Look no further than the Wall Street Journal: “What if the Doctor is Wrong?” by Laura Landro.

As a substantive basis for the conclusion that initial treating physicians are “wrong” when they haven’t yet reached a diagnosis, Ms. Landro interviewed two patients who, in the midst of a workup, left the doctor who was trying to diagnose and treat their problems. Said patients then went to a “mecca” to have their workup completed where … amazingly … the problem is “discovered” and “properly” treated. Even though the initial provider in all likelihood would have done the same testing that the “mecca” performed after reviewing the results of the initial testing – had the patient stuck around long enough to have the testing performed. Even though the “standard of care” may have been to do things exactly the way that the initial provider was doing them. Nope, they’re wrong because they didn’t get to the answer sooner.

When reading about all these “errors” I couldn’t help wondering: Did Ms. Landro have a neutral physician review the patients’ medical records to see whether the care provided to the patients was appropriate? Did Ms. Landro interview the initial treating physicians to determine what the next step in their treatment plans would have been? If so, she kind of left those points out of her article.

I understand the idea that second opinions can be useful and I agree that misdiagnoses are sometimes made. Until we find a single test that is 100% sensitive and 100% specific for diseases such as cancer or complaints such as abdominal pain, there will always be misdiagnoses made. Even once a diagnosis has been made, there are disagreements about how to proceed with treatment. Some prefer one medication for treating certain types of cancer, some prefer another medication. Does that make one side “wrong” and the other side “right”? Hardly.

The title of this article and the slant of this reporting make it appear as if doctors are “wrong” just because they don’t make a diagnosis after the first round of testing. Did Ms. Landro even explore how often the “meccas” get their diagnosis “wrong” on the first visit? Are the “meccas” that much better?

If patients want to mortgage their house to get the tens or hundreds of thousands of dollars necessary for a “down payment” at MD Anderson (original link to WSJ article here) or some other “mecca” when they likely would have gotten similar testing done had they stuck with their initial providers, that’s free market medicine at work.

When journalists imply that excluding diseases on a list of differential diagnoses in the midst of a workup or coming up with “inconclusive” results during testing is “wrong”, shouldn’t we start looking into journalistic malpractice?

What if the Journalist is Wrong?

Internists in Dade County, Florida paid medical malpractice insurance premiums that were 1400% higher than internists in the state of Minnesota. Illinois internists in Chicago paid more than 12 times as much in malpractice insurance premiums as their Minnesota counterparts. In other words, internists in select Florida and Illinois counties pay more for malpractice insurance in one month than internists in the state of Minnesota pay for an entire year.

There are similar premium disparities for general surgeons and obstetricians, with Long Island, NY and Las Vegas NV also consistently being on the list for high malpractice premiums

Does that mean that the Florida and Illinois physicians were 1200% to 1400% more negligent than doctors in Minnesota? Doubtful. It just means that Miami, FL; Chicago, IL; Las Vegas, NV; and Long Island, NY are places where insurance companies have determined that it is much more risky to practice medicine.

When doctors search for the best states in which to practice medicine, they should consider the medical malpractice environment when making that decision. Given these statistics, doctors should not practice in Miami, Chicago, Las Vegas, or Long Island if they want to reduce their medical malpractice risk.

Yet Florida lawmakers reach out to news stations and claim that the state “desperately needs more doctors.”

Suing your way to better health care doesn’t work very well, does it, Senator Nelson?

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.

The FDA has just issued a “safety alert” stating that Zofran may now be potentially deadly.

The FDA is now recommending ECG monitoring in patients who receive Zofran who have potential “electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, bradyarrhythmias, or in patients taking other medications that can lead to QT prolongation.”

After all, Zofran has now gone generic like previous anti-nausea medications that have also received black box warnings. The FDA approved Zofran for use in 1991, meaning that Zofran has been on the market for twenty years.

Now, through diligent research, the FDA has decided that that Zofran may cause QT prolongation — just like most of the other anti-nausea medications. As a result, GlaxoSmithKline has been ordered to perform studies to determine whether Zofran could prolong QT intervals, and, if so, to what extent.

Since the FDA states that it has been performing “ongoing safety studies” … for the past twenty years … why doesn’t the FDA actually publish the results of those safety studies that led to the posting of its alarming “safety notice”?

Now we have one less medication in our armamentarium to treat nausea and vomiting.  I suppose we can always give ginger root until that gets a black box warning, too. It’s only been around for a few centuries.

Whoa. I think that my heart just skipped a beat. Reading FDA safety notices may have caused me to have QT prolongation. I think that we need to put black box warnings on FDA safety notices and no one should read them without proper EKG monitoring.

Who do we get to study that?

The Florida Agency for Healthcare Administration cited an emergency department’s staff for failing to give “adequate care” to 13 week pregnant patient before she had miscarriage of twins.

The timeline of events for the patient was outlined in this article.

At 9:45 a.m. the patient came to the emergency department with pelvic pain and vaginal bleeding.
At 10:30 a.m., the patient was diagnosed with pain and bleeding, a urinalysis and a battery of blood tests ordered, but there was no test ordered that would have revealed her glucose level. There was also no discussion of whether to discontinue or maintain the patient’s insulin pump. Ultrasound tests were ordered, then changed, which “caused a delay.”
At 11:45 a.m., the patient was bleeding heavily and was “in obvious labor” according to state inspectors. The ultrasound scan showed both fetuses had normal heart rates. The state inspectors stated that the emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
At 12:25 p.m., the physician performed a pelvic exam and suctioned some large blood clots from the vaginal canal. The patient then “spontaneously aborted one of the fetuses.” Inspectors noted that the patient was not informed of any risks of performing a pelvic exam, nor did she give informed consent for the pelvic exam.
A second ultrasound was ordered.
By 2 p.m., the second ultrasound showed a normal heartbeat in the remaining fetus. At that point “the doctor took no steps to stop labor or maintain the second pregnancy.” Additionally, the emergency physician’s report showed that the second fetus had no heartbeat, which conflicted with the radiologist’s report.
At 4 p.m., the patient’s blood-sugar level was measured and found to be “critically low.” She then received orange juice and IV dextrose.
At 5:30 p.m., an obstetrician arrived and performed a pelvic exam. He ordered no additional procedures or medications.
At 6:15 p.m., the woman passed the second fetus.

The inspectors stated that the physician failed to monitor blood sugar levels, failed to respond to the patient’s bleeding and pain, and failed to intervene to stop her labor.

In eight of ten other cases that inspectors reviewed, the hospital was cited for failing to document the amount of the patient’s blood loss, failing to record vital signs, and failing to record other case information.

We need more information about the other cases, but even without extra information, I’m still calling out the inspector and the Florida Agency for Healthcare Administration. Many of these citations are uninformed and inappropriate.

#1 No discussion documented about whether to continue or discontinue the patient’s insulin pump.
Such discussions are rarely held in the emergency department. Should the patient’s blood glucose have been checked sooner? Probably. However, if a patient is not having symptoms suggestive of low blood glucose, how often should the glucose level be checked — especially with an unrelated complaint? Should hospitals be cited when glucose levels aren’t checked in a diabetic patient with an ankle sprain or laceration?

#2 The emergency physician “failed to initiate any immediate response to the ultrasound report, the patient’s continued labor pains and the profuse bleeding.”
How much bleeding was there? What were the patient’s vital signs? Notice how the report is vague about the findings? Also notice how the report doesn’t state what the emergency physician should have done, and only made vague accusations about what the emergency physician didn’t do? Expert testimony like this in court would be tossed. In state investigations, it is apparently normal procedure. The treatment of bleeding during a miscarriage is generally either letting the fetus pass or performing a D and C.

#3 The patient was not informed of the risks and benefits of performing the pelvic exam and did not give informed consent.
This citation is so far out in left field, that it makes me wonder whether the inspector knows anything about medicine. It also puts the emergency physician in a no-win situation. Let’s say that the patient doesn’t consent to a pelvic exam – even though she’s having vaginal bleeding. Then the physician would have been cited for failing to do the pelvic exam.
But the physician didn’t discuss the risks and benefits of pelvic exams? OK, oh wise state inspector … what are the risks and benefits that the physician egregiously failed to discuss? Again, you and your department allege error, but then fail to provide all of us other dangerous physicians with the proper procedures to use.
Then there was no consent on the chart. The concept of “implied consent” is well established. If a patient with a gyne problem is told that the physician wants to perform a gyne exam and she gets up in the stirrups, chances are pretty good that she has consented to the exam. But, oh wise state inspector … what procedures require consent and do not require consent? Educate all of us dangerous practitioners. While you’re at it, give us some shred of written documentation that supports your assertions.

#4 After the patient passed one fetus, “the doctor took no steps to stop labor or maintain the second pregnancy.” This has to be the nadir of medical misinformation. Most pre-med college students know that a fetus is not viable until roughly 24 weeks of gestation. If a woman is having labor with a gestation less than 20 weeks, it is called a miscarriage. There is no treatment to save the pregnancy. A 13 week fetus is never, and will never be, viable outside of the uterus — unless the patient is a lion or some other member of the animal kingdom with a short gestation.
So, oh wise state inspector, exactly how should medical personnel “intervene” to stop the labor of a patient who is 13 weeks pregnant? You’ve accused the medical staff of doing something wrong, what should they have done different?

To illustrate the problems in lay terms, imagine being arrested for failing to drive the correct speed. You aren’t told what the correct speed is, you just have to pay a fine because you weren’t driving the correct speed. You have to apologize and promise to drive the correct speed in the future in order to keep your driver’s license.
Or imagine that you were arrested for failing to properly raise your child. No allegation as to what you should have done different, only the assertion that what you are doing is wrong.
These are they types of allegations that the inspector is making against the medical staff in many of these instances.

I hope that everyone realizes the significant effect that “investigations” such as this have on the access to medical care in the communities.

Doctors are publicly accused of inappropriate medical care.
The public trusts that the publicized accusations are accurate … when they may not be accurate.
Public perception that medical care at a hospital or by a caregiver is “bad” then increases.
Hospitals then increase expenditures to correct the publicized “bad” care and to comply with inane and unsubstantiated governmental citations.
Fewer funds are then available to provide medical care.
More doctors leave the state or leave medicine entirely because they’re sick of the administrative burdens.
More hospitals close.
Less care is available.
Safety is paradoxically worsened because fewer providers are available to manage patients.

Oh and throw in some unjustified lawsuits as well. You know that if a governmental agency states that doctors “didn’t do anything” to stop a patient’s 13 week old miscarriage, however uneducated and inappropriate the statement may be, the patient is going to believe that she was wronged and will find a malpractice attorney to file a suit against the physician.

Don’t take this post as me advocating for less oversight of medical practice in the states. I fully believe that there needs to be oversight of medical care and that dangerous physicians need to either improve or have action taken against their licenses. Investigations need to be based in sound medical practice, though.

The issue I have here is that the investigator in this case made multiple vague unsubstantiated and medically inappropriate opinions about several providers’ care and those opinions were taken as fact when instead they should have been recognized largely as calumny. Based on the investigator’s calumny, the hospital was cited and the medical practitioners were publicly chastised. I’d bet that there was action taken against the providers at work as well.

By the way, if someone can get me a copy of this inspector’s actual report, I’d love to post it for further discussion.

Yep, between the “three strikes” rule, the criminalization of medicine, the high medical malpractice premiums, and the quality of the state inspections, doctors would be plum crazy to practice medicine in Florida right now.

Sorry, Senator Bill Nelson, things like this are going to drive doctors away from a state that “desperately needs more doctors.” Have fun rearranging the deck chairs on your Titanic, though.

Now I see the absolute futility in trying to use logic to defend against lawsuits.

Tenet Healthcare has decided to settle the class action lawsuit against it for $25 million.

When the nation’s resources couldn’t even rescue many hurricane survivors, the hospital corporation was sued because of “insufficiencies in [its] backup electrical system” and because it did not have sufficient “plans for patient care and evacuation” during one of the worst hurricanes in the country’s history. The failed levees and the government’s lackluster response are not at issue, though. Plaintiff attorneys called those factors “irrelevant” to the responsibility that the hospital had in the face of the hurricane.

That leaves me wondering. What is a hospital’s duty to patients in the face of a disaster?

I’d ask the lawyers, but I’m sure that no one would answer. And the legal community apparently didn’t set the bar very high for itself during the same disaster. After all, courthouses and law offices in New Orleans were closed after Hurricane Katrina. For heck’s sake, the MAIL wasn’t even being delivered.

The problem is that the civil legal system works retrospectively, saying that “if only you took these measures, the injury would not have occurred” or “if only you hadn’t done this, the injury wouldn’t have occurred.” Of course, it is easy to determine what should or should not be done after the fact. Law is the ultimate Monday Morning Quarterback. I have never seen an attorney issue a press release stating that liability should never ensue if a person or corporation takes or avoids certain measures.

So what can we do prospectively to prevent similar lawsuits against hospitals in the future?

Not defensive medicine … defensive corporate action plans, of course.

I’ve come to the conclusion that everyone really needs to pay hospitals a lot more for providing health care.

After all, in the event of an invasion from outer space, it’s going to cost a heck of a lot of money to have laser canons mounted on top of every hospital in the United States to defend patients from aliens who are hell bent on sucking out the brains of infirm humans with extra-terrestrial soda straws.

The opinion was King v. St. Barnabas Hospital.

The facts of the case are that a 38 year old off-duty prison guard was playing basketball in the prison gym when he collapsed. Seven minutes later, medical clinic staff arrived to find the patient unresponsive and not breathing. CPR was started. A defibrillator was used to check the heart rhythm and the patient’s heart was in asystole, or “flat line.” The patient was defibrillated once – after one first responder thought the patient may have had episodes of ventricular fibrillation. The patient remained in asystole. No IV line was started and the patient was not intubated, even though the first responders had the equipment available. Six minutes later, a doctor arrived and inserted an IV. Epinephrine was given, but the patient remained in asystole and was pronounced dead.

The plaintiff’s expert – unnamed in the appellate opinion – testified that to a reasonable degree of medical certainty that defibrillating someone in asystole “eliminate[s] any chance of recovery for the patient” and that “securing the patient’s airway and administering oxygen is ‘vital’ to avoid hypoxemia.” The failure to provide IV medications “contributed to [the patient's] failed resuscitation and death and diminished his chances of survival.”

The trial court threw the case out, noting that the expert failed to show any studies showing survival rates of patients in asystole or whether medications given post-arrest improves a patient’s chances of survival.

The appellate court reversed the decision of the trial court, stating that the patient was “found in a life-threatening, nonresponsive state” and that ACLS protocols wouldn’t exist if there wasn’t evidence that the protocols improve survival.

I have so many issues with the case and the testimony that I don’t know where to begin.

Let’s start with the appellate court opinion. Dear justices: This patient wasn’t in a “life-threatening” state. He was dead … for seven minutes. Asystole without respirations equals death. If the medical personnel are able to revive a patient, they have brought the patient back from death. Failure to snatch someone out of the Grim Reaper’s hands should not be a compensable harm.

The expert’s opinions also bother me.
Yes, technically defibrillation causes “damage” to heart muscle. There is no evidence that defibrillation decreases survival or recovery for patients in asystole.
While it wasn’t known at the time the incident occurred, Dr. Gordon Ewy showed that delaying resuscitation for intubation actually decreases survival as well.
Failure to provide IV medications similarly has little effect on survival. Epinephrine doesn’t improve immediate survival or hospital discharge in cardiac arrest when AHA guidelines are followed. This paper (.pdf) shows that epinephrine actually tends to cause a trend toward less survival in cardiac arrest.

UPDATE: I forgot to check David Neuman, Graham Walker et al’s incredibly useful site “The Number Needed to Treat” regarding the utility of ACLS medications in cardiac arrest. Evidence-based opinion: 100% of patients receiving the medications “saw no benefit.”

A plethora of case law requires that expert opinions have some basis in fact. There was no basis for causation and there was little if any basis for the expert’s other opinions. A plaintiff should not be able to proceed with a case based on an unsubstantiated expert’s opinion about standards of care and causation. The circuit court was right to throw out the case. If the expert had some studies supporting his theories, he needed to put up or shut up.

I also thought it was … interesting … that the appellate court’s opinion identified the defense expert by name, but did not identify the plaintiff’s expert. Why was that? Afraid that the expert may take heat for his opinions if his name was published?

The appellate court took almost 2 years to come up with this opinion and then blew it.

Hopefully the New York Court of Appeals has better sense.

Man and squirrel fight it out in man’s driveway. Squirrel scratches him twice, man runs inside grabs BB gun and plugs squirrel ala Elmer J Fudd. Man then calls health department for advice about what to do. Health department tells him to go to ED for rabies shots. After waiting for 2 hours the following day in the ED, the patient is told that squirrels don’t carry rabies in the United States and he doesn’t need the rabies shots. Later he is billed $692 for the emergency department visit and doesn’t want to pay the $382 deductible.

The patient stated that “the health department and the hospital should get together and straighten it out.”

Should a hospital and physician be responsible for getting payment from third parties when patients don’t like the medical advice they have received? Isn’t that kind of like someone in a restaurant telling the owner to get payment from the noodle maker because the patron didn’t like the spaghetti?

I occasionally get asked to review charts from other emergency departments in order to determine whether the care provided was appropriate. One of the cases from a visit to a competitor emergency department is below.

A patient with a longstanding history of migraine headaches comes to the hospital for another one of her typical migraine headaches. Light aversion, noise aversion, nausea – all her usual symptoms. She ran out of her Imitrex and when she called her doctor for a refill, she was told to go to the emergency department instead. Her exam showed no physical abnormalities. She got a shot of Imitrex and a shot of morphine. Her headache improved and she was discharged home with her usual headache medications.

Two days later, her headache returned. She happened to be visiting family in a large city and went to the emergency department in a hospital where we often refer patients. This time she was having visual changes. The emergency department physician there gave her more Imitrex and morphine and called neurology to come see the patient. The neurologist evaluated the patient and discovered papilledema on her funduscopic exam. A lumbar puncture confirmed the diagnosis of pseudotumor cerebri.

Fine. The diagnosis may or not have been missed on the first visit. Assume it was.

I got asked to review the chart because the patient complained to the hospital administration. The patient was upset because two of the doctors at the tertiary care hospital told the patient words to the effect of “You’re lucky. If we hadn’t have caught this, you’d be blind in a couple of days.”

Are their self worth that low that they have to make inflammatory statements like this in an effort to aggrandize themselves? You didn’t call the docs involved. I checked. You didn’t request a copy of the chart from her emergency department visit. I checked that, too.

Statements like this, even if they are true, serve little purpose. The patient didn’t lose her vision. Her vision was normal. Woo hoo. You saved her. Don’t dislocate your shoulder patting yourself on the back.

Actually, statements like that do serve one purpose. They make it a pretty good bet that none of the doctors in our department will ever refer another patient to you or your your hospital.
And if a patient tells any of our docs about any of your screw ups, chances are pretty good that the rest of us will hear about it. Chances are also pretty good that our docs will let any other patients who might need your services in the future know about your mistakes and how you aren’t perfect, either.

Good work.

picture credit here

The case involved federal agents who went to a trauma center to question a patient in the emergency department who was being treated for a gunshot wound. During the questioning, another patient was brought in by ambulance for a gunshot wound. The detective watched as doctors “stuck their fingers into defendant’s chest wounds.” After the patient had been wheeled off to surgery, detectives confiscated the clothing that had been left in the room as evidence. The patient was later indicted for shooting the first gunshot victim. The patient-defendant then sought to suppress the evidence against him that was obtained in the emergency department, alleging that detectives were not lawfully present in the emergency department and that the incriminating nature of the confiscated clothing was not readily apparent.

The district court denied the defendant’s motion.

However, it was the reason for the denial that raised my interest.

In order for an officer to be “lawfully” in a given location without violating the Fourth Amendment prohibition against warrantless searches and seizures, the defendant can’t have an “expectation of privacy” where the evidence is obtained.

According to the district court in Georgia – and several other courts cited in the court’s opinions – patients don’t have an “expectation of privacy” in the emergency department. “A defendant does not have a reasonable expectation of privacy in an emergency, operation, or trauma room that the defendant shares with other patients and in which medical staff administers critical treatment.”

However, that whole “expectation of privacy” concept also applies to other areas of law, for example … photography. People can be legally photographed without their permission in public. That’s why paparazzi sit and wait outside their targets’ homes to take their pictures. People cannot be photographed without their permission in places where they have a “reasonable expectation of privacy” – such as in their home, in a hotel room, or in a bathroom. Otherwise, people would be free to videotape you through the cracks in your drapes.

So now it appears that in certain states patients have no privacy right in an emergency department. See a trauma patient being rolled in while you’re waiting in an emergency department bed in Georgia? This court opinion seems to give you permission to whip out your Nikon and snap away.

Or do courts plan to give different rights to those accused of crimes?

A copy of the full opinion, United States v. Martez Howard (1:10-CR-121-ODE, Northern District GA) can be found here (.pdf file)