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PostPosted: Sat Oct 08, 2005 10:11 pm 
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Location: Boston
Just kidding, but wanted your attention. Here's a sad recounting of the nonsense that is ligitation against obstetricians.

Who Will Deliver Our Grandchildren?
Implications of Cerebral Palsy Litigation

Alastair MacLennan, MD; Karin B. Nelson, MD; Gary Hankins, MD; Michael Speer, MD


JAMA. 2005;294:1688-1690.

"It has never been safer to have a baby and never more dangerous to be an obstetrician. In a recent survey, 76% of obstetricians in the United States reported having faced litigation at some point in their careers—most often for having allegedly caused cerebral palsy (CP)." (....)

"The median award for "medical negligence in childbirth cases" is $2.3 million.4 Consequently, obstetricians pay some of the highest premiums for malpractice insurance—up to $200 000 per year in some states. These figures might seem to indicate an epidemic of errors in the delivery room, except that the common assumption that obstetric caregivers can prevent CP by actions taken during labor and delivery is based largely on erroneous assumptions and obsolete science. Despite this, in the United States, 60% of malpractice insurance premiums paid by obstetricians cover lawsuits for alleged birth-related CP.5 Less than 10% of plaintiffs in CP cases receive any compensation, and more than 60% of obstetric premiums are spent on the legal process.5" (....)

Well-designed studies, however, have shown that lack of oxygen causes only a small proportion of CP cases,6-7 and despite serious efforts, CP due to birth asphyxia has not been shown to be preventable.8 Antenatal risk factors for CP under current investigation are indicators of viral infection, fetal thrombophilias, and polymorphisms of genes regulating inflammation, coagulation, and endothelial activation.9-10 Known risk factors for CP include chorioamnionitis, death of a co-twin in utero, arterial ischemic stroke in the fetus or newborn, an umbilical cord wrapped tightly around the neck of the fetus, and premature birth.11 In none of these problems has obstetric intervention been demonstrated to reduce the risk of CP, largely because useful and specific indicators of intrauterine events do not yet exist. In most cases of CP, the cause cannot be determined. Litigation based on assumptions to the contrary, there is no evidence that immediate delivery upon diagnosis of chorioamnionitis or a nonreassuring fetal heart rate pattern prevents or ameliorates CP.8, 12-13 Despite the dramatic account of legal action related to severe brain damage in a survivor of co-twin death,14 there is no evidence that rapid delivery of the survivor prevents CP.15 (....)

[electronic fetal monitoring is mentioned in most CP cases; the claim is made an OB should have acted on it, but] according to a Cochrane Collaborative systematic review of relevant randomized clinical trials, EFM as compared with monitoring by intermittent auscultation is associated with no decrease in perinatal deaths, no fewer admissions to neonatal intensive care units, no fewer Apgar scores below 7 or below 4, and no less incidence of CP (....)

All randomized trials of EFM to date have shown that such monitoring is associated with a higher rate of interventions... .17 In 10 developed countries including the United States, despite a 5-fold increase in cesarean deliveries over recent decades driven in part by the use of fetal monitoring, the incidence of CP has remained steady at about 1 in 500 births, ... with similar rates around the world.18 Thus, action based on interpretation of EFM tracings, which are notoriously difficult to interpret reliably and with validity, has not led to a decreased rate of CP.

(....)
Judges, jurors, and most plaintiffs in CP lawsuits may be unaware of the fallibility of the high-tech gadgetry of modern obstetrics, including EFM, and may not realize that these devices cannot reliably predict or influence obstetric outcome. The plaintiff’s attorney has the double advantage of the undeserved suffering by a child and family and a simple, seemingly reasonable explanation. That may not be enough for outright victory, but it is a potent weapon of intimidation. The result is that 86% of obstetrics malpractice claims are settled out of court, half of them with payment,1 at great cost to the profession, to insurers, and to society at large."

Proposed antidotes in the article:

--better self policing by OBs: "After anesthesiology departments took such measures a few years ago, adverse events and malpractice claims dropped substantially."
--special health courts
--a no fault compensation system
--better public education
--dispute resolution
--policing those who offer expert advice

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PostPosted: Mon Oct 10, 2005 6:29 pm 
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Location: Richmond, VA --- Louisville, KY
It's simply amazing, Ian.

I am glad to see this subject get the attention it deserves. The deeper you look, the more interesting the problem gets.

What I find troubling is that the parasitic activity still goes on, and the perpetrators aren't pursued the way they are bent on pursuing innocent parties associated with money.

I agree with some of the proposed solutions. The problem with the self policing though is that it assumes there is something the OBs could be doing differently (to get a different outcome). But that isn't the case with CP.

I love the bit about adverse outcomes associated with more fetal monitoring. Folks such as Wennberg have been preaching this for years. His work shows cases of a 3-fold difference in resource consumption with certain procedures, and no evidence of better health outcomes. That's a staggering finding. Unfortunately the mentality of our culture is that "doing something" means a good thing. That isn't always the case.

- Bill


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PostPosted: Mon Oct 10, 2005 11:42 pm 
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Well, agreed... honestly, doctors also don't self police that well. It feel like I'm doing awful if I say someone is underperforming on their review. But, we've taken an oath to report impaired physicians (the ones I'm referring to weren't truly impaired but were just underperforming... one wonders how to draw a line), so I've decided not to sugarcoat reviews if anyone makes a truly avoidable error.

However, while there is nothing avoidable about CP for the moment, that doesn't mean other bad outcomes are unavoidable. And, if patients distrust an MD or their institution or feel they are underpolicing, they are more likely to sue. Underpolice for X, get sued more often for CP. Further, if institutions can prove they are practicing the best preventive medicine they can, that can help at trial. Hopefully there's enough money after to police after the 200k insurance premiums! Whoa, people!

I saw my dentist today, about 2 months after seeing another dentist because of insurance reasons. The former dentist recommended $3000 worth of repairs and fillings, this dentist recommended: none. It's one thing that there's no consistency and a lot of the care seems to be a farce (I was offered 400$ antibiotic injections into my crevices; back of package insert notes that the benefit over scaling alone is 0.16mm average reduction in crevice size) but what caught my eye was a LENGTHY waiver asking me to acknowledge the risk associated with a dozen situations and treatments most of which weren't even being discussed, as a precondition of treatment.

Maybe they had a bad experience... maybe we need to make patients sign waivers explaining that CP appears to be unrelated to EFM and C sections and other aspects of prenatal care before they can be accepted onto someone's lisk of potential liabilities... if that's how this is going to work for the OB's. They can barely practice.

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PostPosted: Wed Oct 12, 2005 5:17 pm 
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Location: Richmond, VA --- Louisville, KY
Ian wrote:
Underpolice for X, get sued more often for CP

There are several things that jump out at me with this statement.

On the one hand...

Any good six sigma expert knows you create a process where you measure variation and deal with it. With six sigma it isn't an issue of bad people; it's an issue of a bad process that allows people to perform suboptimally. Getting MDs to agree on anything related to governing their methods and the independence of their doctor-patient relationship is a bit like herding cats, but it can be done.

On the other hand...

Whether or not a person did A matters not - in the eyes of the law - when being judged on B. The reality is a different story, but it shouldn't be. Whenever you give anyone (government, slimebag trial attorneys, attention-seeking politicos) an opportunity to use prosecution as a weapon for their selfish means, you violate the principles upon which our government and constitution were built. In our society, we presume innocence and we frown upon anything that encroaches upon our privacy and looks like unreasonable search and seizure.

I'm all for a process where "fair is fair." I'm all for a class action lawsuit against all trial attorneys who ever litigated a CP case. The damages?

* Time, money, emotional damages, and reputation damages for all the OBs.

* A reduction in access to affordable care (or ANY care in rural areas) for fertile women.

* Damage to the reputation of the AMA, ACOG, and every institution associated with obstetrical practice.

But that ain't gonna happen... Until that scenario is possible, as far as I am concerned the whole legal profession needs major top-to-bottom reform.

- Bill


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PostPosted: Fri Oct 14, 2005 11:28 pm 
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That'd be an interesting case... of course, the only obstacle is you need a lawyer. And like minded people aren't going to persuade them--they'd have to make them/become them. Yet, we can't find one decent person to become president, so....

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