The Board of Directors of the American Academy of Orthopaedic Surgeons (AAOS) kicked Alfred R. Massam, M.D., out of the Academy at their June 8, 2013 meeting. They also suspended three other surgeons, including two separate suspensions for Ronald M. Krasnick, M.D. over an expert witness complaint.
Since 2005, 29 Fellows or members have been kicked out of the Academy. What’s it take to get the boot from AAOS?
Massam Expelled
According to an article in the September issue of AAOS Now, Massam, of Sebring, Florida, was expelled after he was found guilty in federal court of felony, theft, and embezzlement of employee benefit funds. He was sentenced to 24 months in federal prison.
Getting the boot from the Academy is a rare event. Most disciplinary actions result in suspensions and stem from surgeons failing to comply with professional sanctions imposed on them by their individual state boards.
But the most contentious disciplinary actions arise when Academy members file a grievance about expert testimony provided by one member against the other in medical malpractice cases, as was the situation with Krasnick. More on that below.
We asked the Academy about their record in expelling and suspending members.
Suspensions and Expulsions
Since the Academy’s Professional Compliance Program (PCP) was established in 2005, over 150 grievances have been filed. To date, less than 23% have resulted in official compliance action by the AAOS Board, including 24 membership suspensions. Seven of those suspended Fellows or members have been reinstated to full membership.
No one has been expelled from membership as a result of a professional compliance grievance. The PCP is governed by the Article VIII of the Association Bylaws and the Standards of Professionalism (SOP).
The Board has also taken compliance action in matters unrelated to the SOP. These include loss of or restrictions on license to practice medicine or license to dispense medication; felony conviction; guilty plea or no contest plea to felony charge(s). Twenty-nine Fellows or members have been expelled and 32 have been suspended. Seven Fellows or members have been reinstated to full membership status.
“The Board of Directors is obligated to take such measures in order to ensure high standards of professionalism in the field of orthopedic surgery, ” said AAOS President Josh Jacobs, M.D.
The detailed report of Krasnick’s suspensions in AAOS Now provides a rare insight into disciplinary actions taken behind closed door.
Krasnick Double Suspension
Krasnick of Mount Laurel, New Jersey, was suspended for violating the SOP for Orthopaedic Expert Witness Testimony after accusing fellow AAOS members of deviating from standards of care. The members (Grievants) then filed grievances against Krasnick.
The Academy’s Grievance Panel found Krasnick’s conclusions erroneous and determined he was guilty of failing to evaluate the patients’ medical conditions and care in light of the generally accepted standards at the time. The Panel also noted that Krasnick failed to produce any scientific literature to support his conclusions.
First Grievance
The first grievance was filed on October 7, 2011, for statements Krasnick made during deposition testimony on behalf of a plaintiff in a medical liability lawsuit. The plaintiff-patient alleged that she received second-degree burns during an arthroscopic shoulder procedure performed by the Grievant. The lawsuit was dismissed with prejudice after a settlement was reached.
According to AAOS Now, the patient underwent right shoulder arthroscopy and arthroscopic subacromial decompression for rotator cuff tendinitis. At the first postoperative visit, the patient had a burn with blistering over the top of the shoulder. The surgeon broke the blister, removed the superficial dead skin, and applied Silvadene.
The Grievant did not know how the patient sustained the burn. The skin was washed after the surgical procedure and the area had not been taped. He speculated that an allergic reaction might be the cause. The patient was to return four days later, but did not return until three weeks later, at which time the burn appeared to be healing nicely.
In the interim, the patient had seen a dermatologist, who also treated the burn with Silvadene. The dermatologist had diagnosed second-degree burns, possibly related to contact with a hot instrument during surgery.
In his expert report, Krasnick stated that a burr, a shaver, or a trocar may have caused the burn. He opined that the burr will get hot enough to cause second-degree burns because of the “phenomenal” speed of rotation.
He stated that the trocar could get hot from sterilization, immersion in a hot fluid, or exposure to a heat source. However, he later acknowledged that the instruments used in the patient’s surgery had been autoclaved two to four days prior to the procedure and could not have caused the burn.
He added that the shaver’s light attachment could have burned the patient’s skin or could have been put down for a split second, thus branding the skin.
Krasnick testified that the Grievant deviated from the standard of care by not referring the patient to a plastic surgeon for the treatment of her burn and by breaking the blister, which aggravated the situation and had consequences in terms of a greater scar.
Grievance Hearing
During a July 20, 2012, grievance hearing, the Grievant was asked about possible scenarios for the burn. He confirmed the type of dressing used and said that no electrocautery was used during the procedure; that the draping was very wide; and that it is his practice to personally prep the shoulder, suture the incision, clean the shoulder, and place the dressings and slings in arthroscopic shoulder procedures.
When asked by about the heat generated by the burr’s rotation, Krasnick replied that he did not have any scientific data, but that the rotating burr gets very hot and if it is put against the skin, it will cause a burn. He continued that a burn of this size and significance was a deviation from the standard of care. He added that he had performed the occasional shoulder arthroscopy, but that most of his experience had been with knees.
The Panel found that Krasnick violated two standards of the SOP. He was not found to violate a third standard.
They also considered Krasnick’s erroneous conclusion that the Grievant must have deviated from the standard of care because the patient experienced a thermal injury as a complication of the surgery, even though he could not determine with any degree of certainty how this may have occurred. Krasnick provided no literature to support his statements that the burr could reach the boiling point and brand the patient.
The Panel recommended that Dr. Krasnick be suspended from the AAOS for one year. On June 8, 2013, the Board upheld the findings.
Second Grievance
A second grievance was filed by two Fellows against Krasnick on August 11, 2011. The grievance arose from statements Krasnick made in a lawsuit that involved complications following bilateral total hip arthroplasty (BTHA). The lawsuit was concluded through an arbitration proceeding, which found the defendants not negligent.
According to AAOS Now, the patient was first examined by Grievant #1 for bilateral hip pain and restricted function, for which oral medication was minimally effective. Although an appropriate candidate for BTHA, the patient deferred surgery for three years. On her discharge to the rehab facility, postoperative incisions were clean and dry with scant drainage from the left hip. She returned to the emergency department (ED) later that day and was diagnosed with toxic metabolic encephalopathy secondary to her current medications.
The patient returned to the ED five days later due to increased swelling and incisional drainage. Her temperature was 98.5F. Three days later, Grievant #2 performed bilateral irrigation and débridement, exchanged the acetabular liners, and exchanged the right femoral head to correct slight instability.
Gram stains were negative for bacteria, and the wound fluid was serosanguinous and not purulent. Cultures later grew Enterococcus faecalis from broth only from the right hip and very light growth from the left hip. The left hip responded well to treatment, but increasing swelling and erythema developed in the right hip.
Grievant #1 removed the components from the right hip and inserted an antibiotic-impregnated cement spacer. A revision procedure was reportedly anticipated for six to eight weeks later, but the patient elected to transfer her care to a third surgeon for the revision.
Krasnick stated in his expert report that Grievant #1 was quick to recommend and schedule hip replacement surgery and did not offer the patient nonsurgical treatment options. He further opined that the patient should not have been discharged due to the presence of drainage, which is a known sign of infection.
He also stated that the diagnosis of toxic metabolic encephalopathy can indicate an ongoing infection and that the surgeon was negligent in not obtaining an infectious disease consultation at the time. He said that upon the second admission, the patient had a 103F fever and bilateral hip drainage. He further opined that the patient’s ongoing complications resulted from the negligent treatment provided by the Grievants and other healthcare providers.
The Panel found Krasnick in violation of four Standards of the SOP on Orthopaedic Expert Opinion and Testimony.
Grievance Panel Determination
The Panel determined that Krasnick’s testimony was not fair and impartial. On multiple occasions, the medical records contradicted his opinions regarding informed consent, timing of surgery, notification of the surgeon at re-admission, characteristics of wound drainage, patient’s temperature, and timing of the diagnosis of the wound infection.
The Panel also found that Krasnick did not have appropriate knowledge of the standard of care and was uninformed about issues such as wound drainage, indications for infectious disease consultations, and appropriate surgical care of early postoperative infection. He also did not give creditable explanations for his opinions or why they varied from accepted practices.
The Panel recommended that Krasnick be suspended from the AAOS for two years. The AAOS Board upheld those findings.
While physicians enjoy a broad immunity from being sued for their expert testimony, that immunity does not prevent discipline by the AAOS. The lessons from the Krasnick case should inform surgeons who to testify against their colleagues.
For more information on the AAOS Professional Compliance Program, visit www.aaos.org/profcomp.
