully immunized, but that would be an expensive strategy and the added value over rigorous infection control practices is unknown.

It's probably wise to call your local pharmacy and ask if there is likely to be a problem getting the amount of antiviral medication you would need to treat yourself and your staff, should that become recommended.

Chemoprevention of health care staff might be recommended if the virus becomes more virulent as health care workers are waiting to finish a two-dose schedule of vaccine. Make a few calls now to see where supplies could be located should you need chemoprevention drugs quickly.

If patient volume has tapered during the summer months, use the time to do some in-service training on hand washing (wash-in, wash-out practices) for all staff with patient contact. Proper hand washing or sanitizing reduces the risk of infection and needs to be performed correctly and consistently. Teach your staff members by showing them what you want them to do. While the public health message on hand washing has been stressed, the reality is that many clinical settings have become somewhat lackadaisical about enforcing infection control practices.

Also take the time now to check on the supply of personal protective gear such as gloves, masks, and eye protection and review with your staff appropriate use of protective gear for all routine procedures that can lead to exposure to the virus. This includes collecting oropharyngeal and nasopharyngeal specimens for the laboratory.

Stock up on tissues and hand sanitizer and delegate the job of keeping those items in plentiful supply in the patient waiting area and exam rooms. Put up signs instructing patients to use respiratory hygiene in the clinic and instruct staff to politely point out to patients when they are not covering their coughs and sneezes.

Take some time now to do some strategic thinking about how you could maximize your office space to triage and separate potentially infectious patients should the pandemic hit your local region particularly hard. Consider rearranging the appointment schedule so that patients with infectious conditions are seen toward the end of the day.

Finally, delegate someone on your staff to check the local health department Web site regularly, as well as the site of the Centers for Disease Control and Prevention (www.cdc.gov/h1n1flu/

 

▸ Who should receive the vaccine in order of priority.

▸ Who should be treated with antivirals if ill (and what antivirals to use).

▸ Who should receive antivirals prophylactically (and what antivirals to use).

At press time, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices was expected to release recommendations for immunizing target populations against the novel 2009 H1N1 (pandemic) virus and for setting priorities in the likely event of a limited initial vaccine supply. Even with that guidance, though, I'm sure a lot of questions will remain about how this is really going to work.

Rolling out the pandemic influenza vaccine to appropriate high-risk groups, while also keeping up with seasonal influenza immunizations, is going to be highly challenging and complex.

For starters, if the virus continues to be less virulent than expected for a pandemic, it may be difficult to convince even high-risk populations to get vaccinated. And should the virus mutate and become more virulent, how can we get people to stick to the priorities advised by ACIP, especially when the vaccine is likely to be administered in a variety of settings outside of physician offices? And, as additional vaccine supply becomes available, how can we quickly alter the public health message to match the epidemiology of the pandemic and encourage the right people to get their shots?

The only thing that seems clear at this point is that the future of the 2009 H1N1 pandemic virus is unpredictable. The fact that it has persisted through the summer is in itself unusual, and we should be prepared for infection rates to increase this fall when school is back in session.

So what can primary care physicians do right now to prepare their offices?

Make sure that you and your staff are vaccinated, as soon as vaccine is available, against both seasonal and pandemic influenza. The immunization of health care providers should be considered high priority, so set up a system for following up with your staff to make sure that everyone receives vaccine against both seasonal and pandemic flu. Remember that the pandemic vaccine will probably require two doses. Don't assume that everyone is immunized. Data show that up to one-half of health care providers are not immunized against the seasonal flu.

Chemoprevention strategies will change depending on the resistance pattern and availability of antiviral medications. Offices could stock oseltamivir (Tamiflu) or zanamivir (Relenza) to use as chemoprevention for staff until they are fully immunized, but that would be an expensive strategy and the added value over rigorous infection control practices is unknown.

It's probably wise to call your local pharmacy and ask if there is likely to be a problem getting the amount of antiviral medication you would need to treat yourself and your staff, should that become recommended.

Chemoprevention of health care staff might be recommended if the virus becomes more virulent as health care workers are waiting to finish a two-dose schedule of vaccine. Make a few calls now to see where supplies could be located should you need chemoprevention drugs quickly.

If patient volume has tapered during the summer months, use the time to do some in-service training on hand washing (wash-in, wash-out practices) for all staff with patient contact. Proper hand washing or sanitizing reduces the risk of infection and needs to be performed correctly and consistently. Teach your staff members by showing them what you want them to do. While the public health message on hand washing has been stressed, the reality is that many clinical settings have become somewhat lackadaisical about enforcing infection control practices.

Also take the time now to check on the supply of personal protective gear such as gloves, masks, and eye protection and review with your staff appropriate use of protective gear for all routine procedures that can lead to exposure to the virus. This includes collecting oropharyngeal and nasopharyngeal specimens for the laboratory.

Stock up on tissues and hand sanitizer and delegate the job of keeping those items in plentiful supply in the patient waiting area and exam rooms. Put up signs instructing patients to use respiratory hygiene in the clinic and instruct staff to politely point out to patients when they are not covering their coughs and sneezes.

Take some time now to do some strategic thinking about how you could maximize your office space to triage and separate potentially infectious patients should the pandemic hit your local region particularly hard. Consider rearranging the appointment schedule so that patients with infectious conditions are seen toward the end of the day.

Finally, delegate someone on your staff to check the local health department Web site regularly, as well as the site of the Centers for Disease Control and Prevention (www.cdc.gov/h1n1flu/

 

▸ Who should receive the vaccine in order of priority.

▸ Who should be treated with antivirals if ill (and what antivirals to use).

▸ Who should receive antivirals prophylactically (and what antivirals to use).

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

 

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

 

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

If you haven't taken a close look at your managed care plans recently, you may be shocked to find that you have been staying with a doddering old plan whose fee schedule is terrible, and whose few patients are generating negligible remuneration for your practice—when long ago you could have replaced it with a young, aggressive, well-paying organization.

This is the sort of disagreeable task most physicians plan to do in their “free time” (which, of course, is never). But the effort can be well worth it.

It is a pretty safe bet that third-party payers aren't going to take it upon themselves to pay you more. You have to ask for a raise.

Here's how to do it: First, ask your employees to assemble data starting with lists of the last 50 patients affiliated with each third-party contract. Your computer should be able to assemble these. For each patient, compile diagnoses, procedure codes billed, amount billed and paid for each code, and any problems encountered (especially payment delays and requests for records). Ask for any correspondence on file with claims departments and medical directors over the last year.

Next, send out a questionnaire to each provider relations department. Indicate that you are updating your managed care data. Include a list of your 25 most commonly used CPT codes, and ask for the plan's maximum allowable reimbursement for each.

Then ask some basic questions. Here are the five we ask:

▸ Does your organization recognize the “-25” modifier?

▸ If a diagnostic or surgical procedure and an evaluation and management encounter are performed during the same patient visit, does your organization reimburse them as separate services?

▸ If multiple diagnostic or surgical procedures are performed on the same day, how does your organization reimburse such procedures?

▸ What are your official criteria for coding consults versus office visits?

▸ What is your average and maximum time for processing a clean claim?

Have a staffer follow each letter with a telephone call in 10 days to make sure the letter was received and will be answered promptly.

Once the data have been assembled, schedule a meeting with your office manager and your insurance specialist. At the meeting, armed with the answers received from each payer and the data collected, analyze each plan in detail.

How many patients enrolled in the plan are currently active in your office? Is that number increasing or decreasing? How well, compared with other plans, Medicare, and your regular fees, does each one compensate you? How promptly are you paid? What problems have you had with referral and claim forms? Are you permitted to bill patients for noncovered charges?

Now, get more specific. Precisely what is not covered? Which procedures are paid particularly well and which particularly poorly (or not at all), despite being ostensibly “covered”? Are there any weird rules for certain surgical or diagnostic procedures? Do you get an inordinate number of requests for “further information”? Are you asked for the same information repeatedly? Are there problems with “-25,” “-78,” or other modifiers?

Take a look at the numbers. What fraction of accounts receivable is due to each plan at any particular moment? Is that number increasing? Is that because the number of patients in the plan is increasing, or is the plan losing momentum in bill paying? (The latter is a red flag.)

Also, look at mechanics. How easy is it for patients in each plan to get a referral to your office? Do primary care practitioners dole out referrals as if they were diamonds? (Some plans still give PCPs financial incentives not to refer. Review your contracts.) On those all-too-common occasions when patients show up for an appointment without a valid referral, how easy does the plan make it to get them one quickly?

Finally, talk to your staff. Their subjective impressions are just as important as any hard data. They'll separate the “good” plans from the “bad” immediately, but ask some specific questions, too. Are staff constantly cutting through red tape to get patients seen? Are claim forms confusing or hard to file? How hard is it to reach provider relations—and are they helpful and courteous? Are provider relations representatives constantly calling with inappropriate questions?

Now you have your own up-to-the-minute managed care database. Use it immediately to determine which plans to keep and which to cut loose. Repeat this exercise regularly.

And there's one other important use for the database: Use it to renegotiate fee schedules. Any plan whose fees are below your average remuneration should receive a letter informing them of this. However, tell them that you will be pleased to give them the opportunity to remain associated with your practice if their reimbursements are increased.

 

They may not give the entire increase you want, but you'll usually get something. If not, reconsider your decision to keep that plan aboard.

Women who have been treated for cervical intraepithelial neoplasia (CIN) face an elevated risk of recurrence and invasive cervical cancer. That’s the conclusion drawn from a recent population-based study of 37,142 women who were treated for CIN 1, 2, or 3 between 1986 and 2000.

In the first 6 years after treatment, the cumulative rate of CIN 2 or 3 in this group was:

• 14.0% in women originally treated for CIN 3
• 9.3% in women originally treated for CIN 2
• 5.6% in women originally treated for CIN 1.

After 6 years, annual rates of CIN 2 or 3 were less than 1%.

The overall incidence of invasive cancer was 37 cancers for every 100,000 woman-years in the group that had a history of CIN, versus 6 cancers for every 100,000 woman-years in the comparison cohort, which comprised 71,213 women who had normal cytology and no previous diagnosis of CIN.

Cryotherapy was the least “durable” treatment

In addition to the grade of CIN, the woman’s age and type of treatment had a bearing on the likelihood of recurrence. According to the study, the risk of invasive cervical cancer and recurrent CIN 2 or 3 was highest among women who were older than 40, previously treated for CIN 3, or treated with cryotherapy.

For example, among women 40 to 49 years old, the 6-year adjusted rate of CIN 2 or 3 ranged from 2.6% for treatment of CIN 1 using the loop electrosurgical procedure (LEEP), to 34.0% for treatment of CIN 3 using cryotherapy.

Implications of the findings

The study sheds new light on the long-term risks of abnormal cell growth and invasive cancer, and should help in the development of follow-up treatment guidelines for women who have a history of treatment for abnormal cells.

“We now have a much more clear idea of the risks of recurrent abnormal cells and invasive cervical cancer over time after treatment of these cells,” said Joy Melnikow, professor of family and community medicine and associate director of the UC Davis Center for Healthcare Policy and Research, who led the study.

Melnikow said the findings may help physicians determine the optimal intensity of follow-up after treatment of CIN. The findings may also help physicians and patients select a treatment.

For example, although cryotherapy was associated with a higher risk of recurrence, it carries a lower risk of other harmful effects than cone biopsy or LEEP, procedures that have been associated with preterm delivery, Melnikow explained.

This suggests that a younger woman who has CIN 2 and who plans to start a family might opt for cryotherapy, whereas an older woman who has CIN 3—and is therefore at greatest risk of recurrence—might opt for LEEP or cone biopsy.

“These data may help inform that treatment discussion, because we know more about how age and different treatments appear to influence risks,” Melnikow said.

She also noted that the study has different implications for health policy, depending on the health system and resources. In developing countries, where cervical cancer screening and treatment are more limited and the death rate is higher for cervical cancer, cryotherapy, a simpler and less expensive treatment method, is likely to be preferred.

Melnikow said the next step is to compare different treatment and surveillance strategies in terms of cost-effectiveness.

The study was published May 12 in the online issue of the Journal of the National Cancer Institute.

Women who have been treated for cervical intraepithelial neoplasia (CIN) face an elevated risk of recurrence and invasive cervical cancer. That’s the conclusion drawn from a recent population-based study of 37,142 women who were treated for CIN 1, 2, or 3 between 1986 and 2000.

In the first 6 years after treatment, the cumulative rate of CIN 2 or 3 in this group was:

• 14.0% in women originally treated for CIN 3
• 9.3% in women originally treated for CIN 2
• 5.6% in women originally treated for CIN 1.

After 6 years, annual rates of CIN 2 or 3 were less than 1%.

The overall incidence of invasive cancer was 37 cancers for every 100,000 woman-years in the group that had a history of CIN, versus 6 cancers for every 100,000 woman-years in the comparison cohort, which comprised 71,213 women who had normal cytology and no previous diagnosis of CIN.

Cryotherapy was the least “durable” treatment

In addition to the grade of CIN, the woman’s age and type of treatment had a bearing on the likelihood of recurrence. According to the study, the risk of invasive cervical cancer and recurrent CIN 2 or 3 was highest among women who were older than 40, previously treated for CIN 3, or treated with cryotherapy.

For example, among women 40 to 49 years old, the 6-year adjusted rate of CIN 2 or 3 ranged from 2.6% for treatment of CIN 1 using the loop electrosurgical procedure (LEEP), to 34.0% for treatment of CIN 3 using cryotherapy.

Implications of the findings

The study sheds new light on the long-term risks of abnormal cell growth and invasive cancer, and should help in the development of follow-up treatment guidelines for women who have a history of treatment for abnormal cells.

“We now have a much more clear idea of the risks of recurrent abnormal cells and invasive cervical cancer over time after treatment of these cells,” said Joy Melnikow, professor of family and community medicine and associate director of the UC Davis Center for Healthcare Policy and Research, who led the study.

Melnikow said the findings may help physicians determine the optimal intensity of follow-up after treatment of CIN. The findings may also help physicians and patients select a treatment.

For example, although cryotherapy was associated with a higher risk of recurrence, it carries a lower risk of other harmful effects than cone biopsy or LEEP, procedures that have been associated with preterm delivery, Melnikow explained.

This suggests that a younger woman who has CIN 2 and who plans to start a family might opt for cryotherapy, whereas an older woman who has CIN 3—and is therefore at greatest risk of recurrence—might opt for LEEP or cone biopsy.

“These data may help inform that treatment discussion, because we know more about how age and different treatments appear to influence risks,” Melnikow said.

She also noted that the study has different implications for health policy, depending on the health system and resources. In developing countries, where cervical cancer screening and treatment are more limited and the death rate is higher for cervical cancer, cryotherapy, a simpler and less expensive treatment method, is likely to be preferred.

Melnikow said the next step is to compare different treatment and surveillance strategies in terms of cost-effectiveness.

The study was published May 12 in the online issue of the Journal of the National Cancer Institute.

Women who have been treated for cervical intraepithelial neoplasia (CIN) face an elevated risk of recurrence and invasive cervical cancer. That’s the conclusion drawn from a recent population-based study of 37,142 women who were treated for CIN 1, 2, or 3 between 1986 and 2000.

In the first 6 years after treatment, the cumulative rate of CIN 2 or 3 in this group was:

• 14.0% in women originally treated for CIN 3
• 9.3% in women originally treated for CIN 2
• 5.6% in women originally treated for CIN 1.

After 6 years, annual rates of CIN 2 or 3 were less than 1%.

The overall incidence of invasive cancer was 37 cancers for every 100,000 woman-years in the group that had a history of CIN, versus 6 cancers for every 100,000 woman-years in the comparison cohort, which comprised 71,213 women who had normal cytology and no previous diagnosis of CIN.

Cryotherapy was the least “durable” treatment

In addition to the grade of CIN, the woman’s age and type of treatment had a bearing on the likelihood of recurrence. According to the study, the risk of invasive cervical cancer and recurrent CIN 2 or 3 was highest among women who were older than 40, previously treated for CIN 3, or treated with cryotherapy.

For example, among women 40 to 49 years old, the 6-year adjusted rate of CIN 2 or 3 ranged from 2.6% for treatment of CIN 1 using the loop electrosurgical procedure (LEEP), to 34.0% for treatment of CIN 3 using cryotherapy.

Implications of the findings

The study sheds new light on the long-term risks of abnormal cell growth and invasive cancer, and should help in the development of follow-up treatment guidelines for women who have a history of treatment for abnormal cells.

“We now have a much more clear idea of the risks of recurrent abnormal cells and invasive cervical cancer over time after treatment of these cells,” said Joy Melnikow, professor of family and community medicine and associate director of the UC Davis Center for Healthcare Policy and Research, who led the study.

Melnikow said the findings may help physicians determine the optimal intensity of follow-up after treatment of CIN. The findings may also help physicians and patients select a treatment.

For example, although cryotherapy was associated with a higher risk of recurrence, it carries a lower risk of other harmful effects than cone biopsy or LEEP, procedures that have been associated with preterm delivery, Melnikow explained.

This suggests that a younger woman who has CIN 2 and who plans to start a family might opt for cryotherapy, whereas an older woman who has CIN 3—and is therefore at greatest risk of recurrence—might opt for LEEP or cone biopsy.

“These data may help inform that treatment discussion, because we know more about how age and different treatments appear to influence risks,” Melnikow said.

She also noted that the study has different implications for health policy, depending on the health system and resources. In developing countries, where cervical cancer screening and treatment are more limited and the death rate is higher for cervical cancer, cryotherapy, a simpler and less expensive treatment method, is likely to be preferred.

Melnikow said the next step is to compare different treatment and surveillance strategies in terms of cost-effectiveness.

The study was published May 12 in the online issue of the Journal of the National Cancer Institute.

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

 

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

 

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

Mother: 3 ObGyns, nursing staff are all liable for my stillbirth

EIGHT MONTHS INTO HER PREGNANCY, a morbidly obese 27-year-old woman experienced vaginal bleeding. She was examined by Dr. A, an ObGyn. After initial difficulty finding a fetal heart rate, he detected it after 1 hour and sent the woman home. At 42 weeks into her pregnancy, she returned for induction of labor. The nurses found the cervix to be thick and closed. The patient was discharged after Dr. B, another ObGyn, was consulted. She was seen by Dr. C, a third ObGyn, when she returned the next day. At first, the fetal heartbeat was detected, but within a few hours it could no longer be found. An emergency cesarean delivery was ordered, but the infant was stillborn.

PATIENT’S CLAIM Dr. A was negligent for not following the patient more closely after her visit at 8 months. Dr. B should have kept her overnight in the hospital for monitoring. Dr. C delayed ordering the cesarean delivery. And the nurses failed to assess, monitor, and communicate her condition.

PHYSICIANS’ DEFENSE Dr. B claimed (1) his assessment was reasonable based on the patient’s presentation, and (2) attempting a vaginal delivery was preferable because of the mother’s size, so there was no need to rush a cesarean delivery. Dr. C claimed he ordered the cesarean delivery in a timely manner. And the hospital claimed its nurses properly monitored the patient and informed Dr. C of her condition. Also, the fetus died of a thrombosis of the umbilical cord—which could not be detected or prevented—4 to 6 hours before the woman arrived at the hospital.

VERDICT Kentucky defense verdict.

Needle fragment left near uterus. Should the patient be told?

A WOMAN IN HER THIRTIES with uterine fibroids underwent a myomectomy performed by her gynecologist. The patient was not told that a small piece of the surgical needle broke off during the procedure and remained in the vicinity of her uterus. When she developed a bowel obstruction a few months later, she went to the emergency room, where the same gynecologist treated her and sent her home. Eventually, she was treated by another physician, who reviewed her medical records and informed her of the broken surgical needle mishap—which was not associated with the bowel obstruction.

PATIENT’S CLAIM The presence of the broken needle posed a threat to her health. She should have been told and given the option for its surgical removal.

PHYSICIAN’S DEFENSE The portion of the needle that had broken off was insignificant in size and was no medical threat. Breakage of a needle was a known risk of the procedure, and she was not informed because it had no medical significance.

VERDICT New Jersey defense verdict.

Aggressive D & C to blame for Asherman’s syndrome?

A 32-YEAR-OLD WOMAN who had recently given birth presented at the hospital with vaginal bleeding. Her ObGyn performed a dilation and curettage (D & C) procedure, with suction curettage followed by curettage with a sharp curette. This stopped the bleeding, and the patient was put on a 3-month birth-control regimen. When her menstruation did not resume after 3 months, the ObGyn diagnosed Asherman’s syndrome.

PATIENT’S CLAIM (1) The ObGyn should have checked her medical records more carefully, because the D & C was contraindicated. (2) She should have been treated with medical management rather than surgery. (3) The pathology report from the D & C indicated that the uterus and cervix were scraped overzealously during the sharp-curette phase.

PHYSICIAN’S DEFENSE The patient’s symptoms and a hematocrit of 28 showed she was hemodynamically unstable and—in the absence of surgery—at risk of rapid decompensation and death. Also, Asherman’s syndrome is a known risk of a D & C.

VERDICT A $700,000 New York verdict.

Woman learns too late her lump is not swollen milk gland

WHEN A 30-YEAR-OLD WOMAN went to Dr. K for prenatal care, she asked him to check a lump on her left breast. He diagnosed a milk gland that was swollen due to previous breastfeeding—but she had never breastfed. A sonogram was ordered and showed two masses that could be dermal or breast lesions; an excisional biopsy was ordered. Dr. K signed the report, but did not discuss it with the patient. For the remainder of her pregnancy, there was no follow-up examination of the lump. At her 6-month postdelivery checkup, the lump was not mentioned and a biopsy was not ordered. On her next visit, she was seen by Dr. L, whom she asked to examine the lump. No follow-up testing was performed when he concluded the lump was a swollen milk gland. When frequent stomach-related problems sent her to the emergency room, Dr. L prescribed pain medications and sent her home. Several months later, the patient underwent back surgery performed by Dr. M. The following day she learned that the breast lump was, in fact, cancer and that it had spread—and she now had two tumors on her spine and three on her brain. She had a mastectomy and underwent radiation treatment. Three years later, she died.

 

PLAINTIFF’S CLAIM Dr. K was negligent for failing to order the recommended biopsy

PHYSICIAN’S DEFENSE Dr. K admitted negligence, but argued causation. Death was caused by the cancer; nothing he did—or did not do—affected the outcome.

VERDICT $15,000 California verdict against Dr. K. Confidential settlement with Dr. L and his group.

The author reports no financial relationships relevant to this article. Support for the development of the manuscript of this article includes a grant from the American College of Obstetricians and Gynecologists.

The practice of obstetrics is in crisis because of the ever-rising cost of malpractice insurance. Premiums have become so burdensome in many states that they discourage physicians from providing OB care.

And matters grow worse: Many insurance companies are discontinuing liability coverage altogether. With providers unable to afford or obtain insurance, we seem doomed to see a repeat of the loss of OB services that led to harm to patients in the past.^1,2

But if we can discern a crisis at hand, isn’t it reasonable to act to develop a solution that prevents, or solves, the problem? In the past, we waited until the system collapsed—to the detriment of patients, their infants, and physicians. In earlier crises in some states, good solutions ultimately allowed for the return of OB care.^3,4

Experience has taught that, sadly, state legislatures usually act only after the system collapses; then, they may opt for the easiest (often temporary) solution instead of the best one.

In this article, I offer a solution to the malpractice insurance crisis that is easy and that may also be the best one possible. The solution covers three areas of concern:

• payment (including who pays for the policy)
  
• description of the policy (i.e., the benefits provided)
  
• regulations and contracts involved (to optimize medical care and minimize medical costs).
  

A proposal to create “no-fault” pregnancy insurance

I believe that a good solution to the impending crisis in OB medical liability is a form of no-fault, mutual insurance in which policies are written for one pregnancy at a time—just as air travel insurance is written for one flight at a time. A policy would be designed to protect a mother and baby while improving the quality of OB care.

This innovation would provide for continued availability of OB care when the current medical liability system collapses. The physician could pay the premium for the one-pregnancy policy, or it could be paid for directly by the mother’s health insurer, which is paying for the rest of her health care (i.e., an enterprise medical liability solution, which provides a financial incentive for the insurer to help provide excellent, not just the cheapest, OB care).⁵

I call this solution Mothers Mutual Medical Liability Insurance. Here, I refer to it as “3MLI.”

Keeping patients safe

No question: Medical errors that harm patients are far too common in our current system.⁶ But malpractice litigation as a deterrent to medical mishap? That has been a failure. Patients, after all, sue their physician to be made whole after they have suffered an injury—but not for any punitive purpose.

As the Institute of Medicine (IOM) said in its landmark report on medical errors: “When an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.”⁷ What is needed instead, according to the IOM, is creation of an environment “conducive to encourage healthcare professionals and organizations to identify, analyze, and report errors without the threat of litigation and without compromising patients’ rights.”

That is the environment that 3MLI could bring about.

This way to a better way

An ideal 3MLI system for providing OB care would have to:

• ensure continued availability of services
  
• allow for the care of all infants who need help, with expanded opportunities for families to obtain needed medical, economic, and legal assistance
  
• establish an objective, critical evaluation of the quality of care, with built-in incentives for continuous quality improvement
  
• end battles over tort reform
  
• preserve victims’ right to sue
  
• offer a no-fault option sufficiently attractive that most patients would prefer it to the uncertainties of a lawsuit
  
• create a structure in which payers, patients, providers, lawyers, and government are on the same side, with the potential for increased financial efficiencies and improved health-care outcomes
  
• provide the full spectrum of services—possibly lifelong—that an injured infant may require
  
• avoid costly, lengthy, often futile litigation.
  

 

How would the system work?

Coverage comes one pregnancy at a time. A 3MLI policy covers an individual pregnancy. In the event of an adverse outcome, the patient preserves her right to sue. The policy provides liability insurance to cover the cost of a lawsuit and payment for an adverse outcome or a system to assist a disabled infant and its family.

Quality assurance is built in. For a pregnancy to be covered, the system requires a guideline-based, quality assurance system to optimize 1) the quality of care and 2) record keeping. Only OB providers who agree to participate in all aspects of the 3MLI system would have medical liability coverage—coverage that includes full participation in case reviews for adverse outcomes as well as use of record systems and appropriate guidelines for OB care.

It offers an attractive no-fault option. When a disabled infant is born or other adverse outcome of an insured pregnancy occurs, 3MLI provides parents with a no-fault settlement option as an alternative to filing a malpractice suit. Medical care needed by the infant or mother as a result of complications to pregnancy, a congenital defect, or perinatal mis-adventure not otherwise covered by primary insurance or a government agency would be covered by 3MLI for as long as needed—in some cases, for life. Women who choose this option forego the right to sue, with all the delays and uncertainties that malpractice lawsuits typically involve.

Enhanced coverage is part of the policy. Women covered by a 3MLI policy are provided with support services they need to obtain access to medical services (including transportation, if needed) during prenatal care. In an adverse outcome, additional services (such as home nursing care and other appropriate domestic assistance) are included, and are coordinated whenever possible with existing coverage provided by patients’ health insurance or by government programs. Rehabilitation and physical therapy are initiated at the earliest appropriate time to minimize long-term disability.

It provides case management. The no-fault policy also includes the services of a case worker to advocate for mother and child. The case worker coordinates the involvement of the primary health insurance company, HMO, government agencies, and other third-party payers, as well as charities, community support groups, and other agencies—all in the interest of providing the best and most effective care possible.

The case worker receives legal assistance to mobilize resources and assistance in a timely manner, thereby promoting a good medical outcome. Case management services continue to be available for a disabled child, even after the death of parents and other family members. Note that these services can be utilized during the pregnancy (coordinated with the OB provider) to help prevent adverse outcomes, as well as after delivery.

It offers life insurance and legal advocacy. The no-fault settlement option includes life insurance for the mother and offspring and pays for legal counsel to advocate for the rights and benefits of the pregnant woman during pregnancy and the injured or disabled party (if any) afterwards. This lawyer could not serve as a plaintiff attorney, and would be paid for services rendered—not on contingency. Legal tasks could include:

• working with the case worker to secure appropriate and timely care when red tape and bureaucracy threaten to deny or delay it
  
• helping to prevent further adverse outcomes
  
• designing trusts for the long-term maintenance and care of a disabled infant.
  

It promotes quality improvement. The settlement benefit of 3MLI provides for a complete and open review of the circumstances associated with the adverse outcome. Because no lawsuit and no adversarial relationship would exist, it becomes possible to compile cases and promote true quality improvement.

Bad outcomes that arise from a poor system of care, physician error or negligence, government regulation (such as bureaucratic delay in initiating care or regulations that prevent optimal OB care), or any other cause are objectively categorized, and recommendations for improvement are made. Case reviews are undertaken by national professional organizations, such as the Society for Maternal–Fetal Medicine and the American College of Obstetricians and Gynecologists (ACOG), and local committees.

These reviews are then fed into a central database that permits objective understanding of the magnitude, and possible causes, of infant disability. The impact of such studies would be to prevent similar problems, when possible, and to provide the most appropriate care, when necessary. Individual practices and physicians are accredited by ACOG or the American Board of Obstetrics and Gynecology (ABOG) before being allowed to participate in this program.

 

In addition:

The insurer is a nonprofit, mutual insurance company. Each policyholder has a voice in how the system functions. 3MLI must be a mutual company that maintains long-term potential value to the patient who owns the policy. It must never be allowed to demutualize, so to speak, or to be run by a for-profit company.

The policy has a specified life. A 3MLI policy lasts from the time it is purchased, in pregnancy, until the child reaches 21 years of age (unless, in the case of a bad outcome, the lifetime medical and support benefit is activated). At some time, it is possible that the policy could be converted to another form of mutual health insurance for children who do not have a disability.

Coverage. Questions about which infants need assistance and how disability is defined can be resolved by families, physicians, and legal counsel available to each family as part of this plan. Note that no large financial payment occurs under the no-fault settlement option, so a financial incentive for fraud by the family of the disabled child does not exist.

The 3MLI system is a mutual insurance system with potential benefits (such as dividends or paid-up insurance) to the mothers and families only if money is left in the system. This motivates systemic efficiency and appropriate use of resources, and encourages improving OB care from the patient population point of view.

What is the foundation of such a system?

3MLI would be structured as one, or more, insurance companies set up to provide the services that I’ve outlined. Rather than directly providing all health-care funding for disabled infants, 3MLI would obtain access to, and help maintain, existing health insurance policies and draw on other resources, when available. These could include, as needed, Medicaid, SCHIP, charity and government-run early-intervention programs, and private providers. In short, it would use collateral sources of health care and other resources in fulfilling its mission.

A 3MLI insurance system might also arise from physician-owned mutual medical liability companies or from self-insured medical liability systems, such as the ones found in large hospital systems. HMOs or health insurance companies could develop a 3MLI system as well. Government-related institutions and universities or state health departments with a need to find OB care for indigent populations could also develop 3MLI insurance systems. Initial funding could also come through demonstration projects underwritten, in part, by government or foundations.

Who wins with 3MLI?

Everyone, I believe.

Patients win. The continued availability of high-quality OB care—threatened now by the loss of affordable malpractice insurance—is the most important benefit for patients. In the event of an adverse outcome, parents who choose the settlement option have guaranteed access to immediate health care and other assistance, for as long as they need it.

So do physicians. Participation in 3MLI allows physicians to continue practicing OB after they are priced out of the market by the cost of standard medical liability insurance.

Professional organizations win. Participation by organizations like ACOG is a way to support their physician-membership and their members’ patients. In addition, participation ensures that professional organizations have access to databases and that they be able to assist in creating practice guidelines that evolve from their participation.

The states. Many low-income families depend on state assistance for OB care and for the care of disabled children. So, state governments have a substantial stake in the continued availability of OB care and in providing long-term care for the disabled. Many states (New York, for example) already provide a comprehensive system of care for persons who have a significant neurologic disability. 3MLI is designed to coordinate with such state-run systems, thereby increasing their efficiency and effectiveness.

Hospitals. When a significant number of staff physicians participate in a 3MLI system, the hospital benefits from a drop in medical liability claims and suits. Hospitals and hospital systems may find it to their advantage to help initiate or support a 3MLI system.

Attorneys. New, key roles for lawyers will be created in helping to prevent poor medical outcomes before they occur. For example, prenatal care that includes the need for prolonged maternal rest may need legal assistance in a disability dispute. Lawyers also give lifelong assistance to disabled infants and their family.

Lawyers would be paid for these important services without having to participate in litigation. Litigation would continue to be an option if needed or desired by the injured party.

No reason to wait

The progressive severity of the obstetrics liability crisis provides a window of opportunity to propose, consider, and then construct a solution like Mothers Mutual Medical Liability Insurance. Above all, we must consider the needs and well-being of our patients. The time to do this is now—before the loss of OB services places women and their babies at risk.

The author reports no financial relationships relevant to this article. Support for the development of the manuscript of this article includes a grant from the American College of Obstetricians and Gynecologists.

The practice of obstetrics is in crisis because of the ever-rising cost of malpractice insurance. Premiums have become so burdensome in many states that they discourage physicians from providing OB care.

And matters grow worse: Many insurance companies are discontinuing liability coverage altogether. With providers unable to afford or obtain insurance, we seem doomed to see a repeat of the loss of OB services that led to harm to patients in the past.^1,2

But if we can discern a crisis at hand, isn’t it reasonable to act to develop a solution that prevents, or solves, the problem? In the past, we waited until the system collapsed—to the detriment of patients, their infants, and physicians. In earlier crises in some states, good solutions ultimately allowed for the return of OB care.^3,4

Experience has taught that, sadly, state legislatures usually act only after the system collapses; then, they may opt for the easiest (often temporary) solution instead of the best one.

In this article, I offer a solution to the malpractice insurance crisis that is easy and that may also be the best one possible. The solution covers three areas of concern:

• payment (including who pays for the policy)
  
• description of the policy (i.e., the benefits provided)
  
• regulations and contracts involved (to optimize medical care and minimize medical costs).
  

A proposal to create “no-fault” pregnancy insurance

I believe that a good solution to the impending crisis in OB medical liability is a form of no-fault, mutual insurance in which policies are written for one pregnancy at a time—just as air travel insurance is written for one flight at a time. A policy would be designed to protect a mother and baby while improving the quality of OB care.

This innovation would provide for continued availability of OB care when the current medical liability system collapses. The physician could pay the premium for the one-pregnancy policy, or it could be paid for directly by the mother’s health insurer, which is paying for the rest of her health care (i.e., an enterprise medical liability solution, which provides a financial incentive for the insurer to help provide excellent, not just the cheapest, OB care).⁵

I call this solution Mothers Mutual Medical Liability Insurance. Here, I refer to it as “3MLI.”

Keeping patients safe

No question: Medical errors that harm patients are far too common in our current system.⁶ But malpractice litigation as a deterrent to medical mishap? That has been a failure. Patients, after all, sue their physician to be made whole after they have suffered an injury—but not for any punitive purpose.

As the Institute of Medicine (IOM) said in its landmark report on medical errors: “When an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.”⁷ What is needed instead, according to the IOM, is creation of an environment “conducive to encourage healthcare professionals and organizations to identify, analyze, and report errors without the threat of litigation and without compromising patients’ rights.”

That is the environment that 3MLI could bring about.

This way to a better way

An ideal 3MLI system for providing OB care would have to:

• ensure continued availability of services
  
• allow for the care of all infants who need help, with expanded opportunities for families to obtain needed medical, economic, and legal assistance
  
• establish an objective, critical evaluation of the quality of care, with built-in incentives for continuous quality improvement
  
• end battles over tort reform
  
• preserve victims’ right to sue
  
• offer a no-fault option sufficiently attractive that most patients would prefer it to the uncertainties of a lawsuit
  
• create a structure in which payers, patients, providers, lawyers, and government are on the same side, with the potential for increased financial efficiencies and improved health-care outcomes
  
• provide the full spectrum of services—possibly lifelong—that an injured infant may require
  
• avoid costly, lengthy, often futile litigation.
  

 

How would the system work?

Coverage comes one pregnancy at a time. A 3MLI policy covers an individual pregnancy. In the event of an adverse outcome, the patient preserves her right to sue. The policy provides liability insurance to cover the cost of a lawsuit and payment for an adverse outcome or a system to assist a disabled infant and its family.

Quality assurance is built in. For a pregnancy to be covered, the system requires a guideline-based, quality assurance system to optimize 1) the quality of care and 2) record keeping. Only OB providers who agree to participate in all aspects of the 3MLI system would have medical liability coverage—coverage that includes full participation in case reviews for adverse outcomes as well as use of record systems and appropriate guidelines for OB care.

It offers an attractive no-fault option. When a disabled infant is born or other adverse outcome of an insured pregnancy occurs, 3MLI provides parents with a no-fault settlement option as an alternative to filing a malpractice suit. Medical care needed by the infant or mother as a result of complications to pregnancy, a congenital defect, or perinatal mis-adventure not otherwise covered by primary insurance or a government agency would be covered by 3MLI for as long as needed—in some cases, for life. Women who choose this option forego the right to sue, with all the delays and uncertainties that malpractice lawsuits typically involve.

Enhanced coverage is part of the policy. Women covered by a 3MLI policy are provided with support services they need to obtain access to medical services (including transportation, if needed) during prenatal care. In an adverse outcome, additional services (such as home nursing care and other appropriate domestic assistance) are included, and are coordinated whenever possible with existing coverage provided by patients’ health insurance or by government programs. Rehabilitation and physical therapy are initiated at the earliest appropriate time to minimize long-term disability.

It provides case management. The no-fault policy also includes the services of a case worker to advocate for mother and child. The case worker coordinates the involvement of the primary health insurance company, HMO, government agencies, and other third-party payers, as well as charities, community support groups, and other agencies—all in the interest of providing the best and most effective care possible.

The case worker receives legal assistance to mobilize resources and assistance in a timely manner, thereby promoting a good medical outcome. Case management services continue to be available for a disabled child, even after the death of parents and other family members. Note that these services can be utilized during the pregnancy (coordinated with the OB provider) to help prevent adverse outcomes, as well as after delivery.

It offers life insurance and legal advocacy. The no-fault settlement option includes life insurance for the mother and offspring and pays for legal counsel to advocate for the rights and benefits of the pregnant woman during pregnancy and the injured or disabled party (if any) afterwards. This lawyer could not serve as a plaintiff attorney, and would be paid for services rendered—not on contingency. Legal tasks could include:

• working with the case worker to secure appropriate and timely care when red tape and bureaucracy threaten to deny or delay it
  
• helping to prevent further adverse outcomes
  
• designing trusts for the long-term maintenance and care of a disabled infant.
  

It promotes quality improvement. The settlement benefit of 3MLI provides for a complete and open review of the circumstances associated with the adverse outcome. Because no lawsuit and no adversarial relationship would exist, it becomes possible to compile cases and promote true quality improvement.

Bad outcomes that arise from a poor system of care, physician error or negligence, government regulation (such as bureaucratic delay in initiating care or regulations that prevent optimal OB care), or any other cause are objectively categorized, and recommendations for improvement are made. Case reviews are undertaken by national professional organizations, such as the Society for Maternal–Fetal Medicine and the American College of Obstetricians and Gynecologists (ACOG), and local committees.

These reviews are then fed into a central database that permits objective understanding of the magnitude, and possible causes, of infant disability. The impact of such studies would be to prevent similar problems, when possible, and to provide the most appropriate care, when necessary. Individual practices and physicians are accredited by ACOG or the American Board of Obstetrics and Gynecology (ABOG) before being allowed to participate in this program.

 

In addition:

The insurer is a nonprofit, mutual insurance company. Each policyholder has a voice in how the system functions. 3MLI must be a mutual company that maintains long-term potential value to the patient who owns the policy. It must never be allowed to demutualize, so to speak, or to be run by a for-profit company.

The policy has a specified life. A 3MLI policy lasts from the time it is purchased, in pregnancy, until the child reaches 21 years of age (unless, in the case of a bad outcome, the lifetime medical and support benefit is activated). At some time, it is possible that the policy could be converted to another form of mutual health insurance for children who do not have a disability.

Coverage. Questions about which infants need assistance and how disability is defined can be resolved by families, physicians, and legal counsel available to each family as part of this plan. Note that no large financial payment occurs under the no-fault settlement option, so a financial incentive for fraud by the family of the disabled child does not exist.

The 3MLI system is a mutual insurance system with potential benefits (such as dividends or paid-up insurance) to the mothers and families only if money is left in the system. This motivates systemic efficiency and appropriate use of resources, and encourages improving OB care from the patient population point of view.

What is the foundation of such a system?

3MLI would be structured as one, or more, insurance companies set up to provide the services that I’ve outlined. Rather than directly providing all health-care funding for disabled infants, 3MLI would obtain access to, and help maintain, existing health insurance policies and draw on other resources, when available. These could include, as needed, Medicaid, SCHIP, charity and government-run early-intervention programs, and private providers. In short, it would use collateral sources of health care and other resources in fulfilling its mission.

A 3MLI insurance system might also arise from physician-owned mutual medical liability companies or from self-insured medical liability systems, such as the ones found in large hospital systems. HMOs or health insurance companies could develop a 3MLI system as well. Government-related institutions and universities or state health departments with a need to find OB care for indigent populations could also develop 3MLI insurance systems. Initial funding could also come through demonstration projects underwritten, in part, by government or foundations.

Who wins with 3MLI?

Everyone, I believe.

Patients win. The continued availability of high-quality OB care—threatened now by the loss of affordable malpractice insurance—is the most important benefit for patients. In the event of an adverse outcome, parents who choose the settlement option have guaranteed access to immediate health care and other assistance, for as long as they need it.

So do physicians. Participation in 3MLI allows physicians to continue practicing OB after they are priced out of the market by the cost of standard medical liability insurance.

Professional organizations win. Participation by organizations like ACOG is a way to support their physician-membership and their members’ patients. In addition, participation ensures that professional organizations have access to databases and that they be able to assist in creating practice guidelines that evolve from their participation.

The states. Many low-income families depend on state assistance for OB care and for the care of disabled children. So, state governments have a substantial stake in the continued availability of OB care and in providing long-term care for the disabled. Many states (New York, for example) already provide a comprehensive system of care for persons who have a significant neurologic disability. 3MLI is designed to coordinate with such state-run systems, thereby increasing their efficiency and effectiveness.

Hospitals. When a significant number of staff physicians participate in a 3MLI system, the hospital benefits from a drop in medical liability claims and suits. Hospitals and hospital systems may find it to their advantage to help initiate or support a 3MLI system.

Attorneys. New, key roles for lawyers will be created in helping to prevent poor medical outcomes before they occur. For example, prenatal care that includes the need for prolonged maternal rest may need legal assistance in a disability dispute. Lawyers also give lifelong assistance to disabled infants and their family.

Lawyers would be paid for these important services without having to participate in litigation. Litigation would continue to be an option if needed or desired by the injured party.

No reason to wait

The progressive severity of the obstetrics liability crisis provides a window of opportunity to propose, consider, and then construct a solution like Mothers Mutual Medical Liability Insurance. Above all, we must consider the needs and well-being of our patients. The time to do this is now—before the loss of OB services places women and their babies at risk.

The author reports no financial relationships relevant to this article. Support for the development of the manuscript of this article includes a grant from the American College of Obstetricians and Gynecologists.

The practice of obstetrics is in crisis because of the ever-rising cost of malpractice insurance. Premiums have become so burdensome in many states that they discourage physicians from providing OB care.

And matters grow worse: Many insurance companies are discontinuing liability coverage altogether. With providers unable to afford or obtain insurance, we seem doomed to see a repeat of the loss of OB services that led to harm to patients in the past.^1,2

But if we can discern a crisis at hand, isn’t it reasonable to act to develop a solution that prevents, or solves, the problem? In the past, we waited until the system collapsed—to the detriment of patients, their infants, and physicians. In earlier crises in some states, good solutions ultimately allowed for the return of OB care.^3,4

Experience has taught that, sadly, state legislatures usually act only after the system collapses; then, they may opt for the easiest (often temporary) solution instead of the best one.

In this article, I offer a solution to the malpractice insurance crisis that is easy and that may also be the best one possible. The solution covers three areas of concern:

• payment (including who pays for the policy)
  
• description of the policy (i.e., the benefits provided)
  
• regulations and contracts involved (to optimize medical care and minimize medical costs).
  

A proposal to create “no-fault” pregnancy insurance

I believe that a good solution to the impending crisis in OB medical liability is a form of no-fault, mutual insurance in which policies are written for one pregnancy at a time—just as air travel insurance is written for one flight at a time. A policy would be designed to protect a mother and baby while improving the quality of OB care.

This innovation would provide for continued availability of OB care when the current medical liability system collapses. The physician could pay the premium for the one-pregnancy policy, or it could be paid for directly by the mother’s health insurer, which is paying for the rest of her health care (i.e., an enterprise medical liability solution, which provides a financial incentive for the insurer to help provide excellent, not just the cheapest, OB care).⁵

I call this solution Mothers Mutual Medical Liability Insurance. Here, I refer to it as “3MLI.”

Keeping patients safe

No question: Medical errors that harm patients are far too common in our current system.⁶ But malpractice litigation as a deterrent to medical mishap? That has been a failure. Patients, after all, sue their physician to be made whole after they have suffered an injury—but not for any punitive purpose.

As the Institute of Medicine (IOM) said in its landmark report on medical errors: “When an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.”⁷ What is needed instead, according to the IOM, is creation of an environment “conducive to encourage healthcare professionals and organizations to identify, analyze, and report errors without the threat of litigation and without compromising patients’ rights.”

That is the environment that 3MLI could bring about.

This way to a better way

An ideal 3MLI system for providing OB care would have to:

• ensure continued availability of services
  
• allow for the care of all infants who need help, with expanded opportunities for families to obtain needed medical, economic, and legal assistance
  
• establish an objective, critical evaluation of the quality of care, with built-in incentives for continuous quality improvement
  
• end battles over tort reform
  
• preserve victims’ right to sue
  
• offer a no-fault option sufficiently attractive that most patients would prefer it to the uncertainties of a lawsuit
  
• create a structure in which payers, patients, providers, lawyers, and government are on the same side, with the potential for increased financial efficiencies and improved health-care outcomes
  
• provide the full spectrum of services—possibly lifelong—that an injured infant may require
  
• avoid costly, lengthy, often futile litigation.
  

 

How would the system work?

Coverage comes one pregnancy at a time. A 3MLI policy covers an individual pregnancy. In the event of an adverse outcome, the patient preserves her right to sue. The policy provides liability insurance to cover the cost of a lawsuit and payment for an adverse outcome or a system to assist a disabled infant and its family.

Quality assurance is built in. For a pregnancy to be covered, the system requires a guideline-based, quality assurance system to optimize 1) the quality of care and 2) record keeping. Only OB providers who agree to participate in all aspects of the 3MLI system would have medical liability coverage—coverage that includes full participation in case reviews for adverse outcomes as well as use of record systems and appropriate guidelines for OB care.

It offers an attractive no-fault option. When a disabled infant is born or other adverse outcome of an insured pregnancy occurs, 3MLI provides parents with a no-fault settlement option as an alternative to filing a malpractice suit. Medical care needed by the infant or mother as a result of complications to pregnancy, a congenital defect, or perinatal mis-adventure not otherwise covered by primary insurance or a government agency would be covered by 3MLI for as long as needed—in some cases, for life. Women who choose this option forego the right to sue, with all the delays and uncertainties that malpractice lawsuits typically involve.

Enhanced coverage is part of the policy. Women covered by a 3MLI policy are provided with support services they need to obtain access to medical services (including transportation, if needed) during prenatal care. In an adverse outcome, additional services (such as home nursing care and other appropriate domestic assistance) are included, and are coordinated whenever possible with existing coverage provided by patients’ health insurance or by government programs. Rehabilitation and physical therapy are initiated at the earliest appropriate time to minimize long-term disability.

It provides case management. The no-fault policy also includes the services of a case worker to advocate for mother and child. The case worker coordinates the involvement of the primary health insurance company, HMO, government agencies, and other third-party payers, as well as charities, community support groups, and other agencies—all in the interest of providing the best and most effective care possible.

The case worker receives legal assistance to mobilize resources and assistance in a timely manner, thereby promoting a good medical outcome. Case management services continue to be available for a disabled child, even after the death of parents and other family members. Note that these services can be utilized during the pregnancy (coordinated with the OB provider) to help prevent adverse outcomes, as well as after delivery.

It offers life insurance and legal advocacy. The no-fault settlement option includes life insurance for the mother and offspring and pays for legal counsel to advocate for the rights and benefits of the pregnant woman during pregnancy and the injured or disabled party (if any) afterwards. This lawyer could not serve as a plaintiff attorney, and would be paid for services rendered—not on contingency. Legal tasks could include:

• working with the case worker to secure appropriate and timely care when red tape and bureaucracy threaten to deny or delay it
  
• helping to prevent further adverse outcomes
  
• designing trusts for the long-term maintenance and care of a disabled infant.
  

It promotes quality improvement. The settlement benefit of 3MLI provides for a complete and open review of the circumstances associated with the adverse outcome. Because no lawsuit and no adversarial relationship would exist, it becomes possible to compile cases and promote true quality improvement.

Bad outcomes that arise from a poor system of care, physician error or negligence, government regulation (such as bureaucratic delay in initiating care or regulations that prevent optimal OB care), or any other cause are objectively categorized, and recommendations for improvement are made. Case reviews are undertaken by national professional organizations, such as the Society for Maternal–Fetal Medicine and the American College of Obstetricians and Gynecologists (ACOG), and local committees.

These reviews are then fed into a central database that permits objective understanding of the magnitude, and possible causes, of infant disability. The impact of such studies would be to prevent similar problems, when possible, and to provide the most appropriate care, when necessary. Individual practices and physicians are accredited by ACOG or the American Board of Obstetrics and Gynecology (ABOG) before being allowed to participate in this program.

 

In addition:

The insurer is a nonprofit, mutual insurance company. Each policyholder has a voice in how the system functions. 3MLI must be a mutual company that maintains long-term potential value to the patient who owns the policy. It must never be allowed to demutualize, so to speak, or to be run by a for-profit company.

The policy has a specified life. A 3MLI policy lasts from the time it is purchased, in pregnancy, until the child reaches 21 years of age (unless, in the case of a bad outcome, the lifetime medical and support benefit is activated). At some time, it is possible that the policy could be converted to another form of mutual health insurance for children who do not have a disability.

Coverage. Questions about which infants need assistance and how disability is defined can be resolved by families, physicians, and legal counsel available to each family as part of this plan. Note that no large financial payment occurs under the no-fault settlement option, so a financial incentive for fraud by the family of the disabled child does not exist.

The 3MLI system is a mutual insurance system with potential benefits (such as dividends or paid-up insurance) to the mothers and families only if money is left in the system. This motivates systemic efficiency and appropriate use of resources, and encourages improving OB care from the patient population point of view.

What is the foundation of such a system?

3MLI would be structured as one, or more, insurance companies set up to provide the services that I’ve outlined. Rather than directly providing all health-care funding for disabled infants, 3MLI would obtain access to, and help maintain, existing health insurance policies and draw on other resources, when available. These could include, as needed, Medicaid, SCHIP, charity and government-run early-intervention programs, and private providers. In short, it would use collateral sources of health care and other resources in fulfilling its mission.

A 3MLI insurance system might also arise from physician-owned mutual medical liability companies or from self-insured medical liability systems, such as the ones found in large hospital systems. HMOs or health insurance companies could develop a 3MLI system as well. Government-related institutions and universities or state health departments with a need to find OB care for indigent populations could also develop 3MLI insurance systems. Initial funding could also come through demonstration projects underwritten, in part, by government or foundations.

Who wins with 3MLI?

Everyone, I believe.

Patients win. The continued availability of high-quality OB care—threatened now by the loss of affordable malpractice insurance—is the most important benefit for patients. In the event of an adverse outcome, parents who choose the settlement option have guaranteed access to immediate health care and other assistance, for as long as they need it.

So do physicians. Participation in 3MLI allows physicians to continue practicing OB after they are priced out of the market by the cost of standard medical liability insurance.

Professional organizations win. Participation by organizations like ACOG is a way to support their physician-membership and their members’ patients. In addition, participation ensures that professional organizations have access to databases and that they be able to assist in creating practice guidelines that evolve from their participation.

The states. Many low-income families depend on state assistance for OB care and for the care of disabled children. So, state governments have a substantial stake in the continued availability of OB care and in providing long-term care for the disabled. Many states (New York, for example) already provide a comprehensive system of care for persons who have a significant neurologic disability. 3MLI is designed to coordinate with such state-run systems, thereby increasing their efficiency and effectiveness.

Hospitals. When a significant number of staff physicians participate in a 3MLI system, the hospital benefits from a drop in medical liability claims and suits. Hospitals and hospital systems may find it to their advantage to help initiate or support a 3MLI system.

Attorneys. New, key roles for lawyers will be created in helping to prevent poor medical outcomes before they occur. For example, prenatal care that includes the need for prolonged maternal rest may need legal assistance in a disability dispute. Lawyers also give lifelong assistance to disabled infants and their family.

Lawyers would be paid for these important services without having to participate in litigation. Litigation would continue to be an option if needed or desired by the injured party.

No reason to wait

The progressive severity of the obstetrics liability crisis provides a window of opportunity to propose, consider, and then construct a solution like Mothers Mutual Medical Liability Insurance. Above all, we must consider the needs and well-being of our patients. The time to do this is now—before the loss of OB services places women and their babies at risk.

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

 

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

 

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

For most physicians, the resolution of patient complaints ranks second only to firing an employee on the least favorite tasks list. With so many potential problems and the many ways patients can react to them, it seems impossible to construct a template for consistent, mutually satisfactory resolutions.

But it can be done, and it is not as complex as it appears once you realize that the vast majority of complaints have the same basic roots: The patient's expectations have not been met. Sometimes it is your fault, sometimes it is the patient's fault, and often a bit of both, but either way, the result is the same. You have an unhappy patient, and you must deal with it.

I have distilled this unpleasant duty down to a simple three-part strategy:

▸ Discover which expectations went unmet and why.

▸ Agree on a solution.

▸ Learn from the experience to prevent similar future complaints.

In most cases, this is not a job you should delegate. Unless the complaint is trivial or purely administrative, you should address it yourself. It is what you would want if you were the complainant, and it is often too important to trust to a subordinate.

At this point, you may be asking, “Why should I care?” Is the personal expenditure of your time and effort necessary to resolve complaints really worth it? Absolutely, because the old cliché is true: A satisfied patient will refer 5 new ones, while a patient who is dissatisfied will frighten away 20 or more potential patients.

Besides, if the complaint is significant and you do not resolve it, the patient is likely to find someone who will; and chances are you will not like their choice or the eventual resolution.

The easiest way to deal with complaints is to prevent as many as possible. Try to nip unrealistic expectations in the bud. Take the time beforehand to explain all treatments and procedures, and their most likely outcomes, in a clear and honest manner. And, since even the most astute patients will not absorb everything you tell them, make liberal use of written handouts and other visual aids.

And, of course, document everything you have explained. Documentation (I say, yet again) is like garlic: There is no such thing as too much.

But despite your best efforts, there will always be complaints, and handling them is a skill set worth honing. The most important skill is the one most people—especially physicians—do poorly: listening to the complaint. Before you can resolve a problem you have to know what it is, and this is precisely the wrong time to make assumptions or jump to conclusions.

Listen to the patient's entire complaint without interrupting, defending, or justifying. Angry patients do not care why the problem occurred, and they are not interested in your side of the story. This is not about you, so listen and understand.

As you listen, the unmet expectations will become clear. When the patient is finished, I like to summarize the complaint in that context: “So if I understand correctly, you expected “X” to happen, but “Y” happened instead.” If I'm wrong, I modify my summary until the patient agrees that I understand the problem.

Once you know the problem, you can talk about a solution. The patient usually has one in mind—additional treatment, a referral elsewhere, a fee adjustment, or sometimes simply an apology. By all means, let the patient propose a solution.

If the solution is reasonable, I will agree to it; if it's unreasonable, I will try to offer a reasonable alternative. The temptation here is to think more about protecting yourself than making the patient happy, but that often leads to bigger problems. Do not be defensive; remember, this is not about you.

I am often asked if refunding a fee is a reasonable solution. Some patients (and lawyers) interpret a refund as a tacit admission of guilt, so I try to avoid this approach. However, canceling a small fee for an angry patient can be prudent, and in my opinion looks exactly like what it is: an honest effort to rectify the situation. But usually, free (or reduced-fee) additional materials or services are a better alternative than refunding money.

Once you have arrived at a mutually satisfactory solution, document everything. However, consider reserving a “private” chart area for such documentation so that it will not go out to referrers and other third parties with copies of your clinical notes. Consider having the patient sign off on the documentation, acknowledging that the complaint has been resolved.

 

Finally, always try to learn something from the experience. Ask yourself how you might prevent a repetition of the complaint, what you did that you can avoid doing next time, and how you might prevent unrealistic expectations in the future.

Above all, do not take complaints personally—even when they are personal. No matter how hard you try, you can never please everyone.

To respond to this column, e-mail Dr. Eastern at sknews@elsevier.com

Installing an electronic health record system at a primary care practice is a perfect time to also revamp the tasks the office staff performs.

Having all staff members work at the top of their licensure is the guiding principle: If a task does not require an MD or DO, then people with those degrees shouldn't do it. Instead, such a task should be delegated through a standing order to someone else on the staff, often a nurse or medical assistant.

In a standing order, you extend your licensure to lower-level staff. Write the order in detail, sign it, put it into a folder, and keep it up-to-date for accreditation inspections.

With routine clinical tasks delegated to staff members using EHR tools, the typical duration of an office encounter between a primary care physician and patient can be shaved by a third, from 12 minutes to 8 minutes. The time saved can be used to see more patients or for leisure time.

EHRs allow these time savings in two main ways. First, they better enable a staff member, usually a nurse or medical assistant, to collect and enter into the record preliminary clinical information, such as past medical history, family history, vital signs, and reason for visit.

When the physician enters the exam room to see the patient, reviewing what the staff has entered into the medical chart takes half as much time as entering the data initially and then they simply need to add the additional information that they gather.

The scope of preliminary information collected can be expanded and tailored to each patient through disease-specific templates.

For example, a physician can teach staff members how to collect current information from patients with diabetes using a diabetes template, leaving fewer routine tasks for the physician to do. About a quarter of my patients have diabetes, so my nurse knows my diabetes template cold.

The second major time saving is through standing orders that a staff member can perform and that are automatically flagged for appropriate patients. These standing orders would include items such as administering immunizations, arranging for routine lab tests like prostate-specific antigen and hemoglobin A_1c, and reminding patients about and possibly scheduling routine screens like mammography and colonoscopy.

The key to making this sort of practice change work is to introduce new approaches in small steps and evaluate how each change works after a few weeks. The staff must be properly trained, and the changes should take into account how the staff currently works and how new tasks will affect them. Having a staff member on the development and implementation team is a big advantage.

Workflow changes following introduction of an electronic health record is an evolving and continuous process, not a static goal. Once an EHR system is in place and work assignments start to change, delegation of tasks will continue to evolve and the workflow will ideally continue to become more efficient over time.

Installing an electronic health record system at a primary care practice is a perfect time to also revamp the tasks the office staff performs.

Having all staff members work at the top of their licensure is the guiding principle: If a task does not require an MD or DO, then people with those degrees shouldn't do it. Instead, such a task should be delegated through a standing order to someone else on the staff, often a nurse or medical assistant.

In a standing order, you extend your licensure to lower-level staff. Write the order in detail, sign it, put it into a folder, and keep it up-to-date for accreditation inspections.

With routine clinical tasks delegated to staff members using EHR tools, the typical duration of an office encounter between a primary care physician and patient can be shaved by a third, from 12 minutes to 8 minutes. The time saved can be used to see more patients or for leisure time.

EHRs allow these time savings in two main ways. First, they better enable a staff member, usually a nurse or medical assistant, to collect and enter into the record preliminary clinical information, such as past medical history, family history, vital signs, and reason for visit.

When the physician enters the exam room to see the patient, reviewing what the staff has entered into the medical chart takes half as much time as entering the data initially and then they simply need to add the additional information that they gather.

The scope of preliminary information collected can be expanded and tailored to each patient through disease-specific templates.

For example, a physician can teach staff members how to collect current information from patients with diabetes using a diabetes template, leaving fewer routine tasks for the physician to do. About a quarter of my patients have diabetes, so my nurse knows my diabetes template cold.

The second major time saving is through standing orders that a staff member can perform and that are automatically flagged for appropriate patients. These standing orders would include items such as administering immunizations, arranging for routine lab tests like prostate-specific antigen and hemoglobin A_1c, and reminding patients about and possibly scheduling routine screens like mammography and colonoscopy.

The key to making this sort of practice change work is to introduce new approaches in small steps and evaluate how each change works after a few weeks. The staff must be properly trained, and the changes should take into account how the staff currently works and how new tasks will affect them. Having a staff member on the development and implementation team is a big advantage.

Workflow changes following introduction of an electronic health record is an evolving and continuous process, not a static goal. Once an EHR system is in place and work assignments start to change, delegation of tasks will continue to evolve and the workflow will ideally continue to become more efficient over time.

Installing an electronic health record system at a primary care practice is a perfect time to also revamp the tasks the office staff performs.

Having all staff members work at the top of their licensure is the guiding principle: If a task does not require an MD or DO, then people with those degrees shouldn't do it. Instead, such a task should be delegated through a standing order to someone else on the staff, often a nurse or medical assistant.

In a standing order, you extend your licensure to lower-level staff. Write the order in detail, sign it, put it into a folder, and keep it up-to-date for accreditation inspections.

With routine clinical tasks delegated to staff members using EHR tools, the typical duration of an office encounter between a primary care physician and patient can be shaved by a third, from 12 minutes to 8 minutes. The time saved can be used to see more patients or for leisure time.

EHRs allow these time savings in two main ways. First, they better enable a staff member, usually a nurse or medical assistant, to collect and enter into the record preliminary clinical information, such as past medical history, family history, vital signs, and reason for visit.

When the physician enters the exam room to see the patient, reviewing what the staff has entered into the medical chart takes half as much time as entering the data initially and then they simply need to add the additional information that they gather.

The scope of preliminary information collected can be expanded and tailored to each patient through disease-specific templates.

For example, a physician can teach staff members how to collect current information from patients with diabetes using a diabetes template, leaving fewer routine tasks for the physician to do. About a quarter of my patients have diabetes, so my nurse knows my diabetes template cold.

The second major time saving is through standing orders that a staff member can perform and that are automatically flagged for appropriate patients. These standing orders would include items such as administering immunizations, arranging for routine lab tests like prostate-specific antigen and hemoglobin A_1c, and reminding patients about and possibly scheduling routine screens like mammography and colonoscopy.

The key to making this sort of practice change work is to introduce new approaches in small steps and evaluate how each change works after a few weeks. The staff must be properly trained, and the changes should take into account how the staff currently works and how new tasks will affect them. Having a staff member on the development and implementation team is a big advantage.

Workflow changes following introduction of an electronic health record is an evolving and continuous process, not a static goal. Once an EHR system is in place and work assignments start to change, delegation of tasks will continue to evolve and the workflow will ideally continue to become more efficient over time.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.

Baby harmed when couple, unaware of risk, elects induction

AFTER A NORMAL PREGNANCY, a woman opted for induction of labor because the baby’s father was scheduled to leave for a military weekend. When the fetal heart rate showed a concerning pattern, Dr. A, the delivering physician, applied vacuum five times, but failed to achieve delivery. As he lacked privileges to perform a cesarean delivery and a surgical team was unavailable, he sent for Dr. B, a senior partner with such privileges. Dr. B attempted delivery using forceps but failed, and then tried the vacuum extractor twice. The child was delivered—blue and flaccid, with slow irregular respirations. The Apgar score was 3 at 1 minute and 4 at 3 minutes. The infant was resuscitated with bag/mask ventilation for 90 seconds and taken to the nursery of the community hospital, where he was treated as a normal newborn. Although he was brought twice to his mother during the night, he did not feed. The next morning a nurse noticed that he was blue and not breathing. A code was called. The child then suffered seizures with apneic and bradycardic spells. A glucose draw 2.5 hours later showed significant hypoglycemia believed to exacerbate hypoxic injury. After transfer to a specialty-care hospital, a CT scan of the child at 17 hours of age showed brain swelling and subgaleal hemorrhage; the local radiologist, however, read it as normal. A diagnosis of significant brain damage has been given. Now 6.5 years old, the child cannot speak, drools constantly, suffers motor impairment on both sides, has difficulty eating, and is incontinent.

PATIENT’S CLAIM The parents were never told of the risks of induction and did not give informed consent regarding the use of misoprostol. An excessive dosage of the drug was administered, resulting in an abnormal uterine contraction that was not addressed by the nurses or delivering physician.

PHYSICIAN’S DEFENSE The injury was caused by some unknown event 4 to 6 days before delivery. Also, neither the hypoglycemic period nor the trauma contributed to the brain injury.

VERDICT $2 million Minnesota settlement. The case was tried first in the small community (pop. 2,000) where the hospital and clinic are located—despite efforts to have a change of venue—and supporters of the defendants filled the courtroom. A mistrial was declared after the jury deadlocked. Then a change of venue was granted, and the jury in a second trial returned a $9,566,500 verdict. Dr. A and the clinic had reached a high/low agreement of $2 million just before the second trial. Posttrial motions were pending.

In bicornuate uterus, abortion fails on two attempts

IN THE SIXTH WEEK OF PREGNANCY, a 33-year-old woman underwent an abortion. The procedure, performed by an ObGyn, was uneventful, but a later test showed that the abortion had failed. During a second attempt 1.5 weeks after that, the same ObGyn encountered difficulties, suggesting that the uterus had been perforated—and he stopped. Following transfer to a hospital, the patient was confirmed to have suffered perforation of the uterus—and also to have a bicornuate uterus. She was treated with antibiotics and decided to continue her pregnancy. Several weeks later, she miscarried.

PATIENT’S CLAIM The ObGyn was negligent for causing the perforation. She had informed him of her bicornuate uterus, and ultrasonography should have been used to allow proper completion of the abortion.

PHYSICIAN’S DEFENSE Perforation and retained pregnancy are complications of an abortion procedure. Such complications are more likely when the uterus is bicornuate.

VERDICT New York defense verdict.

Hemophilia carrier suffers massive bleed after surgery

A 33-YEAR-OLD WOMAN had a previous tubal ligation reversed by an ObGyn. Following the surgery, she suffered massive bleeding and deep-vein thrombosis, resulting in permanent postphlebitic syndrome in her left leg.

PATIENT’S CLAIM She had notified the anesthesiologist that her son had a history of being Factor IX-deficient, and she brought Factor IX with her for urgent matters.

PHYSICIAN’S DEFENSE The ObGyn claimed the patient never informed him that she was a hemophilia B carrier and Factor IX-deficient. Although the anesthesiologist recorded the information given to him by the patient, the ObGyn was never told about it.

VERDICT Illinois defense verdict.