AJCP / Editorial
The Pathologist in Tortland When Is Ignorance About “Med-Mal” Rational, When Is It Unavoidable, and When Is It a Problem to be Corrected? Elliott Foucar, MD From the Department of Pathology, University of New Mexico School of Medicine, Albuquerque. DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
In this issue of the Journal, Allen et al1 present the results of a study that asked pathologist volunteers to evaluate a series of pathology malpractice cases (so-called med-mal cases). Based on their evaluation, the volunteers answered two very different questions about each case. First, the pathologists rated the defendant’s care on a scale extending from “correct” to “not correct.” Next, they predicted whether the jury found for or against the pathologist. There was a high level of disagreement among the pathologists themselves and between the pathologists and the juries. These disagreements led the authors to their major conclusion that there is a “clear need for additional education” of pathologists about various aspects of the legal system. In this editorial, I discuss some of the issues raised by Allen et al.1 Sometimes I disagree with their point of view, but the reader should understand that most of the interesting topics in law are, and will remain, subject to various equally valid interpretations.
What Exactly Is Standard of Care? Although determining whether we provided the patient with the standard of care is theoretically central to the legal evaluation of our diagnoses, this phrase is virtually never encountered in medical practice. Surgeons do not send out tissue for a “standard of care frozen section.” We do know that pathologists have a near obsession with the difference between the “right” and “wrong” answer, and we have our own methods to distinguish between the two. However, when we conclude that a diagnosis is wrong, it is an error—not below the standard of care. © American Society for Clinical Pathology
It might be tempting to dismiss this as nothing more than different terminology used by different professions to describe the same thing. However, despite some similarities, physicians who have had any contact with the legal system recognize that meeting or not meeting a standard of care is something quite different from a diagnosis being “correct” or “wrong.” Pathologists who are curious about the standard of care will find that in the abstract world of a legal textbook it is easy to find a succinct definition. To wit, the pathologist is expected to exercise the degree of skill, care, and diligence that would be exercised by other pathologists in light of the present state of the field. To fail to provide that level of care is “negligence,” and if a jury decides that negligence is causally linked to damages, then there will be a monetary award to the plaintiff. Most of us would agree that standard of care sounds like a very reasonable benchmark for society to use in the evaluation of an allegation of pathologist negligence. However, the important question isn’t “How good does it sound?” but rather “How well does it function to identify substandard care?” Lawyers have concluded that standard of care is a metric that functions reasonably well in the setting of malpractice litigation, and in general, physicians disagree. Because of this disagreement, standard of care serves as an appropriate symbol of the gulf between how the law and medicine analyze medical practice. Of course, analyzing a case is an experience that is completely familiar to all of us. However, in a legal setting, this quotidian activity is transformed into something not only unfamiliar but often rather bizarre. Lawyers search for the correct standard of care using methodology dependent on tools such as dueling lawyers, dueling paid pathology experts, the opinion of random citizens, and the decisions of a judge. Physicians watching this strange methodology in action can
455
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
455 455
Foucar / The Pathologist in Tortland
experience some of the same feelings that a mentally ill patient endures when disturbed cognition makes the common seem strange—what the psychiatrists refer to as “derealization.” Physician descriptions of being a defendant routinely use terms such as “painful.”2
How Many Standards of Care Are There? The legal system’s definition of standard of care is very general, and the “med-mal” system is adversarial. Any case that isn’t either quickly dropped or quickly advanced to the damages phase is evaluated according to the two opposing sides’ version of standard of care. One potential source for a second standard of care that Allen et al1 mention would be a standard accepted by a “minority” of pathologists. However, we have little guidance from the courts about the required size of that minority (presumably it’s greater than one), how minority pathologists would be counted, or even whether a quote from a textbook or paper establishes a minority. A more important factor leading unbiased pathologists to different conclusions about the standard of care is the inherent complexity of modern practice. Another factor possibly encouraging a diversity of standards is that judges may have difficulty excluding the testimony of expert pathologists receiving fees that could stimulate the creation of previously undiscovered standards of care (i.e., so-called junk testimony). Allen et al1 confirm that unbiased pathologists often disagree about whether a fellow pathologist handled a case “correctly.” Although interpreting the percentages of disagreement that these authors report is difficult to apply to actual legal cases because of the lack of slide review, disagreement among specialists provides no new news for either pathologists or the legal system. What is important for pathologists to understand is that, in the absence of two experts who offer conflicting opinions about whether the pathologist provided the standard of care, a med-mal case changes dramatically. If the plaintiff can’t find a credible “expert” pathologist who agrees to testify that your diagnosis was below the standard, the case is dropped. In contrast, without a defense expert to testify that your diagnosis met the standard of care, you have already lost the initial phase of the case. The only remaining question is, “How much is this going to cost?”
What Role Does a Jury Determination of Standard of Care Actually Play in the Jury Decision? Like many interesting questions, the answer to this question is, “it depends.” It’s true that the jury’s final conclusion at the end of the first phase of the trial is packaged as a conclusion 456 456
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
about whether the pathologist’s care met the standard of care. However, just how much the details of two conflicting opinions about the standard of care influenced the final decision could be quite large or small. Once a case gets in front of a jury, there is much more going on than just the technical aspects of the care delivered. I was once involved in a case in which the plaintiff’s lawyer was so overcome by grief when summarizing for the jury the awful care provided to the patient that he began weeping. These kinds of things can matter in a courtroom much more than a count of mitosis per high-power field—and that’s why they happen! My impression has been that as the technical aspects of a case become progressively more complicated, factors other than the details of conflicting assertions about standard of care become progressively more important to the jury’s final decision about negligence. For example, a juror with little education can easily relate to a sympathetic plaintiff with an obviously adverse outcome but may find both sides’ discussion of standard of care completely incomprehensible. At the end of the day, one side’s position was more “credible” to a given lay jury at a given point in time under a certain set of legal circumstances that will never be exactly repeated. Was the pathologist’s care declared to be negligent because the jury decided that not ordering a certain stain was negligent or because the pathologist seemed arrogant or condescending? If you really want to know, you can attempt to interview the jurors after the trial.
Should Pathologists Be Better at Predicting Jury Verdicts? Allen et al1 found that pathologists had great difficulty predicting jury decisions. When interpreting this finding, it is important to be aware that, while med-mal cases provide many sources of drama for everyone involved, a substantial portion of the drama arises out of the difficulty that even experienced trial lawyers have in predicting what a jury will conclude. As a pathologist reviewing a case, you may have a strong opinion about whether a physician of ordinary learning, judgment, and skill would have come to the same conclusion as the defendant. However, as alluded to above, it represents a fundamental misunderstanding of the tort system to rely too heavily on a purely scientific evaluation of a malpractice case. The clinicopathologic facts of the case are only one part of a very complex montage. Asking a pathologist to predict a jury outcome is not directly analogous to asking a trial lawyer to interpret a breast biopsy specimen, but pathologists have to be realistic about their limitations. Unfortunately, it is only at the extremes of “indefensible error” by the pathologist at one end of the spectrum—and “overtly frivolous” plaintiff claim at the other © American Society for Clinical Pathology
AJCP / Editorial
end—that predictions about a jury’s conclusions about the “standard of care” aspect of a case can be reliable. Remember, the jurors are there to apply community standards to everything that they observe in the courtroom. They cannot and will not become instant pathologists. The surprise is not that unbiased pathologists often disagree with a jury decision but that the two agree so often. It’s worth mentioning that one critical piece of information about a case that a pathologist is in the best position to predict is how easy it will be for each side to find a “credible” expert witness. For example, as the diagnosis in question becomes more and more problematic, the list of “credible” pathologists willing to testify under oath that the diagnosis meets the standard of care becomes shorter and shorter.
Should Pathologists Receive a More Formal Education About Medical Negligence? When Allen et al1 document that pathologists often disagree with their colleagues and with juries about the presence of “medical negligence,” this leads the authors to conclude that pathologists should become better educated about how the tort system functions. They propose that more formal legal training should replace the current informal training, which they refer to as “the lore on the floors” approach. I would agree with the authors that it is necessary for pathologists to supplement the lessons of everyday experience. There are opportunities to learn about malpractice litigation from the pathology literature, from the lay press, and from presentations sponsored by pathology organizations. Gaining a more in-depth understanding of the rather arcane workings of the tort system may not have much of a practical payback when the main objective is to avoid being sued. The education intervention of most help to the pathologist is the residency and postresidency education designed to make the pathologist less likely to make errors. When the latter fails at prevention, it’s time for plan B. With litigation looming, it is extremely important to immediately stop all unnecessary communications about the case and to quickly identify a highly skilled med-mal defense attorney who can competently guide you through the legal aspects of your defense. These lawyers do not stay in business for long if they are losing winnable cases, and a big part of winning is providing the defendant with a needto-know legal education.
Does the Tort Deterrent Signal Work if the Pathologist Doesn’t Understand Negligence? Fear of lawsuits is a prominent part of our practice milieu, and perhaps the lawyers are correct that, in some © American Society for Clinical Pathology
situations, it prompts greater diligence. However, as Allen et al1 point out, the overall effect of this fear on the quality of patient care is unlikely to be positive. Practicing defensive medicine is a widespread response to the threat of litigation, and defensive medicine has substantial downsides. In contrast, I would assert that pathologists who require the fear of a lawsuit to put their best effort into the job are quite rare. When discussing deterrence, we must begin by noting that a basic feature of effective deterrence is that it is only relevant if punishment would be triggered by something that I am inclined to do. For example, the punishment for robbing a bank doesn’t deter me in any way because I have no interest in robbing a bank. The physician’s valid complaint is that the tort system represents a very poorly focused deterrent, similar to randomly punishing people who would never rob a bank along with the people who do rob banks. A consequence of capricious deterrence is that physicians grasp at available defensive measures, such as over-ordering studies to proactively create the impression of thoroughness and diligence. “First do no harm to the patient” is reworked as “first take measures that might prevent harm to me.” Acquiring a more in-depth knowledge of negligence is an interesting hobby, but I am unable to see how anything beyond a very basic knowledge of the legal system would decrease the incentives to practice “defensive medicine,” decrease the risk of a lawsuit, or improve pathologists’ job performance. It’s likely that this knowledge would be even less effective than defensive medicine in keeping you out of court.
Conclusion I would like to conclude with a few comments about “tort reform.” I agree with Allen et al1 that almost any physician who examines how the tort system deals with malpractice would conclude that there must be a better, cheaper way to get this done. However, the authors may have greatly underestimated the difficulties in developing a system “reformed” to their liking. The first problem the reformer faces is that both doctors and trial lawyers are strongly in favor of tort reform, but their reforms have nothing in common. For example, the lawyers would like to see changes that bring many more medical errors into the tort system and that speed the recovery of patient damages caused by these errors. Because there is no obvious middle ground shared by physicians and lawyers, compromise is for practical purposes impossible, and the situation tends to remain close to the status quo. Will things ever change for the better? One of the most frequently quoted “laws” of economics is that things that
457
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
457 457
Foucar / The Pathologist in Tortland
can’t go on forever don’t. Because the med-mal system is so tied up in economics and because some features of the med-mal system seem dysfunctional, I would propose that this “law” applies here as well. However, we also have to acknowledge that things that can’t go on forever can go on for a very long time. I will predict that substantial changes favorable to physicians won’t happen before it becomes apparent that the cost of the current system is decreasing the availability of things that powerful nonprovider interest groups demand. Many informed citizens would agree that the current system
458 458
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
is too expensive, but ask those citizens to name the things that they are deprived of because of that expense. I doubt that you will get an answer.
References 1. Allen TC, Stafford M, Liang BA. Pathology and medical malpractice: academic and trainee empirical review of cases by state of Texas physicians. Am J Clin Pathol. 2014;141:501509. 2. Schwenk TL. The moment of truth (a piece of my mind). JAMA. 2014:311:573-574.
© American Society for Clinical Pathology
Copyright of American Journal of Clinical Pathology is the property of American Society of Clinical Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
The Pathologist in Tortland When Is Ignorance About “Med-Mal” Rational, When Is It Unavoidable, and When Is It a Problem to be Corrected? Elliott Foucar, MD From the Department of Pathology, University of New Mexico School of Medicine, Albuquerque. DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
In this issue of the Journal, Allen et al1 present the results of a study that asked pathologist volunteers to evaluate a series of pathology malpractice cases (so-called med-mal cases). Based on their evaluation, the volunteers answered two very different questions about each case. First, the pathologists rated the defendant’s care on a scale extending from “correct” to “not correct.” Next, they predicted whether the jury found for or against the pathologist. There was a high level of disagreement among the pathologists themselves and between the pathologists and the juries. These disagreements led the authors to their major conclusion that there is a “clear need for additional education” of pathologists about various aspects of the legal system. In this editorial, I discuss some of the issues raised by Allen et al.1 Sometimes I disagree with their point of view, but the reader should understand that most of the interesting topics in law are, and will remain, subject to various equally valid interpretations.
What Exactly Is Standard of Care? Although determining whether we provided the patient with the standard of care is theoretically central to the legal evaluation of our diagnoses, this phrase is virtually never encountered in medical practice. Surgeons do not send out tissue for a “standard of care frozen section.” We do know that pathologists have a near obsession with the difference between the “right” and “wrong” answer, and we have our own methods to distinguish between the two. However, when we conclude that a diagnosis is wrong, it is an error—not below the standard of care. © American Society for Clinical Pathology
It might be tempting to dismiss this as nothing more than different terminology used by different professions to describe the same thing. However, despite some similarities, physicians who have had any contact with the legal system recognize that meeting or not meeting a standard of care is something quite different from a diagnosis being “correct” or “wrong.” Pathologists who are curious about the standard of care will find that in the abstract world of a legal textbook it is easy to find a succinct definition. To wit, the pathologist is expected to exercise the degree of skill, care, and diligence that would be exercised by other pathologists in light of the present state of the field. To fail to provide that level of care is “negligence,” and if a jury decides that negligence is causally linked to damages, then there will be a monetary award to the plaintiff. Most of us would agree that standard of care sounds like a very reasonable benchmark for society to use in the evaluation of an allegation of pathologist negligence. However, the important question isn’t “How good does it sound?” but rather “How well does it function to identify substandard care?” Lawyers have concluded that standard of care is a metric that functions reasonably well in the setting of malpractice litigation, and in general, physicians disagree. Because of this disagreement, standard of care serves as an appropriate symbol of the gulf between how the law and medicine analyze medical practice. Of course, analyzing a case is an experience that is completely familiar to all of us. However, in a legal setting, this quotidian activity is transformed into something not only unfamiliar but often rather bizarre. Lawyers search for the correct standard of care using methodology dependent on tools such as dueling lawyers, dueling paid pathology experts, the opinion of random citizens, and the decisions of a judge. Physicians watching this strange methodology in action can
455
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
455 455
Foucar / The Pathologist in Tortland
experience some of the same feelings that a mentally ill patient endures when disturbed cognition makes the common seem strange—what the psychiatrists refer to as “derealization.” Physician descriptions of being a defendant routinely use terms such as “painful.”2
How Many Standards of Care Are There? The legal system’s definition of standard of care is very general, and the “med-mal” system is adversarial. Any case that isn’t either quickly dropped or quickly advanced to the damages phase is evaluated according to the two opposing sides’ version of standard of care. One potential source for a second standard of care that Allen et al1 mention would be a standard accepted by a “minority” of pathologists. However, we have little guidance from the courts about the required size of that minority (presumably it’s greater than one), how minority pathologists would be counted, or even whether a quote from a textbook or paper establishes a minority. A more important factor leading unbiased pathologists to different conclusions about the standard of care is the inherent complexity of modern practice. Another factor possibly encouraging a diversity of standards is that judges may have difficulty excluding the testimony of expert pathologists receiving fees that could stimulate the creation of previously undiscovered standards of care (i.e., so-called junk testimony). Allen et al1 confirm that unbiased pathologists often disagree about whether a fellow pathologist handled a case “correctly.” Although interpreting the percentages of disagreement that these authors report is difficult to apply to actual legal cases because of the lack of slide review, disagreement among specialists provides no new news for either pathologists or the legal system. What is important for pathologists to understand is that, in the absence of two experts who offer conflicting opinions about whether the pathologist provided the standard of care, a med-mal case changes dramatically. If the plaintiff can’t find a credible “expert” pathologist who agrees to testify that your diagnosis was below the standard, the case is dropped. In contrast, without a defense expert to testify that your diagnosis met the standard of care, you have already lost the initial phase of the case. The only remaining question is, “How much is this going to cost?”
What Role Does a Jury Determination of Standard of Care Actually Play in the Jury Decision? Like many interesting questions, the answer to this question is, “it depends.” It’s true that the jury’s final conclusion at the end of the first phase of the trial is packaged as a conclusion 456 456
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
about whether the pathologist’s care met the standard of care. However, just how much the details of two conflicting opinions about the standard of care influenced the final decision could be quite large or small. Once a case gets in front of a jury, there is much more going on than just the technical aspects of the care delivered. I was once involved in a case in which the plaintiff’s lawyer was so overcome by grief when summarizing for the jury the awful care provided to the patient that he began weeping. These kinds of things can matter in a courtroom much more than a count of mitosis per high-power field—and that’s why they happen! My impression has been that as the technical aspects of a case become progressively more complicated, factors other than the details of conflicting assertions about standard of care become progressively more important to the jury’s final decision about negligence. For example, a juror with little education can easily relate to a sympathetic plaintiff with an obviously adverse outcome but may find both sides’ discussion of standard of care completely incomprehensible. At the end of the day, one side’s position was more “credible” to a given lay jury at a given point in time under a certain set of legal circumstances that will never be exactly repeated. Was the pathologist’s care declared to be negligent because the jury decided that not ordering a certain stain was negligent or because the pathologist seemed arrogant or condescending? If you really want to know, you can attempt to interview the jurors after the trial.
Should Pathologists Be Better at Predicting Jury Verdicts? Allen et al1 found that pathologists had great difficulty predicting jury decisions. When interpreting this finding, it is important to be aware that, while med-mal cases provide many sources of drama for everyone involved, a substantial portion of the drama arises out of the difficulty that even experienced trial lawyers have in predicting what a jury will conclude. As a pathologist reviewing a case, you may have a strong opinion about whether a physician of ordinary learning, judgment, and skill would have come to the same conclusion as the defendant. However, as alluded to above, it represents a fundamental misunderstanding of the tort system to rely too heavily on a purely scientific evaluation of a malpractice case. The clinicopathologic facts of the case are only one part of a very complex montage. Asking a pathologist to predict a jury outcome is not directly analogous to asking a trial lawyer to interpret a breast biopsy specimen, but pathologists have to be realistic about their limitations. Unfortunately, it is only at the extremes of “indefensible error” by the pathologist at one end of the spectrum—and “overtly frivolous” plaintiff claim at the other © American Society for Clinical Pathology
AJCP / Editorial
end—that predictions about a jury’s conclusions about the “standard of care” aspect of a case can be reliable. Remember, the jurors are there to apply community standards to everything that they observe in the courtroom. They cannot and will not become instant pathologists. The surprise is not that unbiased pathologists often disagree with a jury decision but that the two agree so often. It’s worth mentioning that one critical piece of information about a case that a pathologist is in the best position to predict is how easy it will be for each side to find a “credible” expert witness. For example, as the diagnosis in question becomes more and more problematic, the list of “credible” pathologists willing to testify under oath that the diagnosis meets the standard of care becomes shorter and shorter.
Should Pathologists Receive a More Formal Education About Medical Negligence? When Allen et al1 document that pathologists often disagree with their colleagues and with juries about the presence of “medical negligence,” this leads the authors to conclude that pathologists should become better educated about how the tort system functions. They propose that more formal legal training should replace the current informal training, which they refer to as “the lore on the floors” approach. I would agree with the authors that it is necessary for pathologists to supplement the lessons of everyday experience. There are opportunities to learn about malpractice litigation from the pathology literature, from the lay press, and from presentations sponsored by pathology organizations. Gaining a more in-depth understanding of the rather arcane workings of the tort system may not have much of a practical payback when the main objective is to avoid being sued. The education intervention of most help to the pathologist is the residency and postresidency education designed to make the pathologist less likely to make errors. When the latter fails at prevention, it’s time for plan B. With litigation looming, it is extremely important to immediately stop all unnecessary communications about the case and to quickly identify a highly skilled med-mal defense attorney who can competently guide you through the legal aspects of your defense. These lawyers do not stay in business for long if they are losing winnable cases, and a big part of winning is providing the defendant with a needto-know legal education.
Does the Tort Deterrent Signal Work if the Pathologist Doesn’t Understand Negligence? Fear of lawsuits is a prominent part of our practice milieu, and perhaps the lawyers are correct that, in some © American Society for Clinical Pathology
situations, it prompts greater diligence. However, as Allen et al1 point out, the overall effect of this fear on the quality of patient care is unlikely to be positive. Practicing defensive medicine is a widespread response to the threat of litigation, and defensive medicine has substantial downsides. In contrast, I would assert that pathologists who require the fear of a lawsuit to put their best effort into the job are quite rare. When discussing deterrence, we must begin by noting that a basic feature of effective deterrence is that it is only relevant if punishment would be triggered by something that I am inclined to do. For example, the punishment for robbing a bank doesn’t deter me in any way because I have no interest in robbing a bank. The physician’s valid complaint is that the tort system represents a very poorly focused deterrent, similar to randomly punishing people who would never rob a bank along with the people who do rob banks. A consequence of capricious deterrence is that physicians grasp at available defensive measures, such as over-ordering studies to proactively create the impression of thoroughness and diligence. “First do no harm to the patient” is reworked as “first take measures that might prevent harm to me.” Acquiring a more in-depth knowledge of negligence is an interesting hobby, but I am unable to see how anything beyond a very basic knowledge of the legal system would decrease the incentives to practice “defensive medicine,” decrease the risk of a lawsuit, or improve pathologists’ job performance. It’s likely that this knowledge would be even less effective than defensive medicine in keeping you out of court.
Conclusion I would like to conclude with a few comments about “tort reform.” I agree with Allen et al1 that almost any physician who examines how the tort system deals with malpractice would conclude that there must be a better, cheaper way to get this done. However, the authors may have greatly underestimated the difficulties in developing a system “reformed” to their liking. The first problem the reformer faces is that both doctors and trial lawyers are strongly in favor of tort reform, but their reforms have nothing in common. For example, the lawyers would like to see changes that bring many more medical errors into the tort system and that speed the recovery of patient damages caused by these errors. Because there is no obvious middle ground shared by physicians and lawyers, compromise is for practical purposes impossible, and the situation tends to remain close to the status quo. Will things ever change for the better? One of the most frequently quoted “laws” of economics is that things that
457
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
457 457
Foucar / The Pathologist in Tortland
can’t go on forever don’t. Because the med-mal system is so tied up in economics and because some features of the med-mal system seem dysfunctional, I would propose that this “law” applies here as well. However, we also have to acknowledge that things that can’t go on forever can go on for a very long time. I will predict that substantial changes favorable to physicians won’t happen before it becomes apparent that the cost of the current system is decreasing the availability of things that powerful nonprovider interest groups demand. Many informed citizens would agree that the current system
458 458
Am J Clin Pathol 2014;141:455-458 DOI: 10.1309/AJCPO6ZZ3EUNEDRZ
is too expensive, but ask those citizens to name the things that they are deprived of because of that expense. I doubt that you will get an answer.
References 1. Allen TC, Stafford M, Liang BA. Pathology and medical malpractice: academic and trainee empirical review of cases by state of Texas physicians. Am J Clin Pathol. 2014;141:501509. 2. Schwenk TL. The moment of truth (a piece of my mind). JAMA. 2014:311:573-574.
© American Society for Clinical Pathology
Copyright of American Journal of Clinical Pathology is the property of American Society of Clinical Pathologists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
