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Archive for the ‘Defensive Medicine’ Category

Another Example of Defensive Medicine

Thursday, September 18th, 2014

The ultrasound images above show a circular clot in the superficial femoral vein. The image on the left is without compression and the image on the right is with compression. Normally blood vessels flatten out when compressed. Since the vessel did not flatten with compression it confirmed the presence of a blood clot.

While discussing a case with one of the nurses with whom I work, I saw how once again defensive medicine had affected my medical practice.

I gave a few examples of defensive medicine in a post several years ago and I also mentioned how sometimes doctors have to prove a negative when dealing with patients. Both of those posts are pertinent to this case.

A patient with a history of a clotting disorder has arthroscopic knee surgery. He has had two prior blood clots in his leg and one prior blood clot in his lung, so he’s on lifelong Coumadin. His doctors told him to stop taking the Coumadin for the week prior to his surgery to prevent bleeding during surgery. The surgery went well and he was discharged the same day.

The following day he started taking Coumadin again. However, he also noticed some pain in his calf. The pain was there after his surgery, but it seemed to be a little worse the following day. He took some pain medication and kept ice on it.

Two days out from his operation he was still having some pain in his calf, so he called the orthopedist. The orthopedist told him to go straight to the emergency department for an ultrasound of his leg to make sure that he didn’t have another blood clot. The possibility of a blood clot worried the patient, so he followed the doctor’s recommendations.

When I saw him, based on his clinical exam I could tell – with a reasonable degree of medical certainty – that he didn’t have a blood clot. His leg wasn’t red or swollen. We measured the circumference of both legs at the thigh and at the calf. His normal leg was actually a centimeter larger in diameter than the leg that underwent surgery. The pain was in the belly of the calf muscle – where orthopedists will sometimes apply pressure to get the leg in the correct position during a surgery. There was no thigh pain and there were no palpable cords.
It was a Saturday evening, so doing an ultrasound to look for a blood clot meant that we would have to call in the ultrasound tech from home and the patient would have to sit in the emergency department for at least a couple of more hours.

I told him “Based on my exam, it is pretty unlikely that you have a blood clot in your leg. Keep taking your Coumadin, keep putting ice on the tender area, keep taking your pain medications, and follow up with your doctor on Monday.”
He said “I have a history of blood clots in my leg before, it feels like a blood clot now, and my orthopedist said I need an ultrasound. You need to do the ultrasound.”

Now if there wasn’t any concern about liability or other repercussions, I probably would have told him that the ultrasound wasn’t indicated and that we didn’t need to do it that night.

But there is a concern about liability and other repercussions.

Even if the patient didn’t have a blood clot on this visit, what would happen if the patient developed a blood clot the following day? And what if that blood clot broke off, caused a pulmonary embolism, and the patient died? How could I prove that there was no clot present when I evaluated the patient – especially when purported “expert” witnesses testify under oath that it is “grossly negligent” to miss a diagnosis of pulmonary embolism in a teenager after knee surgery? It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
What if the patient had a clot despite the lack of physical findings for a blood clot? We often hear the phrase “nobody’s perfect”, but if you don’t order testing and miss a diagnosis, there is really not much tolerance for less than perfection in cases like this. It is much easier to order a test than it is to defend your reasonable and evidence-based approach for not ordering the test in the event of a bad outcome.
I’ve seen more than a few specialists and primary care docs who send a patient to the emergency department for testing and who then complain to hospital administrators that the dumb emergency physicians don’t do the tests that they wanted.
And let’s not forget that sending a patient home without getting the tests that the patient wanted is a sure way to tank your patient satisfaction scores.

So we ordered the ultrasound and called in the ultrasound tech.

A few hours later we got back the report from the radiologist showing no DVT. The patient got to go home and I’m sure that he slept better.
I’m sure that the orthopedist was able to sleep better, also.
The whole episode didn’t have much of an effect on my sleep pattern. I knew the patient didn’t have a blood clot when I first examined him … but now I had objective proof of my clinical findings and everyone got what they wanted.

Just think, it only cost the system a few thousand extra dollars.

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This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

14.5 Million Reasons Physicians Practice Defensive Medicine

Monday, June 16th, 2014

Fetal Tracing

Cleveland’s MetroHealth Medical Center and a staff physician were recently found liable for a $14.5 million medical malpractice verdict in what is commonly termed a “bad baby” case.

The case as described in the article involved 36 year old Stephanie Stewart who was pregnant with her second child. She went to MetroHealth several times for premature labor when the child was 22-23 weeks gestational age (a full term infant is 40 weeks) and was admitted twice, with labor being stopped using medication and bedrest. There were apparently discussions about her requiring a C-section since her first child was delivered by C-section.
Six days after being discharged from her second hospital admission, she returned for evaluation after her water broke. At that time, she reportedly asked physicians to give her an immediate C-section to deliver her 24 week old baby, but they do not do so. The attending physician arrived later that afternoon and she again requested a C-section, but the attending doctor noted that the baby appeared “healthy” on the monitor. Three and a half hours later, the baby showed signs of distress. Doctors performed an emergency C-section, but the child was unfortunately born with a brain hemorrhage, cerebral palsy, cognitive delays, visual impairments, and “other issues that will require lifelong care.”

The doctor and hospital were sued and after a trial, according to the plaintiff’s attorney, the “jury determined there was medical negligence and Stewart was not informed that there was a significant risk of a brain hemorrhage if a baby goes into fetal distress … [in addition, the mother] was not given any options, and her request for a Caesarian was not granted.”

What would have prevented all of the patient’s medical injuries and what the hospital and physicians should have done, according to the attorney, is to have kept the mother in the hospital after her third admission for three months until she delivered a healthy baby, or alternatively, the doctors should have performed a Caesarian section on the mother when she requested it.

Comments to the article alleged that this “malpractice” isn’t an isolated incident.

However, when you look at the allegations in the case within context, you have to wonder.

20% of premature infants suffer from bleeding in the brain.
In infants born between 22 and 25 weeks of gestation, 73% either die or have some type of neurodevelopmental impairment and 61% die or have “profound impairment.” The risks of adverse outcomes are decreased by increasing gestational age (i.e. allowing the baby to remain in the uterus longer), in addition to administering steroids.
A 2000 study showed that “survival at 23 weeks’ gestation ranges from 2 to 35%, at 24 weeks’ gestation 17 to 62% and at 25 weeks’ gestation 35 to 72%.” Those survival rates have probably improved over the past 14 years, but the data show that even an extra week of keeping a developing fetus inside the uterus has a significant effect on the child’s survival. 

Now a woman who is 24 weeks pregnant – at which time, if delivered, her fetus has a 38% to 83% chance of dying – comes to the hospital and demands to have a C-section.
If the doctors perform the C-section without a proper reason for doing so, more likely than not, the child is going to die. Then the mother will allege that the doctors should never have performed the C-section and will sue the doctors and hospital for performing the C-section. In addition, the state will go after them for causing patient harm without following medical protocols.
If the doctors don’t perform the C-section, the patient has a 60% chance of having some type of neurodevelopmental impairment and a 20% chance of bleeding in the brain. If the child is born with any of those problems that are likely to occur in any premature infant, it creates the appealing plaintiff lawyer argument that if the doctors just listened to the mother’s requests for a C-section none of this would have ever happened. After all, how dumb can the doctors be if a mother knows more about premature pregnancy than they do?

The rule that the plaintiff attorney apparently thinks all physicians should follow is that doctors should always perform all testing or treatment that patients request, even if that testing or treatment is potentially harmful or medically unfounded.

Unless the mother was skilled in evaluating premature labor, the judge should never have let the jury hear that the mother demanded a Caesarian section. Had a C-section been performed and a bad outcome occurred, the fact that the mother demanded the procedure be performed wouldn’t be admissible.
If the defense attorney did not move to have that highly inflammatory testimony excluded, the defense attorney likely committed legal malpractice.

In either case, this scenario reinforces the notion that doctors should fear the bad outcome. Regardless of what actions we take, if a bad outcome occurs, someone will find something that should have been done differently.

Until we address no-win situations involving multimillion dollar liability such as this, defensive medicine, overtesting, and overtreatment will never go away.

FDA’s Latest Deadly Drug: Codeine

Thursday, August 16th, 2012

Get ready for more governmental regulation of opioids and maybe even some black box warnings added to the prescribing information for c0deine-containing drugs … just for everyone’s safety, of course.

According to this FDA Special Bulletin on Safety Information, three pediatric deaths and one case of respiratory depression were documented in the medical literature after children took codeine-containing compounds. The etiology for the deaths was allegedly because the children had a variation in their cytochrome P450 enzyme that caused the codeine to break down faster into morphine, high levels of which, according to the FDA, “may be fatal.” If your child or your patient is an “ultra-rapid metabolizer” of codeine, he or she could DIE.

The FDA also published a “Drug Safety Communication” that disclosed the studies on which its recommendations were based.

One case cited by the FDA as “proof” that codeine can kill you involved a 2 year old child with sleep apnea who underwent tonsillectomy and adenoidectomy and who died three days after surgery. At autopsy, the child had elevated levels of codeine and morphine in his system, had aspirated food particles, and also had bilateral pneumonia. No mention of how much codeine the patient’s parents gave the child, only of the dose that was prescribed. No mention of how bilateral pneumonia or aspiration in a young child can be deadly. The researchers concluded that the elevated morphine levels “may” have contributed to the child’s death. The FDA wants you to believe that there was a causal connection there.

Another article cited by the FDA was from the same authors who now found three additional cases of children who died after having tonsillectomy/adenoidectomy and were prescribed codeine. I didn’t purchase the article, but I also am assuming that there were no controls for dosing of the medication, only for prescription of the medication. In other words, I doubt that the researchers would be able to tell whether the parents accidentally just gave the child too much medication as opposed to whether some genetic variant caused higher than normal blood levels of the medication at normal doses.

I also did a PubMed search for “children codeine p450” and also “pediatric codeine p450“.
There was one Canadian case report of a mother who was an “ultra rapid metabolism phenotype” whose breastfed child had fatal opioid intoxication after the mother used codeine.
There was another case report from Canada of a 5 year old girl who died from hydrocodone overdose when she was taking both clarithromycin for an ear infection and valproic acid for seizures. The medications decreased metabolism of the drug and she also had a genetic defect that decreased the metabolism of the drug.
None of the other articles that I found mentioned pediatric death due to an interaction between opioids and cytochrome P450.

Now, based on 4 deaths out of likely hundreds of millions of codeine prescriptions, the FDA is “currently conducting a safety review of codeine” and is recommending that doctors use low doses of codeine for patients in pain or that doctors just use another medication completely for children in pain. The FDA also recommends that caregivers monitor patients for signs of opioid toxicity. These recommendations are already in the prescribing information for Tylenol with Codeine.

Oh, and the FDA also notes that doctors can always perform “FDA approved” genetic testing to see if children have the gene responsible for rapid metabolism of codeine.

I can’t help wonder what motivation the FDA has to issue this warning about 4 deaths in tens or even hundreds of millions of prescriptions that were hypothesized to have been caused by this mechanism. It’s not like codeine is a new drug or that the cytochrome P450 pathway is a new discovery. Why now?

Trying to justify the FDA’s existence/budget? Getting a cut of the fees for approving the genetic testing? Getting fees for some new pain medication so that it can be approved for use in pediatric patients? Something just doesn’t make sense.

Of course, now if sometime in the future a young patient dies from an alleged codeine overdose, there will be some newspaper article published and some lawsuit for millions of dollars in damages filed alleging that if only the negligent doctor had paid attention to the FDA warnings and performed CYP2D6 genotyping, the patient would probably still be alive today.

And people wonder why doctors practice defensive medicine.

 

UPDATE
Congratulations to the Wall Street Journal, NY Times, Washington Post, ABC News, Bloomberg News, NPR, and the Boston Globe for feeding into the hysteria. Hat tip to EM Today from ACEP for the links.

A Nameless Faceless Killer

Friday, August 3rd, 2012

By BirdStrike M.D.

1) A 40-year-old female sees her family physician for burning chest pain after she eats hot peppers. She had it only once while exercising. Her family physician sends her to the emergency department and she gets admitted for chest pain. Rather than going home with treatment for her GERD, she ends up dead. This never should have happened, but the family never learns what really killed her.

2) A 33-year-old father of 3 dies on a hospice ward, bloated with steroids, on tube feeds with a tracheostomy. He was stricken down too young, his family is told, by a rare form of brain cancer. It was an unlucky fluke, they are told, but that is not the only reason.

3) A 7-year-old boy dies in the Pediatric ICU. His family is stunned, shocked and devastated. How could this have happened? The family is told he died from an ingrown toe-nail infection that spread to his blood stream and caused a severe form of sepsis. “It could happen to any of us.” They do not know that the breeding of this superbug was fed by a nameless killer.

4) A 16-year-old girl is on a CT scan table nervously giggling. Fifteen minutes later, she goes into cardiac arrest. A short time later, a solemn nurse informs her family that the patient has died from an allergic reaction. But her cause of death is something more insidious.

Each of these patients had a different doctor, but a similar contaminant. Much like a baseball slugger whose home run swing at a 100 mph fastball is thwarted when a camera flash from his biggest fan causes him to blink; the doctors were thrown off of their game. The culprit: Defensive Medicine.

In each case presented, the doctor had a very rational fear of being sued for either making a mistake or even for doing everything right. During the last moment in the rapid-fire decision-making process, each doctor had a “flash in the eye.” In each case, the result was a swing and a miss. Over and over, and over again in hospital wards, emergency departments, operating rooms, and doctors’ offices in America doctors are being told they must rule out every possibility or be sued. The ones who suffer are the patients, often tragically so. Why? Rather than trusting their instincts, the treating physicians are instead asking themselves, “What could a medical malpractice attorney possibly say I should have done?” While this may seem like a dangerous way to practice medicine, often the doctors have very little choice but to do so.  Consider the stories behind the cases presented above:

(more…)

More on Perfect Medicine

Thursday, March 8th, 2012

Someone forwarded my the link to this story about a Connecticut woman who filed a multi-million-dollar lawsuit against a hospital and emergency physician for failing to diagnose pulmonary emboli which ultimately killed her husband.

According to the article, the patient went to Stamford’s Tully Hospital emergency department complaining of flank pain. The emergency physician performed a CT scan on the patient’s abdomen “without performing further testing” and then discharged the patient home.

Nine days later, the patient returned to the emergency department in critical condition with blood clots in both lungs. He died the following day.

It is hard to comment specifically about the case without knowing more facts. However, in general, pulmonary emboli are notoriously difficult to diagnose. We do a lot of chest CT scans looking for them, and a vast majority of the time the chest CT scans come back normal. Of course, after the negative result is known, then everyone accuses you of ordering an “unnecessary test” to look for a pulmonary embolism, but that’s another topic for later discussion. So in a patient who comes to the emergency department complaining of flank pain, a blood clot in the lungs is probably not going to be near the top of any reasonable physician’s differential diagnosis list. Flank pain is usually due to kidney problems and the kidneys are in your abdomen at about the level of your belly button. The pulmonary emboli that kill people lodge in the central parts of the lungs, in the center of the chest just to the sides of the heart. See the diagram.

The thing that really bothered me about the article was that the plaintiff’s attorney, Craig Yankwitt, from the Stamford law firm of Silver Golub & Teitell, was quoted as saying:

“They were simply not permitted to discharge without ruling out whether he was suffering from a life-threatening condition.”

This is ridiculous confabulated unsubstantiated calumny. And the purpose of this calumny is to try to bolster the retrospective claim that Mr. Yankwitt will try to use to make millions of dollars:

“Had they performed the additional testing, Mr. Hermann would still be alive.”

There is no rule that a physician or hospital is “not permitted to discharge” a patient without ruling out whether the patient is suffering from a life-threatening condition. To require so would demand perfection in medicine: Doctors are not allowed to miss any life threatening conditions ever, regardless of how obscure or tangential the complaint. Think about if this really were the case.
You come to the emergency department with pain when you urinate and a little bit of blood in your urine. Sounds like a simple UTI … but wait, we are “simply not permitted to discharge you without ruling out whether you are suffering from a life-threatening condition.”
Your could have a pulmonary embolism. That is a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until a pulmonary embolism has been ruled out. We’ll have to do a CT scan of your chest before you can be discharged.
Kidney cancer is also a life-threatening condition. Add a CT scan of the abdomen and pelvis to the list of tests.
And you *could* be suffering from brain cancer. That’s a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until that potential life-threat is ruled out. May as well do a whole body CT scan and get it over with.
But wait, you *could* also be suffering from leukemia. That’s a life-threatening condition. We’ll need to get an oncology consult for a stat bone marrow biopsy just to “rule out” that life threat.
You could also have been poisoned by some unknown chemical. We should probably draw a few dozen tubes of blood and send them to the Mayo Clinic to rule out every possible poisoning “life threat.” Been exposed to any strychnine lately? We’ll have to test for that before we’re “permitted” to discharge you. Looks like you’ll be in the emergency department for a while until the tests come back.
Oh, and you *could* be suffering from a Naegleria fowleri infection. That’s verylife-threatening and it doesn’t show up on CT scan. We’ll call the neurosurgeons for a stat brain biopsy as soon as the oncologists are done with you.

By this time, we’ve increased your risks of cancer from all the extra radiation, have increased the risk of a bad outcome from performing surgical procedures, have left a hole in your brain, and have caused you to incur tens of thousands of dollars in extra testing … and we haven’t even scraped the surface of all the “life-threatening conditions” that we allegedly must rule out before we are “permitted” to discharge you.

According to plaintiff attorney Craig Yankwitt’s logic, we’d have to do this testing on every person who comes to the emergency department – even if it was for a hangnail – because we are “simply not permitted to discharge without ruling out whether [patients are] suffering from a life-threatening condition.”

When you wonder why physicians perform low yield testing and why defensive medicine abounds, think of plaintiff attorneys like Craig Yankwitt who perpetuate medically unjustified myths and who use hindsight bias as a means to become wealthy.

Healthcare Update — 10-03-2011

Monday, October 3rd, 2011

More medical news from around the web at the Satellite Edition of this week’s update on ER Stories

Australian emergency physician punches and slaps restrained patient who spat in his face. He was terminated from his position. A court held that the termination was unfair. Australian doctors considered going on strike after learning how the doctor was treated after the incident.
When you read the comments section of articles describing patients who assault emergency department staff, many people seem to think that staff should accept abusive behavior due as being “part of the job.” Shouldn’t patients therefore accept abusive behavior from medical staff as being “part of the visit”?

A view of medical malpractice reform misconceptions from physician-attorney William Sage. I disagree with several of his premises. For example, one question Dr. Sage asks “How likely is it, really, that ‘sinister forces’ outside [of medicine] are the reason why tens of millions of Americans lack access to services, or why even those who can afford it often get mediocre care at inflated prices?”
Ask physicians who don’t provide care to patients with certain government insurance plans and who stop taking emergency call or stop performing certain procedures (such as brain neurosurgery) due to liability concerns. Ask doctors who won’t or can’t prescribe medications that are safe through billions of prescriptions because the FDA issues a black box warning that the drugs might have caused adverse reaction in one millionth of a percent of the people receiving them. Then ask patients who can’t afford to purchase certain drugs such as albuterol, colchicine, or (soon to be) Primatene Mist because drug companies jacked up their prices based upon a governmental technicality in approving the medications.
Nah. No “sinister forces” here.

Recent Massachusetts Medical Society survey shows many interesting findings. Specialties in critical short supply included internal medicine, urology and psychiatry. Primary care specialties had severe shortages for 6 straight years. More than half of physicians would be unwilling to participate voluntarily in either global payment programs or accountable care organizations. Oh – and “the fear of being sued continues to be a substantial negative influence on the practice of medicine, affecting access to and availability of physician services.”
Nah. No “sinister forces” here, either.

Another timely rebuttal to some assertions in Dr. Sage’s article. Study in Archives of Internal Medicine shows that 42% of physicians believe that their patients are receiving too much care. Guess what factor contributed to more aggressive care in 76% of cases. Click this link to find out. Hint: “Sinister force” alert.

CMS coming out with bundled payment plans for 2012. Look for the pendulum of clinical care and testing to swing the other way. And look for more people to accuse “greedy doctors and hospitals” of limiting care in order to make more money when, in reality, the government is limiting care through underpayments to providers.

Another reason that getting a ZeePack for your cough might not be a good idea (aside from the fact that it won’t work) … it might cause you to get Crohns disease or ulcerative colitis. Twelve percent of patients diagnosed with Crohns or UC had been prescribed three or more doses of antibiotics in the two years prior to their diagnosis. Only 7% of patients who had developed Crohns or UC had not been prescribed antibiotics. In other words, people prescribed frequent antibiotics were up to 50 percent more likely to get Crohn’s disease or ulcerative colitis within next two to five years. My guess is that they were more likely to get MRSA and C. difficile as well. Study abstract here.

More Florida shenanigans. Physicians Regional Medical Center in Naples, FL has tells specialists that they have to take call for the emergency department in both the system’s hospitals or resign. Many doctors call the hospital’s bluff and resign or change to inactive status. Now emergency patients have less access to specialist care. The comments section has many people blaming “greedy doctors” for the problem.

This case was from last year, but still surprised me. A physician was sued and settled for $500,000 after failing to recommend a pneumococcal vaccination.

Excellent post over at ACP Internist about the costs of medical malpractice.

LA Times reporter gets a glimpse of an evening in one of the busiest emergency departments in the country. Read her story here. Then read the comments section for insight into how “illegal aliens” are causing the problem. The multimedia presentation also has some great pictures.

$4.9 million awarded to patient who suffered brain injury in hospital.

$4 million verdict against emergency physician who diagnosed a 42-year-old patient with “chest pain of unclear cause and bronchitis.” Patient found unresponsive at home 11 days later. Jury decided that a more thorough examination in the emergency department “would have revealed warning signs of an impending heart attack.”

Finally, if you want to learn a more about evidence based medicine, go check out Graham Walker and company’s site at TheNNT.com (the number needed to treat). Lots of new studies and interesting information that is in an easy to understand format for physicians and patients.

Healthcare Update — 12-02-2010

Thursday, December 2nd, 2010

Also see the satellite edition of this week’s update over at ER Stories.

Problems with Canadian health systems getting worse.
“We’re trying to get a Size 13 foot into a Size 8 shoe.” Emergency department overcrowding increasing due to lack of available beds. The president of the Edmonton Emergency Physicians Association described the situation as a “potential catastrophic collapse” of emergency medicine. Edmonton plans to decrease hospital emergency department crowding by moving patients out of the emergency departments sooner once the hospitals meet certain criteria such as the ED being 110% full or there are more than 35% boarding patients in the emergency department.
Five times this past year, Dr. Raj Sherman’s 73-year-old father almost died after waiting hours on a stretcher in an ambulance parked outside the hospital waiting for a bed. As a parliamentary assistant on health, he decided he had had enough and blasted the government, the Alberta Health Services chairman, the former health minister, and Premier Ed Stelmach. As a result of his statements, he has been fired from his government position.

California emergency physicians sue to keep the state from cutting reimbursement – and win.

Medicaid insurance versus Medicaid access. Yes, they have insurance, but one patient had to drive 2.5 hours to see an orthopedist that would accept her insurance. He fitted her with a brace and sent the patient for physical therapy. Now the “insurance” won’t pay for the brace. Plans that are running Medicaid managed care plans are viewed as “managing costs, not managing the care.” When patients can’t get the care they need, where will they end up? Emergency department waiting rooms.

Six California hospitals fined because employees inappropriately accessed patients’ medical information. How do we change the system to prevent this from reoccurring?

Malpractice judgments and settlements in the news:
$16.2 million Chicago settlement for neurosurgical injury after patient sustains a brainstem herniation.
$6 million Wisconsin settlement in birth injury case where patient born with cerebral palsy.
Largest verdict in Belize history for child who was delivered 2 weeks early due to miscalculation in gestational age and premature Caesarian section.

Maine preparing to repeal its universal health care plan due to funding issues. The Governor elect states that the state has paid $160 million to cover 3,400 eligible residents. The outgoing governor disagrees with the numbers.

Girlvet has another intriguing post about those warning labels on cigarettes. If cigarette packs are required to have graphic pictures on them, why aren’t beer cans required to have graphic pictures of DWI accidents? Why doesn’t McDonalds have to put graphic pictures of obese people on their bags?

A real life “Catch Me If You Can.” Fake doctor works in Fayetteville, NC emergency department for 3 weeks before getting caught.

SWAT team descends on hospital as Florida gunman fires shots in hospital cafeteria and then barricades himself inside hospital room.

Canadian man has diabetic “seizure” while visiting his wife and newborn daughter. Instead of bringing him to the emergency department, the hospital calls an ambulance and paramedics bring the man to the emergency department where he is later released. Now there’s the little matter of that $400 ambulance fee that he’s being charged – even though he never set foot in an ambulance.

One reason that some medical providers are reluctant to disclose errors: 25% of patients stated that they would file a medical malpractice lawsuit if they were told about a medical error. Many actions considered “medical errors” have no effect on patient outcomes. Giving a medication five minutes after the time it was ordered is a medical “error”. Giving ice chips to a patient who is “NPO” is a medical “error.” Giving NSAIDs without checking a creatinine may be considered a medical “error.” Giving a patient medication to which the patient has claimed an “allergy” may be considered a medical error – even if that allergy is nausea. Heck, failing to disclose a medical error may be considered a medical error. Should there be full disclosure of even inconsequential errors? If so, how many professionals are going to want to practice under ubermicromanagement every day of their careers?

Odd news story of the week:
Hey doc – be careful of those sharp points on the fork. You could poke your eye out (remember the scene at the right from Dirty Rotten Scoundrels?) Doctor Arturo Carvajal is suing a restaurant because, after Dr. Carvajal ordered a grilled artichoke and was served a grilled artichoke, no one showed him how to eat the grilled artichoke. He ate the whole artichoke and later was found to have artichoke leaves lodged in his bowel. The restaurant’s lawyer issued a statement warning restaurant patrons not to eat the bones in the barbecue ribs – which I thought was pretty damn funny.
Even though the news article was dated November 19, Walter Olsen had the story published on his “Overlawyered” blog November 5. I just can’t beat him to the scoop on these stories.

New Defensive Medicine Survey

Saturday, November 20th, 2010

“Every word that I write on every form is crafted with the idea that a malpractice attorney will challenge me to defend my practice.”

Just one of the quotes in the survey about defensive medicine published by Jackson Healthcare.

The survey of more than 3000 physicians showed that 92% admitted practicing defensive medicine and that, based on physician responses, the annual estimated cost of defensive medicine in the US each year is $650 billion to $850 billion – accounting for $1 out of every $4 spent on US health care.

You probably shouldn’t believe any of the statistics or quotes from physicians in the survey, though. Trial lawyers have a much better idea about why physicians order so many tests and why defensive medicine has no impact on the availability of health care in our system.

Dr. WhiteCoat Goes to Washington

Thursday, May 20th, 2010

Sorry about the sparse posting lately – have been away in Washington at an ACEP conference

Just so Matt and others don’t think that all I’m all talk and no action, I’ll let you in on some things that I did at the conference.

I attended some excellent lectures about leadership.

  • Colonel Thomas Kolditz gave a great talk about leadership in extreme circumstances. He described his interviews with many soldiers, Iraqi prisoners, sports team captains and their teammates, and various other people in leadership positions to determine what makes a good leader. Why do people follow some leaders and not others? Commitment is important. If a leader doesn’t believe in a mission, neither will the rest of the team. Effective leaders work with the team – they get down in the trenches and don’t sit on the sidelines barking orders and cheerleading. Trust is also important. If team members are worried about whether their leader might throw them under the bus, they will second-guess the leader’s intentions. The biggest factor in being an effective leader is competence. Col. Kolditz described his interview with a group of soldiers in an elite army unit. Almost all of them hated their commander. They thought he was a jerk. But every one of them said that when the rubber met the road he knew what he was doing and that there was no one else they would rather have leading them in their missions.
  • I listened to Dr. Melissa Givens, a Lieutenant Colonel in the US Army, describe how difficult it was to manage the shootings at Fort Hood and all of the unexpected difficulties they had in trying to save the wounded soldiers. Ever wonder what it’s like to watch one of your co-workers die right in front of you? She told us how she was in the same room where the shootings took place only two days prior to when the shootings occurred. Very informative and very emotional.
  • I watched a room full of physicians throw up their hands in frustration when a California physician showed how his group and other groups in the state are having difficulty staying solvent because California does not allow medical groups to bill patients fair prices for the care that they provide. Insurers lowball payment to the physicians and the California government made it illegal for the physicians to bill the patients for the remainder of the payments. Many physicians are considering whether or not to leave the state. California patients may soon be getting what they – or their insurers – pay for.

There were other lectures about how health care reform fell short and some possible options for the future.
One of the most informative lectures I attended was given by a former Congressional aide and current consultant who described his impressions about how legislators come to decisions and what does and does not influence a legislator’s decision-making. Personalized letters to legislators really do make a difference.

And I went to legislators’ offices.
The legislators weren’t in town when I went to visit, so I was lucky enough to get appointments with some of their staff.
I discussed ideas for health reform and medical malpractice reform with one legislator’s assistant. He took my name and said that he was going to have another assistant get in touch with me to get some more ideas and input.

I spent 45 minutes talking with one legislator’s assistant who is the go-to person for health care policy. I didn’t try to sell anything to him, I asked him if he had any questions that I could answer for him. We sat there for 45 minutes talking. Below are some of the things we discussed.

“What do you think about the SGR?” He asked.

  • Honestly, I don’t think they should fix it. Nobody cares about it right now. All they know is that they can keep kicking it down the road until it becomes a big enough problem that someone is forced to fix it. The only way to deal with the issue right now is not to fix it. Cut payments to physicians. Let most of them drop out of the system. Let the patients who depend on Medicare be stuck without medical care. Almost immediately, the AARP will pay for a bunch of buses for all the grandmas and grandpas with their pink hair and canes with the tennis balls on them (probably my own mother included) to go to Washington and demand a fix. Only then will legislators realize that the current system is unsustainable and unfixable. We can’t patch this system and expect that it will continue to work. We must focus on starting over and creating an entirely new system that will be sustainable in the future. And a side note – if you try to create another system without extensive input from physicians, it will fail in the same manner that the current system is failing.

“Do you think that the AMA represents the views of physicians across the country?”

  • Not really. I believe there is a lot of attrition from the AMA and know of many physicians who have dropped their membership. At the same time, membership in specialty societies is growing. ACEP is a perfect example. ACEP’s membership is going up, not down.

“How would you make the health care system better?”

  • Patients must have more skin in the game. Right now many people think that the value of the health care they receive is their $20 copay. You can’t get work done on your car for that much. A plumber would laugh at you if you told him that was all you would pay him. But, in practical terms, all a physician visit is worth is $20. That mindset has to change. $20 per visit won’t even keep the lights on.
    There is a tremendous demand for high technology and for extensive testing that is often low yield. That is because a majority of patients have no direct responsibility for paying the cost of the testing. There is no incentive for patients not to want a test and there is no incentive for a physician not to order the test. In fact, with the push toward “patient satisfaction” as a basis for reimbursement, the incentive for physicians to order extensive testing will only increase. If patients don’t have skin in the game, costs will continue to rise no matter what regulations are put in place. I guarantee it.
  • The only instance in which patients and physicians work together to decrease costs is when patients have to pay out of pocket for their medical care. If a patient’s medication goes off formulary for their health plan, the patient goes to the physician to find an alternative or to get the physician to request an exception from the insurance company. If a physician would like an MRI on an patient’s back after the patient was injured at work, the patient will not get the exam done until worker’s compensation agrees to pay for the test. This is what we need – patients need to be responsible for the costs and physicians need to help them determine what they really need and don’t really need. If patients want a low yield test, no problem – but they have to pay for it out of their pocket. Let them have ten low yield tests if they want. The only one who bears the cost of the testing is the patient.
    Homeowner’s insurance doesn’t cover the cost of someone mowing your lawn and it doesn’t cover the cost of your kid breaking a window.
    Auto insurance doesn’t cover the cost of oil changes or fixing your tire.
    Why should health insurance cover routine medications and routine medical care? It shouldn’t.
  • Health savings accounts have to become an integral part of our culture. Use the money in those accounts to pay for routine health care costs. Make money in the accounts tax-free to encourage people to use them. Allow patients to carry some of the money in the accounts over to future years, but require that they spend at least some of the money in the account each year to encourage people to engage in preventative health care practices. Family practitioners could drop all their insurance plans and could all go “cash only.” No insurance hassles. Money at time of services. They’re happier and more productive. More people go into family medicine. Patients get seen quicker. What a concept.
  • Mandatory insurance isn’t fair and it probably isn’t Constitutional. You want everyone to pay into the system, increase taxes in an amount proportionate to the amount you’ll need to provide for medical care and provide the care at government-run hospitals for free. You don’t have to pay for an insurance policy, you have to pay 5% more in taxes. In return, you have access to health care at any VA hospital. Include county hospitals if you need more access. Will the care be the best available? Probably not. Will everyone get a same-day appointment? Not likely. Will everyone have access? Absolutely. Do this and you could eliminate much of the costs that are currently wasted on insurance companies.

“What do you think still needs to be included in the health care bill?”

  • Malpractice reform. The AAJ has talking points stating how direct medical malpractice costs are an infinitesimal amount of total medical expenditures in this country. The statistics are true, but are only half of the story. The AAJ states that instilling fear in medical practitioners is good for medical quality of care. That fear drives defensive medicine. Defensive medicine accounts for hundreds of billions of dollars in indirect medical costs – at little gain to the system. If lawsuits improve quality of care, then the trial lawyers have failed. They’ve been suing doctors for decades and mistakes are still being made. The only thing that seems to go up is the size of the judgments. We can’t sue our way to better health care. Yes, I said that and yes the assistant laughed. I think he even wrote it down on his pad.
  • Damage caps are a tricky subject. Capping a patient’s damages at $250,000 isn’t fair to the patient, but neither is making a doctor liable for a $60 million judgment. There has to be some reasonable limit to damages, but even those limits won’t decrease the physician fear of being sued. [I actually agree with Matt on this point - in almost all cases, caps don't save physicians money, they save insurance companies money - but if insurance companies go out of business, hike rates, or stop offering coverage because of a $60 million judgment, physicians will have a more difficult time finding coverage and won't be able to practice. There has to be a happy medium].
  • Like it or not, we will likely need to provide some type of limited liability protection to certain providers if we want to increase the numbers of those providers. Few physicians like being on call at hospitals because they know that they probably won’t be paid for the care and that they are highly likely to be sued if anything goes wrong. We have to ask ourselves whether we value the ability to find a physician to care for us in an emergency more than we value the right to sue that physician if anything goes wrong. Which is more important to us: Perfect care or available care?

We had other discussions, but this post is already getting too long.

You naysayers want my ideas? Here they are.

Now try to show me how they won’t work and come up with some better ideas.

Shotgun Testing

Tuesday, April 27th, 2010

Part of a resident’s job is to learn the ropes in preparing for independent practice. While you’re a resident, you get the benefit of having someone looking over your shoulder to critique you as you determine how you are going to manage patients.

I frequently tell residents that different attending physicians practice medicine in different ways. Some practice defensive medicine more than others, some prescribe antibiotics more than others and some work harder than others. The resident’s job is to figure out whose practice they are going to emulate when they begin practicing on their own.

That being said, I usually practice conservatively. I don’t tend to shotgun a lot of cases. When residents present cases to me, I make them give me a differential diagnosis and justify why they order the tests that they order. If they can’t justify why they’re doing the tests, then I won’t approve the tests.

A resident rotating on the first day in our emergency department presented a case to me and his comments made me think.

A woman in her 40’s came in complaining of tender lymph nodes to her neck for the previous 36 hours. That was it. She had pain in her neck when she turned her head to one side and thought she had cancer.

The resident ordered a CBC, comprehensive metabolic panel, cardiac enzymes, coags, chest x-ray, urinalysis, influenza swab, and strep test. He wanted to know whether I wanted to do a soft tissue x-ray of the neck or a CT scan of the neck.

“So what do you think is causing the swollen glands?”
“Maybe strep, maybe cancer.”
“Why the cardiac enzymes and coags?”
“If it is cancer and she needs surgery, the surgeons require a baseline.”
“Any other symptoms besides the swollen glands?”
“Nope.”
“Why the urinalysis?”
“I figured they could do that while they’re getting the pregnancy test.”
“Why the pregnancy test?”
“She’s going to need x-rays, right?”
“We can’t do an abdominal shield?”
“Sure.”
“Is a $200 flu swab going to be worthwhile?”
“It could cause the swollen glands.”
“In a patient with no fever, no cough, no pharyngitis, and the incidence of influenza sporadic according to the CDC?”
“Didn’t think of that.” He was obviously getting annoyed. “Fine. What do you want me to order?”
“Anything else on the physical exam?”
“Not really. No nodes anywhere else. No signs of infection.”
“Let’s go look.”

I’m typing this case up on the fly and was going to finish describing the interaction, but then I thought that maybe you all would like to take a crack at guessing what was causing the bilateral tender lymphadenopathy in the patient’s neck.

I’ll give you a couple of hints, since the diagnosis was rather obvious on examination and therefore I can’t tell you what the exam showed. First, the resident didn’t perform a good physical examination and didn’t take a good history. Both of those would have led to the correct diagnosis.

Remember, the nodes were bilateral and the diagnosis was obvious.

What do you think?

I’ll post the answer in the comments in a couple of days.

UPDATE APRIL 29, 2010
The answer is posted in the comments section.
The point of the post was not to belittle the resident, but was more to make a statement about how another resident felt that residency training was lacking.

Another resident in our program lamented that most of their didactic teaching doesn’t involve close physical examination or a thorough history any more. She felt that the overwhelming teaching points during the residency program were to perform procedures and to work up patient complaints to avoid being sued: Take the patient’s chief complaint, order tests that can rule out all the things that doctors commonly get sued over, and have them follow up with their family physician. You make the diagnosis – great. If not – that’s why they have family practitioners. Patients with high risk complaints and any risk factors for bad outcomes get admitted.

I actually got pegged as someone the residents like working with because I make them think about what they’re doing  – although the resident above avoided me the rest of the day.

If defensive medical practice is as entrenched in our residency programs as this resident seems to believe, our system will get worse, not better with health reform. More “insured” patients will be dumped into the system, health care access will become more disjointed, and patient will end up bouncing from emergency department to emergency department getting shotgun testing that will rule out remote life threats and protect the physicians from lawsuits but that will never really get to the bottom of the patient’s problems.

This patient probably would have had a high WBC count if labs were ordered. Maybe she would have been discharged on antibiotics and improved without making the diagnosis. The cost to the system for the proposed workup, though, would have been immense. Is this the way we want to spend our health care dollars?

Until we address the fear of malpractice that drives defensive medicine (and I’ll even cede that some of that fear is irrational), we’ll never reduce our healthcare spending.

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