Archive for January, 2010

Study Finds Regional Hospitals Often Are Better At Preventing Medical Errors Than Academic Centers – Kaiser Health News

January 31, 2010

Wonder how places like Johns Hopkins and George Washington University Medical Center feel about this observation:  Study Finds Regional Hospitals Often Are Better At Preventing Medical Errors Than Academic Centers – Kaiser Health News?

One item of concern – other than the obvious failure to prevent medical errors at all medical facilities – are the comments of the medical students from Harvard Medical School who wrote an essay in the New York Times in which they acknowledged their unique position to observe and correct medical errors and their confusion about why this was not a focus of attention in the curriculum of medical schools in this country.

Have our medical schools lost perspective?  It’s wonderful for these extremely bright men and women to learn how to make a diagnosis, what tests to order and how to interpret them and all the other wonderful skills our medical training institutions offer.  However, ignoring the principle message relating to minimizing medical errors and patient safety contained in a report  written more than 10 years ago is disheartening.

Since the publication of the well-known Institute of Medicine reportin 1999 estimating that medical errors kill as many as 98,000 people a year, the topic has become part of the national conversation. More recently, a study in The New England Journal of Medicine and a new book, “The Checklist Manifesto,” by Dr. Atul Gawande (Metropolitan Books, 2009), have testified to the efficacy of surgical checklists and the value of encouraging all members of a surgical team to speak up about potential sources of error.

But so far, the conversation has been slow to trickle down to medical schools.

2008 survey by the Liaison Committee on Medical Education, which accredits United States medical schools, reported that two-thirds of medical schools mentioned patient safety in a required course, with an average of two sessions on the topic.

But another survey of 391 medical students by the nonprofit Institute for Healthcare Improvement found that four out of five felt their exposure to the topics of patient safety and quality improvement had been fair at best. And Dr. David Davis, senior director for continuing education and performance improvement at the Association of American Medical Colleges, told us there was “still some debate” about how and when to teach this material.

They’re confused on ‘how and when to teach this material’?  Try each and every course.

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Questioning The Change In Mammography Guidelines

January 31, 2010

Recently, I posted a blog on the new guidelines for mammograms  issued in November 2009 by the US Preventive Services Task Force.

A new posting on Medical News Today provides ‘the other side of the argument.’  Specialist in diagnostic imaging have questioned these new guidelines.  A recent article – Questioning The Change In Mammography Guidelines – takes the position that –

The methodology and evidence behind a widely publicized change in national mammography guidelines is questionable, according to a review in the Journal of Diagnostic Medical Sonography (JDMS), published by SAGE

For those who have been following the history of these ‘guidelines,’ you know that they have changed a number of times.  One wonders if they shouldn’t be required reading on Twitter for physicians so that they can keep up with the ‘standard of care’ when treating their patients.  Where will it all end?  Who knows.  I stand by the advice given in our prior post:

Perhaps the best advice – Women be knowledgeable about the recommendations and discuss them and their application to you and your risk factors for breast cancer with your gynecologist.  If you are a young woman or are unfamiliar with what a mammogram is all about, you may want to consider watching a video of what this test is all about and how it is performed.

Bariatric Surgery Can Be Safer Than Living With Obesity

January 31, 2010

For those of us in the law, who have litigated dozens of bariatric surgery cases, the following article from Medical News Today (Bariatric Surgery Can Be Safer Than Living With Obesity) must be read with the following paragraph from the article kept in the forefront when patients are decided WHERE to go to have this surgery performed:

To help alleviate a patient’s fears before surgery, the bariatric team ensures that patients and their families are thoroughly informed and comfortable with the procedure. Prior to surgery, patients undergo medical, psychological and nutritional evaluations, plus they attend two patient support groups and three educational classes.

Wondering what this surgery is all about?  It’s the medical term for what may commonly be called ‘weight loss’ surgery.  To get a basic understanding of the procedure as well as the ‘before and after’ care issues that are key to a successful procedure, here’s a video from YouTube.

Keep in mind that there are a lot of surgeons doing bariatric surgery; however, in most instances, the way you avoid a visit to your lawyer’s office is to chose the right surgeon and facility.

The American Society for Metabolic and Bariatric Surgery has a useful website on which there’s a patient primer about this procedure.  You can learn about the Centers for Excellence Program of the Society and get a listing of the members of the organization, who perform this surgery in your area.  It’s definitely worth checking out before you sign-up with a surgeon to have this potentially life-saving but nonetheless risky procedure performed.

Patients – Know Thy Physician!

What’s Going On? – Birth Weights In The US On The Decline

January 30, 2010

A recent article  in Medical News Today reports a perhaps concerning trend in lower birth weights for infants in the United States.  The research was performed by the Harvard Pilgrim Health Care Institute’s Department of Population Medicine, an affiliate of Harvard Medical School, and analyzed 15 years of data from National Center for Health Statistics Natality Data Sets, looking at 36,827,828 U.S. babies born at full-term between 1990 and 2005.

As the author of the Medical News Today article, Jessica Cerretani, points out, there are potentially serious concerns about this trend.

While the decline may simply represent a reversal of previous increases in birth weights, it may also be cause for concern: babies born small not only face short-term complications such as increased likelihood of requiring intensive care after birth and even higher risk of death, they may also be at higher risk for chronic diseases in adulthood.

This study was published in Obstetrics & Gynecology, February 2010, Volume 115, No. 2, Part 1.

Maybe that picture of the chubby little cherub was ‘just right.’

As the authors of the Harvard-based study noted:

Future research may identify other factors not included in the current data that might contribute to lower birth weight, such as trends in mothers’ diets, physical activity,stress, and exposure to environmental toxins. “There’s still a lot we don’t know about the causes of low birth weight,” says Oken. “More research needs to be done.”

Medical News: Sorting Out the Mammography Mess – in Hematology/Oncology, Breast Cancer from MedPage Today

January 30, 2010

Confused about when you should start undergoing screening mammography?  A recent article in medpage today –Medical News: Sorting Out the Mammography Mess – in Hematology/Oncology, Breast Cancer from MedPage Today – attempts to educate women about this seemingly ever-changing set of guidelines.

The article contains an audio interview with Dr. Len Lichtenfeld, Deputy Chief Medical Officer of the American Cancer Society, which is worth a ‘listen.’

This whole new discussion as to when women should get screening mammograms arose when the US Preventive Services Task Force issues its recent recommendations.

Perhaps the best advice – Women be knowledgeable about the recommendations and discuss them and their application to you and your risk factors for breast cancer with your gynecologist.  If you are a young woman or are unfamiliar with what a mammogram is all about, you may want to consider watching a video of what this test is all about and how it is performed.

RISKY BUSINESS: NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor

January 30, 2010

In December 2003, ACOG, the American College of Obstetricians  and Gynecologists, issued a Practice Bulletin (#49) for its members, in which it recommended the use of intrauterine monitoring of contractions during augmentation or induction of labor in select patients, such as those suffering from obesity.  There were some obstetrical organizations who were recommending the routine use of internal contraction monitoring to assess contractions more accurately.

Of course, the intent behind such recommendations was ostensibly to provide the attending obstetrician with better/more accurate information with which to make clinical decisions regarding the need for an operative birth (i.e. C-section or instrument assisted birth), dosing effectively with oxytocin nad avoidance of complications in such labor situations – the common end-result being to improve fetal and maternal outcomes in such deliveries.

On the other side of the risk/benefit equation, it is only common sense that the use of an internal monitor would increase certain risks – the medical literature speaks of the most common of these as being placental and/or fetal vessel damage, infection and anaphylactic reaction.

A new study by the Academic Medical Center in Amsterdam, led by Jannet J. H. Bakker, MSc, and reported by The New England Journal of Medicine on January 28, 2010 – NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor raises serious questions about the use of such monitoring when one applies a science-based risk/benefit analysis.

The study reports in pertinent part:

In summary, the results of our trial do not support the routine use of internal tocodynamometry for monitoring contractions in women with induced or augmented labor.

In this multicenter, randomized trial we found no significant difference in rates of operative delivery with internal tocodynamometry as compared with external monitoring of uterine contractions among women in whom oxytocin was used for induction or augmentation of labor. On the basis of the lower boundary of the confidence interval around the observed relative risk of the primary outcome, our data are plausibly consistent with no more than a 9% reduction and up to a 20% increase in the risk of operative delivery associated with internal tocodynamometry. For cesarean section alone, plausible results range from a 17% reduction in risk to a 30% increase in risk with internal tocodynamometry. These results are in concordance with those of three previous small trials that compared internal and external uterine monitoring (each including between 127 and 250 patients), all of which showed a nonsignificant increase in the frequency of cesarean sections in the internal-tocodynamometry group.

Our trial also showed no significant difference between the two types of monitoring in the rates of adverse neonatal outcomes, rates of use of analgesia or antibiotics, or time to delivery. Similarly, none of the earlier studies showed significant benefits in terms of other maternal or neonatal outcomes with the use of an intrauterine pressure catheter.

For a full review of the patient population, the limitations of the study, please refer to the NEJM article.

Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today

January 23, 2010

Over the course of my career in litigating  catastrophic newborn injury cases, a rather common  ‘defense tactic’ involves trying to prove a limited life expectancy for these catastrophically injured children.  Essentially, defense lawyers attempt to convince a jury that such children have a very limited chance of survival for more than 8 to 15 years of life.  The reason for this approach is  quite simple – the shorter the period of time that such children survive, the lower the potential damage award for future care needs and future pain and suffering.

Lawyers for the inured child and family, on the other hand, contend that with appropriate medical care, such children will live a relatively normal life expectancy – therefore, there is an absolute need for a substantial amount of money for future care needs.

The issue often becomes:  given a certain type of injury, what is the ‘probable’ life expectancy for such children?

A recent study published in the British medical journal, The Lancet, and reported in MedPage Today on January 19, 2010,  provides some further insight into this issue.   Medical News: Survival Rates Vary with Congenital Anomalies – in Pediatrics, General Pediatrics from MedPage Today.

It has long been suspected that if a child is unable to protect his/her airway because of an inability to roll-over and clear secretions, that child is at increased risk for breathing complications – potentially leading to early death.  A number of limited studies are cited for other ‘factors’ leading to limited life expectancy.

This new study offers some interesting insights into various types of anomalies and the probability of survival for children suffering from them.

Just a sampling of the data (see the article for more details) gives a sense of the ‘predictability’ of survival based on specific defects:

The investigators analyzed survival among specific subtypes of anomalies and found rates of 20-year survival exceeding 95% for the following:

  • Ventricular septal defects, 98.3% (95% CI 96.6 to 99.1)
  • Pulmonary valve stenosis, 98.1% (95% CI 96.1 to 99.1)
  • Cleft lip and palate, 97.7% (95% CI 94.6 to 99.1)
  • Atrial septal defects, 96.3% (95% CI 93.3 to 98)
  • Cleft palate, 96.3% (95% CI 92.8 to 98.1)
  • In contrast, subtypes with less than 50% one-year survival included arhinencephaly/holoprosencephaly, common arterial trunk, and hypoplastic left heart.

    What the study also goes on to say, however, is that certain conditions, survivability is contingent on the quality of care being provided to these children.

    What is obvious and beyond any argument is that funding is desperately needed for further long-term studies to clarify this issue for not only the physicians rendering care to these children, but also for the parents seeking a clearer picture of what the future holds for their families in terms of financial needs and planning.

Physician Warning – Opioids – ‘Know Thy Patient’ – Reuters Health – News Page

January 19, 2010

For those lawyers, such as those in our firm, it is well known that there is a true risk to a patient/client on prescribed pain killers/opioids that such people may well become addicted and ‘at risk’ for greater harm – namely a lifetime of addiction or even worse – death.

There is an important posting in today’s Reuters Health – News Page,which speaks to this issue quite well.

A well-placed quote from a physician with the Centers for Disease Control summarizes the problem:

As a society, we have underestimated the possible risks from the dramatic increase in use of opioids,” said Dr. Leonard Paulozzi of the U.S. Centers for Disease Control and Prevention, who was not involved in the new study.

The study, conducted by a team headed by Michael Von Korff, ScD, a  senior investigator at Group Health Research Institute, was  published in the Annals of Internal Medicine and is summarized well in a posting found at ScientificBlogging.com.

From our standpoint as lawyers, in terms of good medical practice and standards of quality care, the key elements of interest were outlined by the author:

The team said that this research and the data reviewed cannot determine whether higher doses are a cause of overdose, but he noted that physicians should carefully evaluate and closely monitor patients using opioids long-term. (emphasis added)

Previous research had not tracked nonfatal overdoses. “Fatal overdose may be only the tip of the iceberg,” said Dr. Von Korff. “For every fatal overdose in our study, 7 nonfatal overdoses occurred, and most of the nonfatal overdoses were medically serious.”

The keys – ‘evaluate’ and ‘monitor.’  How many times over my 35 year career have I heard stories of patients ‘doctor shopping’ and dealing with the receptionist or office nurse in the seemingly never-ending quest to just get more drugs.  Their motives are rarely for financial gain – they are simply out of control and in need of good, quality of care oversight and monitoring.


Parents – be aware and read this article: Children Don’t Have Strokes? Just Ask Jared About His, at Age 7 – NYTimes.com

January 19, 2010

The New York Times reports a fascinating story about a 7 year old boy, Jared, who one day was a healthy, happy, fully functioning boy and a few short days later was lying in a hospital bed unable to walk, virtually unable to speak and hooked to tubes and wires to support his life.

NY Times photo of Jared

The theme of the story – Children Don’t Have Strokes? Just Ask Jared About His, at Age 7 – NYTimes.com – relates to a medically inaccurate concept – ‘children don’t have strokes.’

The author of the article, Jared’s father, has sage advice, based on accurate medical information:

How little we knew. It turns out that stroke, by some estimates, is the sixth leading cause of death in infants and children. And experts say doctors and hospitals need to be far more aggressive in detecting and treating it.

Dr. Rebecca N. Ichord, director of the pediatric stroke program at Children’s Hospital of Philadelphia, who continues to be deeply involved in Jared’s care, said that while conditions like migraines and poisoning could cause similar symptoms, “front-line providers need to have stroke on their radar screen as a possible cause of sudden neurologic illness in children.”

The sixth leading cause of death in infants and children and many in the medical profession believe that ‘children don’t have strokes’?!   Maybe, just maybe, the article has some wisdom not only for parents – but perhaps also for the doctors treating these children.

The ‘Times’ article has a good link for a basic understanding of the signs and symptoms of stroke.  Take a moment and familiarize yourself with these so that when you are told ‘children don’t have strokes’ – maybe you can ‘share’ the news that this is nonsense so that precious hours of needed care are not wasted!

Boston Anesthesiologist Charged with Fraud: The United States Department of Justice – United States Attorney’s Office – District of Massachusetts

January 18, 2010

This past Friday, January 15, 2010, the FDA issued an announcement regarding a criminal information/charge being filed by the United States Department of Justice against Dr. Scott Reuben.  The details of the charge are contained in the official announcement of the DOJ – The United States Department of Justice – United States Attorney’s Office – District of Massachusetts.

In essence, here is the nature of the charge:

The Information alleges that REUBEN solicited and obtained research grants from pharmaceutical companies to perform research studies on pain management, often associated with various surgical procedures, but that he did not actually perform the research studies. Instead he made up patient data, submitted it to medical journals and caused false articles to appear in a number of medical journals.

If convicted on this charge, REUBEN faces up to 10 years imprisonment, to be followed by 3 years of supervised release and a $250,000 fine.

As the DOJ correctly notes, this is only a charge against Dr. Reuben.  To use its words, “The details contained in the Information are allegations. The defendant is presumed to be innocent unless and until proven guilty beyond a reasonable doubt in a court of law.”

It does make you wonder, however, just how carefuly so-called ‘peer reviewed’ articles and research papers ARE scrutinized and ‘reviewed.’