DC Medical Malpractice & Patient Safety Blog

One hundred thousand preventable deaths from medical errors in hospitals each year: That is the usual statistic cited by patient safety advocates. It comes from a 10-year-old report issued by the Institute of Medicine of the National Academy of Sciences. The fact is, though, that the death and injury rate could be substantially higher. No one is sure, because no one is counting "adverse events" in a rigorous, systematic way, and evidence keeps piling up that hospitals under-report these events to health authorities and worse, cover them up.

An investigation by the New York Daily News of the city's municipal hospital system -- with eleven hospitals and 1.1 million patients treated last year, the nation's busiest city-run system -- found dozens of examples of failures to report egregious errors, and subsequent cover-ups including alteration of medical records to make it look like nothing had gone wrong.

The Daily News reported:

The coverups hid a trail of human suffering among patients who were maimed and relatives who were never told the truth about how their loved ones died or were injured unnecessarily.

The newspaper found a pattern of failures by state health authorities to act on evidence of fraudulent behavior in covering up the injuries. Moreover, it found that the state reporting agency itself was dysfuctional. According to the article:

The state is supposed to track and analyze all medical incidents and implement improvements. The problem is this oversight system — the New York Patient Occurrence Reporting and Tracking System (NYPORTS) — is a disaster.

Since 1999, all New York hospitals have been required to self-report a long list of medical incidents to NYPORTS, which in turn analyzes the incidents and implements patient safety reform.

Sunday NYPORTS barely functions. The Statewide Council that oversees it hasn't met in more than two years. Though NYPORTS is supposed to release "annual" reports, the last one filed is dated 2004.

To avoid needless injury, patients have to be vigilant about their own health care. That is why I wrote my book, "The Life You Save," which lays out a system of nine simple steps for patients to follow to get the best medical care and avoid the too-frequent disasters that happen in our fragmented care system.

Everyone who has had any medical or surgical procedure has signed a consent form -- usually lots of intimidating words, hard to read, and seldom explained well.

There is a better way, and it involves recognizing that true "consent" is not about signing a form, but it's about old-fashioned conversation -- a real dialogue between the doctor and the patient that gives the patient a chance to really understand what is about to happen to their body, and gives both doctor and patient a chance to start developing a bond.

Dr. Pauline Chen wrote a helpful column on the subject in the New York Times.

Quoting another doctor who has studied the consent process, Dr. Chen writes that "'Informed consent is about forging a partnership with the patient.'” And she says:

That partnership is essential and requires what Dr. Martin F. McKneally, a professor emeritus of surgery and bioethics at the University of Toronto in Canada describes as a “leap to trust.” Patients must feel they have a certain degree of trust in their doctors before they can give consent, and that trust is built, in part, from the kind of difficult conversations that can arise.

My comment posted on the Times' "Well" blog:

This article is another reminder of what I tell people as a patient advocate, and the approach I put into my book “The Life You Save”: “Informed trust is good; blind trust is bad. Ask questions until you’re really comfortable knowing what’s going to happen. It’s your body.” With conscientious doctors like Dr. Chen, this can really happen. (And contrary to what “Jack” says, the fact that it may be routine for the doctor doesn’t make it routine for the patient and doesn’t make it acceptable to rush through the consent dialogue.) The payoff for physicians is a much more accepting attitude by patients of the bad things that can occasionally happen despite good care. The payoff for patients is better care.

I wrote a column posted on Huffington Post about the ninth annual Patient Safety Day on Saturday, July 25.

Here's an excerpt:

As Congress tinkers with health care reform, lawmakers should listen to what a special group of advocates is trying to tell them. There is no better day to listen than Saturday, July 25, the ninth annual Patient Safety Day.

These patient safety advocates are laypeople who have turned their own tragic losses -- of husbands, wives, sons and daughters -- into personal crusades to make our hospitals and clinics cleaner, safer places so that others won't have to go through the pain they have experienced. And one demand that many of them express is that the medical industry become more open and honest in dealing with its tragic mistakes -- so that errors can become learning experiences.

Candlelight vigils are taking place across the country on Saturday to mark this date. The advocates who started this quiet annual commemoration do not have, for the most part, medical or nursing degrees, but they know patients and their families can make valuable contributions to improving the quality and safety of the health care system. I learned many of their stories while researching my book on how patients can protect themselves and get the best medical care by becoming active participants in their own care. These heroes of patient safety include people like ...

Web sites are proliferating that offer candid -- sometimes brutally so -- reviews by patients of doctors. The sites include Angie's List, RateMDs, Yelp, DrScore and Vitals.com.

Now some doctors burned by reviews are striking back. A growing number of them are asking new patients to sign up-front agreements promising not to post anything about them on-line, or in any other media, "without prior written consent," according to an article by Sandra Boodman in the Washington Post.

The ethics and legality of such "gag orders" are questionable. But to my lights, they serve a useful purpose: Any doctor who would be so sensitive to criticism that he or she would ask me to sign such an agreement is not a doctor whom I would want to trust with my life. Period.

As for the web sites themselves, they have varying amounts of useful information. RateMDs, for example, one of the biggest, covers some 200,000 physicians across the country, but most of the doctors have only one or two reviews. It's not fair to make a judgment about a doctor based on such a limited survey. I would want to see at least ten or more reviews of a doctor, and see how consistent the ratings were among the responders, before thinking this was useful information.

The popularity of these web sites is a sign of how hungry patients are for reliable information in making the important choice of a doctor. And the fact is that there is very little reliable objective information on which patients can make informed decisions. I devoted a chapter of my book, "The Life You Save," to finding a top primary care doctor, and another to finding a top surgeon. I believe there is no easy shortcut for the hard work of:

* Checking credentials to make sure the doctor is board-certified by one of the officially recognized boards (Michael Jackson's live-in doctor, for example, was not certified in anything).

* Experiencing the doctor's care, at least once, to gauge his or her listening skills and empathy. These are important not just for making patients feel good, but for making accurate diagnoses and giving patients confidence in the care plan the doctor develops.

* Making sure the doctor has adequate backup for when the doctor is out of town.

* Learning that the doctor is on staff at a good nearby hospital.

A detailed discussion of how to find top doctors and surgeons can be found in Chapter 5, Chapter 6 and Chapter 10 of "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Imagine if every 50-year-old woman thinking about whether to have a mammogram received the following "balance sheet" showing the "credits" and "debits" as understood by the latest research:

For every 1,000 women who have a yearly mammogram over the next ten years: Credits

1 woman will avoid dying from breast cancer

Debits
2-10 women will be overdiagnosed and treated needlessly

10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis

100-500 women will have at least one "false alarm" (about half of these women will undergo a biopsy)

These numbers appear in an editorial in the British Medical Journal in July 2009, written by Dartmouth researcher H. Gilbert Welch, M.D., in response to news that the British National Health Service had scrapped a proposed pamphlet that would have described the benefits of mammograms, but failed to talk about their downside.

The key comparison in the above balance sheet is the ratio of one woman's life saved for every two to ten lives harmed by overdiagnosis. The one-to-two ratio comes from a study three years ago by Zackrisson and colleagues. The one-to-ten ratio is from a more recent study by Gotzsche. The tipping point for women in deciding whether to undergo annual mammogram screening is probably somewhere on this sliding scale. The test might not feel worthwhile if ten women are hurt for every one helped, but might seem worth it if only two were hurt for every one helped.

As the author writes:

Mammography is one of medicine’s "close calls"—a delicate balance between benefits and harms—where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.
To inform that choice, women need a simple tabular display of benefit and harms—a balance sheet of credits and debits.

Unfortunately, medicine hasn't yet pinned down the precise numbers on the balance sheet. For now, women need to be informed that there are varying estimates, and they need to make their own decisions.

Readers should note that this discussion applies only to cancer screening in low-risk women who have no noticeable lumps; women who can feel a lump in their breast are in a different risk category and need to see a doctor promptly.

Everyone has seen the ads: for cancer of the breast, prostate, colon and now thyroid cancer -- urging Americans to get a test to see if they have cancer and can get early life-saving treatment.

The new thyroid campaign says: "Don't forget to check your neck." However, it's a rare disease that kills about 1,600 Americans a year, but that many millions now may worry about because of this well-meaning campaign.

The trouble with cancer screening, as previously discussed in this blog about mammograms and prostate cancer PSA screening, is that in completely healthy people who have no symptoms and no special risk factors, screening can turn up far more false alarms and bring about dangerous and unneeded treatment, than the good that is done when a few cancers are caught.

A new article by Natasha Singer in the New York Times makes this point about the new thyroid media campaign, plus a proposal by Florida Congresswoman Debbie Wasserman Schultz to spend $45 million in federal money on a campaign to teach women under age 40 about how to examine their breasts. Critics of that proposal, including cancer surgeon Susan Love, say there is no benefit in early testing of women in their 20s and 30s for breast cancer. Dr. Love wrote the congresswoman: "Once you have made women more 'aware' of their potential risk, you will have nothing to tell them to do!"

The U.S. Preventive Services Task Force, a group of independent experts, recommends routine screening for only a few kinds of cancers, and breast mammograms for women under age 50 are the weakest of their recommendations. According to the article:

for otherwise healthy people with no symptoms,[Dr. Ned Calonge, chairman of the Task Force] said, only a few routine tests have proven to significantly reduce cancer deaths among certain age groups. The task force recommends pap smears for cervical cancer beginning no later than age 21; regular mammograms to screen for breast cancer in women starting at age 40; and tests for colon cancer starting at age 50. And the task force notes that the evidence supporting the breast cancer screening is not as strong as for cervical and colon cancers.

Most other types of screening, meanwhile, have not been proved to reduce the death toll from cancer, said Dr. Kramer at the National Institutes of Health.

“You need a high bar of evidence to start advertising screening to healthy people, most of whom will not benefit,” Dr. Kramer said.

One important caveat: Nobody should ignore symptoms. Once something bothers you or changes or seems unusual, you are no longer in the category of routine screening. Your risk is much higher and you should be checked promptly.

I discuss the reality behind cancer screening numbers in Chapter 8 of my new book on health care, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst." The title of Chapter 8 is: “Should I Be Tested?” Why Understanding the Numbers Is Crucial.

A good book entirely focused on this topic is by Dr. H. Gilbert Welch of Dartmouth, called "Should I Be Tested for Cancer?: Maybe Not and Here's Why."

Medicare has just published new information that helps patients determine if their local hospitals have a dangerous "revolving door" problem with some of their treatments.

The revolving door happens when a patient is sent home but then has to be readmitted to the hospital within one month. That means either that the patient was sent home too soon in the first place, or didn't get appropriate followup care outside the hospital to prevent the need to be rehospitalized.

Medicare's Hospital Compare website has added "readmission rate" reports for all U.S. hospitals for three types of illnesses: heart attacks, heart failure and pneumonia.

USA Today has done its own analysis of the Medicare data and made it easier to search for hospitals near you.

I discuss finding a top hospital using the Medicare information and other tools in Chapter 14 of my new book on health care, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

They seem so benign -- those free samples of prescription drugs in bubble packs that your doctor hands out at the end of an office visit. But there are plenty of hidden costs in free samples, and two prominent doctors have written an essay asking that the pharmaceutical industry stop the $15 billion a year practice of what is called "sampling." In an article by Susan Chimonas and Jerome Kassirer (former top editor at the New England Journal of Medicine), they write:

The samples that drug representatives offer are almost never time-worn and well-tested drugs, nearly never generics, and usually comprise the newest agents on the market. As such, they expose patients to risks not yet identified in clinical trials. The experience with Vioxx is a case in point. By 2002, only three years after Vioxx was introduced, it became the most widely distributed sample [3], and two years later the drug was withdrawn from the market because of an excess risk of myocardial infarctions and strokes [9]. Needless to say, Vioxx was not the only drug given extensively as samples and later found to enhance risk. Samples given to pediatric patients have similarly been associated with notable safety concerns. In 2004, four of the 15 medications most frequently given as samples to children in the US received new or revised “black box” warnings from the US Food and Drug Administration within two years of approval [10]. Finally, patients may not be the only ones at risk from distribution of free samples. Physicians who offer samples to patients and fail to supply appropriate cautions and warnings about the use of these drugs may be subject to liability, along with the company that promoted the drug [11].

There are plenty of other problems with "sampling." It encourages casual use and misuse of potent drugs. It doesn't really help indigent people get affordable medications. It bypasses the pharmacist, who provides user-friendly educational pamphlets that can alert patients to potential problems with the drug.

The authors conclude:

The tradition of physicians dispensing samples has many serious disadvantages and is as anachronistic as bloodletting and high colonic irrigations. As the profession begins to slowly extract itself from the influential grip of industry, it must also deal with the undue influence of free samples.

The article is also reprinted in Public Citizen's "Worst Pills, Best Pills" newsletter.

In Chapter 7 of my new book on health care, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, I discuss the idea that safe and wise use of prescription drugs includes not taking a drug during its first five to seven years on the market. That's because the real hazards of a new drug are not well known until it has been widely used. For the same reason, it's a good idea to avoid free samples, which usually are newer drugs that don't have the safety track record of established drugs. The only exception is for "breakthrough" drugs that truly offer treatment where no drug was available before.

Patrick Malone's new book was featured on the Today show in an interview with Matt Lauer. Click here to see the video and read Chapter 2 of the book. The book is "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Topics discussed on the Today show interview included why you need to read your own medical records, guidelines for finding a top primary care doctor, and the importance of second and third opinions at every major medical crossroads.

A column in the New York Times by Pauline Chen, M.D., relates how a colleague of hers named "Ed" crashed and burned on his way to becoming a general surgeon, seemingly because of his difficulty in learning from his own mistakes.

The blog comments by both doctors and patients are revealing. Many make the point that physicians can deal with the stresses of medical practice, and become better at their craft, by being less obsessed with perfection and more open to working with others in a supportive, teamwork environment. I particularly enjoyed a comment (No. 121) from "Susan," that linked the issue to the recent story by Jane Gross in the Times about the Sisters of St. Joseph near Rochester, New York, who have figured out that putting the patient's wishes at the heart of the enterprise makes for more humane and better health care.

Here is the comment I posted on the Times' site:

Susan’s comment is right on target. A team ethic, and the recognition that “we’re all in this together” — patients included, goes a long way toward making the inevitable small mistakes a teaching moment rather than one step toward a disaster for the patient. And when disaster does happen, honesty is always the best policy. I represent patients in lawsuits against hospitals and doctors, and can say emphatically that the medical industry could greatly reduce its exposure to legal actions if hospitals and doctors would just respond with maturity and complete candor when mistakes happen.

One more change in philosophy could help reduce the toll of medical error. If patients were more involved at every step of the process, we could help nip a lot of disasters in the bud and get better care for ourselves and loved ones. There is much that we can do, starting with reading our own medical records. I just wrote a book about this called “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.” Chapter One can be read at http://www.lifeyousave.com.

Several letters to the editor in the New York Times have good thoughts on the critical topic of reducing hospital-acquired infections. It's important not just to exhort hospital administrators to try harder, but to set up incentives that reward safety and punish harm. One incentive not discussed in these letters is a national mandatory disclosure system. That would require hospitals to measure and publicly report all their infections. Consumers would then be able to make intelligent decisions about which hospitals to seek care at.

As previously discussed in this blog, Consumers Union has been advocating such a disclosure system for several years and has made headway in various states, but a national system is needed.

Chapter 13 in my new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, talks about, as the chapter title says: "The Scandal of Infections in Hospitals and Other Health-Care Facilities, and What You Can Do." Patients and family members can do a lot to enforce hygiene rules and avoid infection.

Many elderly patients suffer protracted, and expensive, deaths as health care providers pummel them with technological fixes for bodies that have already worn out. The dilemma is that while no doctor wants to give futile care that tortures more than it heals, no one also wants to be guilty of euthanasia or abandoning their patient.

A group of Roman Catholic nuns at a convent near Rochester, New York, has a new/old answer to this dilemma: Involve the patient in a warm and loving community where the patient's wishes are always paramount, but death is faced with realism, and care goals are clarified long before any final crisis. As Jane Gross reported in a beautiful article in the New York Times:

A convent is a world apart, unduplicable. But the Sisters of St. Joseph, a congregation in this Rochester suburb, animate many factors that studies say contribute to successful aging and a gentle death — none of which require this special setting. These include a large social network, intellectual stimulation, continued engagement in life and spiritual beliefs, as well as health care guided by the less-is-more principles of palliative and hospice care — trends that are moving from the fringes to the mainstream.

For the elderly and infirm Roman Catholic sisters here, all of this takes place in a Mother House designed like a secular retirement community for a congregation that is literally dying off, like so many religious orders. On average, one sister dies each month, right here, not in the hospital, because few choose aggressive medical intervention at the end of life, although they are welcome to it if they want.

“We approach our living and our dying in the same way, with discernment,” said Sister Mary Lou Mitchell, the congregation president. “Maybe this is one of the messages we can send to society, by modeling it.”

I recommend reading the entire article, which is one more example of a spirit that I have tried to imbue in my book, “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.” When patients become actively involved in understanding their own health care, they can make decisions that best fit their own values.

The recent news that an FDA advisory panel has proposed that Vicodin and Percocet be taken off the market because of their acetaminophen content has prompted a discussion about the overall safety of this drug, which is best known as Tylenol and is present in a number of both prescription and over-the-counter pain drugs.

The New York Times' Tara Parker-Pope had a good summary in her Well blog, in which she said acetaminophen is generally safe when taken within the maximum dosing guidelines of no more than four grams -- 4,000 milligrams or 8 extra-strength tablets -- per day. But there is one big exception that she didn't discuss: for people who regularly drink alcohol, the daily limit of acetaminophen should be much lower. I explained this in a comment to her blog entry. Here is the text of what I posted:

The link between acetaminophen and alcohol deserves to be clarified because it is not that straightforward but is actually pretty easy to understand. Regular alcohol drinking “induces” a metabolic pathway in the liver called P-450 2E1, making the liver more efficient at breaking down alcohol with this 2E1 enzyme. This happens within a few days of drinking 2 or 3 or 4 drinks a day. That’s why steady drinkers can “hold” their liquor better, because they are breaking it down faster and so less alcohol gets in the blood. When you stop drinking for a few days, the liver reverts back to its old self and so the first time you drink again, your liver is less efficient at breaking down the alcohol so you get a “buzz” with the first drink. Here’s how this relates to acetaminophen: The same 2E1 enzyme turns acetaminophen into the toxic byproduct (called NAPQI) that can destroy the liver. So regular drinking produces more 2E1 and hence more NAPQI, and the more acetaminophen you take, the more the NAPQI can overwhelm the liver’s other defense mechanisms and cause liver cell death. But here’s the twist: drinking alcohol at the same time as you take acetaminophen puts both drugs into the liver at the same time, competing for the same 2E1, and thus drinking at the same time actually can protect against liver damage. The deadly pattern is when a drinker gets sick, with the flu for instance, stops drinking and starts taking acetaminophen near the maximum 4 grams a day, and that can cause catastrophic liver failure (because the 2E1 has nothing else to do but turn the acetaminophen into the NAPQI). I know about this because as a lawyer I represented a number of Tylenol victims in lawsuits in the mid-1990s that helped get the alcohol warning onto acetaminophen labels. I took many depositions of the medical people at McNeil, the Tylenol manufacturer.

Anyone who drinks regularly should take no more than 2 grams of acetaminophen a day. Any liver specialist will tell you that.

I talk about what I call the safe and skeptical approach to taking medicines in my new book: “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.”

The news from Colorado that a drug-addicted surgery technician had exposed thousands of patients to the Hepatitis-C virus raises questions about the institutions' procedures for protecting patients.

According to news accounts, the surgery tech, Kristen Parker, swapped her dirty syringes, filled with saline, for clean ones filled with Fentanyl, in operating rooms at Rose Medical Center in Denver and Audubon Ambulatory Surgery Center in Colorado Springs. That way she could steal Fentanyl, a powerful morphine-based drug that is used for surgical anesthesia, and inject it into herself to feed her drug habit. Ms. Parker has just been charged in a federal criminal complaint.

The institutions are sending certified letters to 4,700 patients at Rose and 1,000 at Audubon advising them to get tested for Hepatitis-C. That's because Ms. Parker tested positive for Hepatitis-C, and several patients already have tested positive.

Hepatitis-C is a virus that causes chronic liver infection in about 75 to 85 of every 100 persons who get an acute infection. A few of those who get chronic infection go on to develop cirrhosis or liver cancer. There is no known cure for Hepatitis-C infection.

The Colorado Springs Gazette reports:

Parker worked at Rose from October 21, 2008 until April 2009. She resigned on April 20 from Rose, but the hospital refused to accept her resignation and instead fired her.
She went to work for Audubon shortly after being fired from Rose. She worked there from May 4 until Monday, said Dr. J. Michael Hall, Audubon's medical director.
Hall said certified letters are being sent to all patients who had outpatient surgery at the center's Circle Drive and Union Boulevard location May 4-July 1 advising them they may have been exposed and with instructions on what to do.

Surgical technicians are not licensed health care providers. Yet because their job involves preparing operating rooms for surgery, they have access to powerful drugs, so it's foreseeable the job can attract addicts. A similar incident occurred in Washington, D.C., a few years ago, where a tech at a major hospital was caught swapping out syringes filled with powerful pain reliever drugs for plain salt water so that he could inject himself with the narcotic drugs.

According to the Gazette:

Prior to being hired at Rose, she [Ms. Parker] submitted to a pre-employment blood test which tested positive for hepatitis C. She was allowed to start work but hospital officials counseled her about the disease and exposure possibilities.
Rose placed her on administrative leave following an incident in which a co-worker was pricked by a needle in Parker's pocket on March 23, 2009.
According to the affidavit, Parker quickly disposed of the needle and denied any use of narcotics. She was allowed to return to work after a drug screening test came back negative.
The hospital placed her on administrative leave again after a co-worker reported seeing Parker in an operating room to which she was not assigned. She was tested again for drugs and this time the results were positive for Fentanyl.

The questions yet to be answered include:

1. Why hire someone positive for a contagious disease like Hepatitis-C and give them access to needles which can spread the disease?
2. Why not fire her the first time she was found with a needle?
3. Why did the second institution hire her so quickly after she was fired by the first? Were references checked? Shouldn't she have been required to advise the surgery center who her most recent employer had been?
4. Should there be a central data bank so that health care employers can find out about fired or disciplined employees, so they cannot easily travel from job to job? There is such a data bank for licensed health care workers, but perhaps it should apply to unlicensed ones as well.

Malpractice payouts to injured patients and families declined for the third year in a row and amount to somewhere between 0.18% and 0.6% of U.S. medical costs, according to a new study from Public Citizen.

It would be great if improved patient safety was responsible for the decline, but that is highly unlikely, according to the consumer group's analysis, which said that the reduced payouts appear to be because fewer injured patients are being compensated.

The study also undercuts the idea that the system is glutted with large numbers of "frivolous" lawsuits. According to a press release from Public Citizen:

More than 80 percent of the money paid out for medical malpractice in 2008 was for cases involving "significant permanent injuries"; "major permanent injuries"; injuries resulting in quadriplegia, brain damage or the need for permanent care; or death, according to NPDB [National Practitioner Data Bank] reporting.

Despite the hysteria surrounding debates over medical malpractice litigation, experts have repeatedly concluded that several times as many patients suffer avoidable injuries as those who sue. The best known such finding was included in the Institute of Medicine’s (IOM) seminal 1999 study, "To Err Is Human," which concluded that between 44,000 and 98,000 Americans die every year because of avoidable medical errors. Fewer than 15,000 people (including those with non-fatal outcomes) received compensation for medical malpractice that year, and in 2008, the number receiving compensation fell to just over 11,000.

As an advocate for patient safety and author of a new book on how we can all improve the quality and safety of the health care we receive, I agree that the only humane way to reform medical malpractice is to take seriously patient safety and implement systematic improvements to cut the numbers of injuries.

Elderly patients are different. They are more sensitive to some drugs, less to others, have unusual presentations of common conditions, and otherwise are not that easy to diagnose and treat when the doctor is used to dealing with younger patients.

Bemoaning the lack of required geriatric training in medical schools, geriatrician Dr. Rosanne Leipzig gave this example in a recent op-ed piece she wrote in the New York Times:

Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.

Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.

This shouldn’t happen.

Dr. Leipzig co-authored an article for medical educators listing 26 areas of competency in treating elderly patients that medical students should have to demonstrate before getting out of school; the list is nicknamed the "Don't Kill Granny" list.

For the rest of us, the takeaway lesson is that when we're advocating for an elderly relative with a new doctor, we need to find out if the doctor has deep experience in treating elderly folks, and if not, ask for a second opinion from a doctor who does. This can make a huge difference in quality of medical care -- and quality of health for our relatives' twilight years.

More tips on being a patient advocate can be found in Patrick Malone's new book, "The Life You Save."

Having an ally to help you negotiate the health care maze can be absolutely critical to obtaining the best medical care, especially if you are sick enough that you're not thinking as clearly as usual. A patient advocate does not need any special training in medicine or nursing -- just an inquisitive mind and persistence in asking questions and getting answers.

As this blog has previously reported, patients in some parts of the country now can find professional patient advocates to help them. People who have tried it say these advocates are lifesavers who are worth every penny of their fee.

A group that does this for free with volunteers is called Bedside Advocates in the Boston area, founded by retired physician Jonathan Fine. The group was featured in a recent story by NPR health reporter Richard Knox. The problem is that volunteers working part-time can only help a limited number of patients, and the need is vast.

Nurse Dianne Savastano has set up a professional patient advocacy service, also in the Boston area. The NPR story quotes one of her clients, Barbara Porter, who hired Ms. Savastano to help manage the complex care needs of her elderly father, for which she pays Ms. Savastano $15,000 a year. Says Ms. Porter: "I tell him, 'Dad, you got resurrected.' He literally did get resurrected. He would either be dead or in a nursing home right now if it wasn't for Dianne."

Patrick Malone's new book, "The Life You Save," gives a list of pointers for how family members can become effective advocates for their elderly relatives who cannot manage their own care. If you live in an area with professional patient advocates, that should be an option you should consider. None of us can go it alone in this complex health care system.