Standard of practice of the community should be consistent with the national standard of practice

If the standard of care varies, then there can be no consistency in defense of a physician’s care.

Issue: June 2012

For this month’s 4 Questions interview, I have asked Jack M. Bert, MD, to share his thoughts about community standards and community collegiality. Over the years, I have had the opportunity to work closely with Dr. Bert who has been in private and academic practice for more than 33 years. Among his many accomplishments, he has served as president of the Arthroscopy Association of North America (AANA). He is also an instructor for AANA and the American Academy of Orthopaedic Surgeons on the care and treatment of osteoarthritis of the knee, particularly articular cartilage disease and injuries. In addition, he has spoken extensively on practice management issues and has testified in the defense of multiple orthopedic surgeons in cases determined to be below the standard of care.

Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: What is commonly defined as the standard of practice of the community?

Jack M. Bert, MD: The standard of practice in the community should be consistent with the standard of practice nationally. The issue is clearly that if a particular physician is performing procedures that are consistent with national standards, even if they may not be the local community practice preferences, then the local community physicians may be critical of the care. However, if the local surgeon’s care meets national standards, then that should be the community of accountability.

Jack M. Bert

Jackson: How does this standard of care play out in the medical legal setting? What are some ramifications?

Bert: In my experience from testifying on behalf of physicians in several different states, the national standard must be adhered to and hopefully can be substantiated by the orthopedic literature. If the standard of care varies from community to community, then there can be no consistency in defense of a physician’s care. I recently successfully served as an expert witness for a physician who did not administer preoperative antibiotics for a routine meniscectomy. The patient developed a postoperative infection, and the physician was sued based upon the local community’s routine of administering IV Ancef (cefazolin, GlaxoSmithKline) preoperatively for a routine meniscectomy.

Five years ago, I was involved in publishing an article comparing infection rates in several thousand arthroscopic surgeries. There was no statistical difference in infection rates in the patients who obtained preoperative prophylactic antibiotics compared with the patients who did not. We used this article in the defense of the case and the jury agreed.

Jackson: How can the standard of care be interpreted in the hospital setting?

Bert: The hospital situation can be especially difficult in the peer-review setting. If a local group of orthopedists believes that a physician has deviated from the care in their community but are unaware or have not performed a specific technique, then they may condemn that orthopedist’s care. We should all try to avoid acrimony and show support amongst orthopedic groups and individual physicians when we can. This reminds me of a comment that Mark Coventry used to say during my residency, “If you have not had a complication doing a particular procedure, it just means you have not done enough of them.” There is no place for arrogance in medicine, and we should be kind to our colleagues, treat them like brothers, and avoid being overly critical of their care.

Jackson: How can being openly critical of another physician cause consequences for a physician?

Bert: If a local physician is critical of the care of a particular surgeon and a comment is made at the time of a second opinion, when the patient is in the hospital or has been overheard in clinic staff discussions and it gets back to that patient or family, then it can result in the initiation of a lawsuit. “Jousting” is defined in medical circles as being critical of another surgeon’s care and treatment and unfortunately, it is a national problem.

Often the basis for some criticisms are the result of several factors, including simply disliking the surgeon or simple jealousy that the operating surgeon is busier or perhaps more popular in the community. The most common criticism I hear from physician groups that can not seem to get along is that they feel other groups in the community “are not as good as ours and they do not practice as high a quality of medicine as we do.” Ironically, I have visited groups that eventually merge together either through an umbrella or full-asset merger. Once they get to know one another, this attitude disappears.

I feel strongly that “what goes around comes around,” and it is never a good idea to criticize another surgeon’s care because this may come back to haunt the criticizing surgeon if and when he or she has a complication. Newer innovative procedures, which a hospital peer-review committee or local surgeon may not have performed, may cause considerable issues if the outcome of the newer procedure is suboptimal. Again, if “jousting” occurs in the community when a newer technique is tried and a less than satisfactory outcome or complication occurs, this can result in litigation for the operating surgeon.

For more information:

Jack M. Bert, MD, is an adjunct clinical professor, University of Minnesota School of Medicine, Cartilage Restoration Center of Minnesota, Institute for Bone & Joint Care, Hennepin County Medical Center, Minneapolis, MN 55430; 612-347-2663; email: bertx001@gmail.com.
Disclosure: Bert has no relevant financial disclosures.