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Choucha A, Beucler N, Leroy HA. Ultrasound-guided needle aspiration of immediate postoperative symptomatic spinal epidural hematoma after lumbar stenosis surgical decompression in the elderly: a proof-of-concept case. Neurosurg Rev 2024; 47:233. [PMID: 38789643 DOI: 10.1007/s10143-024-02468-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/07/2024] [Accepted: 05/19/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Symptomatic spinal epidural hematoma (SSEH) is one of the most feared complications and source of litigation in spine surgery. Its occurrence rises up to 2% in minimally invasive spine surgery. In parts of the world where the population is aging, more fragile patients are expected to undergo degenerative spine surgery. Management of the SSEH includes emergent spine MRI, though some experts advocate for direct second-look surgery without imaging. Then, an urgent revision surgery under general anesthesia for hematoma evacuation is warranted. We report the case of a threatening SSEH in an 88-year-old patient after lumbar spine stenosis surgery. In order to spare a second general anesthesia for this fragile patient, we opted for a percutaneous ultra-sound guided drainage of the hematoma under local anesthesia as a first line treatment. The procedure was successful, we report an instant relief of his neurological deficit while performing the procedure. CONCLUSION Ultra-sound guided percutaneous drainage of hyperacute SSEH successfully avoided a revision surgery. It spared a second general anesthesia in a fragile patient. This procedure could be an alternative first-line treatment of SSEH for fragile patients.
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Affiliation(s)
- Anis Choucha
- APHM, UH Timone, Department of Neurosurgery, Aix Marseille Univ, Marseille, France.
- Laboratory of Biomechanics and Application, UMRT24, Gustave Eiffel University, Aix Marseille University, Marseille, France.
| | - Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, 83800, Toulon Cedex 9, France
| | - Henri-Arthur Leroy
- Department of Neurosurgery, CHU Lille, 59000, Lille, France
- AO Spine, 7270, Davos, Switzerland
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Debono B, Lonjon G, Guillain A, Moncany AH, Hamel O, Challier V, Diebo B. Spine surgeons facing second opinions: a qualitative study. Spine J 2024:S1529-9430(24)00155-4. [PMID: 38556219 DOI: 10.1016/j.spinee.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/04/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND CONTEXT The social and technological mutation of our contemporary period disrupts the traditional dyad that prevails in the relationship between physicians and patients. PURPOSE The solicitation of a second opinion by the patient may potentially alter this dyad and degrade the mutual trust between the stakeholders concerned. The doctor-patient relationship has often been studied from the patient's perspective, but data are scarce from the spine surgeon's point of view. STUDY DESIGN/SETTING This qualitative study used the grounded theory approach, an inductive methodology emphasizing field data and rejecting predetermined assumptions. PATIENT SAMPLE We interviewed spine surgeons of different ages, experiences, and practice locations. We initially contacted 30 practitioners, but the final number (24 interviews; 11 orthopedists and 13 neurosurgeons) was determined by data saturation (the point at which no new topics appeared). OUTCOME MEASURES Themes and subthemes were analyzed using semistructured interviews until saturation was reached. METHODS Data were collected through individual interviews, independently analyzed thematically using specialized software, and triangulated by three researchers (an anthropologist, psychiatrist, and neurosurgeon). RESULTS Index surgeons were defined when their patients went for a second opinion and recourse surgeons were defined as surgeons who were asked for a second opinion. Data analysis identified five overarching themes based on recurring elements in the interviews: (1) analysis of the patient's motivations for seeking a second opinion; (2) impaired trust and disloyalty; (3) ego, authority, and surgeon image; (4) management of a consultation recourse (measurement and ethics); and (5) the second opinion as an avoidance strategy. Despite the inherent asymmetry in the doctor-patient relationship, surgeons and patients share two symmetrical continua according to their perspective (professional or consumerist), involving power and control on the one hand and loyalty and autonomy on the other. These shared elements can be found in index consultations (seeking high-level care/respecting trust/closing the loyalty gap/managing disengagement) and referral consultations (objective and independent advice/trusting of the index advice/avoiding negative and anxiety-provoking situations). CONCLUSIONS The second opinion often has a negative connotation with spine surgeons, who see it as a breach of loyalty and trust, without neglecting ego injury in their relationship with the patient. A paradigm shift would allow the second opinion to be perceived as a valuable resource that broadens the physician-patient relationship and optimizes the shared surgical decision-making process.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, Santecite Group. St Jean de Vedas, Montpellier Metropole, France
| | - Antoine Guillain
- AMADES (Medical Anthropology, Development and Health), Centre de la Vieille Charité, Marseille, France
| | - Anne-Hélène Moncany
- Department of Psychiatry and Addictive Behaviour, Gerard Marchant Hospital Center, Toulouse, France
| | - Olivier Hamel
- Department of Neurosurgery, Ramsay Santé-Clinique des Cèdres, Cornebarrieu, France
| | - Vincent Challier
- Department of Orthopedic Surgery, Hôpital privé du dos Francheville, Périgueux, France
| | - Bassel Diebo
- Department of Orthopedic surgery, Brown University Warren Alpert Medical School, East Providence, RI, USA
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Debono B, Baumgarten C, Guillain A, Lonjon N, Hamel O, Moncany AH, Magro E. Becoming a neurosurgeon in France: A qualitative study from the trainees' perspective. BRAIN & SPINE 2023; 3:102674. [PMID: 38021020 PMCID: PMC10668099 DOI: 10.1016/j.bas.2023.102674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/03/2023] [Accepted: 09/17/2023] [Indexed: 12/01/2023]
Abstract
Introduction The training of neurosurgeons is evolving in a world of socio-professional changes, including the technological revolution, administrative pressure on stakeholders, reduced working hours, geographical heterogeneity, generational changes, to name but a few. Research question This qualitative study aimed to explore experiences and feedback of French neurosurgical trainees concerning their training. Material and methods The grounded theory approach was used with 23 neurosurgical trainees' interviews. Inclusion was continued until data saturation. Six researchers (an anthropologist, a psychiatrist, and four neurosurgeons) thematically and independently analyzed data collected through anonymized interviews. Results Data analysis identified three superordinate themes: (1) The Trainee-Senior Dyad, where the respondents describe a similar bipolarity between trainees and faculty (trainees oscillating between those who fit into the system and those who are more reluctant to accept hierarchy, faculty using an ideal pedagogy while others refuse to help or invest in training); (2) The difficulty to learn (describing pressure exercised on trainees that can alter their motivation and degrade their training, including the impact of administrative tasks); (3) A pedagogy of empowerment (trainee' feelings about the pertinent pedagogy in the OR, ideal sequence to progress, progressive empowerment especially during the shifts, and stress of envisioning themselves as a senior neurosurgeon). Discussion and conclusion Respondents emphasize the heterogeneity of their training both intra- and inter-university-hospital. Their critical analysis, as well as the formalization of their stress to become autonomous seniors, can be an important link with the reforms and optimizations currently being carried out to improve and standardize the training of young French neurosurgeons.
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Affiliation(s)
- Bertrand Debono
- Department of Neurosurgery, Paris-Versailles Spine Center, Hôpital Privé de Versailles, Les Franciscaines, 78000, Versailles, France
| | - Clément Baumgarten
- Department of Neurosurgery, University Hospital of Grenoble, Grenoble, France
| | - Antoine Guillain
- AMADES (medical Anthropology, Development and Health), Centre de la Vieille Charité, 2 rue de la Charité, Marseille, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
| | - Olivier Hamel
- Department of Psychiatry and Addictive Behaviour, Gerard Marchant Hospital Center, Toulouse, France
| | - Anne-Hélène Moncany
- Department of Neurosurgery, Ramsay-Clinique des Cèdres, Cornebarrieu, France
| | - Elsa Magro
- Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
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Yue L, Sun MS, Mu GZ, Shang MX, Zhang YZ, Sun HL, Li CD. Spine-Related Malpractice Claims in China: A 2-year National Analysis. Global Spine J 2023; 13:1566-1575. [PMID: 34519250 PMCID: PMC10448087 DOI: 10.1177/21925682211041048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective cross-sectional study. OBJECTIVE To investigate the prevalence, characteristics, and risk factors of spine-related malpractice claims in China in a 2-year period. METHODS The arbitration files of the Chinese Medical Association (CMA) were reviewed for spine-related malpractice claims. Descriptive statistics and correlation analysis were conducted on claim characteristics, clinical data, plaintiff's main allegations, and arbitration outcomes. RESULTS A total of 288 cases of spinal claims filed in the CMA between January 2016 and December 2017 were included. Most claims were found in lumbar degenerative disorders (59.4%), lumbar trauma (13.2%), and cervical degenerative disorders (11.8%). The most common adverse events (AEs) leading to claims were new neurologic deficit (NND) (47.6%), infection (11.5%), and insufficient symptom relief (10.4%). The most common patient allegation was surgical error (66.0%), although the main arbitrated cause of AEs was disease/treatment itself (49.0%), while providers were judged as mainly responsible in only 47.3% cases. In multivariate regression analysis, cervical spine, misdiagnosis/mistreatment, and unpredictable emergency correlated with more severe damage to patients; minimally invasive surgery was predictive of judgment in plaintiff's favor, while claims in the eastern region and unpredictable emergencies were predictive of defendant's favor; only NND was associated with being arbitrated as surgical error in surgical cases where surgeons accepted major liability. CONCLUSION The current study provided a descriptive overview and risk factor analysis of spine-related malpractice claims in China. Gaining improved understanding of the facts and causes of malpractice claims may help providers reduce the risk of claims and subsequent litigation.
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Affiliation(s)
- Lei Yue
- Department of Orthopedics, Peking University First Hospital, Beijing, China
| | - Ming-Shuai Sun
- General Surgery Department, Peking University First Hospital, Beijing, China
| | - Guan-Zhang Mu
- Department of Orthopedics, Peking University First Hospital, Beijing, China
| | - Mei-Xia Shang
- Department of Medical Statistics, Peking University First Hospital, Beijing, China
| | - Ying-Ze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hao-Lin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing, China
| | - Chun-De Li
- Department of Orthopedics, Peking University First Hospital, Beijing, China
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Rougereau G, Marty-Diloy T, Bonaccorsi R, Vialle R, Boisrenoult P, Pascal-Moussellard H, Langlais T. Malpractice litigation after spinal surgery: A review of allegations in France in 1990-2020. Orthop Traumatol Surg Res 2023; 109:103510. [PMID: 36509364 DOI: 10.1016/j.otsr.2022.103510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/05/2021] [Accepted: 07/05/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Spinal surgery is among the specialities with the highest rates of complications and of peri-operative morbidity and mortality. The number of spinal surgeries performed is rising year on year in France. The objectives of this study were to identify the main reasons for malpractice claims after spinal surgery in France, to evaluate the impact of avoidable errors, and to examine differences between civil lawsuits (private institutions) and administrative lawsuits (public institutions). HYPOTHESIS The leading reasons for malpractice litigation are avoidable errors such as inadequate patient information, errors in indications, and inadequate post-operative monitoring. MATERIAL AND METHODS We reviewed malpractice claims related to spinal surgery and recorded in two French databases (Legifrance and Doctrine) in 1990-2020. We combined the indexing term "surgery" with any of the following terms: "disc", "spine", "cervical", "vertebral", "lumbar", "scoliosis", "disc replacement", and "fusion". The search was performed by three orthopaedic surgeons who were blind to patient data and recorded the allegations, verdicts, and pay-outs. RESULTS We included 275 claims. The main plaintiff allegations were inadequate information (34.5%), infection (22%), spinal-cord injury (17%), and errors in indication (13%). Among these reasons, 56.7% may have been partly avoidable. In private institutions, claims for infection and for erroneous indication were significantly more common than in public institutions (p=0.02 for both), whereas the opposite was true for spinal-cord injury (p<0.001). CONCLUSION After spinal surgery in France, the most common malpractice allegation was inadequate information. Over half the claims were related to potentially avoidable factors. Among allegations, errors in indication were significantly more common in civil than in administrative lawsuits. LEVEL OF PROOF IV, retrospective observational database study.
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Affiliation(s)
- Grégoire Rougereau
- Département d'orthopédie et traumatologie, CHU Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | | | - Raphaël Bonaccorsi
- Département d'orthopédie et traumatologie, CHU Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Raphaël Vialle
- Département de Maladies Musculo-Squelettiques et Innovations Thérapeutiques (MAMUTH), Sorbonne Université, Paris, France; Département d'orthopédie pédiatrique, CHU Trousseau, AP-HP, Sorbonne Université, Paris, France
| | - Philippe Boisrenoult
- Département d'orthopédie et traumatologie, CH Versailles A. Mignot, Le Chesnay, France
| | - Hugues Pascal-Moussellard
- Département d'orthopédie et traumatologie, CHU Pitié-Salpêtrière, AP-HP, Sorbonne Université, Paris, France
| | - Tristan Langlais
- Département d'orthopédie pédiatrique, CHU Trousseau, AP-HP, Sorbonne Université, Paris, France; Département d'orthopédie pédiatrique, CHU Purpan, Toulouse Université, Toulouse, France.
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Hawkins AT, Rothman R, Geiger TM, Bonnet KR, Mutch MG, Regenbogen SE, Schlundt DG, Penson DF. Surgeons' Perspective of Decision Making in Recurrent Diverticulitis: A Qualitative Analysis. ANNALS OF SURGERY OPEN 2022; 3:e157. [PMID: 35528025 PMCID: PMC9074822 DOI: 10.1097/as9.0000000000000157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/04/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study employs qualitative methodology to assess surgeons' perspective on decision making in management of recurrent diverticulitis to improve patient-centered decision making. Summary Background Data The decision to pursue colectomy for patients with recurrent diverticulitis is nuanced. Strategies to enact broad acceptance of guidelines for surgery are hindered because of a knowledge gap in understanding surgeons' current attitudes and opinions. Methods We performed semi-structured interviews with board-certified North American general and colorectal surgeons who manage recurrent diverticulitis. We purposely sampled specialists by both surgeon and practice factors. An iterative inductive/deductive strategy was used to code and analyze the interviews and create a conceptual framework. Results 25 surgeons were enrolled over a nine-month period. There was diversity in surgeons' gender, age, experience, training, specialty (colorectal vs general surgery) and geography. Surgeons described the difficult process to determine who receives an operation. We identified seven major themes as well as twenty subthemes of the decision-making process. These were organized into a conceptual model. Across the spectrum of interviews, it was notable that there was a move over time from decisions based on counting episodes of diverticulitis to a focus on improving quality of life. Surgeons also felt that quality of life was more dependent on psychosocial factors than the degree of physiological dysfunction. [What about what surprised you/]. Conclusions Surgeons mostly have discarded older dogma in recommending colectomy for recurrent diverticulitis based on number and severity of episodes. Instead, decision making in recurrent diverticulitis is complex, involving multiple surgeon and patient factors and evolving over time. Surgeons struggle with this decision and education- or communication-based interventions that focus on shared decision making warrant development.
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Affiliation(s)
- Alexander T Hawkins
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy M Geiger
- Division of General Surgery, Section of Colon & Rectal Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Matthew G Mutch
- Department of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - David F Penson
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
- Geriatric Research Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN
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Calder LA, Whyte EM, Neilson HK, Zhang C, Barry TK, Barry SP. Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery. Spine (Phila Pa 1976) 2022; 47:E469-E476. [PMID: 35102116 DOI: 10.1097/brs.0000000000004332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective descriptive study. OBJECTIVE The aim of this study was to describe closed medicolegal cases involving physicians and spine surgery in Canada from a trend and patient safety perspective. SUMMARY OF BACKGROUND DATA Spine surgery is a source of medicolegal complaints against surgeons partly owing to the potential severity of associated complications. In previous medicolegal studies, researchers applied a medicolegal lens to their analyses without applying a quality improvement or patient safety lens. METHODS The study comprised a 15-year medicolegal trend analysis and a 5-year contributing factors analysis of cases (civil legal and regulatory authority matters) from the Canadian Medical Protective Association (CMPA), representing an estimated 95% of physicians in Canada. Included cases were closed by the CMPA between 2004 and 2018 (trends) or 2014 and 2018 (contributing factors). We fit a linear trend line to the annual rates of spine surgery cases per 1000 physician-years of CMPA membership for physicians in a neurosurgery or orthopedic surgery specialty. We then applied an ANOVA type III sum of squares test to determine the statistical significance of the annualized change rate over time. For the contributing factors analysis, we reported descriptive statistics for patient and physician characteristics, patient harm, and peer expert criticisms in each case. RESULTS Our trend analysis included 340 cases. Case rates decreased significantly at an annualized change rate of -4.7% (P = 0.0017). Our contributing factors analysis included 81 civil legal and 19 regulatory authority cases. Most patients experienced health care-related harm (89/100, 89.0%). Peer experts identified intraoperative injuries (29/89, 32.6%), diagnostic errors (14/89, 15.7%), and wrong site surgeries (16/89, 18.0%) as the top patient safety indicators. The top factor contributing to medicolegal risk was physician clinical decision-making. CONCLUSION AND RELEVANCE Although case rates decreased, patient harm was attributable to health care in the majority of recently closed cases. Therefore, crucial opportunities remain to enhance patient safety in spine surgery.Level of Evidence: 4.
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Affiliation(s)
- Lisa A Calder
- Department of Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Eileen M Whyte
- Department of Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Heather K Neilson
- Department of Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | - Cathy Zhang
- Department of Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ontario, Canada
| | | | - Sean P Barry
- Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
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The Personal and Professional Impact of Patients' Complaints on Doctors-A Qualitative Approach. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010562. [PMID: 35010822 PMCID: PMC8744646 DOI: 10.3390/ijerph19010562] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/28/2021] [Accepted: 01/02/2022] [Indexed: 02/04/2023]
Abstract
Background: Complaints regarding medical practice represent a harsh reality of the current world. Patients have the right to receive explanations and compensation when they are injured during the medical act, but the increased potential for exposure to complaints determines personal and professional consequences for the doctors, with significant impact on their health and practice. Thus, the aim of our research was to analyze in depth the impact of complaints on the doctors involved. Materials and methods: The authors conducted a qualitative study, using a semi-structured interview, addressed to doctors who had complaints from patients. The participants in our research were identified using an adapted version of the snowball method. Results: After the analysis of the interviews using the inductive method, nine themes resulted, seven of which are addressed in this paper: injustice, personal impact, professional impact, difficulties, supportive factors, the attitude of the hospital management and the attitude of colleagues. At the personal level, the doctors were overwhelmed by insomnia, nightmares, stress and anxiety, and at the professional level by doubts about medical decisions, fear, anxiety and the tendency to avoid patients with severe diseases. Conclusions: The study revealed that physicians who had complaints from patients are deeply affected by the complaint itself and the associated investigation procedure, even if, to a lesser extent, some of the participants found motivation for a better management of the situation. The study also showed the need for changes in the legal and medical systems in order to create mechanisms to support the doctors during the investigation process.
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Debono B, Gerson C, Le Moing V, Houselstein T, Bougeard R, Lonjon G, Lonjon N. Spine Surgery Infection, Litigation, and Financial Compensation: Analysis of 98 Claims Involving French Spine Surgeons Between 2015 and 2019. World Neurosurg 2021; 159:e161-e171. [PMID: 34902601 DOI: 10.1016/j.wneu.2021.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/04/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Since 2002, France has adopted the Patients' Rights Law, an alternative malpractice scheme creating a faster, less expensive out-of-court settlement ensuring compensation even in the absence of fault. We aimed to describe the implications of this system by analyzing 5 years of claims for infections related to spinal surgeries collected by the main insurer of French spine surgeons. METHODS We retrospectively analyzed 98 anonymized malpractice claims from 2015 to 2019 (20% of overall claims), including anonymized medical records of the patients, reports of the independent experts, final judgments, and entities supporting the compensation if any. RESULTS Claims included 8 deaths and 17 newly acquired neurological sequelae. The conclusions identified 22 faulty cases. The most frequent fault was a delay in diagnosis (10 cases), followed by inadequate surgical management (6 cases), inadequate antibiotic therapy (5 cases), and inadequate follow-up (1 case). Among the 67 cases (68.4%) proved not to be at fault, 10 were covered by the national solidarity fund because of their severity, and the remaining 57 were covered by hospitals. CONCLUSIONS Since the 2002 Patients' Rights Law, patients with postoperative infections have always received compensation. The out-of-court settlement offers the patients incurring morbidities the assurance of faster compensation. Although certainly subject to selection criteria, this procedure is free and does not necessitate the presence of a lawyer. The analysis of expert reports and the resulting court decisions imply prevention, anticipation, and collaboration of all health care providers and open an opportunity to improve their practices to limit these crucial followings.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Carole Gerson
- Compensation and Medical Communication Department, Mutuelle d'Assurances du Corps de Santé Français (MACSF), Paris, France
| | - Vincent Le Moing
- Department of Infectious and Tropical Diseases, Montpellier University Medical Center, Montpellier, France
| | - Thierry Houselstein
- Compensation and Medical Communication Department, Mutuelle d'Assurances du Corps de Santé Français (MACSF), Paris, France
| | - Renaud Bougeard
- Department of Neurosurgery, Clinique du Val d'Ouest, Ecully, France
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean-Sud de France, Santé Cite Group. St Jean de Vedas, Montpellier Metropole, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
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Leroy HA, Portella T, Amouyel T, Bougeard R, Assaker R, Mourier KL. Management of symptomatic postoperative epidural hematoma in spine surgery: Medicolegal implications. Orthop Traumatol Surg Res 2021; 107:103024. [PMID: 34329762 DOI: 10.1016/j.otsr.2021.103024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Spine surgery is one of the specialties with the highest medicolegal risk, with a legal action initiated every 17 months per practitioner. One of the most dreaded complications is an epidural hematoma with postoperative deficit. The treatment of this complication is still being debated. We therefore conducted a retrospective study of the database of a medical liability insurer to assess perioperative factors determining the liability of the surgeon or paramedical team during an expert review in the event of a postoperative symptomatic epidural hematoma. HYPOTHESIS To identify the factors determining the liability of the medical team in the event of a postoperative symptomatic epidural hematoma. MATERIALS AND METHODS We retrospectively analyzed the largest French register of medicolegal expert reviews between 2011 and 2018. We identified 68 cases by entering the following keywords in this database: "spine surgery," "complications," and "epidural hematoma." After a thorough review of each case, only 14 were deemed to be truly relevant to our study. We collected for each patient the perioperative data, complications (including neurologic deficits) and their clinical course. RESULTS Only one surgeon was accused and found liable for failing to perform a surgical revision within a reasonable timeframe (time to revision of 11 days). In 2 cases, the liability of a nurse working in the surgical department was called into question for failing to contact the surgeon upon the onset of symptoms. In the other cases (11 patients, 79%), the occurrence of a symptomatic epidural hematoma was considered a no-fault medical accident that was not caused by the surgeon. The presence of a drain did not have any medicolegal impact in the cases reviewed. CONCLUSION The key element in medicolegal decisions is the reaction time of the healthcare teams, in particular the time between the onset of symptoms and surgical revision. According to these expert reviews, the placement of a drain was not taken into consideration during the medicolegal assessment of a postoperative symptomatic epidural hematoma. LEVEL OF EVIDENCE II; retrospective prognostic study, investigation of patient characteristics and their impact on functional outcome.
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Affiliation(s)
- Henri-Arthur Leroy
- University Lille, CHU Lille, Département de Neurochirurgie, 1, rue Émile Laine, 59000 Lille, France.
| | - Thibault Portella
- CHU Dijon, Département de Neurochirurgie, 14, rue Paul Gaffarel, 21000 Dijon, France
| | - Thomas Amouyel
- University Lille, CHU Lille, Département de Chirurgie orthopédique, 1, rue Émile Laine, 59000 Lille, France
| | - Renaud Bougeard
- Clinique du Val D'Ouest, Département de Neurochirurgie, 39, chemin de la Vernique, 69130 Écully, France
| | - Richard Assaker
- University Lille, CHU Lille, Département de Neurochirurgie, 1, rue Émile Laine, 59000 Lille, France
| | - Klaus-Luc Mourier
- CHU Dijon, Département de Neurochirurgie, 14, rue Paul Gaffarel, 21000 Dijon, France
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Beucler N, Sellier A, Desse N, Joubert C, Dagain A. Letter to the Editor. Rethinking the mentorship system in neurosurgery. J Neurosurg 2021; 135:659-660. [PMID: 33578382 DOI: 10.3171/2020.11.jns204050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nathan Beucler
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 2Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France; and
| | | | - Nicolas Desse
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
| | | | - Arnaud Dagain
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 3Val-de-Grâce Military Academy, Paris, France
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12
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Sankey EW, Mehta VA, Wang TY, Than TT, Goodwin CR, Karikari IO, Shaffrey CI, Abd-El-Barr MM, Than KD. The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States. Neurosurg Focus 2020; 49:E20. [PMID: 33130620 DOI: 10.3171/2020.8.focus20600] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem.This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Litigation resulted in average payouts of $1,204,422 ± $753,832 between 1995 and 2019, when adjusted for inflation. The median time to case closure was 56.3 (35.2-67.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.4-77.2) months for defendant (surgeon) verdicts (p = 0.117).
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Affiliation(s)
- Eric W Sankey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Vikram A Mehta
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Timothy Y Wang
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | | | - C Rory Goodwin
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Isaac O Karikari
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Christopher I Shaffrey
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Muhammad M Abd-El-Barr
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
| | - Khoi D Than
- 1Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and
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13
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Larkin CJ, Roumeliotis AG, Karras CL, Murthy NK, Karras MF, Tran HM, Yerneni K, Potts MB. Overview of medical malpractice in neurosurgery. Neurosurg Focus 2020; 49:E2. [PMID: 33130621 DOI: 10.3171/2020.8.focus20588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 11/06/2022]
Abstract
Annually, 20% of all practicing neurosurgeons in the United States are faced with medical malpractice litigation. The average indemnity paid in a closed neurosurgical civil claim is $439,146, the highest of all medical specialties. The majority of claims result from dissatisfaction following spinal surgery, although claims after cranial surgery tend to be costlier. On a societal scale, the increasing prevalence of medical malpractice claims is a catalyst for the practice of defensive medicine, resulting in record-level healthcare costs. Outside of the obvious financial strains, malpractice claims have also been linked to professional disenchantment and career changes for afflicted physicians. Unfortunately, neurosurgical residents receive minimal practical education regarding these matters and are often unprepared and vulnerable to these setbacks in the earlier stages of their careers. In this article, the authors aim to provide neurosurgical residents and junior attendings with an introductory guide to the fundamentals of medical malpractice lawsuits and the implications for neurosurgeons as an adjunct to more formal residency education.
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Affiliation(s)
| | | | | | | | - Maria Fay Karras
- 2Pritzker School of Law, Northwestern University, Chicago, Illinois; and
| | - Huy Minh Tran
- 3Department of Neurosurgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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14
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Debono B, Gerson C, Houselstein T, Lettat-Ouatah L, Bougeard R, Lonjon N. Litigations following spinal neurosurgery in France: “out-of-court system,” therapeutic hazard, and welfare state. Neurosurg Focus 2020; 49:E11. [DOI: 10.3171/2020.8.focus20582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVESpinal surgeries carry risks of malpractice litigation due to the random nature of their functional results, which may not meet patient expectations, and the hazards associated with these complex procedures. Claims are frequent and costly. In France, since 2002, a new law, the Patients’ Rights Law of March 4, 2002, has created an alternative, out-of-court scheme, which established a simplified, rapid, free-of-charge procedure (Commission for Conciliation and Compensation [CCI]). Moreover, this law has optimized the compensation provided to patients for therapeutic hazards by use of a national solidarity fund. The authors analyzed the consequences of this alternative route in the case of claims against private neurosurgeons in France.METHODSFrom the data bank of the insurer Mutuelle d’Assurances du Corps de Santé Français (MACSF), the main insurance company for private neurosurgeons in France, the authors retrospectively analyzed 193 files covering the period 2015–2019. These computerized files comprised the anonymized medical records of the patients, the reports of the independent experts, and the final judgments of the CCI and the entities supporting the compensation, if any.RESULTSDuring the 5-year study period (2015–2019), the insurance company recorded 494 complaints involving private neurosurgeons for spinal surgery procedures, of which 126 (25.5%) were in civil court, 123 (24.9%) were under amicable procedure, and 245 (49.6%) were in the out-of-court scheme administered by the CCI. Out of these 245 cases, only 193 were closed due to delays. The conclusions of the commission were rejection/incompetence decisions in 47.2% of the cases, therapeutic hazards in 21.2%, nosocomial infections in 17.6%, and practitioner fault in 13.5%. National solidarity compensated for 48 complaints (24.8%). The final decision of the CCI is not always consistent with the conclusions of the experts mandated by it, illustrating the difficulty in defining the concept of hazards. The authors found that the therapeutic hazards retained and compensated by the national solidarity included decompensated spondylotic myelopathies (15% of the 40 cases) and cauda equina syndromes (30%). As allowed by law, 11.5% of the patients who were not satisfied triggered a classical procedure in a court.CONCLUSIONSIn the French out-of-court system, trial decisions resulting in rulings of proven medical malpractice are rare, but patients can start a new procedure in the classical courts. The therapeutic hazard remains a subtle definition, which may be problematic and require further discussion between experts and magistrates. In spite of the imperfections, this out-of-court system proposes a major evolution to move patients and medical providers from legal battles to reconciliations.
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Affiliation(s)
- Bertrand Debono
- 1Centre Francilien du Dos, Neurosurgery Department, Paris
- 2Neurosurgery Department, Private Hospital of Versailles–Ramsay Santé, Versailles
| | - Carole Gerson
- 3Compensation and Medical Communication Department, Mutuelle d’Assurances du Corps de Santé Français (MACSF), Paris
| | - Thierry Houselstein
- 3Compensation and Medical Communication Department, Mutuelle d’Assurances du Corps de Santé Français (MACSF), Paris
| | | | - Renaud Bougeard
- 5Department of Neurosurgery, Clinique du Val d’Ouest, Ecully; and
| | - Nicolas Lonjon
- 6Department of Neurosurgery, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
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15
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Gadjradj PS, Ghobrial JB, Harhangi BS. Experiences of neurological surgeons with malpractice lawsuits. Neurosurg Focus 2020; 49:E3. [PMID: 33130609 DOI: 10.3171/2020.8.focus20250] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE As a specialty that treats acute pathology and refractory pain, neurosurgery is at risk for high liability, making the practice of defensive medicine quite common. The extent to which the practice of defensive medicine is linked to experience with malpractice lawsuits remains unclear. The aims of this study were to clarify this by surveying neurosurgeons about the frequency of experiencing medical lawsuits and to show how neurosurgeons reflect on facing such lawsuits. METHODS A survey consisting of 24 questions was distributed among members of the Congress of Neurological Surgeons. The survey consisted of four parts: 1) demographics of participants; 2) the way malpractice lawsuits affect the way respondents practice medicine; 3) experiences with medical malpractice lawsuits; and 4) the effect of the medical malpractice environment on one's own practice of medicine. RESULTS There were a total of 490 survey respondents, 83.5% of whom were employed in the US. Of the respondents, 39.5% stated they were frequently or always concerned about being sued, and 77.4% stated their fear had led to a change in how they practice medicine. For 58.4%, this change led to the practice of defensive medicine, while for others it led to more extensive documentation (14.3%) and/or to referring or dropping complex cases (12.4%).Among the respondents, 80.9% at some time were named in a medical malpractice lawsuit and 12.3% more than 10 times. The main concerns expressed about being sued included losing confidence and practicing defensive medicine (17.8%), personal assets being at risk (16.9%), and being named in the National Practitioner Data Bank (15.6%). Given the medical malpractice environment, 58.7% of respondents considered referring complex patient cases, whereas 36.5% considered leaving the practice of medicine. The fear of being sued (OR 4.06, 95% CI 2.53-6.51) and the consideration of limiting the scope of practice (OR 3.08, 1.80-5.20) were both independently associated with higher odds of considering leaving the practice of medicine. CONCLUSIONS The current medicolegal landscape has a profound impact on neurosurgical practice. The fear of being sued, the financial aspects of practicing defensive medicine, and the proportion of neurosurgeons who are considering leaving the practice of medicine emphasize the need for a shift in the medicolegal landscape to a system in which fear of being sued does not play a dominant role and the interests of patients are protected.
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Affiliation(s)
- Pravesh S Gadjradj
- 1Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden; and
| | - Julian B Ghobrial
- 1Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden; and
| | - Biswadjiet S Harhangi
- 2Department of Neurosurgery, Erasmus MC: University Medical Center Rotterdam, The Netherlands
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16
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Debono B, Hamel O, Guillain A, Durand A, Rué M, Sabatier P, Lonjon G, Dran G. Impact of malpractice liability among spine surgeons: A national survey of French private neurosurgeons. Neurochirurgie 2020; 66:219-224. [PMID: 32540341 DOI: 10.1016/j.neuchi.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/03/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE In the general context of medical judicialization, spine surgeons are impacted by the part that medical responsibility and the risk of malpractice play in their actions and decisions. Our aim was to evaluate possible shifts in practices among private neurosurgeons who are highly exposed to this judicial risk and detect alterations in their pleasure in exercising their profession. We present the first national survey on French physicians' perception of surgical judicialization and consequences on their practice. METHODS An online survey was submitted to the 121 members of the French Society of Private Neurosurgery, who represent 29.1% of the total number of spine surgeons and perform 36.0% of the national total spine surgery activity. The French law (no-fault out-of-court scheme) significantly impacts these surgeons in the event of litigation. RESULTS A total of 78 surveys were completed (64.5% response rate): 89.7% of respondents experienced alteration of doctor-patient relationship related to judicialization and 60.2% had already refused to perform risky surgeries. Fear of being sued added negative pressure during surgery for 55.1% of respondents and 37.2% of them had already considered stopping their practice because of this litigation context. CONCLUSION The increasing impact of medical liability is prompting practitioners to change their practice and perceptions. The doctor-patient relationship appears to be altered, negative pressure is placed on physicians and defensively, some neurosurgeons may refuse high-risk patients and procedures. This situation causes professional disenchantment and can ultimately prove disadvantageous for both doctors and patients.
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Affiliation(s)
- B Debono
- Ramsay-clinique des cèdres, neurosurgery, Cornebarrieu, France.
| | - O Hamel
- Ramsay-clinique des cèdres, neurosurgery, Cornebarrieu, France
| | - A Guillain
- Sorbonne study group on methods of sociological analysis of the Sorbonne (GEMASS), Sorbonne university, Paris, France; SiRIC CURAMUS (Integrated cancer research site), Assistance publique-Hôpitaux de Paris, Sorbonne university, Paris, France
| | - A Durand
- Infirmerie protestante, neurosurgery, Caluire, France
| | - M Rué
- Endoscopic spine center, Bordeaux, France
| | - P Sabatier
- Ramsay-clinique des cèdres, neurosurgery, Cornebarrieu, France
| | - G Lonjon
- Orthosud, spine surgery department, Montpellier, France
| | - G Dran
- Clinique du millénaire, neurosurgery, Montpellier, France
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