Rachel A. Lindor

Gender differences in academic productivity and leadership appointments of physicians throughout academic careers

Purpose Because those selected for leadership in academic medicine often have a record of academic productivity, publication disparities may help explain the gender imbalance in leadership roles. The authors aimed to compare the publication records, academic promotions, and leadership appointments of women and men physicians longitudinally throughout academic careers. Method In 2007, the authors conducted a retrospective, longitudinal cohort study of all 25 women physicians then employed at Mayo Clinic with ≥20 years of service at Mayo and of 50 male physician controls, matched 2:1 by appointment date and career category, to women. The authors recorded peer-reviewed publications, timing of promotion, and leadership appointments throughout their careers. Results Women published fewer articles throughout their careers than men (mean [standard deviation] 29.5 [28.8] versus 75.8 [60.3], P = .001). However, after 27 years, women produced a mean of 1.57 more publications annually than men (P < .001). Thirty-three men (66%) achieved an academic rank of professor compared with seven women (28%) (P = .01). Throughout their careers, women held fewer leadership roles than men (P < .001). Nearly half (no. = 11; 44%) of women attained no leadership position, compared with 15 men (30%). Conclusions Womens publication rates increase and actually exceed those of men in the latter stages of careers, yet women hold fewer leadership positions than men overall, suggesting that academic productivity assessed midcareer may not be an appropriate measure of leadership skills and that factors other than publication record and academic rank should be considered in selecting leaders.

Adult Intussusception: Presentation, Management, and Outcomes of 148 Patients

BACKGROUND Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians. STUDY OBJECTIVES We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period. METHODS A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9(th) Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors. RESULTS Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery. CONCLUSIONS Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention.

Physician liability: the next big thing for personalized medicine?

Liability is likely to be a major driver for the future direction and implementation of personalized medicine, spurring the adoption of genetic tests and other pharmacogenomic technologies, in some cases appropriately, and in other cases prematurely or as inefficient defensive medicine. While all entities in the personalized medicine chain will face liability risks, physicians will be at the greatest risk owing to their lack of defenses, limited experience in dealing with genetics and the growing disparities within the profession in implementing new medical technologies. The history of liability for genetic testing, primarily in the prenatal testing context, suggests that liability will often be both unpredictable and influential in changing medical practice. It is critical to anticipate and attempt to prevent such liability risks in a proactive manner so to minimize the disruptive impact that liability can cause.

Shared Decision Making to Support the Provision of Palliative and End‐of‐Life Care in the Emergency Department: A Consensus Statement and Research Agenda

BACKGROUND Little is known about the optimal use of shared decision making (SDM) to guide palliative and end-of-life decisions in the emergency department (ED). OBJECTIVE The objective was to convene a working group to develop a set of research questions that, when answered, will substantially advance the ability of clinicians to use SDM to guide palliative and end-of-life care decisions in the ED. METHODS Participants were identified based on expertise in emergency, palliative, or geriatrics care; policy or patient-advocacy; and spanned physician, nursing, social work, legal, and patient perspectives. Input from the group was elicited using a time-staggered Delphi process including three teleconferences, an open platform for asynchronous input, and an in-person meeting to obtain a final round of input from all members and to identify and resolve or describe areas of disagreement. CONCLUSION Key research questions identified by the group related to which ED patients are likely to benefit from palliative care (PC), what interventions can most effectively promote PC in the ED, what outcomes are most appropriate to assess the impact of these interventions, what is the potential for initiating advance care planning in the ED to help patients define long-term goals of care, and what policies influence palliative and end-of-life care decision making in the ED. Answers to these questions have the potential to substantially improve the quality of care for ED patients with advanced illness.

Personalized medicine and genetic malpractice

Angelina Jolie’s recent revelation that she had prophylactic surgery to reduce her breast cancer risk after BRCA genetic testing has increased public interest in preventive genetic testing. This so-called “Angelina effect” exemplifies a growing consumer interest and medical uptake of genetic testing in response to the increased availability and utility of clinically relevant genetic data. The advent of next-generation DNA sequencing will fur ther accelerate this trend toward increased reliance on genetic data in the health-care system, and health-care providers, in almost every specialty, will be required to have some familiarity with genetic data. Yet, as the use and usefulness of genetic information in clinical decision making continues to expand, the specter of lawsuits against physicians and other health-care entities for genetic malpractice also becomes a reality. Consider the following three cases from the past year, which illustrate three major areas of genetic testing in which potential liability is a growing concern—cancer predisposition screening, prenatal testing, and pharmacogenomic profiling. A woman from Connecticut sued her physician for failing to warn that her extensive family history of breast cancer suggested a genetic risk of ovarian cancer. The Connecticut Supreme Court recently upheld a

EMTALA and Patients With Psychiatric Emergencies: A Review of Relevant Case Law

4 million jury verdict to her after she went on to develop ovarian cancer. 1 A couple from Oregon successfully sued their physicians and hospital for negligence in performing and interpreting prenatal genetic testing for Down syndrome. The jury awarded the par ents

Prudent Precaution in Clinical Trials of Nanomedicines

3 million in damages after the child was born with Down syndrome. 2 A woman from California sued her health-care providers for prescribing carbamazepine without first recommending genetic testing as recommended by the label approved by the Food and Drug Administration for patients of Asian ancestry. The woman, who is of Asian descent, developed Stevens– Johnson syndrome after being prescribed the drug. Her case is currently in arbitration. 3 It is too early to tell whether the initial wave of lawsuits against health-care providers for their alleged failure to recommend or properly interpret genetic testing will turn out to be a ripple, a rough chop, or a tidal wave. Of course, physicians are not the only potential target of such genetic malpractice lawsuits, as drug manufacturers, device makers, testing laboratories, health insurers, hospitals, genetic counselors, and even pharmacists face liability risks relating to genetic data or testing, although most of these potential targets often have effective defenses that shield them from liability. For example, drug manufacturers are protecting themselves from failure-to-warn claims by increasingly putting genetic information in the patient package insert, which shifts the liability exposure for warning patients about such risks to physicians under the learned intermediary doctrine. Healthcare payers and pharmacists often have statutory defenses that help limit their liability, which again are unavailing to physicians. Thus, physicians have been the targets of most genetic malpractice lawsuits to date and are likely probably to be at the greatest risk going forward. As we enter the era of personalized medicine, noninvasive prenatal testing and whole-genome sequencing, several factors suggest that physicians, in particular, will face growing risks of legal claims for genetic malpractice. 4 First, and most generally, history demonstrates that new medical technologies usually spur increases in medical malpractice litigation. 5 In part, this is a reflection of the reality that the more a provider is capable of doing, the more he or she should do, and the more something can go wrong and lead to a lawsuit. For example, before the advent of renal dialysis, most patients with renal failure died with few lawsuits filed; however, after dialysis became available, many more patients survived, yet more patients also filed lawsuits based on mistakes in using the technology or because the expectations of patients outpaced the actual performance of the new technology. 6 Similar trends have been documented surrounding the emergence of antiseptic practices, laparoscopic techniques and, now, even medical robotics. Moreover, when a new technology such as genetic testing is taken up by medical professionals unevenly, a gap develops between the care provided by early adopters versus that by late adopters, again providing an opening for liability based on the disparity in treatment, with both early adopters and late adopters facing potential risks for being too quick or not quick enough to adopt the new technology. Second, and more unique to personalized medicine, there are significant disagreements about the scope and timing of the implementation of genetic testing in the clinical context. Some experts contend that many personalized medicine applications are ready to be used now, whereas others advocate for a more cautious approach. For example, there is disagreement on whether genetic testing should be required before prescribing drugs such as warfarin or clopidogrel. These types of disagreements provide rich fodder for litigation. Moreover, given the rapid pace at which technology and clinical applications are

Regulatory and Reimbursement Innovation

STUDY OBJECTIVE Emergency department (ED) care for patients with psychiatric complaints has become increasingly challenging given recent nationwide declines in available inpatient psychiatric beds. This creates pressure to manage psychiatric patients in the ED or as outpatients and may place providers and institutions at risk for liability under the Emergency Medical Treatment and Labor Act (EMTALA). We describe the patient characteristics, disposition, and legal outcomes of EMTALA cases involving patients with psychiatric complaints. METHODS Jury verdicts, settlements, and other litigation involving alleged EMTALA violations related to psychiatric patients between the laws enactment in 1986 and the end of 2012 were collected from 3 legal databases (Westlaw, Lexis, and Bloomberg Law). Details about the patient characteristics, disposition, and reasons for litigation were independently abstracted by 2 trained reviewers onto a standardized data form. RESULTS Thirty-three relevant cases were identified. Two cases were decided in favor of the plaintiffs, 4 cases were settled, 10 cases had an unknown outcome, and 17 were decided in favor of the defendant institutions. Most patients in these 33 cases were men, had past psychiatric diagnoses, were not evaluated by a psychiatrist, and eventually committed or attempted suicide. The most frequently successful defense used by institutions was to demonstrate that their providers used a standard screening examination and did not detect an emergency medical condition that required stabilization. CONCLUSION Lawsuits involving alleged EMTALA violations in the care of ED patients with psychiatric complaints are uncommon and rarely successful.

Medical Malpractice Lawsuits Involving Surgical Residents

Clinical trials of nanotechnology medical products present complex risk management challenges that involve many uncertainties and important risk-risk trade-offs. This paper inquires whether the precautionary principle can help to inform risk management approaches to nanomedicine clinical trials. It concludes that prudent precaution may be appropriate for ensuring the safety of such trials, but that the precautionary principle itself, especially in its more extreme forms, does not provide useful guidance for specific safety measures.

Failure to Obtain Computed Tomography Imaging in Head Trauma: A Review of Relevant Case Law

Coverage with evidence development and parallel review for molecular diagnostics aid regulation and reimbursement. Coverage with evidence development and parallel review for molecular diagnostics aid regulation and reimbursement.