Rethinking Peer Review: Detecting and Addressing Medical Malpractice Claims Risk

A medical center department chair has just been notified that a physician in his department, Dr. G, is being sued for the fifth time in seven years. The CEO of co-defendant hospital wants the chair to solve Dr. G\u27s claims problems. At the chair\u27s request, the hospital peer review committee evaluates Dr. G\u27s malpractice cases. While committee members note some minor concerns in the cases, they conclude that in each circumstance he has met the standard of care. They cannot identify any specific technical or educational need, nor can they supply justification for a disciplinary action. The chair is in a vexing situation. Is Dr. G. the victim of bad luck, or is something more systematic at work? Is there some failure or deficiency other than technical incompetence which is making this physician vulnerable to malpractice suits? If so, is it remediable? In this Article, we analyze the ability of peer review to recognize and reduce physicians\u27 risk of medical malpractice claims. Critics argue that peer review neither consistently identifies substandard physicians, nor ensures their removal, while it unfairly targets colleagues for reasons such as economic competition. They suggest that the solution may be to modify statutes governing privilege and immunity, or to increase penalties for healthcare institutions that violate reporting statutes. Critics\u27 concerns may be misplaced. We will argue that peer review is not deficient in its basic conception, but rather aspects of its design and implementation which often do not directly link it to an institution\u27s risk management activities. We assert that peer review can effectively identify a physician\u27s risk of generating a disproportionate share of medical malpractice claims ex ante, and present a sample methodology which allows peer review to more effectively help physicians address that risk. Part I of this Article discusses the background and authority for peer review. Part II outlines common criticisms of peer review and discusses shortcomings in these analyses. Part III describes background medical malpractice research and introduces the Patient Advocacy Reporting System ( PARSSM ) program for peer review. In Part IV we conclude with a discussion of programmatic elements which, if incorporated into the legal framework for peer review, may allow peer review committees to systematically evaluate, monitor, and, potentially reduce physicians\u27 medical malpractice claims risk

Electromagnetic Polarisability of the Nucleon in Chiral Perturbation Theory

We compute the polarisability of the nucleon to leading order in chiral perturbation theory. The contributions from kaons and baryon resonances as intermediate states are included in addition to the contribution from pions and nucleons that had been previously computed. The isoscalar operators are dominated by the infrared behaviour of pion loops giving rise to a $1/m_{\pi}$ coefficient. In contrast, the isovector operators are dominated by loops involving kaons, giving a $1/m_{k}$ coefficient, and further demonstrates that the strange quark is an important component of the nucleon. In addition, the inclusion of the decuplet of baryon resonances as intermediate states substantially modifies the result found from the octet baryons alone for the isoscalar polarisability.Comment: 11 pages (uses harvmac, figures available upon request) , UCSD/PTH 92-30, QUSTH-92-0

Cepheid Calibration of the Peak Brightness of SNe Ia -- IX. SN 1989B in NGC 3627

(Abridged) Repeated imaging observations have been made of NGC 3627 with the HST in 1997/98, over an interval of 58 days. Images were obtained on 12 epochs in the F555W band and on five epochs in the F814W band. The galaxy hosted the prototypical, `Branch normal', type Ia supernova SN 1989B. A total of 83 variables have been found, of which 68 are definite Cepheid variables with periods ranging from 75 days to 3.85 days. The de-reddened distance modulus is determined to be (m-M)_0= 30.22+/-0.12 (internal uncertainty) using a subset of the Cepheid data whose reddening and error parameters are secure. The photometric data of Wells et al. (1994), combined with the Cepheid data for NGC 3627 give M_B(max)= -19.36+/-0.18 and M_V(max)= -19.34+/-0.16 for SN 1989B. Combined with the previous six calibrations in this program, plus two additional calibrations determined by others gives the mean absolute magnitudes at maximum of = -19.48+/-0.07 and = -19.48 +/-0.07 for `Branch normal' SNe Ia at this interim stage in the calibration program. The second parameter correlations of M(max) of blue SNe Ia with decay rate, color at maximum, and Hubble type are re-investigated. The dependence of on decay rate is non-linear, showing a minimum for decay rates between 1.0< Delta m_15 <1.6. Magnitudes corrected for decay rate show no dependence on Hubble type, but a dependence on color remains. Correcting both the fiducial sample of 34 SNe Ia with decay-rate data and the current 8 calibrating SNe Ia for the correlation with decay rate as well as color gives H_0= 60+/-2 (internal) km/s/Mpc, in both B and V. The same value to within 4% is obtained if only the SNe Ia in spirals (without second parameter corrections) are considered.Comment: 32 pages (with 7 tables and 14 figures) LaTeX, uses emulateapj.sty; a full-resolution version with complete figs. 4 and 5 is available at http://www.astro.unibas.ch/cosmology/papers.html ; accepted for publication in Ap

Higher Order Polarizabilities of the Proton

Compton scattering results are used to probe proton structure via measurement of higher order polarizabilities. Values for $\alpha_{E2}^p,\beta_{E2}^p,\alpha_{E\nu}^p,$ $\beta_{E\nu}^p$ determined via dispersion relations are compared to predictions based upon chiral symmetry and from the constituent quark model. Extensions to spin-polarizabilities are also discussed.Comment: 18 pages, revised version with one reference adde

Electric Polarizability of the Nucleon in the Nambu--Jona-Lasinio Model

The electric polarizability of the nucleon is calculated in the soliton approach to the Nambu--Jona-Lasinio model. We analyze the leading-$N_c$ contributions, as well as the effects of rotational $1/N_c$ corrections and $\Delta$-$N$ mass splitting. Our model prediction is substantially reduced compared to other soliton calculations, and is closer to the experimental value.Comment: 16 pages, RevTeX, 3 figures (included, PS, uuencoded), RUB-TPII-55/93 and TPR-93-3

The IN-mode in the TCV tokamak

A new improved L-mode has been found in TCV with high confinement properties, high edge and global density and no edge temperature barrier. The ohmic IN-modes are presented. They have been obtained in two ways. One thanks to a transient H-mode, even though the plasma is limited, and another with a high reference density at t=0. H98y2~1, H89P=1.6 has been obtained with q95=2.7-3.5, kappa~1.5 and betaN~1.4

The Apolipoprotein M/S1P Axis Controls Triglyceride Metabolism and Brown Fat Activity

Summary: Apolipoprotein M (apoM) is the carrier of sphingosine-1-phosphate (S1P) in plasma high-density lipoproteins. S1P is a bioactive lipid interacting with five receptors (S1P1–5). We show that lack of apoM in mice increases the amount of brown adipose tissue (BAT), accelerates the clearance of postprandial triglycerides, and protects against diet-induced obesity (i.e., a phenotype similar to that induced by cold exposure or β3-adrenergic stimulation). Moreover, the data suggest that the phenotype of apoM-deficient mice is S1P dependent and reflects diminished S1P1 stimulation. The results reveal a link between the apoM/S1P axis and energy metabolism. : Apolipoprotein M (apoM) is the carrier of sphingosine-1-phosphate (S1P) in lipoproteins. Christoffersen et al. show that lack of apoM in mice increases the amount of brown adipose tissue, accelerates the turnover of fat, and protects against obesity. The results reveal a link between the apoM/S1P axis and energy metabolism. Keywords: apolipoproteins, sphingolipids, sphingosine-1-phosphate, lipoproteins, lipid metabolism, triglyceride, brown adipose tissue, apo

Indirect measurement of poloidal rotation using inboard–outboard asymmetry of toroidal rotation and comparison with neoclassical predictions

An alternative experimental spectroscopic measurement of poloidal plasma rotation in toroidally confined plasmas is proven effective in the TCV tokamak. Charge exchange recombination measurements of the toroidal rotation profile over the full mid-plane plasma diameter are used to infer the complete bi-dimensional flow structure of the intrinsic C6+ impurity, which includes its poloidal component. For divergence free flows, the difference between the toroidal rotation frequency ft = ut/R at the inboard and outboard locations on the same flux surface is proportional to the poloidal rotation. This indirect measurement provides increased accuracy as the measured quantity ft,in − ft,out ≈ 4qup/Raxis (q is the local safety factor) is larger than the intrinsic uncertainties of a direct spectroscopic measurement of poloidal velocity. The method is applied in a variety of TCV ohmic and electron cyclotron heated L-mode plasmas in the banana-plateau collisionality regime (0.2 < ν∗ii < 2.4). In the radial range of normalized poloidal flux ρψ < 0.8, an impurity poloidal velocity of up = 0.5–2.5 kms−1 is observed, always in the electron diamagnetic drift direction. The measurements are compared with neoclassical calculations and they agree in magnitude and sign to within <1 kms−1

Dirac-Foldy term and the electromagnetic polarizability of the neutron

We reconsider the Dirac-Foldy contribution $\mu^2/m$ to the neutron electric polarizability. Using a Dirac equation approach to neutron-nucleus scattering, we review the definitions of Compton continuum ($\bar{\alpha}$), classical static ($\alpha^n_E$), and Schr\"{o}dinger ($\alpha_{Sch}$) polarizabilities and discuss in some detail their relationship. The latter $\alpha_{Sch}$ is the value of the neutron electric polarizability as obtained from an analysis using the Schr\"{o}dinger equation. We find in particular $\alpha_{Sch} = \bar{\alpha} - \mu^2/m$ , where $\mu$ is the magnitude of the magnetic moment of a neutron of mass $m$. However, we argue that the static polarizability $\alpha^n_E$ is correctly defined in the rest frame of the particle, leading to the conclusion that twice the Dirac-Foldy contribution should be added to $\alpha_{Sch}$ to obtain the static polarizability $\alpha^n_E$.Comment: 11 pages, RevTeX, to appear in Physical Review