At its meeting in Chicago on Nov.18, the AANS Board of Directors decided seven professional conduct cases. In one case the board approved the recommendation of the Professional Conduct Committee that the charges against the member be dismissed. In six other cases the board approved the PCC’s recommendations that disciplinary actions be imposed, resulting in two expulsions, a two-year suspension, two one-year suspensions and a six-month suspension of membership.
|
||||||||||||||||||||||
Martin Krell, MD
Two-Year Suspension
The charges against Dr. Krell were based on his deposition testimony as an expert witness in a lawsuit involving a 10-year-old boy who was severely injured when the bicycle on which he was riding collided with a truck. In this accident the boy was thrown an estimated 40 feet, was immediately unconscious, apneic, and ultimately became a ventilator-dependent quadriplegic.
The boy was first seen by the neurosurgeon several hours after an exploratory laparotomy and a CT scan of the head. A later MRI showed a cord injury at the cervicomedullary junction. Dr. Krell testified that the CT scan showed an epidural hematoma anterior to the cord at the cervicomedullary junction and that immediate surgery plus methylprednisolone would have resulted in the patient retaining useful movement of his arms and legs and being able to breathe on his own.
The PCC concluded, and the board agreed, that the CT scan did not show an epidural hematoma and that while steroid treatment was and is widely used in spinal cord injuries, Dr. Krell’s prognosis for recovery with the use of methylprednisolone was entirely too optimistic. The PCC concluded that Dr. Krell’s testimony reflected inadequate subject matter knowledge in his reading of the CT scan and in his unrealistically optimistic prognosis for recovery if methylprednisolone had been used. It was unclear to what extent intentional improper advocacy may have also played a role, but in either case Dr. Krell’s testimony was highly inappropriate and unprofessional.
Sidney Peerless, MD
One-Year Suspension
The charges against Dr. Peerless were based on his expert opinion letter to plaintiff counsel supporting the filing of a medical malpractice lawsuit and his subsequent deposition testimony in that case. The patient was an obese 43-year-old man with a history of alcohol abuse, secondary liver damage, hepatitis C, and hypersplenism. He was admitted to the hospital with an acute subarachnoid hemorrhage, hypertension and lethargy, and then was transferred to another hospital for further management. There he developed reduced platelets and probable disseminated intravascular coagulopathy. A chest X-ray showed bilateral infiltrates suggestive of congestive heart failure. He had cirrhosis and an elevated blood ammonia level. With vigorous medical care he improved remarkably over the next week or so and became medically stable. He then underwent cerebral angiography that showed a large (12 mm) right pericallosal aneurysm.
After consultation with the treating neurosurgeon, the patient and his family elected to proceed with an attempted clipping of the aneurysm. The operation involved a right frontal craniotomy with interhemispheric approach, and ultimately a wrapping of the aneurysm with muslin gauze when the neurosurgeon concluded that clipping threatened continuity of the parent vessel. The operation was difficult because of adhesions and took nearly nine hours. Postoperatively, the patient was slow to arouse, was aphasic, and was not moving his lower extremities. Postoperative CT scans showed a hemorrhagic contusion of the right frontal lobe and an infarct in the distribution of the left anterior cerebral artery. Repeat angiography showed a patent left anterior cerebral artery. A subsequent neurology consultant documented a complete paraplegia with a sensory level at T6 and ordered an MRI which failed to demonstrate the cause of the paraplegia. A later MRI did show a probable T6 cord infarct. The patient developed increasing difficulty with decubitus ulcers and urinary sepsis and ultimately died. The family brought a malpractice suit against the treating neurosurgeon which, after a full trial, resulted in a defense verdict.
Dr. Peerless testified that it was below the acceptable standard of care to have recommended surgery for this patient because of an unfavorable risk-benefit ratio and that the treating neurosurgeon was negligent for allowing decubiti and urinary infection to develop. Dr. Peerless’ adamant assertion that surgery should not have been offered in this circumstance failed to represent the full range of neurosurgical thought and practice. The PCC noted that the aneurysm was large and appeared amenable to clipping. The PCC and the board considered that proceeding with surgery was reasonable and that Dr. Peerless improperly characterized the decision to proceed with surgery as substandard. The PCC and the board also considered that Dr. Peerless’ testimony showed bias through inflammatory language used in several areas of his deposition.
Lawrence F. Marshall, MD
Six-Month Suspension
The charges against Dr. Marshall were based on his statements made during a discovery deposition as a plaintiff medical expert in a medical malpractice suit involving a 58-year-old woman with lumbar scoliosis, stenosis, and complaints of persistent low back and leg pain. The patient underwent a bilateral decompression from L1 to S1 with a posterior lumbar interbody fusion at L2-L3 and L3-L4. A posterior lateral instrumented fusion was then done from L1 to the sacrum. During the decompression a dural laceration occurred at about the L3-L4 level and this was repaired. Postoperatively the patient was found to be severely paraparetic and was returned promptly to the operating room where re-exploration failed to demonstrate any neural compression. At this reoperation an L2 pedicle screw on the right was removed, an L3 pedicle screw was revised, and an L5 pedicle screw was noted to have become “stripped.” The patient gradually regained useful strength in her legs but did not recover to the level of her immediate preoperative neurological state. The patient brought suit against the treating neurosurgeooon and a trial resulted in a defense verdict.
In his deposition, Dr. Marshall was highly critical of the preoperative planning and of the surgical performance. Dr. Marshall testified that the treating neurosurgeon’s conduct would have resulted in a “criminal referral” in California and made references to the cord having been “whacked.” The PCC concluded, and the board agreed, that Dr. Marshall’s deposition testimony viewed as a whole did not adequately represent the range of neurosurgical thought and practice and that his reference to “criminal referral” and a “whacked” cord constituted improper advocacy rather than impartial testimony.
Ignacio A. Magana, MD,
and Richard B. Small, MD
Expelled from AANS Membership
Ignacio A. Magana, MD, and Richard B. Small, MD, were expelled from the AANS because each lost his certification by the American Board of Neurological Surgery, which is a prerequisite for AANS membership. In addition, Dr. Magana lost his state license to practice medicine, which is also a prerequisite for membership in the AANS.
PCC: Working for Nearly 25 Years
The AANS Professional Conduct Committee evaluates complaints by one or more AANS members about another member or members and makes recommendations to the Board of Directors. Established in 1982, the PCC has served as a model for other professional associations to structure and adopt similar professional conduct programs. In June of 2001, the AANS Professional Conduct Committee’s work was examined by the 7th Circuit Court of Appeals in a landmark case for professional associations, Austin v. AANS. This opinion strongly supported the AANS Professional Conduct Program and the importance to a professional association of having an internal mechanism for self-regulation. The program also received an honor roll designation from the American Society of Association Executives in 2002.
W. Ben Blackett, MD, JD, is chair of the AANS Professional Conduct Committee. Russell M. Pelton, JD, is AANS general counsel.
For Further Information
The AANS rules for expert witness testimony, the AANS Code of Ethics and more information related to association governance is available online at www.aans.org/about in the Governance and Leadership area.