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The various types of cancers are classified on the basis of the Cancer tissue in which they develop 100 mg extra super levitra sale erectile dysfunction zyprexa. Lymphoma extra super levitra 100mg generic erectile dysfunction doctors in maine, for example, is a cancer of lymphoid tissue; osteogenic cancer is a type of bone cancer; Cancer refers to a complex group of diseases characterized by un- myeloma is cancer of the bone marrow; and sarcoma is a general controlled cell replication. The rapid proliferation of cells results term for any cancer arising from cells of connective tissue. How- frequently called tumors, are classified as benign or malignant ever, initiating factors, or carcinogens (kar-sin′o˘-jenz), such as based on their cytological and histological features. Benign neo- viruses, chemicals, or irradiation, may provoke cancer to de- plasms usually grow slowly and are confined to a particular area. Cigarette smoking, for example, causes various respiratory These types are usually not life threatening unless they grow to cancers to develop. The tendency to develop other types of can- large sizes in vital organs like the brain. The origi- Because the causes of cancer are not well understood, emphasis is nal malignant neoplasm is called the primary growth and the new placed on early detection with prompt treatment. Generally they do not mature before they divide and are Aging not capable of maintaining normal cell function. Cancer causes death when a vital organ regresses because of competition from Although there are obvious external indicators of aging—graying cancer cells for space and nutrients. The pain associated with can- and loss of hair, wrinkling of skin, loss of teeth, and decreased cer develops when the growing neoplasm affects sensory neurons. The mitochondria, for example, may change in struc- ture and number, and the Golgi complex may fragment. Down, English physician, 1828–96 carcinogen: Gk, karkinos, cancer Van De Graaff: Human III. Cytology © The McGraw−Hill Anatomy, Sixth Edition of the Body Companies, 2001 74 Unit 3 Microscopic Structure of the Body The chromatin and chromosomes within the nucleus ies, and its deterioration is thought to be associated with such show changes with aging, such as clumping, shrinking, or frag- vascular diseases as arteriosclerosis in aged persons. There is strong evi- dence that certain cell types have a predetermined number of mitotic divisions that are genetically controlled, thus determin- ing the overall vitality and longevity of an organ. If this is true, Clinical Case Study Answer identifying and genetically manipulating the “aging gene” might be possible. Giving a substance that competes for the enzyme alcohol dehydrogenase can inhibit the reaction that forms the toxic metabolite of ethylene gly- Extracellular substances also change with age. Thus, infusing a nearly intoxicating dose of alcohol can spare the strands of collagen and elastin change in quality and number in kidneys from harm. Elastin plays an important role in the walls of arter- Chapter Summary Introduction to Cytology (p. Carbohydrates are organic compounds (a) Endoplasmic reticulum provides a referred to as metabolism and the study of containing carbon, hydrogen, and oxygen, framework within the cytoplasm and cells is referred to as cytology. Cellular function depends on the specific (a) The carbohydrate group includes the ribosomes. It functions in the membranes and organelles characteristic starches and sugars. Lipids are organic fats and fat-related and RNA that function in protein substances. Golgi complex is extensive in compound in cells and is an excellent secretory cells, such as those of the solvent. The cell membrane, composed of fluid loss exceeds fluid intake, may be a folded membranous extensions phospholipid and protein molecules, serious problem—especially in infants. Electrolytes are inorganic compounds that The mitochondria produce ATP regulates the passage of substances into form ions when dissolved in water. Mitochondria are lacking (a) The permeability of the cell membrane acids, bases, and salts. They are electrical currents, and in regulating abundant in the phagocytic white (b) Cell membranes may be specialized the activity of enzymes.

A world that won’t stand still: enterprise liability by private contract generic extra super levitra 100 mg visa erectile dysfunction medications. Regulating through information: disclosure laws and American health care order extra super levitra 100mg with amex goal of erectile dysfunction treatment. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Not afraid to blame: the neglected role of blame attribution in medical consumerism and some implications for health policy. To err on humans is not benign: incentives for adoption of medical error reporting systems. The adverse event of unaddressed medical error: identifying and filling the holes in the health-care and legal systems. A public health approach to reducing error: medical malpractice as a barrier. To err on humans is not benign: incentives for adoption of medical error reporting systems. Institute of Medicine, Fostering Rapid Advances in Health Care: Learning from System Demonstrations, (Corrigan JM, Greiner A, Erickson SM, eds. Paths to reducing medical injury: profes- sional liability and discipline vs. Apology and organizations: exploring an example from medical prac- tice. No-fault compensation for medical injuries: the pros- pect for error prevention. Index 279 INDEX A ALH, 162 Abdominal pain Allegations emergency room, 109–110 family physician risk manage- Abdominoplasty ment, 91–92 generating malpractice claims, 192 Allocated loss adjustment expense (ALAE), 206 Accelerated compensation events Alternative dispute resolution (ACEs), 273 (ADR), 266–268 proposals, 267 Ambiguous questions, 55–56 Access to health care, 218–222 American Academy of Actuaries evaluating, 219 effective medical malpractice MICRA, 221, 222 reforms, 215 Accident compensation systems American College of Emergency no-fault, 266–267 Physicians (ACEP) ACEP temporary holding orders, 106 temporary holding orders, 106 Anesthesiologists ACEs, 273 malpractice suits, 135–137 proposals, 267 Anesthesiology, 115–137 Actuarial science, 5–6 disasters, 126–132 ADH, 161–162 documentation, 120–121 Administrability injury prevention, 122–125 vs accountability, 267 dental, 122–125 Administrative compensation literature search, 136 schemes, 241 malpractice claims, 116–120 Admissible expert testimony, 28 newly identified risks, 132–135 ADR, 266–268 records, 120 Adversarial system risk management, 120–122 governing malpractice disputes, Anger 260 plastic and reconstructive sur- Adversarial witnesses, 27 gery medical liability, Adverse events 196–197 limited disclosure of, 271 Annual pap smear Affirmative duty, 182 importance, 170–171 Affordability, 219 Answers vs fairness, 267 physician witness, 61 Aftercare instructions Antibiotic-resistant infections, 95 emergency medicine, 105 Anticipation Agency for Healthcare Research physician witness, 61 and Quality Antishock trousers, 147 effective tort reforms, 219–220 Aortic aneurysm ALAE, 206 dissecting, 94 279 280 Index Appellate attorneys, 13 Atypical duct hyperplasia (ADH), Appellate practice, 13 161–162 Appendicitis Atypical lobular hyperplasia emergency room, 109–110 (ALH), 162 Arbitration, 239t Atypical squamous cells of undeter- Artificial blood vessels, 220 mined significance (ASC- Art of Cross-Examination, 46 US), 168 ASC-US, 168, 173–174 Authentication Assets online communications, 83 insurance companies, 7 Authoritative information Assimilation online communications, 84–85 pause for, 68 Authoritative sources, 56 Attendant costs, 202 Authoritative textbooks, 56 Attention Authority feigning, 66 physicians Attorney–client relationship, 25–26, erosion of, x 46–48 physician witness subject to, 42 physician witnesses, 46–48 Autonomy Attorneys, 25–26 doctrine of, 141 appellate, 13 medical profession, xii–xiii Autopsy biographical information about, dead fetus, 144 26 Avoidability standard, 240 butterfly plaintiff, 59 Avoidable injuries, 255–256 client solicitation, 203 Awards doctors and, 249 caps on, 237 educating about case, 38–39 size of, 237 fee limits, 239t freight train plaintiff, 58–59 B ignoramus, 59 litigation, 25–26 Baby deliveries meeting with immediately, 31– cessation of, 220 33 Bad doctor fallacy, ix, 209–211 pal plaintiff, 58 Bad faith malpractice claims, 217 plaintiff Bedpan mutuals, 231 contingency fees, 18–19 Binding arbitration, 239t at deposition, 58–59 Birth injury compensation funds perspective on risk reduction, no-fault, 266–267 35–40 Blepharoplasty sliding contingency fee scale, generating malpractice claims, 18 191–192 provided by liability insurance Body dysmorphic disorder company, 25–26 plastic and reconstructive sur- time bomb, 59 gery medical liability, Atypical angina pectoris, 94 197–198 Index 281 Body language, 69–70, 141 effect on health care costs, Bowel injuries 221 during surgery, 149 noneconomic damage limit, Breach, 16–17 213–217 Breast augmentation periodic payments, 214 generating malpractice claims, provisions of, 213t 191 savings from, 215f Breast biopsy, 160–163 reforms, 214 malpractice claims, 161–163 Cancer diagnostic errors, 162 delayed diagnosis of, 143 Breast cancer Canons of statutory interpretation, delayed diagnosis of, 143 23 microscopic diagnosis of, 160– CAP, 168 163 Caps, 259 Breast cancer litigation, 153–165 Carefulness clinical context, 153–160 physician witness, 45 Breast cancer malpractice claims Cauda equina syndrome age, 159f, 159–160 emergency room, 111 diagnosis delay, 157–158 Causation, 16–17, 140 lymph node status, 159 legal, 16 mammography, 156–157 Centers for Medicare and Medicaid mass discovery, 155 Services (CMS), 273 overall outcomes, 155 Cephalosporin prophylaxis physician specialties, 155–156, for hysterectomies, 142–143 156f Cervical cancer presenting symptoms, 155 delayed diagnosis of, 143 tumor size, 158–159 Cervical spine Breast fine needle aspiration emergency room, 110 false-negative, 160–161 Cesarean sections (C-sections) malpractice claims, 160–163 rates of, 217–218 triple test strategy, 161 Change-of-shift Breast reduction emergency medicine, 106 generating malpractice claims, Charges 191 fee-based online consultation But for causation, 16 eRisk guidelines, 86 Butterfly plaintiff attorneys, 59 Charting anesthesiology, 120–121 C Chest pain California emergency room, 109 health care system, 221–222 Childhood vaccines MICRA, 201 cost affected by tort tax, 202 attorneys’ contingency fees Choice limit, 214 information, 269–272 caps, 213–217 Citing textbooks or journals collateral source rule, 214 physician witness, 43–44 282 Index Claims. See Informed consent Combined ratio, 7 Constitutions Commercial information state, 23 online communications, 85 Consultants Common Good, 203 jury, 26 Common law rules, 22 standard of care, 141 Communication Consumers emergency medicine, 102–103 decision making, 270 failure to, 140 Contemporary medical malpractice nurse–physician litigation, ix problems of, 70–71 Contemporary medical practice online eRisk Guidelines, 83–85 exacerbating medical malprac- online patient–physician, 86 tice liability, 204 patient–physician Contingency fees, 237 e-mail, 80–81 plaintiff attorneys, 18–19 patient safety, 65–74 Contingency fee scale plastic and reconstructive sur- sliding gery medical liability, 196 plaintiff attorneys, 18 Community clinics Contributory negligence, 23–24 volunteer physicians, 221 Conventional tort reform, 237t Compensable injuries, 16–17 Cooperativeness Compensation physician witness, 45 poor, 258–260 Cost-based reimbursement, 253 Complications Costs failure to document, 140 future, 4 Composed Court physician witness, 61 limiting access to, 236 Index 283 Courteousness duty to plaintiff, 16 physician witness, 42 plaintiff’s knowledge of strate- Court-made rules, 22 gies and information, 54– Courtroom 55 defendant familiarizing one’s testimony self with, 60 plaintiff summarizing, 56–57 Courts Defensive medicine, 217–218, 256– specialized medical, 265 257 CPT cost of, 218 for telephone-based care, 79 medical community, 234 Credibility impeached negative, 257 defendants, 55–58 Delay, 257–258 Crier, Catherine, 203 Delayed lab or x-ray reports Criminal penalties emergency medicine, 105–106 faced by physicians, x Delivery C-sections, 147 anesthesia disasters, 127–128 rates of, 217–218 regional anesthesia, 150 vaginal birth after, 148 Demeanor Cultural variation physician witness, 44 emergency medicine, 103 Dental injuries Current malpractice crisis anesthesiology, 124–125 policy issues, 234–235 Deposition, 39–40, 53–61 Current Procedural Technology objections raised during, 59 (CPT) oral, 29–30 for telephone-based care, 79 Diagnosis online vs fee-based online con- D sultation eRisk guidelines, Damages 86 cap, 239t Diagnostic errors economic, 259 breast biopsy malpractice claims, noneconomic, 17 162 caps on, 216, 237 Digital divide, 81 recoverable noneconomic Dignity limitations on, 18–19 patient, 92 scheduling, 267 Disclosure Danzon, Patricia, 270 plastic and reconstructive sur- DCIS, 161–162 gery medical liability, misdiagnosis, 162 182–183 Dead fetus requirements, 235 autopsy, 144 Discovery, 54–58 malpractice, 143–144 plan Defendants importance of, 31–33 breaching standard of care, 16 procedural rules of, 17 causing injury to plaintiff, 16 process credibility impeached, 55–58 time, 29–30 284 Index Dissatisfaction Emergency Medical Treatment and with medical profession, xii–xiii Active Labor Act Dissecting aortic aneurysm, 94 (EMTALA), 106–107 Distractions, 66–67, 67 Emergency medicine, 101–113 Doctors. See Physician(s) communication, 102–103 Doctors Company (TDC) documentation, 103–104 breast cancer claims, 154–163 lack of English, 103 pap smear litigation, 167–179 Emergency subject matter Doctrine of autonomy, 141 online communications, 84 Doctrine of vicarious liability, 90–91 Emotion-laden words, 67 Documentation, 97 Employee Retirement Income Secu- anesthesiology, 120–121 rity Act (ERISA), 204, 268 emergency medicine, 103–104 Employer-sponsored health care nursing notes, 104–105 workers compensation analogy, patient explanations, 38 274 plastic and reconstructive sur- EMTALA, 106–107 gery medical liability, Endotracheal intubation 185–186 emergency room, 111–112 template charts, 104 End-tidal carbon dioxide monitors, Double-dipping, 237–238 116 Double-negatives, 56 English Dress lack of physician witness, 47, 60 emergency medicine, 103 Drug addicts Enhance expertise, 265 emergency room, 112 Enoxaparin (Lovenox) Ductal carcinoma in situ (DCIS) epidural hematomas with, 130 low-grade, 161–162 Enterprise liability, 241, 268, 273 misdiagnosis, 162 hospital-based, 269 Duty, 16–17 Epidural abscess E emergency room, 111 Early offers, 273 Epidural blocks, 130 program, 240, 241 Epidural hematoma reforms, 266–268 after epidural block, 129–130 Economic damages, 259 ERISA, 204, 268 Economic loss, 16 ERisk guidelines, 82–85 Economy fee-based online consultation, downturn in, 234 85–86 Edema of preeclampsia, 149–150 ERisk Working Group, 82 Electronic fetal heart rate monitor- Errors ing, 144 diagnostic E-mail, 87 breast biopsy malpractice patient–physician communica- claims, 162 tion, 80–81 disclosure mandates E-medicine Pennsylvania, 271 physician’s office, 75–87 interpretation Index 285 pap smears, 173–174 F medical, 269, 270 Facelift IOM report, 235 generating malpractice claims, limited disclosure of, 271 191–192 public awareness of, 234 Facts Texas case, 251–252 interpretation, 14–15 prescription Factual causation test, 16 family physician risk manage- Failure to communicate, 140 ment, 99 False-negative breast fine needle public skepticism about, 234 aspiration, 160–161 sampling False-negative pap smears, 168 pap smears, 171 screening Families pap smears, 171–172 communication with in emer- Esophageal intubation gency room, 102–103 anesthesia disasters, 126–127 Family physician risk management, Ethics 89–100 physician witness, 51 allegations, 91–92 Evidence clinical issues, 93–95 scientific differential diagnosis, 93 relevant and reliable, 28 issues, 96–97 substantial, 26 language barrier, 100 Evidentiary rules, 17 most common claims against, Exclusivity, 267 93–94 Expectations physician extenders, 93 failure to clearly define, 140 procedures, 99–100 patient rules, 92–93 Internet-based care, 80–81 standards of care, 91 plastic and reconstructive telephone, 98 surgery medical liability, unforeseen legal pitfalls, 90–91 188 Federal anti-kickback statute, 268 Experience rating Federal government of physicians, 229 Medicare spending reduction, x Expertise-based arguments, 265 Federal health programs Expertise-related reforms, 264 liability issues, 249 Expert resolution, 264–266 Federally funded state demonstra- Experts accountable to nonexperts, tion projects, 272–273 264 Federal patient protection act, 250 Expert testimony Fee-based online consultation eRisk admissible, 28 guidelines, 85–86 Expert witnesses, 26–29, 230 Feedback necessity of, 50–51 pause for, 68 Explanations Fees patient contingency, 237 documentation, 38 disclosure 286 Index fee-based online consultation Freight train plaintiff attorneys, 58– eRisk guidelines, 85 59 limits, 239t Frequency, 205–206 sliding contingency scale reduction of, 236 plaintiff attorneys, 18 by specialty, 205–206, 206f usual and customary, 253 Frequently asked questions, 87 Feigning attention, 66 Future costs, 4 Fetal heart rate (FHR) monitoring Future losses electronic, 144 estimating, 5 Fetus dead G autopsy, 144 Game players, 14–15 malpractice, 143–144 GAO. See General Accounting FHR Office (GAO) electronic monitoring, 144 General Accounting Office (GAO) Financial markets, 5–6 malpractice insurance cost report Fine needle aspiration (FNA) (2003), 208 breast premium rate adjustments (2000 false-negative, 160–161 to 2002), 209 malpractice claims, 160–163 tort reform, 220 triple test strategy, 161 Generosity, 267 Fires Government structure, 249 operating room, 131–132 Governor’s Select Task Force on oropharyngeal airway, 132 Healthcare Professional Li- pediatric airway, 132 ability Insurance in Florida. First do no harm, 92 See Florida, Governor’s Se- Flat caps on noneconomic or total lect Task Force damages, 259 Grooming Florida physician witness, 47 access to care, 219 Gynecology and obstetrics commission on malpractice malpractice, 139–150 crisis, 207 H Governor’s Select Task Force, 207, 216, 219 Harvard Medical Practice Study, pilot project endorsement, 210, 232, 255–256 241 Headaches malpractice insurers decline, 212 emergency room, 110 Florid adenosis postsubdural puncture, 130–131 misdiagnosis, 162 Health care FNA. See Fine needle aspiration access to, 218–222 (FNA) evaluating, 219 For-profit corporate medicine, xi MICRA, 221, 222 Fostering Rapid Advances in employer-sponsored Health Care: Learning From workers compensation anal- System Demonstration, 272 ogy, 274 Index 287 Health care system Identity disclosure California, 221–222 fee-based online consultation Health Insurance Portability and eRisk guidelines, 86 Accountability Act (HIPAA), Ignoramus attorneys, 59 79, 82, 90 Income Health policy review insurers, 7 medical malpractice, 227–241 Incurred loss, 6–7 Health system change Industrial base, 261–262 Texas case, 251–252 Industrial litigation Heart valves, 220 liability and health system Hemabate change, 252–253 for obstetric hemorrhage, 146 Information Hemorrhage and choice, 269–272 obstetrics, 147 fee-based online consultation subarachnoid eRisk guidelines, 86 emergency room, 110 online communications Heparin authoritative, 84–85 epidural hematomas with, 130 commercial, 85 HIE, 145 Informed consent, xii, 96–97, 140, 230 High-grade squamous intraepithelial anesthesiology, 120–122, 123f– lesion (HSIL), 168 124f High-risk specialties, 234 elements of, 185 HIPAA, 79, 82, 90 fee-based online consultation Hospital-based enterprise liability, 269 eRisk guidelines, 85 Hospitals online communications, 83–84 sole locus of legal responsibility, plastic and reconstructive sur- 240 gery medical liability, 183 House Resolution 4600, 216 regional blocks, 130 Howard, Philip, 203 Informed refusal, 96–97 HSIL, 168 Injuries Huber, Peter, 202 avoidable, 255–256 Humility bowel physician witness, 41 during surgery, 149 Hypertension compensable, 16–17 pregnancy, 148 dental Hypothetical questions, 56 anesthesiology, 124–125 Hypoxic-ischemic encephalopathy iatrogenic (HIE), 145 deterrence, 254 Hysterectomy negligent, 233 patient selection, 149 Institute of Medicine (IOM), 272, 273 I patient safety, 255–256 Iatrogenic injuries pilot project endorsement, 241 deterrence 2000 Report on medical error, reducing rates, 254 235 288 Index Institutional liability, 268–269 Interpersonal relationships Institutional self-insurance arrange- with patients, 37–38 ments, 231 Interpretation, 14–15 Insurance. See also Medical mal- Interpretation errors practice insurance; Medical pap smears, 173–174 practice insurance Interpreters liability, 260–262 emergency medicine, 103 byproduct of, 262 Interruptions, 57–58 professional, 4 Invasive ductal carcinoma pricing misdiagnosis, 162 according to legal risks, 261 Invasive lobular carcinoma pricing according to legal risks, 261 failure to recognize, 162 professional liability, 4 Investments Insurance companies. See also income, 6 Medical malpractice insur- fall in, 209 ance companies premium, 5–6 assets, 7 IOM. See Institute of Medicine expenses, 4 (IOM) liability Ischemic optic neuropathy, 133–134 providing attorneys, 25–26 J mutual, 4 ownership, 4 Joint-and-several liability publicly traded commercial, 4 eliminating, 236 reciprocal, 4 Joint underwriting associations, 230 Insurance cycle, 231 Journals Insurance premiums citing by physician witness, 43– burden equitably apportioned, 5 44 impacts on, 238 Judge-made rules, 22 Insurance rates Judges, 26–27 interest rates, 6 physician witness actions to- Insurers ward, 45 income, 7 Judicial nullification Integrated delivery systems of tort reforms, 209 sole locus of legal responsibility, Judicial process, 53–61 240 Jurors Internet-based care, 79–87 prospective appropriateness, 81–82 voir dire, 26 patient expectation, 80–81 Jury, 26 physician perspective, 80 Jury consultants, 26 practical, technical, financial K considerations, 87 privacy, 82–86 Kindness security, 82–86 physician witness, 42 standards of care, 82–83 Knee injury value, 81–82 emergency room, 110–111 Index 289 L Legal standards of care Labor and delivery replacing medical standards of anesthesia disasters, 127–128 care, xii regional anesthesia, 150 Liability Labor epidurals and spinals comprehensive reform anesthesia disasters, 127–128 approaches to, 263–272 Labor induction doctrine of vicarious, 90–91 complications, 144 enterprise, 241, 268, 273 Lab reports and health system change, 251– delayed 254 emergency medicine, 105– cost containment, 253 106 industrial litigation, 252–253 Lack of English medical progress, 251–252 emergency medicine, 103 hospital-based enterprise, 269 Language institutional, 268–269 tailoring, 69–70 insurance companies, 7 Language barrier joint-and-several family physician risk manage- eliminating, 236 ment, 100 medical Language variations economic analysis of, 270 emergency medicine, 103 expansion of, 203 Laparotomy sponge medical malpractice losing during delivery, 148 exacerbated by managed care, Laryngeal mask airways (LMA), 204 116 organizational, 268 Laws pap smear impact on medical practice, xi– limiting, 170–171 xii professional Lawsuits refusal to offer, 209 per physician, 12 rising costs for skilled nursing Lawyers. See Attorneys facilities, 260 LCIS, 161–162 vicarious misdiagnosis, 162 doctrine of, 90–91 Legal causation, 16 Liability crisis Legal defense professional estimating costs, 5 states facing, 215 as insurance company expenses, Liability insurance, 260–262 4 byproduct of, 262 Legal doctrine professional, 4 impact of changes in, 230 Liability insurance company Legal process, 257–260 providing attorneys, 25–26 Legal reform Liability law case for, 201–223 expansion of, 202 medical context of, 204 Liability reform value of, 213–214 and patient safety, 255 290 Index Liability rule of negligence LSIL, 171 substantive, 15–17 Lump sum judgment rule, 20–22 MICRA, 18 Liability rules M modification of, 236 MAC, 116 Libby Zion case, 271 Malpractice, 248 Licensing jurisdiction expert driven cases, 28 online communications, 84 gynecology and obstetrics, 139– Limitations period, 18–19 150 Limiting access to court, 236 Malpractice claims. See also Breast Listening, 66–68, 140 cancer malpractice claims bad habits, 66–67 abdominoplasty, 192 for facts only, 67 analysis skills, 67–68 Milliman USA, 216 Literature search anesthesiology, 116–120 anesthesiology, 136 brain damage, 119f Litigation. See also Malpractice cardiovascular injuries, 118 litigation death, 119f emotionally burdened physi- dental injuries, 119f cians, 218 indemnity payments, 118– nonmeritorious, 206 119, 119f Litigation cells, 172 by injury, 117, 117f Litigation game neurologic injuries, 117–118, players importance in, 24–25 120 Litigation rules, 14–15 patient death, 117 importance, 15–22 surgical complications, 118 Li v. See also 208–209 Patient safety affecting physician behavior, incidence of, ix 218–219 IOM report, 235 lowering, 222 limited disclosure of, 271 Medical malpractice insurance public awareness of, 234 companies Texas case, 251–252 decline of, 212 Medical Injury Compensation Re- and legal defense cost, 206 form Act (MICRA) and markets, 211–213 California, 13, 17–22, 201, 214 numbers of, 212 attorneys’ contingency fees role of, 207–213 limit, 214 Medical malpractice insurance caps, 213–217 raters collateral source rule, 214 determinants of, 211 effect on health care costs, Medical malpractice law 221 links liability to negligent behav- noneconomic damage limit, ior, 261 213–217 Medical malpractice liability periodic payments, 214 exacerbated by managed care, provisions of, 213t 204 savings from, 215f Medical malpractice litigation Ohio’s tort reforms, 214 changing conventional rules, 17– Oregon’s tort reforms, 215 22 substantive liability rule of neg- Medical malpractice reforms ligence, 18 American Academy of Actuar- Medical innovation, 234 ies, 215 Medical Insurance Feasibility Study Medical malpractice settlements, (MIFS), 231–232 211 Medical liability. See also Plastic Medical malpractice tort cost, 205 and reconstructive surgery Medical meltdown medical liability trends contributing to, x economic analysis of, 270 Medical miracles, 204 expansion of, 203 Medical practice new directions in reform, 247– contemporary 275 exacerbating medical mal- Medical malpractice, 248. See also practice liability, 204 Malpractice laws impact on, xi–xii expert driven cases, 28 in new millennium, x–xi Medical malpractice insurance. See regulations impact on, xi–xii also Medical practice insur- ance Index 293 Medical practice insurance, 3–8.

Although these characteristics are impossible to predict with absolute accuracy purchase extra super levitra 100mg visa erectile dysfunction treatment natural remedies, it is possible to establish some objective criteria for patient selection order extra super levitra 100 mg overnight delivery erectile dysfunction 43. Figure 1 depicts a patient’s objective deformity along the horizontal axis (as judged by the surgeon) vs the patient’s degree of concern over that deformity (vertical axis; as perceived by the patient). This is a patient with an obvious major deformity in whom it is clear that any degree of improvement will be regarded with satisfaction. Second, there is the patient with the minor deformity but extreme concern. In contrast, this is the patient with a deformity that the surgeon perceives to be minor but who demonstrates an inordinate degree of concern and emotional turmoil. These are the patients who are most likely to be dissatisfied with any outcome. The anxiety expressed over the deformity is merely a manifestation of inner turmoil, which is better served by a psychiatrist’s couch than a surgeon’s operating table. Most who seek aesthetic surgery fit somewhere on a diagonal between the two contralateral corners shown in Fig. The closer the patient comes to the upper left-hand corner, the more likely an unfavor- ably outcome is perceived, as is a visit to an attorney. Effective Communication Most litigation in plastic surgery has the common denominator of poor communication. This doctor–patient relationship can be shattered by the surgeon’s arrogance, hostility, coldness (real or imagined), or simply by the fact that “he [or she] didn’t care. Although the doctor’s skill, reputation, and other intangible factors contribute to a patient’s sense of confidence, rapport between patient and doctor is based on forthright and accurate communication. This will normally prevent the vicious cycle of disappointment, anger, and frus- tration by the patient and reactive hostility, defensiveness, and arro- gance from the doctor, which deepens the patient’s anger and ultimately may provoke a lawsuit. Anger: A Root Cause of Malpractice Claims Patients feel both anxious and bewildered when elective surgery does not go smoothly. The borderline between anxiety and anger is tenuous, and the conversion factor is uncertainty—fear of the unknown. A patient frightened by a postoperative complication or uncertain about the future may surmise: “If it is the doctor’s fault, then the responsibil- ity for correction falls on the doctor. At this delicate juncture, the physician’s Chapter 14 / Plastic and Reconstructive Surgery 197 reaction can set in motion or prevent a chain reaction. The physician must put aside feelings of disappointment, anxiety, defensiveness, and hostility to understand that he or she is probably dealing with a fright- ened patient who is using anger to gain control. The patient’s perception that the physician understands that uncer- tainty and will join with him or her to help to overcome it may be the deciding factor in preserving the therapeutic relationship. One of the worst errors in dealing with angry or dissatisfied patients is to try to avoid them. It is necessary to actively participate in the process rather than attempting to avoid the issue. Body Dysmorphic Disorder As the popularity of aesthetic surgery increases, one is reminded of the fairy tale that asks the question: “Mirror, mirror on the wall, who’s the fairest of them all? Beyond the unrealistic expectations of aesthetic correction, many patients are seeking surgery when the need for it is dubious at best. The physical change sought through surgery usually is more a manifestation of flawed body image than a measurable deviation from physical normal- ity. Body dysmorphic disorder (BDD) represents a pathological pre- occupation by the patient about a physical trait that may be within normal limits or so insignificant as to be hardly noticeable. As the trend to advertising and marketing cosmetic surgery grows worldwide there is greater probability that those living in the shadow of this diagnosis will eventually decide on the surgeon’s scalpel as an answer to their problem rather than the psychiatrist’s consultation. Increasingly, we see traditional surgical judgment replaced either by financial consideration or plain ego on the part of the surgeon. Because patients with BDD never carry that diagnosis openly into the consulta- tion with the plastic surgeon, medical disputes about the surgical out- come depend entirely on what was said vs what was understood.

Although this pro- Adjustment to vision loss is not necessar- vides some protection purchase 100 mg extra super levitra visa erectile dysfunction treatment options exercise, it does not account ily correlated with the degree of remain- for objects above the waist that are in the ing vision buy discount extra super levitra 100mg erectile dysfunction with age statistics. In an attempt to com- do not have fewer adjustment issues than pensate for this type of obstacle, some those who are totally blind, and in fact canes have tone-emitting radar units that may have more adaptation difficulties be- give a differential pitch for the direction cause their partial sight presents an am- and height of obstacles in front of the biguous situation for others. Some individuals prefer col- individuals with partial sight may exhib- lapsible, folding, or telescopic canes, it high levels of anxiety because they may which are less obtrusive and can be col- be unsure about whether or when they lapsed and slipped into a purse or under will lose more of their residual vision. Even when individuals with severe Electronic travel aids may also be used. When the light beam or ultrasound activities for which they are more depend- wave hits an object in the individual’s ent on assistance from others. In other instances individu- Partially Sighted als, in an attempt to demonstrate self- reliance and independence, may reject Individuals with low vision or who are help from family and friends, causing partially sighted do not quite fit into the alienation and social isolation. Counseling category of either the blind or sighted pop- individuals to understand sighted people’s ulation. Consequently, they often have reactions may facilitate social interactions special needs that are overlooked. The and enhance the development of con- social community often lacks understand- structive and realistic interactions. At ing of the true nature of vision impair- times, individuals with visual impair- ment, so that individuals with low vision ment may find it helpful to share their are ridiculed in public for appearing to see experiences and problems with others more than would be expected by a person who also have low vision. Because of their lack of visual expe- avoid potential rejection or avoidance by riences in their environment, such as the others. They may deny their disability observation of others’ tasks or behaviors, altogether and associate only with sight- concepts that sighted individuals often ed persons in an attempt to be accepted take for granted must be learned by oth- by the mainstream of society. This adaptive learning of tasks make excuses for awkward behavior or then becomes a natural part of their devel- attempt in other ways to conceal the fact opment, so that adjustment to visual lim- that they have low vision. They may itations is incorporated into their self- refuse to use low-vision aids, such as a perception and daily activities as a normal cane, for mobility or reject suitable orien- part of growing up. In extreme Individuals with loss of vision later in cases they may engage in dangerous life have the advantage of being able to activities such as illegal driving. People draw on visual experiences in the environ- often view the ability to drive as very ment as a frame of reference for physical important to the maintenance of inde- concepts, but they may find it more dif- pendence. This makes it extremely diffi- ficult to accept blindness than those who cult for individuals who are losing their have never had vision. Further- lose vision later in life must modify their more, by its very nature, the gradual loss self-perception as a result of physical of vision creates a time period in which changes and the subsequent need to re- the decision to stop driving is particular- structure daily activities. The emphasis on self-care and are newly blind may experience grief and independence for individuals with partial despair over their loss of visual function. Some may become reluctant to interact in social sit- Psychological Issues in Conditions of uations because they want to avoid the the Eye and Blindness awkwardness of initial attempts at social interactions. Loss of control over standard Vision loss often precipitates a sense of methods of initiating conversations (e. Visual impairments may be of sighted persons, and often prolonged present at birth, or they may develop sud- gaps in conversations may lead newly denly or slowly at any time in an individ- blind individuals to believe that they are ual’s life. Individuals with a on many factors, including the degree of visual loss must adjust their self-concept loss and the age at which the individual and personal goals to take into account becomes visually impaired. Activities eye, or chemical burn) may have to cope such as bathing, combing the hair, shav- not only with sudden loss of vision but ing, applying makeup, and dressing in a also with insurance company representa- coordinated fashion can all be performed tives, attorneys, and other legal and independently through skills training and bureaucratic aspects surrounding the cir- systematic organization and labeling of cumstance of their disability. Some individ- Vision is crucial for many activities of uals have difficulty adjusting to this loss daily living. In other instances, documents vision must learn new techniques for car- or forms must be translated into Braille or rying out routine activities of self-care and read to the individual, perhaps reducing mobility. They must orient themselves to the efficiency of action or response to the the home environment so that they may document. Family members can con- severe visual impairments can learn tribute to their sense of mobility by nev- techniques of mobility in new environ- er moving furniture within a room ments with the use of a cane or guide dog. Individuals can continue or cutting meat may seem insurmountable to enjoy a number of leisure activities, for the individual with visual impairment.