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Crowdsourcing from the general population is an efficient, inexpensive method of surgical performance evaluation. In this study, we compared the discriminatory ability of experts and crowdsourced evaluators (the Crowd) to detect differences in robotic automated performance metrics (APMs). APMs (instrument motion tracking and events data directly from the robot system) of anterior vesico-urethral anastomoses (VUAs) of robotic radical prostatectomies were captured by the dVLogger (Intuitive Surgical). Crowdsourced evaluators and four expert surgeons evaluated video footage using the Global Evaluative Assessment of Robotic Skills (GEARS) (individual domains and total score). Cases were then stratified into performance groups (high versus low quality) for each evaluator based on GEARS. APMs from each group were compared using the Mann-Whitney U test. 25 VUAs performed by 11 surgeons were evaluated. The Crowd displayed moderate correlation with averaged expert scores for all GEARS domains (r > 0.58, p < 0.01). Bland-Altman analysis showed a narrower total GEARS score distribution by the Crowd compared to experts. APMs compared amongst performance groups for each evaluator showed that through GEARS scoring, the most common differentiated metric by evaluators was the velocity of the dominant instrument arm. The Crowd outperformed two out of four expert evaluators by discriminating differences in three APMs using total GEARS scores. The Crowd assigns a narrower range of GEARS scores compared to experts but maintains overall agreement with experts. The discriminatory ability of the Crowd at discerning differences in robotic movements (via APMs) through GEARS scoring is quite refined, rivaling that of expert evaluators.

The insurance branch that covers the risk of occupational disability ranks among the most important private entities for offering security as far as the limitation or loss of one's ability to work is concerned. The financial risk of the insurer, the existential concerns and expectations of the claimant, as well as the legal framework and the need for a careful interdisciplinary evaluation, necessitate a professional review and assessment of the facts conducted with a sense of both responsibility and sensitivity. Carefully deliberated and sustainable decisions benefit both insurers and the insured. In order to achieve this, an opinion is required in many--and especially the more complex--cases from an external medical expert, which in turn can only be plausible and conclusive when based on a comprehensive review of the claimant's working environment and its particular (and often unique) requirements. This article is intended to increase the reader's understanding of the coherencies of workplace analysis and medical assessments, as required by insurance law and legislation. In addition, the article delivers valuable clues and guidance, both for medical experts and claims managers at insurance companies. Primarily, the claimant's occupation, as conceived in the terms and conditions of the insurance companies, is explained. The reader is then introduced to the various criteria to be considered when a claimant has several jobs at the same time, is self-employed, could be transferred to another job, is simply unable to commute to the workplace, or is prevented from working due to legal restrictions related to an illness. The article goes on to address the crucial aspect of how the degree of disability is to be measured under different circumstances, namely using the quantitative and the qualitative approach. As a reliable method for obtaining the essential data regarding the claimant's specific working conditions, which are required by both the medical expert and the insurance company's claims manager, the reader is provided with an insider's insights into on-site workplace analysis. The value of this pragmatic and proven method is subsequently demonstrated when the article addresses the often decisive part of the medical expert's assessment. In its conclusion the article points out the importance of workplace analysis to the entire process of evaluating occupational disability claims and the effort and monies to be saved by attaching value to thorough workplace analysis at an early stage.

Due to the spread of intervertebral disc degeneration, insurance companies and experts are regularly confronted with related assessments of insured persons under their private accident insurance. These claims pose a particular challenge for experts, since, in addition to the clinical assessment of the facts, extensive knowledge of general accident insurance conditions, case law and current study findings is required. Each case can only be properly assessed through simultaneous consideration of both the medical and legal facts. These guidelines serve as the basis for experts and claims.managers with respect to the appropriate individual factual assessment of intervertebral disc degeneration in private accident insurance.

Health-care systems are currently facing tremendous budget constraints resulting in growing pressure on decision makers and health-care providers to obtain the maximum possible health benefits of the resources available. Choices have to be made, and health economics can help in allocating limited health-care resources among unlimited wants and needs. Attempts to achieve cost reductions often focus on severe pathologies and chronic diseases as they commonly represent high health-care expenditures. In this context, awareness of the considerable financial burden caused by disease-related malnutrition (DRM) is lacking. Possibilities of reducing costs by optimising the management of DRM through medical nutrition will mostly not even be taken into account. During a European expert meeting, the total evaluation of medical nutrition was viewed and discussed. The aim of this meeting was to gain an experts' outline of the key issues relating to the health economic assessment of the use of medical nutrition. This article provides a summary of the observations per discussed item and describes the next steps suggested.

The 2011 International Commission on Radiological Protection (ICRP) statement on tissue reactions suggested a significant reduction in the threshold dose for radiation induced cataracts. This, combined with the potential for a long delay between exposure and cataract diagnosis, may result in an increased requirement to evaluate eye dose from past exposures in order to settle current compensation claims. This article highlights how compensation claims relating to radiation exposure are assessed within the UK legal system and suggests that in vivo Electro Paramagnetic Resonance (EPR) dosimetry of teeth has utility for the retrospective quantification of radiation doses to the eye. It was identified that in vivo EPR in its current form may be sufficiently sensitive to support cataract compensation claims, although further work is required to enable appropriate dose conversion coefficients to be quantified.

The authors showed that at the present time military much more servicemen, suffering from obstructive pulmonary disease, may receive medical examination in outpatient conditions. Series of researches allow us to perform a medical examination on an outpatient basis. The calculation of the cost-effectiveness of health services to such patients during a military medical examination in the hospital and clinics was made. Savings during the examination in the clinic for 1 patient was 2829 rubbles.

Analysts and decision makers frequently want estimates of the cost of technologies that have yet to be developed or deployed. Small modular reactors (SMRs), which could become part of a portfolio of carbon-free energy sources, are one such technology. Existing estimates of likely SMR costs rely on problematic top-down approaches or bottom-up assessments that are proprietary. When done properly, expert elicitations can complement these approaches. We developed detailed technical descriptions of two SMR designs and then conduced elicitation interviews in which we obtained probabilistic judgments from 16 experts who are involved in, or have access to, engineering-economic assessments of SMR projects. Here, we report estimates of the overnight cost and construction duration for five reactor-deployment scenarios that involve a large reactor and two light water SMRs. Consistent with the uncertainty introduced by past cost overruns and construction delays, median estimates of the cost of new large plants vary by more than a factor of 2.5. Expert judgments about likely SMR costs display an even wider range. Median estimates for a 45 megawatts-electric (MWe) SMR range from $4,000 to $16,300/kWe and from $3,200 to $7,100/kWe for a 225-MWe SMR. Sources of disagreement are highlighted, exposing the thought processes of experts involved with SMR design. There was consensus that SMRs could be built and brought online about 2 y faster than large reactors. Experts identify more affordable unit cost, factory fabrication, and shorter construction schedules as factors that may make light water SMRs economically viable.

Psychiatric diseases and comorbidity have increased over the past years. Commonly used psychotropic drugs contain a high risk of drug interactions and adverse drug events (ADE). With a frequency of 10-12% psychotropic drugs are, among all pharmaceuticals, the most common cause of hospitalisation due to ADE. During a hospital stay the application of psychotropic drugs can also lead to adverse drug events--sometimes due to drug interactions. Currently, ADEs and drug interactions are the most frequent cause of death for in-patients (18% of all causes of death) with an overall mortality of 0.95%. As studies have shown, hospitals as well as insurers could save a considerable amount of resources by implementing a system with on-ward pharmacists, hereby reducing ADE and re-hospitalisation rates. In recent studies a large amount of current ADEs were rated as preventable. Patient impairment due to ADE is leading to an increase in liability cases with an expected 5% increase of compensation payments in 2011. To evaluate these ADE-related cases, a pharmaceutical assessment should be included in the expert trials, especially since a lack of awareness of medication errors is prevalent. When aiming towards a successful drug therapy, physicians must also consider that cheaper substances may often have an unfavourable drug interaction profile.

Introduction: We postulated that a closed claim review of surgical cases would identify not only the quality of care elements but also factors that will predict successful legal outcomes., Methods: One hundred eighty-seven closed surgical cases from a single carrier, which insured physicians practicing in 4 university hospitals in New York State, were reviewed, cataloged, and analyzed., Results: Most suits occurred during midcareer and routine operations. Seventy-three percent of cases were won. The average payment and expenses per case were $220,846 ± $38,984 and $40,175 ± $4,204, respectively. Poor communication was identified in 24% of cases and was a predictor of a negative outcome (41% lost, P < .05), as was inadequate attending supervision (46% lost, P < .05). Expert reviews incriminated or exculpated physician defendants in 85 cases, which affected the outcome and cost. The quality of the physician defendant as a witness also affected the outcome., Conclusions: Most surgical malpractice claims are won. Although supervision, communication, and aggressive risk management are important, the use of quality experts and establishing credibility of the physician defendant are critical for successful legal outcome., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: The importance of powers of attorney and legal guardians for patients in hospitals who are unable to make decisions for themselves is growing. Without an authorized person in these cases, treatment and discharge are more difficult. The goal of this study was to describe the problem from the point of view of an acute geriatric department and discuss the problems with respect to duration and expense of hospitalization. In addition, an attempt was undertaken to improve cooperation with the legal authorities in order to reduce the time required to process the request for the appointment of a legal guardian., Materials and Method: A total of 24 consecutive patients appointed a legal guardian during their hospitalization were compared with 25 patients after the intervention., Results: Of all patients treated in 2008, 2.1% needed an application for an appointed legal guardian (4.6% in 2009). These patients were more seriously ill and treated longer in the hospital compared to all patients. The intervention reduced the length of stay on average by 2.8 days. Independent risk factors for longer treatment were more seriously ill patients and later submission of the application after admittance to the hospital. For patients above the maximum length of stay, the move to a nursing home and the need of a professional legal guardian prolonged significantly the hospital treatment compared to those below the maximum length of stay., Conclusion: The data demonstrate that the German DRG system does not sufficiently consider the difficult management caused by patients without the ability to give consent to treatment and without a valid power of attorney. The time required until a professional legal guardian is appointed is too long for patients in a hospital. The necessity of a power of attorney has to be promoted more intensely to the public. Currently, the only two ways to minimize the problem is to identify the patients without, but needing a power of attorney as quickly as possible and to remain in close contact with the legal authorities.

Evaluation of dizziness in patients who are involved in litigation can deviate significantly from the evaluation of patients who have no ongoing litigation. This article presents the basic principles of the physician's role in the evaluation of litigating patients. Considerations for physical examination, diagnostic testing, and review of medical records are discussed. Topics of malingering and legal "pearls" are presented in the context of providing an objective and unbiased evaluation of the litigating patient., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This article examines the reliance placed on expert evidence in prosecutions of health professionals for gross negligence manslaughter, where juries must decide whether conduct goes beyond civil negligence and constitutes the crime of involuntary manslaughter. It argues that the test for liability is vague and examines some of the consequences of this. Given the vagueness of the offence, jurors are likely to place great reliance on expert medical evidence. Little is known about how experts negotiate the legal process, empirically speaking: how they approach their task, how they view their role as expert witnesses, and the attitudes, biases, and beliefs that may underpin their testimony. Drawing on the experiences and perceptions often medical experts, this article explores how experts manage the vagueness inherent in the task of interpreting and applying gross negligence. Experts appear to go beyond offering purely medical opinion and enjoy engaging with law and the legal process.

There is no doubt about the need for tort reform. The current state of the legal system imposes great costs on the U.S. health care system and society in general-an astounding $865 billion each year. Physicians are forced to practice defensive medicine to protect themselves from litigation. Caps on non-economic damages have helped reduce malpractice insurance rates and encouraged young physicians to pursue specialties such as obstetrics. Collective insurance pools and national insurance programs for physicians and hospitals are some options that other countries employ to reduce malpractice rates. Regulation of expert testimony by medical societies would curb false or biased testimony. Other recommendations to improve the tort system include establishing expert health courts similar to those that currently exist for tax and patent law, using mediation, creating patient compensation funds, making acknowledgment of errors inadmissible in court, providing certificates of merit or pretrial screening panels to confirm the validity of lawsuits, and developing treatment contracts. Clearly some action must be taken to amend our current wasteful tort system.

The legal system depends on the medical expert for evidence. Doctors readily complain about frivolous cases that go to trial, yet a lawyer cannot bring a frivolous claim to trial without a physician expert witness stating that the claim is not frivolous. An insurance company cannot raise premiums without medical expert witnesses servicing the increasing litigation against the insured. Physicians must look to themselves as a major contributor to rising malpractice insurance costs. For without the physician expert witness, no medical malpractice lawsuit can take place. It is the expert physician, not the attorneys or insurance companies, who defines "meritless" and "frivolous" and who ultimately controls the courts' medical malpractice caseload.

Aim: To gather information about current structures in rheumatologic ambulatory health care in Germany. Based on the results recommendations on future structures will be evaluated., Methods: Data collection and statistical analysis via a structured 10-page questionnaire answered by members of the German Association of Rheumatologists. Questions in this second part of the study related to two topics: economic factors and a subjective assessment of the health care structures by the participants., Results: Data from 197 ambulatory rheumatologists who participated in health care could be included in the analyses. Extensive and detailed data on economic issues surrounding ambulatory patient treatment and practice management from the perspective of ambulatory rheumatologists are presented (e.g., revenue, income, income differences between regions or practice size). In addition, perceptions of participating rheumatologists on future perspectives of patient treatment, health policy, and their own economical survival are reported., Conclusions: As in other specialties there is a significant difference not only between the eastern and western regions in Germany but also between the north and the south looking at e.g., revenue, income, with rheumatologists in the east treating significantly more patients. Reasons for those differences are not only related to regional remuneration schemes or the number of patients with a private but statutory health insurance, but are also driven by the number of different services provided (e.g., own laboratory). Physicians perceptions towards their own future in rheumatology are generally positive. Scepticism was reported for the individual economic survival in ambulatory treatment and future changes in health policy.

Legal procedures, dealing with medical issues like body damages or medical malpractice, are based upon expert medical witnesses. These are essential because the parties involved in the process do not hold the knowledge needed for the correct evaluation of the medical facts relevant to the discussed case. When such cases arrive at court, there are always at least two contradictive medical expert testimonies that are based on the same facts (otherwise, the case would have been settled outside the courtroom). The medical experts are paid for their services, a fact which raises criticism by both legal and medical systems and also creates an atmosphere of suspicion towards their testimony. Many questions are raised in light of the potential damage of such testimonies on the one hand, and the known difficulties of defining "the reasonable standard of care" for a particular case on the other. Worldwide, attempts are made to unify and standardize medical expert testimonies. In this review we present and elaborate on some of the criticism, as well as possible solutions (including one proposed by the authors) with regard to expert medical witnesses.

Aims: To identify and evaluate tobacco industry strategies to recruit medical expert witnesses., Methods: A systematic search was made of internal tobacco industry documents available on the Internet and at British American Tobacco Guildford Depository. Litigation by a plaintiff with laryngeal cancer against the tobacco industry in Finland was used as a case study of tobacco industry strategies to manipulate science and its use and deployment in defending a product liability claim., Results: Thirty-three of 45 medical expert witnesses for the defence received research funding before or after testifying. One strategy was to employ those scientists as witnesses with whom the industry had worked since the 1960s. The older witnesses testified to the existence of a controversy which they had, in fact, helped to create. Those appearing in Helsinki District court apparently downplayed the importance of their involvement with the industry. Another strategy was the use of research funding to establish contacts with new potential witnesses, to strengthen existing contacts or to pay back helpful experts., Conclusions: The tobacco industry funded the majority of expert witnesses appearing for it, beyond simple recompense for the time involved. This may have unconsciously influenced the testimony given by the witnesses. This funding should be considered in court, but links between experts and the industry were often downplayed or, in some cases, the financial ties were being forged at the time and were not revealed. It would be helpful to establish norms to guide courts to understand the influences exerted by the tobacco industry in the preparation of cases requiring expert evidence.

This article presents an overview of the issues presented to physicians and lawyers in evaluating, treating, litigating, and concluding an upper extremity workers' compensation claim. This analysis includes a review of the unique considerations involved in the workers' compensation patient/claimant, a general examination of workers' compensation law, and the interplay between litigation and the medical management of the patient.