Patient Safety Blog

The convenience of the Internet allows consumers to evaluate and compare their experiences with anything from piercings and dog walking to a visit to their doctor’s office. Although the website ratings may be helpful in an initial survey of local doctors, patients should not look to them as their sole source of information when determining to whom they’ll entrust their health care, says Dr. Pauline W. Chen in a New York Times article.

Dr. Chen noted that on a particular consumer reviews website, doctors are evaluated in five categories (price, quality, responsiveness, punctuality and professionalism) and given a grade according to user input. She found that doctors who are “warm, concerned and focused” receive A’s or B’s, whereas the less friendly may be given failing grades.

While these ratings correctly reflect the fact that patients feel more at ease with compassionate and caring doctors, one would be hard-pressed to find in these report cards an evaluation of the doctors’ medical skills. Such is not the case in consumers’ evaluation of other trades, such as roofing or body piercing, where they are quick to comment on the quality of services or craftsmanship.

Dr. Chen suggests that, instead of simply relying on some generic grades that could very well be a mere personality assessment, patients should find out about their doctor’s “training, board certification, experience, membership in a respected professional society, safety records and hospital affiliations.”

The American College of Surgeons found this year that more than a third of patients did not review the credentials of the surgeons who operated on them, but on average they spend 10 hours researching a job change or 8 hours on a new car.

Patients should not blindly trust their doctors. “[M]edicine and surgery are team sports,” said Dr. Thomas Russell, executive director of the American College of Surgeons. Patients make the ultimate decisions about who will give them health care and, in that capacity, they have an important role in the team. They should be diligent in educating themselves.

Dr. Russell’s book, “I Need an Operation…Now What? A Patient’s Guide to a Safe and Successful Outcome,” encourages patients to equip themselves with knowledge of their illnesses and doctors and be more effectively involved in their own treatment plan.

Patrick Malone has written a book on how consumers can be pro-active in their medical care. The book is: The Life You Save: Nine Steps to Finding the Best Medical Care and Avoiding the Worst. Read about the book here. It can be pre-ordered here on Amazon. Several chapters detail the steps needed to find both top primary care doctors as well as specialists.

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Posted In: Communication , Doctor-Patient Relationship , General

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Colonoscopy is widely known as a powerful screening/early detection test for colorectal cancer, capable of preventing, or so it was thought, up to 90% of cancers. However, recent studies show that colonoscopy misses many cancers, according to the New York Times in an article by Gina Kolata.

A newly published Canadian study documents the low success rate of colonoscopy in picking up cancer in the right side of the colon, an area where 40 percent of cancers occur. In the left side of the colon, the area directly above the rectum, where cancers should be easier to detect, colonoscopy missed a third of occurrences.

Does that mean patients should dismiss colonoscopy as an ineffective test? Quite the contrary. Although colonoscopy is now found to prevent only 60% of colon cancer deaths, it’s still “a good test,” said Dr. Ransohoff, gastroenterologist at the University of North Carolina. In the Times article, Kolata points out that colonoscopy works relatively well, in contrast with other screening tests: Mammograms prevent 25 percent of breast cancer deaths and the Prostate-Specific Antigen (PSA) test has not been proven to prevent prostate cancer deaths.

In addition, patients can help maximize colonoscopy’s effectiveness by doing their homework. Dr. Douglas Rex, Indiana University’s director of endoscopy and professor of medicine, said that polyps in the colons may be obscured if patients did not thoroughly cleanse the bowels. Taking half of the laxative the night before the test and the other half in the morning – a procedure not always done – can help clear out patients’ systems and improve the visibility of the inner wall of the colon.

Researchers also urge patients to seek out the best colonoscopists who are skilled in performing the test consistently. Patients should ask how many colonoscopies the doctor does each year (a good volume would be three to four colonoscopies a day), what percent of those turn up polyps (it should be around 25% in men and 15% in women; much lower suggests that the doctor is missing some), and how long the scope is in the colon (colonoscopists should take at least eight minutes to withdraw the endoscope; too short a time suggests a hurried look).

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Posted In: Cancer , Medical Error , Testing

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A torn meniscus that shows up on the MRI scan may not be the reason why your knee is hurting. For Cheryl Westein, who demanded an MRI and saw a torn cartilage on the scan, the culprit behind her painful knee was actually arthritis. Gina Kolata in a New York Times article reports recent scientific findings that further support what many physicians already believe: radiological imaging is a presurgical tool and “does not help with a diagnosis.”

Dr. Felson and Dr. Modic, in their separate studies, found that abnormalities in scans are common and are not conclusive evidence of a diagnosis. For example, 60 percent of healthy people who do not complain of back pain will turn out to have degenerative changes in their spines. Many abnormalities go away on their own in a few months, requiring no medical intervention.

Relying on scans for diagnoses can lead referring physicians to recommend “unnecessary or sometimes even harmful treatments, including surgery.” If the root cause of the knee pain is arthritis and not the torn meniscus, the pain will return even after a surgery repairing the meniscus, as the arthritic bones continue to wear down the cartilage.

It is important for patients to know that getting radiological imaging is often not the best way to find out what is causing their discomfort. More importantly, since scans reveal abnormalities that may not be “catastrophic findings”, doctors could be misled to recommend harmful regimens that result in extra expenses.

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Posted In: General , Medical Error , Testing

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Seroquel is an atypical antipsychotic drug used to treat mental illnesses, such as bipolar disorder and schizophrenia. But patients who take Seroquel are 70% more likely to become diabetic than those who don’t take this drug, a risk that the drug manufacturer AstraZeneca was aware of as early as 2000. Joe Schneider and Margaret C. Fisk of Bloomberg.com report AstraZeneca’s release of its internal studies that suggested causal links between Seroquel and “diabetes and related conditions.”

Not only should patients watch out for the increased risk of diabetes that Seroquel and similar drugs (they are in a class called “atypical antipsychotics,” including Abilify, Zyprexa, and others), they need to be aware of the mental illnesses that these drugs are approved to treat. A Reuters article reports that an AstraZeneca sales representative marketed Seroquel as a depression-treating drug to a physician, which is an unapproved use of the drug. Although it is not clear from the article what dangers are associated with treating depression with Seroquel, it is safest to limit use of these powerful drugs to what they're approved to treat.

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Posted In: General , Medications , Product Safety

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Despite reforms in medical training, many resident doctors are still sleep-deprived and therefore more likely to make mistakes than well-rested doctors in training, according to an Institute of Medicine study, as reported by Tara Parker-Pope of the New York Times.

In 2003, the Accreditation Council for Graduate Medical Education capped resident doctors’ working hours at 80 per week. Before that, young medical school graduates could average 110 hours a week. But even now, with the hours capped at 80 hours a week, the Institute of Medicine report reveals that there are common violations of the 80-hour cap, although residents rarely complain. Eighty hours itself is a demanding routine even without the excess hours.

Consequences of sleep deprivation are many – including irritability, impaired judgment, and inability to concentrate – and each of these can debilitate the doctors in performing and thinking through their tasks. For better patient care and the health of the resident doctors, the Institute of Medicine recommends allowing an uninterrupted nap time for up to five hours.

It's not clear from this latest study how reform will be instituted and who will pay for it. Leaders in the field acknowledge that it will be expensive to put in place the same kind of mandatory rest periods that workers in other industries, like truck drivers, have.

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Posted In: General , Medical Error

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Nearly every nurse can tell stories about doctors who yelled at them in public, threw scalpels across the operating room, ignored calls to come to a patient's bedside, or otherwise acted in an arrogant and abusive way. While this behavior used to be tolerated as an inevitable byproduct of working in a high-stress environment, health care leaders are increasingly recognizing that bad behavior can endanger patients' lives. And they're taking action. As the New York Times reports, the Joint Commission which accredits hospitals is urging hospitals to send disruptive doctors to anger management classes and to take other steps to curb abusive behavior.

The problem for patients is that for health care to work well, members of the health care team need to be able to communicate freely with each other, without fear of having their heads bitten off by someone with a superior attitude. Surveys have shown time and again that errors such as "wrong site surgery" or medication overdosing happen in part because someone who knew better, but who lacked status in the pecking order, was afraid to speak up -- or was ignored when they did.

The Times article reported how one boy with a shunt in his brain almost died because of his on-call resident’s arrogance. The resident dismissed the nurse’s warning each time when she called to inform him that the boy was showing signs that the shunt was blocked, telling her “You don’t know what to look for – you’re not a doctor.” The nurse eventually notified the attending doctor, who operated on the boy immediately and barely prevented brain damage.

At a California hospital, a baby died because the resident who feared the attending doctor, “who was notorious for yelling and ridiculing the residents,” didn’t call him about a problem with a fetal monitoring strip. This resident is only one in many others who don’t feel “empowered enough to speak up” about preventable tragedies that include doing the wrong surgery on patients, says Dr. Angood of the Joint Commission.

While patients are the direct victims of overstressed physicians (especially in neurosurgery, orthopedics and cardiology), nurses often bear the direct brunt of the abuse on a regular basis.

These doctors are a small minority, perhaps 3 to 4 percent of all practicing physicians, according to one doctor who gives anger management classes. But even that is too many.

Disruptive doctors are being challenged by nurses who are backed up by hospital officials, sent to anger management courses, or (eventually) dismissed by the hospitals. Hospitals are also developing ways to cultivate a better working relationship between doctors and nurses.

Disruptive and abusive behaviors create communication barriers that can interfere with diagnosis in addition to causing medical errors. But poor communications can be an issue even when there is no out-and-out abusive behavior. Often doctors just need to slow down and listen to their patients. The Washington Post's Sandra Boodman writes about a patient saved by a doctor who listened. Carol Welsh didn’t know she had something growing in her head until she saw a doctor who “[took] the time to listen” and figured out that an undiagnosed brain tumor was the cause behind her nausea, vomiting, weight loss and mental fuzziness. Dr. Clifford Henderson saved Welsh's life by finding the tumor and getting it removed. A few more weeks and she would have died. That there might be a brain tumor did not cross the mind of the previous doctor who treated her for five months.

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