Neurosurgeons in Congress: the 25th amendment and United States Presidency.

In 2020, realizing that a President was not immune to a public health emergency, United States Speaker of the House Nancy Pelosi recommended the passing of a Bill (Raskin J (2021) A Bill To establish the Commission on Presidential Capacity to Discharge the Powers and Duties of the Office, and for other purposes. 116th Congress, 2nd Session. https://raskin.house.gov/sites/raskin.house.gov/files/Commission%20on%20Presidential%20Capacity%20Act%20%5BFINAL%5Dpdf.pdf ) that would create a bipartisan group of experts to evaluate the Commander-in-Chief's mental and physical health and advise Congress on whether a President could be demoted under the 25th Amendment. Neurosurgeons are equipped to advice Congress in the advent of such a need. The authors aimed to provide a brief history of the 25th amendment during US history and implications for neurosurgeons within the jurisdictions of US Congress.

Neurosurgical Malpractice Litigation: A Systematic Review and Meta-Analysis.

BACKGROUND: Neurosurgery has 1 of the highest risks for medical malpractice claims. We reviewed the factors associated with neurosurgical malpractice claims and litigation in the United States and reported the outcomes through a systematic review of the literature. METHODS: We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines using the Medline, Embase, Cochrane, PubMed, and Google Scholar databases. We sought to identify pertinent studies containing information about medical malpractice claims and outcomes involving neurosurgeons in the United States. RESULTS: We identified 15 retrospective studies spanning from 2002 to 2023 that reviewed over 7890 malpractice claims involving practicing neurosurgeons in the United States. Disparities were evident in neurosurgical litigation, with 474 cases linked to brain-related surgeries and a larger proportion, 1926 cases, tied to spine surgeries. The most commonly filed claims were intraprocedural errors (37.4%), delayed diagnoses (32.1%), and failure to treat (28.8%). Less frequently filed claims included misdiagnosis or choice of incorrect procedure (18.4%), occurrence of death (17.3%), test misinterpretation (14.4%), failure to appropriately refer patients for evaluation/treatment (14.3%), unnecessary surgical procedures (13.3%), and lack of informed consent (8.3%). The defendant was favored in 44.3% of claims, while in 31.3% of lawsuits were dropped, 17.7% of verdicts favored the plaintiff, and 16.6% reached an out of court settlement. Only 3.5% of lawsuits found both parties liable. CONCLUSION: Neurosurgery is a high-risk specialty with 1 of the highest rates of malpractice claims. Spine claims had a significantly higher rate of filed malpractice claims, while cranial malpractice claims were associated with higher litigation compensation. Predictably, spinal cord injuries play a crucial role in predicting litigation. Importantly, nonsurgical treatments are also a common source of liability in neurosurgical practice.

Medicolegal Issues: Perception, Awareness, and Behavioral Changes Among Italian Neurosurgical Community: Survey-Based Analysis.

BACKGROUND: Despite the rising trend of medicolegal challenges in Italy, there is a significant lack of literature on this topic. To provide better understanding of awareness toward medicolegal aspects, defensive behavior, consent-taking practice, and general perceptions of Italian neurosurgeons on this issue, a cross-sectional survey was conducted. METHODS: A questionnaire covering various aspects of medicolegal issues, in an anonymous online form, was sent to neurosurgeons practicing in Italy via e-mail-through a national mailing list-and social media platforms. The data collection period was November 1, 2020 to December 31, 2020. RESULTS: A total of 64 single responses were included. We assessed 1) awareness of Italian neurosurgeons about a legal framework: a low level of knowledge has been reported-87.5% were unaware of the terms and conditions outlined by the contract with the institution, 75.6% of respondents stated they didn't know the main body of law that governed the medical community; and 2) perception toward defensive medicine: 92.2% believed that they were not trained to face possible medicolegal issues, but only a few tried to acquire more knowledge about medical legal issues, such as learning how to obtain a proper informed consent for a surgical procedure (34.4%). CONCLUSIONS: This study marks the first survey to identify the perceptions among Italian neurosurgeons of medical legal issues and related "defensive medicine" practices: This is of relevance given its exorbitant cost in terms of public expenditure, psychologic burden, and its relevant impact on health care delivery.

"There's got to be a better way": Global Perspectives of Medicolegal Environment and Neurosurgical Socioeconomics.

Neurosurgery is considered to have one of the greatest risks of medical malpractice claims. However, medicolegal issues in neurosurgery are often disregarded and underrated worldwide. Medical errors in the neurosurgical field can be attributed to multiple factors, including highly morbid pathologies, the technical difficulty of neurosurgical procedures, and the involvement and interaction of a multidisciplinary team in the care of neurosurgical patients. Health care providers worldwide are at risk of lawsuits, sometimes even when no deviation from the standard of care had occurred in a given case. Often, governments use additional tactics to decrease the burden on compensators and extrajudicial institutions and to decrease the court's flow of irrational litigation. Continuous amendments to health care acts and newer reforms to address these issues have materialized worldwide. In the present narrative review, we have reviewed the global perspectives of medicolegal issues, with a focus on neurosurgical discipline.

The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges.

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.

Developing a Professionalism and Harassment Policy for Organized Neurosurgery.

Annual conferences, educational courses, and other meetings draw a diverse community of individuals, yet also create a unique environment without the traditional guard rails. Unlike events held at one's home institution, clear rules and jurisdiction have not been universally established. To promote the open exchange of ideas, as well as an environment conducive to professional growth of all participants, the leading neurosurgical professional organizations joined forces to delineate the expectations for anyone who participates in sponsored events. The One Neurosurgery Summit Taskforce on Professionalism and Harassment developed a foundational policy that establishes common expectations for behavior and a unified roadmap for the prompt response to untoward events. We hope that publishing this policy will inspire other medical organizations to establish their own meeting and conference policies. More importantly, we wish to bring greater attention to everyone's responsibility for ensuring a safe and respectful space for education, scientific debate, and networking during organized events.

Implementation of duty of candour within neurosurgery: a national survey and framework for improved application in clinical practice.

INTRODUCTION: Statutory duty of candour was introduced in November 2014 for NHS bodies in England. Contained within the regulation were definitions regarding the threshold for what constitutes a notifiable patient safety incident. However, it can be difficult to determine when the process should be implemented. The aim of this survey was to evaluate the interpretation of these definitions by British neurosurgeons. MATERIALS AND METHODS: All full (consultant) members of the Society of British Neurological Surgeons were electronically invited to participate in an online survey. Surgeons were presented with 15 cases and asked to decide in the case of each one whether they would trigger the process of duty of candour. Cases were stratified according to their likelihood and severity. RESULTS: In all, 106/357 (29.7%) members participated in the survey. Responses varied widely, with almost no members triggering the process of duty of candour in cases where adverse events were common (greater than 10% likelihood) and required only outpatient follow-up (7/106; 6.6%), and almost all members doing so in cases where adverse events were rare (less than 0.1% likelihood) and resulted in death (102/106; 96.2%). However, there was clear equipoise in triggering the process of duty of candour in cases where adverse events were uncommon (0.1-10% likelihood) and resulted in moderate harm (38/106; 35.8%), severe harm (57/106; 53.8%) or death (49/106; 46.2%). CONCLUSION: There is considerable nationwide variation in the interpretation of definitions regarding the threshold for duty of candour. To this end, we propose a framework for the improved application of duty of candour in clinical practice.

The Medical Review Panel in Louisiana Neurosurgery and Beyond.

For the past several decades, medical malpractice claims in the state of Louisiana have been screened by a pretrial medical review panel (MRP). Composed of 3 physicians and 1 attorney, these panels are a method of filtering nonmeritorious lawsuits while expediting creditable claims. Currently, 14 jurisdictions in the United States require medical liability/malpractice cases be heard by an MRP or screening panel prior to trial. In this article, we review the MRP process in Louisiana and compare it to those in other states. Data are presented for the past 10 yr of malpractice claims in Louisiana with an emphasis on the neurosurgery specialty. Finally, the benefits and challenges of pretrial screening panels are discussed.

Professional Practice and Neurosurgery: What Every Neurosurgeon Should Know about Malpractice

Introduction The objective of the present study was to review the epidemiological aspects of malpractice in neurosurgery and to identify preventive measures regarding malpractice for neurosurgeons. Methods The following terms (alone or in combination) were searched in the PubMed and Biblioteca Virtual em Saúde databases: neurosurgery (neurocirurgia), lawsuits (ações judiciais), malpractice (erro médico), and litigation (litígio) and identifying studies on these topics published from 2000 to April 2018. Literature Review In Brazil, 6.9% of the physicians are sued per year. The most common type of malpractice alleged in litigation is negligence. According to the literature, the neurosurgical disease that has sparked the most litigation is spinal disease. The outcomes of these cases vary: sometimes the neurosurgeon prevails, and at other times the plaintiff prevails. To prevent or reduce malpractice claims, the neurosurgeon should take the following precautions: 1. follow medical protocols; 2. perform surgeries in an environment consistent with good medical practice; 3. evaluate and monitor antibiotic prophylaxis; 4. develop a good relationship with the patient based on ethics, good faith and transparency; 5. request the presence of the patient and of his or her family when there is a problem in order to didactically explain the case; 6. keep good medical records to document all of the actions performed (informed consent and description of the surgery and of the pre and postoperative); 7. always seek technical improvement (continuing education/professional development); 8. in the case of attending physicians, monitor patients, treating any postoperative complications; and 9. conduct multidisciplinary team meetings to optimize treatment decisions and to share responsibility for making difficult decisions.

Why do surgeons receive more complaints than their physician peers?

BACKGROUND: Compared with other doctors, surgeons are at an increased risk of medicolegal events, including patient complaints and negligence claims. This retrospective study aimed to describe the frequency and nature of complaints involving surgeons compared with physicians. METHODS: We assembled a national data set of complaints about surgeons and physicians lodged with medical regulators in Australia from 2011 to 2016. We classified the complaints into 19 issues across four domains: treatment and procedures, other performance, professional conduct and health. We assessed differences in complaint risk using incidence rate ratios (IRRs). Finally, we used a multivariate model to identify predictors of complaints among surgeons. RESULTS: The rate of complaints was 2.3 times higher for surgeons than physicians (112 compared with 48 complaints per 1000 practice years, P < 0.001). Two-fifths (41%) of the higher rate of complaints among surgeons was attributable to issues other than treatments and procedures, including fees (IRR = 2.68), substance use (IRR = 2.10), communication (IRR = 1.98) and interpersonal behaviour (IRR = 1.92). Male surgeons were at a higher risk of complaints, as were specialists in orthopaedics, plastic surgery and neurosurgery. DISCUSSION: Surgeons are more than twice as likely to attract complaints as their physician peers. This elevated risk arises partly from involvement in surgical procedures and treatments, but also reflects wider concerns about interpersonal skills, professional ethics and substance use. Improved understanding of these patterns may assist efforts to reduce harm and support safe practise.

Medical Malpractice in Neurosurgery: A Comprehensive Analysis.

BACKGROUND: Of all specialists, neurosurgeons have the highest probability of facing a medical malpractice claim. Here we report the first specialty-wide review of malpractice claims in neurosurgery performed using a well-established national online legal database. METHODS: The Westlaw legal research service (Thomson Reuters, Eagan, Minnesota, USA) was queried for jury verdicts and settlements related to neurosurgery and medical malpractice between 1985 and 2015. Case files were examined, and factors recorded included the age and sex of the patient, the state and year in which the verdict was reached, defendant specialties, award payouts, and alleged reasons for malpractice. Case files were sorted into neurosurgical subspecialties based on the nature of the condition and the type of treatment administered. RESULTS: A total of 516 cases were identified, and 343 cases were analyzed. A defendant's verdict was reached in 165 (48.1%) cases, and a plaintiff's verdict was reached in 93 (27.1%) cases. A settlement was reached in 81 cases (23.6%). The median payout for plaintiff's verdicts was $2,550,000 (range, $80,000-$216,849,187), and that for settlements was $1,300,000 (range, $100,000-$13,300,000). Procedural error (45.5%), a failure to diagnose (41.4%), or a failure to treat (42.9%) were the most commonly cited reasons for litigation. Neurosurgeons accounted for 21.1% of defendants. The median plaintiff award payout was highest for pediatric cases ($10,100,000). CONCLUSIONS: A defendant's verdict was reached in nearly one-half of the cases. In instances where a plaintiff's verdict was reached, large payouts were common, especially in pediatric and cerebrovascular cases. An emphasis on reducing procedural error, and making timely differential diagnoses, may reduce future litigation.

Co-management Strategies for Hospitals and Orthopedic and Neurosurgery Practices.

Co-management arrangements can be a very effective means of aligning physicians and their hospitals to gain care delivery efficiencies, control costs, and reduce variation in practices. In an era of value-based care delivery all aspects must be examined and the appropriate incentives put in place to reduce waste and optimize asset and resource utilization. This article will review legal considerations, define basic co-management structure and goals, and suggest examples of metrics used to achieve success.

Neurosurgery and Telemedicine in the United States: Assessment of the Risks and Opportunities.

BACKGROUND: Telemedicine has seen substantial growth in the past 20 years, related to technologic advancements and evolving reimbursement policies. The risks and opportunities of neurosurgical telemedicine are nuanced. METHODS: We reviewed general and peer-reviewed literature as it relates to telemedicine and neurosurgery, with particular attention to best practices, relevant state and federal policy conditions, economic evaluations, and prospective clinical studies. RESULTS: Despite technologic development, growing interest, and increasing reimbursement opportunities, telemedicine's utilization remains limited because of concerns regarding an apparent lack of need for telemedicine services, lack of widespread reimbursement, lack of interstate licensure reciprocity, lack of universal access to necessary technology, concerns about maintaining patient confidentiality, and concerns and limited precedent regarding liability issues. The Veterans Health Administration, a component of the U.S. Department of Veterans Affairs, represents a setting in which these concerns can be largely obviated and is a model for telemedicine best practices. Results from the VA demonstrate substantial cost savings and patient satisfaction with remote care for chronic neurologic conditions. Overall, the economic and clinical benefits of telemedicine will likely come from 1) diminished travel times and lost work time for patients; 2) remote consultation of subspecialty experts, such as neurosurgeons; and 3) remote consultation to assist with triage and care in time-sensitive scenarios, including acute stroke care and "teletrauma." CONCLUSIONS: Telemedicine is effective in many health care scenarios and will become more relevant to neurosurgical patient care. We favor proceeding with legislation to reduce barriers to telemedicine's growth.

MACRA: background, opportunities and challenges for the neurointerventional specialist.

The legislative branch of government took many by surprise when it announced the Medicare Access and CHIP Reauthorization Act of 2015. Once the Act was passed, President Obama quickly signed this bipartisan, bicameral effort into law. A foundational element of this legislation was the permanent repeal of the sustainable growth rate formula. Physicians and their patients were appropriately enthusiastic about this development. The Medicare Access and CHIP Reauthorization Act of 2015 included additional elements of considerable interest to neurointerventional specialists.

Integrating risk management data in quality improvement initiatives within an academic neurosurgery department.

OBJECT While malpractice litigation has had many negative impacts on health care delivery systems, information extracted from lawsuits could potentially guide toward venues to improve care. The authors present a comprehensive review of lawsuits within a tertiary academic neurosurgical department and report institutional and departmental strategies to mitigate liability by integrating risk management data with quality improvement initiatives. METHODS The Comprehensive Risk Intelligence Tool database was interrogated to extract claims/suits abstracts concerning neurosurgical cases that were closed from January 2008 to December 2012. Variables included demographics of the claimant, type of procedure performed (if any), claim description, insured information, case outcome, clinical summary, contributing factors and subfactors, amount incurred for indemnity and expenses, and independent expert opinion in regard to whether the standard of care was met. RESULTS During the study period, the Department of Neurosurgery received the most lawsuits of all surgical specialties (30 of 172), leading to a total incurred payment of $4,949,867. Of these lawsuits, 21 involved spinal pathologies and 9 cranial pathologies. The largest group of suits was from patients with challenging medical conditions who underwent uneventful surgeries and postoperative courses but filed lawsuits when they did not see the benefits for which they were hoping; 85% of these claims were withdrawn by the plaintiffs. The most commonly cited contributing factors included clinical judgment (20 of 30), technical skill (19 of 30), and communication (6 of 30). CONCLUSIONS While all medical and surgical subspecialties must deal with the issue of malpractice and liability, neurosurgery is most affected both in terms of the number of suits filed as well as monetary amounts awarded. To use the suits as learning tools for the faculty and residents and minimize the associated costs, quality initiatives addressing the most frequent contributing factors should be instituted in care redesign strategies, enabling strategic alignment of quality improvement and risk management efforts.