Brain glucose metabolism in violent psychiatric patients: a preliminary study.

Positron emission tomography with 18F-deoxyglucose was used to evaluate regional brain glucose metabolism in eight normal subjects and eight psychiatric patients with a history of repetitive violent behavior. Seven of the patients showed widespread areas of low brain metabolism. Although the location of the abnormal regions varied among patients, they showed significantly lower relative metabolic values in medial temporal and prefrontal cortices than did normal comparison subjects. These regions have been implicated as substrates for aggression and impulsivity, and their dysfunction may have contributed to the patients' violent behavior.

The admissibility of scientific evidence in psychiatric malpractice: junk science and the Daubert case.

The defence in malpractice cases has traditionally relied upon a commonly accepted body of knowledge. According to the American 'Frye rule', this knowledge could either have been accepted generally or by a 'respectable minority' of physicians. The US Supreme Court, however, has recently ruled in the Daubert case that conclusions not subject to peer review are acceptable in malpractice cases. The authors analyse the implications of the Daubert decision using the case-study method. Two alternative-scenarios of a hypothetical case are analysed. The potential effect of Daubert places the US psychiatrist-defendant in an untenable position. Either use or non-use of non-peer-reviewed studies in clinical practice could produce a finding of negligence. Furthermore, the responsibility to assess scientific acceptability in US courts has shifted from expert witnesses to judges who are usually without scientific training.

Advancing the epidemiology of injury and methods of quality control: ACEs as an outcomes-based system for quality improvement.

Accelerated-compensation events (ACEs) are classes of avoidable medical injuries. Originally, these classes were used in tort reform to speed payment for avoidable injuries. However, ACEs also have potential as tools to monitor and improve the quality of health care. ACEs are developed by physicians, based on medical decision making. Rather than simply identify an adverse outcome, they link that outcome to clinical processes. Therefore, ACEs can help identify the critical elements of care that would result in desirable outcomes. Also, ACEs are discerning: they identify only events of which the vast majority are preventable. In one project, ACEs have been developed for obstetrics/gynecology, general surgery, and orthopedic surgery, using a three-phase process of sifting data and honing definitions. Future plans include improving these ACEs, statistically evaluating them, and testing them for utility in quality monitoring and improvement.

Creating outcomes-based systems for quality and malpractice reform: methodology of accelerated compensation events (ACEs).

Today's unduly erratic and expensive payment system for medical malpractice undercuts its own goal of compensating victims. Its lack of scientific legitimacy hampers its other main goal of deterring injury. Reform is needed, but most "tort reform" fails to make fundamental changes and does not promote quality of care. Alternative systems using "Accelerated Compensation Events" (ACEs) offer a better way to replace or improve judicial resolution of liability claims as well as independent, quality-oriented reform. ACEs do not cover all injuries, just classes of adverse outcomes that are normally avoidable, given good care. This article explains the scientific methodology of ACE development and the benefits of ACE-based reforms.

Obstetrics and malpractice. Evidence on the performance of a selective no-fault system.

Most malpractice litigation in obstetrics could be replaced with an alternative insurance system based on "accelerated-compensation events," which are classes of medical injuries determined in advance by medical experts to be readily identifiable, normally preventable with good care, and nondistorting of medical decision making. This professionally derived system would help prevent injury and improve the resolution of injuries. Prior work on accelerated-compensation events was largely conceptual, so to study the likely effects of accelerated-compensation events, we applied the events to a large database of obstetrical malpractice claims. Results refute prior criticisms. Accelerated-compensation events (1) are definitely feasible to develop and apply, (2) would probably cover two thirds of currently paid claims and three quarters of indemnity dollars, (3) would likely involve substantial savings in time and expense per case, and (4) would probably not introduce an unmanageable number of large new claims.

Biological correlates of mental activity studied with PET.

The development of newer imaging techniques that allow direct investigation of the function of the human brain under normal and pathological conditions has affected the way in which we conceive of the mind/brain relation. In this report the authors use examples from findings obtained with positron emission tomography (PET) to illustrate the highly interactive organization of the brain. Because operations in the brain require the participation of various brain areas, a model that does not require a one-to-one relationship between the physical and mental, but rather allows an association between clusters of physical processes and one or more mental phenomena, may reflect better the relation between physical brain phenomena and mental activities.

Malpractice and tardive dyskinesia: a conceptual dilemma.

This discussion focuses on three basic areas relevant to tardive dyskinesia (TD). The first area includes an overview of some specific acts of negligence that have been the basis for successful malpractice cases involving TD. Some of these acts of negligence include inappropriate assessment of the patient, failure to properly care for TD, and failure to obtain a proper informed consent. The second area involves the problems of uncertainty, which are particularly manifested where the only treatment available has a high benefit but a low risk of serious adverse effects. The uncertainty rests on the limited information regarding detection of the serious consequences, or cure, once the full-blown condition develops. The third involves exploring alternatives to the tort system, such as an automatic system of compensation, which might be more appropriate for dealing with an outcome such as TD. Alternative systems might be more effective in combining incentives for quality care with adequate compensation for the injured where the condition might have been avoided.