Friday, April 30, 2010

Suit-Proof Physicians in Ohio?

An Ohio Supreme Court ruling has limited a patient's opportunity to sue for medical malpractice based on where the treatment occurred and who was present for the treatment.

In Theobald v. University of Cincinnati, the Court ruled that when a physician is negligent in treating a patient, the physician will be immune from liability as long as a medical student or resident was present during the treatment. Basically, under these circumstances, the physician is legally considered to be a state employee acting within the scope of his or her employment, and therefore is immune from civil liability.

Keith Theobald, the plaintiff in the above-referenced case, was injured in a serious auto accident. Afterward, Theobald was treated at University Hospital, a private hospital, but one which is affiliated with the University of Cincinnati. After treatment, Mr. Theobald awoke to find himself blind and with worsened paralysis. He sued the treating physicians but, ultimately, was precluded from having his day in court.

The Supreme Court first determined that Theobald's treating physicians were immune from liability as employees of the state because they were “teaching” or supervising students from a state medical school. The physicians had privileges at University Hospital, and they performed the treatment resulting in this case at the hospital.

Even though the physicians were employees of the state, they would only enjoy immunity from civil liability if the Court determined that they were acting within the scope of their state employment during the time of the alleged negligence.

Theobald argued that because the doctors’ private practice billed for the procedure, this was evidence that the doctor was not “teaching.” However, the Supreme Court determined that the focus must be on the “employment relationship” as opposed to the business or financial arrangements. If the physician was “educating a student or resident when the negligence occurred,” then the physician will be immune. In other words, the doctor is immunized whenever negligence occurs in the presence of a student.

The Court's ruling in this regard creates a controversial precedent for Ohio citizens and physicians. One of the roles of an attending physician at University Hospital is to teach the medical students and residents. The Court determined that the treating physicians were acting within the scope of their state employment because they were teaching a resident while delivering medical care to Theobald. The Court found this to be true no matter what “percentage” of the procedure was actually teaching. However, as Justice Pfeifer noted in his dissenting opinion, “the mere presence of a student does not establish that instruction is taking place.” The ruling extends immunity to a physician merely because a student was present, even if the only thing the student was doing was observing. Pfeifer also noted that when the state is a defendant, the Court of Claims has jurisdiction. However, jury trials are not permitted in the Court of Claims. This would effectively deny medical malpractice plaintiffs their constitutional right to a jury trial.

This ruling will change the remedies available to Ohio patients who find themselves the victim of medical malpractice when a student is involved in any aspect of the procedure. By allowing physicians (and their malpractice insurance companies) to avoid liability by having a resident present for treatment, patients who are treated at hospitals will be left with no one to sue if they are injured and legitimately deserve to be compensated.

ABC6 News Report

Cleveland Primary Care Doctors Fired For Lack of "Productivity"

Physicians for a National Health Program
April 29, 2010

Dear PNHP board members and activists,

We're writing to call your attention to an extremely significant event in the Cleveland area, which is sadly an increasingly frequent experience of physicians working for corporate entities.

Dr. George Randt and his colleague are board-certified internists who have had a contractual relationship with St. John Medical Center covering some 2,500 patients for several years. These two doctors have excellent records with the hospital, high patient satisfaction and retention rates, and have never had an unfavorable review. Both were awarded bonuses in 2009, and Dr. Randt's contract was renewed in January of this year.

This past month they were notified by the president of their hospital, Mr. Cliff Coker, that their contracts were being terminated due to lack of productivity and their having incurred excessive overhead expense. In other words, they weren't sufficiently profit-driven. At a previous staff meeting, the staff physicians were told by the CFO to admit just "one more Medicare patient a month" to improve hospital revenues.

If you can, please join Dr. Randt, his patients, and others at a rally at St. John Medical Center, 29000 Center Ridge Road, Westlake, Ohio, this Sunday, May 2, at 1:00 p.m. to call for the reinstatement of these two physicians and for the elimination of policies which are justified solely on the basis of maximizing the profits of a health care system. Speakers at the rally include PNHP's congressional fellow, Dr. Margaret Flowers, and Dr. Carol Paris. (See the press release below for more information.)

Call Mr. Cliff Coker today and demand that these physicians be reinstated to their position. His office number is (440) 827-5008. He can also be reached by e-mailing

We welcome you to share your views that patients should come before profits with the newspapers in the area by writing a letter to the editor to the The Plain Dealer or Sun News.

Dismissing these physicians without cause, merely to maximize hospital revenues, is the embodiment of the derangement of our system of health care finance. This was done without any semblance of due process. The livelihood and status of skilled professionals are being sacrificed to assure profitability; this is rapidly becoming the norm within our profit-driven system. As a result, it poses the gravest threat to professionalism and patient primacy. These issues would be greatly alleviated under a single-payer health financing system that places value on health outcomes, continuity of care, and quality.

Please join us in calling for the reinstatement of Dr. Randt, a longtime PNHP member, and his colleague and an end to health care practices that place the goals of profitability over the care of patients.

Health care for all,

Quentin Young, M.D.
National Coordinator, PNHP

Johnathon Ross, M.D.
Past-president, PNHP
State Coordinator, PNHP Ohio

Sunday, April 11, 2010

C Difficile Surpasses MRSA as the Leading Cause of Nosocomial Infections in Community Hospitals

Emma Hitt, PhD

March 23, 2010 (Atlanta, Georgia) — Hospital-onset healthcare-facility-associated Clostridium difficile infections (CDI) have increased in incidence and have surpassed methicillin-resistant Staphylococcus aureus (MRSA) infections, according to a new study of a large cohort of patients from community hospitals.

Becky A. Miller, MD, an infectious disease fellow from Duke University in Durham, North Carolina, presented the findings during an oral session here at the Fifth Decennial International Conference on Healthcare-Associated Infections 2010.

"This is the first time this has been described using patient-level data (i.e., with the number of cases as the numerator and the number of patient days as the denominator)," Dr. Miller told Medscape Infectious Diseases.

"We think this trend, particularly in community hospitals, would not have been captured without our large network of 39 hospitals where we perform infection control and surveillance," she said. "We were also unaware that cases of nosocomial C difficile infection had increased and surpassed MRSA."

The researchers performed a prospective cohort study in 28 community hospitals participating in the Duke Infection Control Outreach Network between January 2008 and December 2009.

The cohort consisted of 3,007,457 patient-days. Numerically, nosocomial CDI was the most common healthcare-associated infection (847 cases), followed closely by nosocomial bloodstream infection (838 cases).

Nosocomial infections due to MRSA and intensive care unit device-related infections were approximately equal, at 680 and 681 cases, respectively.

Patients with nosocomial CDI (n = 840) and nosocomial MRSA (n = 655) were equally likely to be male, and to have diabetes or end-stage renal disease requiring hemodialysis. However, patients who developed nosocomial CDI were, on average, older than patients who developed nosocomial MRSA infection (65 vs 59 years; P < .0001). In addition, time to infection was, on average, 8 days for CDI and 7 days for MRSA infection (P < .0001), and overall mortality was higher among patients with MRSA infection than CDI (P < .0001).

The rate of nosocomial CDI was 0.28 cases per 1000 patient-days, whereas the rate of nosocomial MRSA infection was 0.23 cases per 1000 patient-days. Thus, nosocomial CDI occurred 25% more frequently than nosocomial MRSA infection.

Since 2007, rates of healthcare-associated MRSA infection have steadily decreased, whereas rates of CDI have increased, Dr. Miller said during her presentation.

According to Dr. Miller, C difficile spores are shed in stool, and these spores can persist in the hospital environment for months. "These infections are not being prevented by methods that are clearly working to prevent nosocomial infections due to MRSA," she said. She added that "we think that this study represents the tip of the iceberg, as we did not include nosocomial C difficile cases diagnosed after patients leave the hospital."

In another presentation on C difficile, researchers described a targeted strategy to eliminate C difficile using ultragermicidal bleach wipes. Robert Orenstein, DO, from the Mayo Clinic in Rochester, Minnesota, reported the findings here in a poster session.

"The beauty of this project was that implementation was relatively simple — it required putting together a committed team and emphasizing our goal of improving patient outcomes," Dr. Orenstein told Medscape Infectious Diseases.

The researchers targeted 2 units with a focused intervention of daily cleaning of all patient rooms with Clorox brand ultragermicidal bleach wipes containing 6.15% sodium hypochlorite, and cleaning after the patient had been discharged.

Cleaning was assessed by environmental services supervisors, and Clean-Trace technology was used. Patients and environmental services employees who cleaned the rooms responded to a survey regarding satisfaction and tolerance of the cleaning procedure.

Before the intervention was initiated, the incidence of CDI was 18.4 per 10,000 patient-days; after the intervention was initiated, the incidence was 3.76 per 10,000 patient-days, "far exceeding" their goal of a reduction in incidence of 30%, Dr. Orenstein said.

According to the authors, patients tolerated the cleaning well, and although environmental services "employees initially had concerns regarding odor and irritation, these were resolved." The cost of the intervention was estimated at $18,671 per year.

"I am struck by the fact that our highest-risk unit has gone 6 months without a hospital-acquired case attributable to their unit, despite the fact that the overall incidence (i.e., cases admitted with this infection) continues to rise," Dr. Orenstein said. "This suggests what we did really had a great impact," he added. "This is especially gratifying knowing the impact that C difficile disease can have on our patients lives."

"C difficile has been in the news for the last decade," said Carlene A. Muto, MD, medical director for infection control at the University of Pittsburgh School of Medicine in Pennsylvania. "What has taken focus this year is that the environment matters," she said.

According to Dr. Muto, an analysis by their group presented in the late-breaking session described the undetected reservoir in patients who asymptomatically carry C difficile (~6% of the patients tested).

"Many studies have described noncompliance with cleaning patient rooms and how a focused effort can change this behavior," Dr. Muto told Medscape Infectious Disease. "Our group implemented a bleach/detergent cleaning program years ago, but since June 2009, we have used this product on every surface, every time, not just in the rooms of patients known to be positive."

She noted that "patients not known to be colonized/infected one day may be so the next. We did see a decrease in C difficile healthcare-associated infections using this approach."

Neither study was commercially funded. Dr. Miller, Dr. Orenstein, and Dr. Muto have disclosed no relevant financial relationships.

Fifth Decennial International Conference on Healthcare-Associated Infections (ICHAI) 2010: Abstract 386, presented March 20, 2010; Abstract 142, presented March 19, 2010.

Friday, April 9, 2010

New State Regulation Could Affect California's Low Physician Disciplinary Rate

California is one of the least likely states to take serious disciplinary action against physicians, according to a new study. But a new state regulation might soon change that.

Starting in June, California's 125,000 physicians will be required to post signs in their offices or otherwise inform patients about how to contact the Medical Board of California to file quality of care complaints.

The new regulation comes in response to concerns that California patients are not lodging complaints about quality of care very often, a position given credence by a report released this week showing California ranks 41st in the country in disciplinary action against physicians.

Using data from the Federation of State Medical Boards, consumer group Public Citizen found an average of 3.05 serious disciplinary actions per 1,000 physicians nationally. In comparison, California's medical board took 2.36 serious disciplinary actions per 1,000 doctors last year. Researchers defined serious discipline as license revocations, surrenders, suspensions, probation or restrictions.

Under the state's new regulations, physicians must provide a notice with the name, phone number and Web site of the medical board. Proponents hope more consumer information will help uncover misconduct and increase quality of care in the state.

The California Medical Association criticized the new rule, claiming it could undermine the doctor-patient relationship.

Meanwhile, here's a rundown of health care bills making their way through the Legislature.

Health Plans

AB 2586 by Assembly member Wesley Chesbro (D-Santa Rosa) would require health insurers to demonstrate that a planned modification to its health care provider network meets certain standards. The measure also would require insurers to provide consumers with an accurate list of contracting providers upon request. In addition, the bill would require insurers post an interactive map on their Web sites to help consumers locate providers in their area (Bill text, 4/5). The bill is before the Assembly Committee on Health (Bill status, 4/5).

Doctors and Nurses

Under AB 2699 by Assembly member Karen Bass (D-Los Angeles), health care providers licensed in another state would be exempt from California's medical licensure requirements if they provide care on a short-term, voluntary basis in association with certain registered sponsoring entities. The bill also would state the intent of the Legislature that the voluntary services be primarily provided to uninsured and underinsured populations (Bill text, 4/5). The bill is before the Assembly Committee on Rules (Bill status, 4/5).

Prescription Drugs

SB 1106 by Sen. Leland Yee (D-San Francisco) would require prescribers who dispense prescription drug samples to either provide patients with a copy of the FDA-approved package insert for the medication or ensure that the manufacturer's warnings are on the packaging of the samples (Bill text 4/5). The bill is before the Senate Committee on Appropriations (Bill status, 4/5).

Health Care Reform

SB 1378 by Sen. Tony Strickland (R-Moorpark) would prohibit the state from enacting any Medi-Cal expansions mandated under the national health care reform law unless the federal government fully funds the expansion. Medi-Cal is California's Medicaid program (Bill text, 4/5). The bill is before the Senate Committee on Rules (Bill text, 4/5).