Do anesthesiologists have the highest malpractice insurance rates?
In a word, “No.”
Anesthesia mishaps can lead to critical events such as death or coma, but in recent decades improvements in operating room technology and education have led to fewer such events.
Prior to 1985, anesthesia malpractice claims for death or brain death were most often due to lack of oxygen the patient’s heart or brain. Two significant breakthroughs arrived in the 1980’s to help anesthesiologists care for you: 1) the pulse oximeter, and 2) the end-tidal carbon dioxide monitor.
The pulse oximeter, developed by Nellcor and Stanford anesthesiologist William New, M.D., is a device that clips to a patient’s fingertip. A light-emitting diode shines a red light through the finger, and a sensor on the opposite side of the finger measures the degree of redness in the pulsatile blood flow within the finger. The more red the color of the blood, the more oxygen is present. A computer in the pulse oximeter calculates a score, called the oxygen saturation, which is a number from 0-100%. An oxygen saturation equal to or greater that 90% correlates with a safe amount of oxygen in the arterial blood. A score of 89% or lower correlates with a dangerously low oxygen level in the blood. The pulse oximeter monitor enables doctors to know, second-to-second, whether a patient is getting sufficient oxygen. If the oxygen saturation goes below 90%, doctors will act quickly to diagnose and treat the cause of the low oxygen level. A patient can usually sustain a short period low oxygen saturation, e.g. up to 2 or 3 minutes, without permanent damage to the brain or cardiac arrest by an oxygen-starved heart.
The end-tidal carbon dioxide (CO2) monitor is a device that measures the concentration of CO2 in the gas exhaled by a patient on every breath. During normal ventilation, every exhaled breath contains CO2. When no CO2 is measured, there is no ventilation, and the doctor must act quickly to diagnose and treat the cause of the lack of ventilation.
Prior to the invention of these two monitors, it was possible for an anesthesiologist to mistakenly place a breathing tube in a patient’s esophagus, instead of the trachea, and not know of the error until the patient sustained a cardiac arrest. With the addition of the two monitors, the lack of CO2 (there is no CO2 in the stomach or esophagus) from the end-tidal CO2 monitor immediately indicates that the tube is in the wrong place. The anesthesiologist can then remove the tube, resume mask ventilation with oxygen, and attempt to replace the tube into the windpipe. If the oxygen level to the patient’s blood dips below 90%, this is a second piece of data that indicates that the patient is in danger of brain damage or cardiac arrest.
In addition, in the early 1990’s the American Society of Anesthesiologists created the Difficult Airway Algorithm, which is a step-by-step approach for anesthesiologists to follow when the task of placing a breathing tube for an anesthetic is challenging or difficulty. This Algorithm dictates a standard of care for practitioners, and this advance in education lowered the number of mismanaged airways.
In the 1980’s, surgical anesthesia claims were 80% of closed malpractice claims against anesthesiologists (American Society of Anesthesiologists Closed Claims database). By the 2000’s, this number dropped to 65%. Brain damage represented 9% of claims, and nerve injury accounted for 22% of claims (23% were permanent and disabling, including loss of limb function, or paraplegia or quadriplegia) Less common claims were airway injury (7% of claims), emotional distress, (5% of claims), eye injuries including blindness (4% of claims), and awareness during general anesthesia (2% of claims).
Decreasing anesthesiologist malpractice premiums reflect the decrease in the number of catastrophic anesthesia claims for esophageal intubation, death, and brain death.
In 1985, the average malpractice insurance premium was $36,224 per year for a $1 Million per claim/$3 Million per year policy. By 2009, this decreased to $21,480, a striking 40% drop. (Anesthesia in the United States 2009, Anesthesia Quality Institute http://aqihq.org/Anesthesia%20in%20the%20US%202_19_10.pdf).
Specialties with the highest risk of facing malpractice claims are neurosurgery (19.1 percent), thoracic and cardiovascular surgery (18.9 percent) and general surgery (15.3 percent). Specialties with the lowest risks are family medicine (5.2 percent), pediatrics (3.1 percent) and psychiatry (2.6 percent). Anesthesiologists rank in the middle of the pack, at 7%. (Malpractice Risk According to Physician Specialty, Jena, et al, N Engl J Med 2011; 365:629-636.) From 1991 to 2005, this article identified 66 malpractice awards that exceeded $1 million dollars, which accounted for less than 1% of all payments. Obstetrics and gynecology accounted for the most payments (11), followed by pathology (10), anesthesiology (7), and pediatrics (7).
At the American Society of Anesthesiologists (ASA) Annual Meeting in San Diego in October 2015, the following numbers were presented from the National Practitioner Data Bank (presented as abstract A2097):
- The yearly spending on malpractice payments against anesthesiologists decreased from $174.4 million in 2005 to $91.1 million in 2013, a decrease of $83.3 million, or a 41.4% decrease.
- Of the 2,408 payments made during the 9-year period from 2005 – 2013, 567 (23.5%) were for outpatient events, and 1,841 (76.5%) were from inpatient events.
- The average payment was $245,000, with inpatient anesthesia claims being significantly more expensive ($261,742 to $189,349 respectively). Inpatient claims accounted for 82% of the total amount paid.
- Death was the most common outcome in both the inpatient and outpatient claims.
A second abstract from the same ASA meeting (abstract A1009) showed that non-operating room payments were significantly higher than operating room payments ($554,000 vs. $285,000; p=0.003).
A take home message is that anesthesia has serious risks, but those risks have decreased significantly in recent years, most likely because of improvements in monitoring and education. Compared to other specialties, the risk of an anesthesiologist being sued is about average among American medical specialties.
Introducing … THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
Publication date September 9, 2014 by Pegasus Books.
On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s #1 bestselling anesthesia Kindle book on Amazon.com.
To reach the Amazon webpage, click on the book image below:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press firstname.lastname@example.org, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
From the author, Dr. Rick Novak:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in a small Midwestern town with an exceptional high school. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged nurse anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a series of twists that will keep readers guessing.
The book brings the issue of CRNA independent practice to a national audience, and this conflict drives the plot. Most of all, The Doctor and Mr. Dylan is a page-turning mystery, guaranteed to keep readers riveted until the final page.
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: