Questionable Conduct
What Were These Surgeons Thinking?
A New Jersey orthopedic surgeon made national headlines last month when a patient sued for invasion of privacy and battery after she woke up from spine surgery with a temporary tattoo of a red rose below her panty line. Steven Kirshner, MD, applied the tattoo as a joke to cheer up his patient. However, Elizabeth Mateo didn't appreciate it, especially since the tattoo was nowhere near her surgery site. Dr. Kirshner didn't seem to understand the inappropriateness of his actions. Neither have other well-publicized surgeons over the years.

• Ten women sued James Guiler, MD, in 2003 for branding "UK" on their uteruses during hysterectomies. Dr. Guiler used the acronym of his alma mater, the University of Kentucky, as a marker for the surgery (see photo). The women learned of the brand from surgery videos that Dr. Guiler gave them.
• In 2002, seven hours into spine surgery, Boston-area surgeon David Arndt, MD, left the OR to cash a check. He returned about 35 minutes later and finished the case. His license was suspended. A month later, Dr. Arndt was arrested for statutory rape and possession of methamphetamine and ketamine hydrochloride (Special K). In June 2005 he pleaded guilty to drug trafficking.
• During gallbladder surgery in December 2007, Adam Hansen, MD, chief resident of general surgery at the Mayo Clinic in Scottsdale, Ariz., used his cell phone to take a picture of a patient's penis, which had a tattoo that said, "Hot Rod." Dr. Hansen, who showed the photo to others, left the Mayo Clinic shortly afterwards.
• Timothy Brown, MD, left the OR at Boston Medical Center in 2005 to deliver a lecture in another part of the hospital. OR staff couldn't reach him by pager, so residents implanted a plate and screws in the patient's arm. Dr. Brown was disciplined and given five years' probation.
• At Beth Israel Medical Center in New York in 2005, Robert Klinger, MD, and Marc Sklar, MD, used equipment without proper training and pumped too much saline into a patient during surgery to remove fibroid tumors. They also allowed a sales rep to operate equipment during the procedure, in which the patient died of cardiac arrest. The physicians were cleared of criminal wrongdoing but the hospital was fined $30,000.
• Ohio gynecologist James Burt, MD, performed vaginal reconstruction and clitoral circumcision, which he called "surgery of love," on hundreds of patients in the 1970s and 1980s, often without their consent while they were sedated for other procedures. Dr. Burt's license was revoked in 1989.
• Memphis orthopedic surgeon Bret Sokoloff, MD, was charged in 2007 with five counts of sexual battery and two counts of attempted rape based on complaints from three nurses who worked with him in a Memphis surgery center. In May 2008 Sokoloff pleaded guilty to misdemeanor assault.
• Obstetrician Allan Zarkin, MD, in 1999 carved his initials above the wound closure for a caesarean section at the Beth Israel Medical Center in New York. Dr. Zarkin said he was proud of his work and that the closure was worthy of a signature. Dr. Zarkin, who suffers from Pick's Disease, pleaded guilty to assault and agreed to never practice medicine again.

Why do surgeons act like this? Because they're human and the system lets them get away with it, says psychologist Wayne Sotile, PhD, a specialist in counseling physicians and author of the book, The Resilient Physician (American Medical Association Press, 2001).

Physicians are like everyone else. They suffer the stress of a changing healthcare system, can have family and financial problems, can be become depressed or addicted to alcohol and drugs, and can develop behavioral disorders, says Kent Neff, MD, a psychiatrist in Portland, Ore., who has counseled hundreds of disruptive physicians. Another factor is the long years of training, during which physicians put their social lives on hold. This can lead to poor social skills and sometimes psychosexual immaturity.

Medicine is becoming less tolerant of inappropriate behavior. Last month the Joint Commission issued a Sentinel Event Alert about lateral violence in healthcare. That's good news, says Dr. Neff. "They did us a great favor."

— Kent Steinriede

Breaks in Technique
What's Wrong With This Picture?

Aching Upon Waking
General Anesthesia Contributes to Post-op Pain
Some "noxious" general anesthetics excite sensory neurons that cause peripheral pain in patients once they wake from surgery, researchers say.

In a study published in the June 24 issue of Proceedings of the National Academy of Sciences, researchers at Georgetown University in Washington, D.C., have confirmed what anesthesia providers have known anecdotally for many years.

The more noxious general anesthetics activate a protein called TRPA1, known as the mustard-oil receptor, which is a principal receptor in the pain pathway. In nature, plants that produce chemicals such as mustard oil and capsaicin to prevent animals from eating them act upon the same receptor, says co-author Gerard Ahern, PhD, an assistant professor of pharmacology at Georgetown University Medical Center, in a press release.

The results of the study, which was performed on mice and rats, may explain why many surgery patients experience burning or inflammation in airways or at IV injection sites. Some anesthetics seem to cause a stronger reaction than others. "The choice of anesthetic appears to be an important determinant of post-operative pain," says Dr. Ahern. Sevoflurane, for example, seems to cause less swelling than isoflurane, according to the authors.

— Kent Steinriede

Get Your Free Wrong-site Surgery Posters from AAOS
Wrong-site surgery prevention should be a collaborative effort between physicians and their patients — that's the message of the American Academy of Orthopaedic Surgeons' "Sign Your Site" initiative. Want to get the point across at your facility? Try posting some of these eye-catching public service ads in your pre-op and waiting rooms, or hand them out as postcards to patients when they arrive. To place an order (they're available to the public free of charge), contact Pat Julitz at (847) 384-4036 or [email protected].

— Irene Tsikitas

CMS Proposes 2009 Payment System Changes
Highlights of CMS's proposed rule that would update payment policies and rates for both hospital outpatient departments and ASCs for 2009:

• Hospital outpatient departments would receive a 3-percent annual inflation update next year, but those that don't meet quality reporting requirements will see that pay rate increase to just 1 percent. It would mark the first time Medicare outpatient pay rates have been associated with the quality of service. In order to receive the full OPPS payment update for services furnished in CY 2009, hospitals must report data in CY 2008 on seven quality measures of emergency department and perioperative surgical care.
• Rates are still frozen for ASCs. The good news: 2009 will be the last year of the zero-percent inflation update for ASCs.
• The update to ASC rates constitutes the second year of a four-year phase-in that aligns ASC rates with the ambulatory payment classification (APC) groups that are used to pay for services in hospital outpatient departments. Next year, 50 percent of ASC rates for old services will be based on the old system and 50 percent on the new. Services newly added to the ASC list will receive the new payment rate immediately.
• CMS is proposing to add nine surgical procedures to the list of procedures for which Medicare will pay when performed in an ASC. This includes three procedures that have new codes and descriptors — 0190T (placement of intraocular radiation source applicator) at $890.60, 0191T (insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach) at $968.22 and 0192T (insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach) at $968.22 — and six procedures that were previously excluded from payment under the ASC payment system: 31293 (nasal/sinus endoscopy, surg) at $946.08, 34490 (removal of vein clot) at $1,624.13, 36455 (Bl exchange/ transfuse non-nb) at $136.99, 49324 (Lap insertion perm ip cath) at $1,515.47, 49325 (Lap revision perm ip cath) at $1,515.47 and 49326 (lap w/ omentopexy add-on) at $1,515.47.

Comments on the proposed rule will be accepted until Sept. 2 and a final CY 2009 OPPS/ASC payment rule will be issued by Nov. 1.

— Dan O'Connor