Expert Witness Blog

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

One of the first clinical problems targeted for standards development was Chest Pain. As a prototypic example of clinical policy development, the Specialty Board responsible for the development and implementation of this standard created three conceptual entities which can be applied to all clinical problems. They are “actions”, “variables”, and “findings”.

Actions are defined as either “rules” (principles of good practice in most situations) such as ordering an electrocardiogram on an elderly patient with shortness of breath and severe chest pain, or “guidelines” (actions that should be considered but may or may not be performed depending on the patient, the circumstances, and a multitude of other factors) such as ordering imaging studies on any patient with chest pain. In those situations where a rule isn’t followed, the physician would be required to document in writing his justification for its avoidance.

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

Potential limitations should be recognized and dealt with such as the possibility that a particular standard becomes obsolete because of new discoveries or advances; or situations where environmental factors such as disaster, overcrowding, or multiple high acuity emergencies negate the applicability of standard clinical policies. Likewise, policy standards can never supersede the physician’s clinical judgement which must be taken as the final word in making patient care decisions. This is because of the immense number of clinical variables and continually changing circumstances in both stable and unstable patients with complex multifactorial systemic medical problems.

For maximum effectiveness and utility, it is clear that standards should be developed in the areas that place the patient at highest risk for death or debility. For the physician, these are often the areas of greatest liability. Also, it is important that standards are developed for common presenting complaints rather than for obscure uncommon entities. Finally, because cost-containment has become a central issue, clinical standards should also target those conditions or situations that may result in high charges.

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

The existence of clinical standards would enable malpractice litigators to be more selective in their choice of cases. In situations where a clinical standard was followed but where there was an adverse patient outcome, litigators would be less inclined to pursue the matter. In situations where deviation from clinical standards, the litigation process would still allow physicians to explain their reasoning and, in and of itself, is not de facto proof of negligence.

The actual development of clinical standards is complex, time consuming and expensive. In general, these standards should be developed by physician organizations, particularly the specialty societies utilizing appropriate ancillary input from administrators, economists, etc. They should be based on current information and clinical experience and be as comprehensive and specific as possible. They should be periodically reviewed and revised and widely disseminated.

McClatchy Company, the third largest newspaper company in the US, reports that America’s five largest banks, which already have received $145 billion in taxpayer bailout dollars, still face potentially catastrophic losses from exotic investments if economic conditions substantially worsen, their latest financial reports show.

Corporate governance expert witness and president of Everest Management Gary Kopff has scrutinized the big banks’ financial reports. He noted that Citibank now lists 60 percent of its $301 billion in potential losses from its wheeling and dealing in derivatives in the highest-risk category, up from 40 percent in early 2007. Citibank is a unit of New York-based Citigroup. In Monday trading on the New York Stock Exchange, Citigroup shares closed at $1.05.

McClatchy.com writes:

In Clinical Standards in Medicine medical expert witness Barry E. Gustin, MD, MPH, FAAEM, writes:

Forces both inside and outside of medicine are responsible for the trend towards the development of clinical standards. Physicians have been motivated by their desire to establish acceptable levels of care within the various specialties. This ultimately homogenizes and standardizes the basic approach to patient’s problems, is patient-centered, allows for the development of quality assurance and improvement programs, and demonstrates to the public that physicians as a group are concerned about the quality of care they provide to their patients.

Forces outside of medicine, however, are probably more potent than these internal forces at bringing increasing pressure to the issue of standards development. Malpractice carriers see the creation of widely-accepted clinical standards as one route towards reduced malpractice losses. Ditto for several states, including Maine and New Jersey, which have mandated the development of clinical standards because of their involvement in underwriting malpractice insurance plans.

In Discussion of Insurance Capital as a Shared Asset, actuarial expert witness Robert Bear discusses what he describes as Donald Mango’s ground breaking work Insurance Capital as a Shared Asset:

Mr. Mango differentiates between consumptive and non-consumptive use of an asset. A consumptive use involves the transfer of a portion or share of the asset from the communal asset to an individual, such as in the reservoir water usage and fishery examples. Nonconsumptive use involves temporary, limited transfer of control which is intended to be non-depletive in that it is left intact for subsequent users. Examples of non-consumptive use indude boating on a reservoir, playing on a golf course or renting a hotel room.

While shared assets are typically used in only one of the two manners, some shared assets can be used in either a consumptive or non-consumptive manner, depending on the situation. Mr. Mango gives the example of renting a hotel room. While the intended use is benign occupancy (non-consumptive), there is the risk that a guest may fall asleep with a lit cigarette and burn down a wing of the hotel (clearly consumptive).