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Saturday, June 7, 2003 - Page updated at 12:00 AM

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A neurosurgeon 'crisis': Insurer drops doctors' group

Seattle Times staff reporter

Neurosurgeons' work


Nationally, the typical neurosurgeon performs 200 to 300 procedures each year, according to Dr. Richard Wohns, president of the Washington Association of Neurological Surgeons. Wohns offered this profile of neurosurgeons and their work:

• Procedures range from a surgery on a carpal tunnel problem in a wrist, which might take 10 minutes under local anesthetic, to a complex brain surgery that could take all day or longer.

• A surgeon may perform three to six procedures in one day.

• Typically, surgeries break down this way: about 75 percent on spines, about 20 percent on heads, and about 5 percent on peripheral nerves.

• Spine surgeries typically include repairs and fusions of disks and removal of bone or other material.

• Head, or cranial, surgeries most commonly involve removing blood clots caused by trauma or stroke, removing tumors, and clipping aneurysms, which are dangerously weakened areas of blood vessels.

• Peripheral nerve surgeries include those to correct carpal tunnel syndrome or compression of the ulnar nerve that runs through the elbow.

Surgeons affected


Members of Neurosurgical Consultants of Washington are doctors James Blue, James Raisis, Jacob Young, Timothy Steege, Steven Klein, Stephen Houston, Eric Kohler, Joseph Arguelles, Darin Smith and Christopher Smythies.

Several Puget Sound-area hospitals have no neurosurgeons this weekend and will have to transfer patients with back, neck or head emergencies to other hospitals — a scramble brought about because a large surgical group lost its malpractice insurance.

The challenge will continue into next week and beyond for local hospitals, though some will have intermittent coverage by other neurosurgeons.

In the short term, neurosurgeons practicing at Harborview Medical Center and the University of Washington can absorb the emergency patients, says Dr. Rich Ellenbogen, head of the UW department of neurological surgery.

But he likened the situation to "putting your finger in the dike," saying area neurosurgeons cannot absorb the estimated 3,000 surgeries done each year by the 10 doctors who have lost their insurance.

Hospitals were especially concerned heading into this weekend. Typically, weekends are busy in most local emergency rooms. An on-call neurosurgeon might see half a dozen or more urgent patients and do two to four surgeries, in addition to checking on patients recuperating in the hospital.

The affected hospitals, which normally depend on the 10 neurosurgeons for on-call weekend care, include Swedish Medical Center's First Hill, Providence and Ballard hospitals; Northwest Hospital near Northgate; Valley Medical Center in Renton; and Stevens Hospital in Edmonds. But because the surgeons' group, Neurosurgical Consultants of Washington (NCW), recently lost its malpractice-liability insurance, the doctors say it's too risky for them to see new patients.

The doctors, who believe their lawsuit track record is much better than average, are puzzled about why they lost insurance and are appealing the decision. The California-based company that canceled them, The Doctors Company, declined to comment specifically about their case but indicated that neurosurgery is a risky specialty.

Bruce Crile, the insurer's chief operating officer, said about half of all neurosurgeons nationwide are sued each year. "They clearly are not all bad doctors," he said.

For the hospitals, it means a rush to arrange care for patients, both those who might come into the emergency room and those who are already in the hospital but who might suddenly experience a problem needing a neurosurgeon.

Swedish Medical Center's three hospitals have been left with one of its five affiliated neurosurgeons. Since the other four lost coverage, the remaining neurosurgeon has been providing on-call coverage, said Dr. Nancy Auer, vice president of medical affairs. "She can't do it 24-7, 365," Auer said. "She has to sleep sometime."

"If this crisis is not over in a week, we'll be stuck."

There are 59 neurosurgeons in the Everett-Seattle-Olympia corridor, according to the state medical association. But some practice part-time, some are available only to members of particular health systems, such as Group Health Cooperative, and some do only particular types of surgery, such as pediatric.

In South King County, the only hospital that typically has neurosurgeons on-call, Valley Medical Center, won't have any this weekend.

"Our ER, since Tuesday morning, has had no neurosurgery back-up call," said Dr. Terry Block, chief medical officer at Valley. He said the hospital's three other neurosurgeons would be stretched further.

At Northwest, Dr. Gregory Schroedl, vice president of medical quality and assistant director of the emergency room, said the hospital already has transferred three patients with intercranial hemorrhages to Harborview since the neurosurgeons group was notified two weeks ago that its insurance would not be renewed.

Around Puget Sound, patients with major trauma or who need complicated neurosurgery typically would be sent to Harborview, which is designated to take the most complex trauma cases, or to the University of Washington.

But for patients who come into another hospital's ER or who are already in a hospital, not having a neurosurgeon available could mean losing valuable time, said Valley's Block.

"What happens to patients already in the hospital who have a problem and require a neurosurgical consult urgently?" asked Dr. Christopher Smythies, an NCW doctor who was scheduled to be on-call at Valley this weekend. "Packing them up, putting them in an ambulance takes time."

Valley's three other neurosurgeons are already signed up for on-call coverage for the next three weeks. "You can only cover so much," Smythies said.

Like most doctors, the neurosurgeons are quick to blame the situation on the lack of liability-insurance reform, both in this state and nationally. They say malpractice insurers are shying away from high-risk specialties.

Doctors and insurers are lobbying both nationally and in the state for limits on jury awards.

But consumer groups and trial lawyers say limiting jury awards to injured patients isn't the answer. Studies go both ways, but the latest, a report by an independent financial-analysis firm, said caps haven't slowed increases in malpractice-insurance premiums.

Still, the doctors are desperate to soothe spooked insurers, afraid they'll dump high-risk specialists such as neurosurgeons completely — or worse, bail out of this and other states that don't have limits on jury awards.

The canceled group can't get insurance from the other large malpractice insurer in the state, either. Physicians Insurance, which posted a $19.5 million loss last year, says it's not taking any new doctors or groups.

In general, said the UW's Ellenbogen, the group has a clean record. "This is a good group of guys," he said. "This is one of the best groups of neurosurgeons in the country. The majority of guys never had a legal suit."

Court records indicate that doctors in the group have four active cases and one case in which the doctor won but the plaintiffs appealed. Insurers say even cases that doctors win cost money, because of legal-defense fees.

Dr. Jacob Young, one of the Swedish-affiliated surgeons in the group, says information provided by the insurer showed that 65 percent of its payouts were for legal defense of doctors who were cleared of wrongdoing; only two of the surgeons had ever paid settlements or judgments for malpractice lawsuits, he said.

The doctors, with help from some hospital administrators and national neurosurgical leaders, are scrambling to find insurance so they can start seeing new patients. Meanwhile, one is writing a novel, another is working on his golf game, and still another is spending more time in the garden.

Dr. James Raisis, who has practiced neurosurgery for 25 years — since 1989 at Swedish, and before that at Virginia Mason — worries the insurance crunch will lead surgeons to avoid risky medical problems for fear of lawsuits.

"Those are the kinds of cases we love to do — we're trained to do them, and they're challenging and enjoyable," Raisis said. "We like to help people who have big-time problems."

Although the surgeons' insurance doesn't expire until Aug. 15, the hospital administrators say that doctors who operate on patients are obligated to treat complications that might arise for 90 days, which would take them past Aug. 15 if they operated now. Some finished up urgent surgeries on previously-scheduled patients this week, but all say they've canceled future surgeries and will not see new patients.

One hospital that may have found a short-term solution is Providence St. Peter in Olympia. Dr. Joseph Arguelles, one of the group who was scheduled to be on-call this weekend, said he typically consults in six or seven cases and does two or three surgeries over an on-call weekend.

Because St. Peter is relatively isolated and cares for patients from a five-county area, the hospital is arranging short-term liability coverage so Arguelles can cover this weekend, said spokeswoman Deborah Shawver.

Arguelles said if he gets that coverage, he'll answer calls. "It's a pretty long ambulance ride to Harborview ... and that's pretty much the only option," he said. "I think we all feel some obligation to try and ensure that this problem doesn't have a life-threatening impact on anyone."

Shawver said because of federal rules, such coverage can only be instituted in an emergency.

Ellenbogen, of the UW, said he's most concerned about the long-term problem. The 3,000 surgeries done by this group is about the same number done by the UW's group of 14 surgeons.

"That's a lot of surgery," he said. "We'd need to recruit 10 more neurosurgeons to absorb that kind of capacity, and that would take months and years. This is a crisis."

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com

Copyright © 2003 Seattle Times Company, All Rights Reserved.

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