MEDLINE Selects The AMEDD Journal.
In the mythical ideal world, the practice of medicine would always be a straightforward proposition. The skilled practitioner applies the knowledge, experience, and insights gained from years of education and dedicated practice to address the patient's problems. The patient, in turn, understands and accepts the limitations, complexities, and risks associated with medical treatment, and makes every effort to cooperate and assist the healthcare provider in his or her care. Both the caregiver and patient benefit, the former obtaining more experience and knowledge with which to pursue the practice, and the latter satisfied with the outcome. Of course that ideal world scenario presupposes that work within medical science and the practice of medicine are undertakings free from external complications and constraints.
Unfortunately, the reality is that medical professionals, both civilian and military, pursue their occupations in an extraordinarily complex, intensely regulated, and highly litigious world. No area of medicine is immune, certainly not the healthcare providers, but also those in research, manufacturing, pharmacology, training, logistics, and even those who are responsible for the facilities that house the various functions of modern medical practice--and that list is far from complete. Such concerns and external factors severely complicate the application of the actual medical skills and training that practitioners have dedicated years to perfect, and too often are distractions to their work.
Fortunately for those of us who work as Army medical professionals, there are specialized legal professionals of the Army Judge Advocate General (JAG) Corps who are our partners in navigating the labyrinth of overlapping, interlocking, and often obscure laws, regulations, rules, protocols, procedures, and restrictions that are involved in work in the medical sciences. They are an invaluable resource that is absolutely necessary for us to do what we should do best, care for the health and well-being of our Soldiers, their families, and our military retiree community. The attorneys, paralegals, and administrative personnel are actively involved, both directly and behind the scenes, in decision processes, planning, and drafting and publishing all manner of procedures, protocols, directives, and guidelines. Additionally, they provide consult on the myriad of issues that are encountered at literally every level of the Army Medical Department every single day. It is not exaggeration to say that the delivery of healthcare would be almost impossible without their involvement as our advisers, advocates, and sometimes defenders--truly our partners in our chosen professions.
MAJ Joseph Topinka, the Deputy Staff Judge Advocate for the Army Medical Command at Fort Sam Houston, has assembled a collection of articles from the JAG community within Army medicine. These 12 articles touch some of the more important and often-encountered legal subjects in military medicine. The articles address concerns of patients, those of the institutions (medical commands, hospitals, clinics, research activities, etc), and topics of direct interest to healthcare providers. However, as diverse and complete as these articles are, they represent only a fraction of the many areas in which Army medicine relies on the knowledge and experience of the Army JAG Corps.
As the level of capabilities and sophistication of medical science has markedly increased over the years, so has the ability of military medicine to save the lives of our wounded Warriors on the battlefield. Many more of the wounded survive their injuries than ever before in history, but sometimes with the prospect of living with a disability for the rest of their lives. Of course the military provides extensive rehabilitative care and resources, but many of those Warriors' injuries render them unfit for continued military service. Mr Duke Dorotheo's detailed, comprehensive article addresses the processes and participants in the various stages that the disabled Soldier may experience in the determination of his or her discharge from active duty, or, in some cases, retention in active status. This article gives great insight into the complexity of the structure that exists to comply with the Department of Defense and Army instructions, regulations, and directives, which themselves are necessary to implement the federal laws governing disabled military personnel. Mr Dorotheo provides a wealth of information useable by everyone with an interest in the process, including injured Soldiers themselves.
Peer review is usually thought of in the context of the evaluation of an individual's capabilities, conduct, or other aspects of professional qualifications. However, Army medicine employs peer review in an important role in risk management at medical treatment facilities and hospitals. Risk management peer review is actuated by an event that occurs during patient care that results in injury, the filing of a medical claim, or notification of payment of a claim settlement or award. It is an essential part of the inquiry into the facts and circumstances involved in the incident in question. LTC Anthony Kutsch's article clearly presents a description of the processes, the underlying regulations and federal statutes, and the various possible outcomes. The article provides a detailed discussion about this extremely important component of the Army Medical Department's robust quality control structure, which itself is an essential element in maintaining the high level of care that our Soldiers and other eligible patient populations deserve every day.
Karin Zucker and her coauthors have contributed an article which explores a topic that, on the surface, seems simple, but in reality is a potentially complicated element of patient care with serious legal implications. Today, a patient's consent is an obvious requirement before a healthcare provider may begin treatment, whether a simple action, a surgical procedure, or a complex, long-term course of treatments, perhaps involving extended discomfort or actual risk. However, it has not always been that way. As detailed in the article, today's concept of informed consent has actually evolved over the years through a series of legal decisions. Although most people may think that they intuitively understand what it means to give consent to medical treatment, from a legal perspective nothing could be further from the truth. This article expands the concept into its elements and subelements to provide an understanding of the importance of addressing the smallest details of judging the patient's capability to understand information, presenting the details of the treatment such that the patient can make an informed decision, and ensuring that decision is completely voluntary (free from coercion or overt influence). This is an eye-opening look at just one of the basic parts of healthcare delivery in which legal expertise is absolutely vital.
At the other end of the treatment decision spectrum are the physician's decisions as to whether to begin treatment, or to end treatment already underway, notwithstanding the desires of the patient or those legally responsible for the patient. This area involves the concept of medical futility. As Mark Sposato defines it in his article, "medical futility generally refers to interventions that are unlikely to produce any significant benefit for the patient." Although several states have attempted to address this difficult decision area through statutes, the experience of healthcare providers continues to demonstrate that attempts to legislatively stipulate items within an area of so many conjectural, even hypothetical components are usually insufficient, and often complicate the predicament even further. Mr Sposato's excellent article contains a number of examples and case studies demonstrating the twists and turns in such decision situations, and the complications that arise as conflicting interests and legal actions become involved. Further, he discusses some of the various statutory efforts to address medical futility, and explains both their strong points and shortcomings. This is a comprehensive, very informative overview of this difficult subject, and is a "must-read" for healthcare practitioners who could potentially face such decisions.
Medical research makes extensive use of computer models, laboratory experiments, and animal studies, but at some point human subjects must be involved to validate everything that has been learned through the other techniques. Unfortunately, human history contains far too many horrific examples of human experimentation that was not bound by any moral or ethical concerns, and was conducted on imprisoned subjects without regard to their welfare, sometimes with government sponsorship. Stephen Maleson's article is a comprehensive, well researched discussion of the evolution of this very sensitive topic which bridges statutes, regulations, international agreements and protocols, and, perhaps most important, ethics. Similar to the parameters surrounding informed consent to treatment, the overriding principle that has been championed in international codes and declarations, various national protocols and guidelines, and codified into national laws is that researchers must have the voluntary, informed consent of a prospective subject or a subject's legal representative before any experimentation may begin. Mr Maleson develops the topic from the historical, global perspective and moves into the details of the rules and regulations that apply for involvement of human subjects in research by US companies and agencies, specifically that conducted by Department of Defense and Army researchers. This article is replete with important information and details, and should be a valuable reference source for those considering or developing a research project that will ultimately involve human subjects.
As we all know, military personnel, retirees, and their dependents are eligible for treatment at military medical treatment facilities, no matter the cause for the condition requiring treatment. However, not so well-known is that the military may seek reimbursement for the costs of treatment which is necessitated by action of a third party (not associated with the federal government). Further, the government may also seek reimbursement of the wage costs for those service members unable to perform their duties due to injury by a nonfederal source. In her excellent article, Melissa Hartley describes one structure for recovery, the Medical Affirmative Claims Program, in detail, including the authorizing laws, regulations, and directives, and the various situations and conditions that apply in the process. The recovery may be from several avenues, depending on the circumstances involved in the patient's condition. The effort required in the reimbursement recovery process is directly compensated in that the bulk of the recovered funds are retained by the facility where the care was rendered. The information in this article should be carefully reviewed at military medical treatment facilities and hospitals to ensure that the Medical Affirmative Claims Program is used to the maximum extent to recover every cost to which the facility may be entitled.
One of the unfortunate realities of any profession is that, despite sophisticated accreditation and certification requirements, there will be practitioners of the profession who are not completely competent in their chosen field, for any number of reasons. The practice of medicine, including that within the military, is not immune to this problem. Rosalind Gagliano has contributed an important article that details the process by which the military monitors the competence of its practitioners, and the actions that are available to address suspected problems. A healthcare practitioner is granted clinical privileges to practice in a military medical treatment facility by the credentials committee, under the authority of the facility commander. Actions taken to limit or remove those privileges are called adverse privileging actions, and are a serious step which can sometimes mean the end of a career. For this reason, a considerable statutory and regulatory structure governs the system by which adverse privileging actions are initiated, processed, and reported. The legal and practical implications of any such actions are considerable, and close involvement of specialized legal professionals in the process is a must. Ms Gagliano lays out the history of the existing structure from the original federal legislation in 1986, and describes the military implementation of those requirements with Department of Defense and Army regulations. This article is a carefully constructed, clearly written, specifically referenced discussion of this extremely important aspect of quality assurance in the Army Medical Department. The health and safety of our Soldiers and all other patients in the military medical system depend upon unwavering attention to any indication of less than the best from our healthcare providers.
The creativity, initiative, and spirit of innovation that exists throughout Army medicine are invaluable assets for maintaining the extremely high level of healthcare service that is provided to our Warriors throughout the world. Our professionals are constantly seeking ways to do it better, faster, and more efficiently, no matter what "it" may be. A search for improvement may result in a device, a book, or a software package that is applicable in both military and civilian environments. Such things are originally ideas, and are now recognized as important legal entities called intellectual property, with the same possible economic value as the physical inventions with which we are familiar. Army medicine formally pursues a considerable amount of research, representing a significant amount of value in intellectual property, all of which must be protected. Elizabeth Arwine and Jill Caldwell have written a very interesting and informative article that provides an overview of the many federal laws and agency regulations that govern the legalities involved in creating and protecting inventions in the course of federal employment, to include intellectual property. As they define and describe the various protections established by law, they also carefully frame the relationship of those protections to those of us who may conceive or create a useful item or idea as part of our job. Also, there are provisions for sharing in any royalties that the government may receive for one's invention. This article is a primer for those who may be interested in developing an idea or device to improve their work efficiency or effectiveness.
MAJ Joseph Topinka opens his article with the following: "Medical personnel in the US military are extensively educated, trained, and experienced professionals whose expertise is in high demand." With that sentence, he defines the essence of the high quality level of military medicine that exists today, but he also sets the framework for potentially serious problems for those highly skilled medical practitioners. The "high demand" that exists for those individuals comes from numerous private sources: professional organizations, private companies, universities, hospitals, etc. Such entities are more than willing to fund the travel costs of those invited to various forums to share their expertise. Therein lies the potential for problems. Federal government employees may only accept travel benefits within a rigid framework strictly defined by several statutes and regulations. MAJ Topinka's article is an excellent, comprehensive presentation of the various situations and conditions that dictate whether or not travel benefits may be accepted, and the approval processes for the types of travel that are allowed. This article should be made available as an easy to understand resource for those who may receive inquiries or invitations from outside organizations.
The same professional expertise and capabilities that create the demand for military medical professionals at conferences and seminars also make them highly employable while off-duty. Employers recognize that a military healthcare provider represents the entire "package" of education, training, experience, skill, and discipline, an unquestionable value. The military does not prohibit such employment in most cases, but there are specific limitations and conditions that apply to these arrangements. CPT Holly Bryant's article discusses the regulations and policies that govern off-duty employment of military healthcare providers. The article categorizes the types of employment of concern, addresses the limitations of such employment, and outlines the procedures to obtain approval from the provider's commander. The rules and requirements are specific and detailed, but are necessary to ensure that the potential off-duty employment will have no effect on the provider's primary obligation--the health and well-being of the American Warrior.
Another demand for military healthcare practitioners comes directly from the legal community. Providers are often sought as witnesses in litigation, but their participation in such a venue is conditional and highly regulated. CPT Ean White has provided a succinct, clear discussion of the types of litigation, the limitations of provider participation, and the approvals that must be obtained before an individual may participate. His article makes it very clear that a healthcare provider should immediately contact the military legal counsel serving the facility as soon as he or she is notified of the request to be a witness. Even if the circumstances seem straightforward and innocuous, unrecognized factors may make participation risky for the individual, both professionally and personally. The military legal counsel is there to ensure that neither the provider nor the military are placed in a position of embarrassment or financial risk.
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|Title Annotation:||Perspective; Army Medical Department Journal|
|Author:||Czerw, Russell J.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Jan 1, 2010|
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|Next Article:||The Army Physical Disability Evaluation System.|