DC Medical Malpractice & Patient Safety Blog

Infections in the large-bore tubes that keep patients in intensive care units alive are often lethal but readily preventable. A simple checklist of sanitary practices was proven to cut the rate of these "central line infections" to nearly zero. But that was in one chain of hospitals in Michigan. What about the rest of the country?

Peter Pronovost, the Johns Hopkins safety guru who ran the study in Michigan proving that these infections could be eliminated, was given big grant money by the U.S. government and private foundations to spread the learning to the other 49 states. So what has he found? Here's an excerpt from what he wrote recently in the Journal of the American Medical Association:

Hospital enrollment in the program has been surprisingly slow. In many states, less than 20% of hospitals have volunteered to participate. Some hospitals have reduced infection rates, most have not. Some hospitals claim they use the checklist, despite having high or unknown infection rates. Some hospitals are content to meet the national average, despite evidence that these rates may be reduced by half. Some hospital administrators say their patients are too sick; these infections are inevitable. Yet, intensive care units in several large academic hospitals have nearly eliminated CLABSIs [central line infections]. Some hospitals blame competing priorities for their inattention to these infections. If these lethal, expensive, measurable, and largely preventable infections are not a priority, what is?

Perhaps most concerning is the response from nurses in participating hospitals when asked: "if a new nurse in your hospital saw a senior physician placing a catheter but not complying with the checklist, would the nurse speak up and would the physician comply?" The answer is almost always, "there is no way the nurse would speak up." Doubly disturbing, physicians and nurses uniformly agree patients should receive the checklist items. What other industry would
accept a routine safety violation that is associated with the deaths of tens of thousands of patients and not be held accountable? The US health care culture still does not support the questioning of physician behavior.

That last sentence is perhaps the most chilling -- because it shows, once again, that many patients are going to be doomed to preventable injuries and death until the medical culture begins to change, and doctors get off their pedestal and join the rest of the team trying to keep patients safe.

Doctors repeatedly blame patients for the high rate of Cesarean sections in this country. As one claimed in today's New York Times letters column, parents demand "nothing short of a perfect outcome" from childbirth and sue when they don't get it.

The reality is quite different.

Here's what I wrote in a letter published in the same New York Times issue:

A fundamental patient safety issue is at the heart of our high C-section rate. The reason that hospitals must have staff “immediately available” for an emergency C-section is that when a mother’s uterus ruptures, the baby’s lifeline is cut off and brain damage begins in around 17 to 18 minutes, according to the best studies.

Rupture occurs in about 1 percent of vaginal birth after Caesarean (VBAC) attempts. That’s a high enough risk — with lifelong consequences to the child and his or her family — that only the reckless or the ill informed would tempt fate by trying delivery in a facility without an obstetrician immediately available to do an emergency C-section.

According to your article, hospitals complain of the risk of being sued for a bad outcome if they follow the old guideline of having the surgical team “readily available,” which allows calling in a team from outside the hospital, as opposed to “immediately available.”

We should not let semantics obscure safety. Instead of blaming lawsuits for the high C-section rate, the focus should be on hospitals that don’t want to invest the resources necessary to make VBAC safe for mothers and families.

Many patients (and a few doctors) continue to be amazed that the law requires that patients be able to obtain a copy of their own medical records. And reading them is good for your health, I and other patient safety advocates maintain.

Here's what I wrote on a New York Times blog about this:

Getting and reading your own medical records is Step One of the advice I give patients to become involved, intelligent, and actrive in their own care. There are at least three things the patient learns:

1. Am I communicating well with this doctor? Is the history of my problems recorded in the records recognizable to me and reasonably complete?

2. Is there some lab test result that I need to know about where the communications has fallen through the cracks somehow?

3. Are there any errors that need correcting?

These are vital questions that help patients get to the right doctor and make sure tragedies don’t occur. Top providers like Brigham & Women’s Hospital, the Cleveland Clinic and the Veterans system make it easy for patients to read their own records online. Eventually, we will all read our records routinely, and we’ll be healthier for it.

Read comments from other Times' readers here.

A lot of doctors fret about patients reading over their shoulders, but as a non-physician who reads medical records every day, I can say without doubt: It's a good thing.

A long article in the New York Times brings home the dangers of women undergoing disfiguring surgery or radiation for breast cancer they never had. The story is a familiar one to malpractice attorneys but not well enough known to the public: The critical job of determining if breast tissue is cancerous or not is sometimes left in the hands of inexperienced pathologists who are prone to error.

The problem is worse with diagnosis of "ductal carcinoma in situ" (DCIS), an early form of cancer that may or may not progress to truly invasive cancer. The criteria for DCIS are sometimes subtle and not all pathologists agree on them.

What can patients do to protect themselves?

As I write in my book, "The Life You Save," you should never have any kind of cancer surgery without at least one second opinion on the biopsy. You can have a top cancer pathologist review your tissue slides for a cost of at most a few hundred dollars, and it might even be covered by your insurance.

Second, make sure the pathologist who interprets your specimen has enough experience. The College of American Pathologists now says 250 cases a year are the minimum for competence in this field, and it is starting a special certification program for breast cancer pathology.

The Times' article features Monica Long, a nurse in northern Michigan who had disfiguring breast surgery for DCIS, only to learn later that she never had it. She also learned too late that the pathologist at her hospital had only seen 50 cases a year and was not yet certified in any kind of pathology when he gave the reading on her tissue.

Some women get so scared by the diagnosis of DCIS that they have BOTH breasts removed. As previously reported in this blog, having a healthy breast removed does not improve a woman's statistical odds of survival. And as many as two out of three cases of DCIS never progress to full-fledged cancer. But such is the power of the "C" word to frighten people into doing anything -- even undergoing mutilation unnecessarily -- to try to stay alive.

This makes it all the more imperative for the pathology community to develop better criteria for the diagnosis of DCIS, and to improve the certification program so that this scary diagnosis is not made unless it's truly warranted.

The Times' "Well" blog has compelling accounts written in by other patients. Click here to browse them.

Reading these stories compels me to make another point: Unless you are financially destitute, I think it's a bad idea to let insurance coverage drive important medical decisions. If the insurance company won't pay for getting a second reading on the biopsy, scrape up the dough and get it done yourself. You'll be glad you did.

Among other second opinion providers, the Armed Forces Institute of Pathology in Washington, DC, gives second readings at a modest cost.

A newly minted M.D. doctor wandering the halls of a hospital, working long hours with little sleep as he or she begins years of residency training, can be a potential disaster waiting to happen. That's the source of the old bromide about July being the most dangerous month to get sick, since that's when residency programs start their new year.

In theory, all junior doctors receive careful supervision from senior doctors in training and from full-fledged "attending" physicians. But in practice, in busy institutions junior doctors can work long hours with little supervision, and mistakes that cause injuries to patients can result.

In 2003, residency programs accredited by the official supervisory body, the ACGME, were required to cut resident work weeks from 120 to 80 hours. But in December 2008, the Institute of Medicine, part of the National Academies of Sciences, recommended more changes to improve patient safety in residency programs.

One of them was to end the practice of 24-hour shifts.

The ACGME is now following that advice, but only in part. As of July 2011, first-year residents will be limited to 16-hour shifts, but after the first year, residents will still be able to work a 24-hour shift. Many experts believe the longer shifts are dangerous for patient safety because of sleep deprivation.

The 16-hour limit for first-years is part of a series of recommendations being submitted to the ACGME board for final approval in a few months.

Sidney Wolfe, MD., head of Public Citizen Health Research Group, is critical of the failure of the ACGME to propose a 16-hour limit across the board. He says: "The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously."

In the new proposal, first-year residents would also be barred from moonlighting at other jobs and from being "on call" in hospitals.

See the article in American Medical News for more details.

A new survey in a medical journal says the overwhelming majority of doctors believe that defensive medicine is costing the nation billions of dollars a year and they need protection from malpractice lawsuits. But does it really add up?

There is no question that U.S. patients undergo many more tests and procedures than any other country, and that we don't show anything good for it in our health statistics compared to other countries with much more inexpensive care.

Doctors typically say their peers order unnecessary tests because the patient will sue them if they don't.

This has always struck me as a strange admission.

To get paid, doctors have to attest to the necessity of any test they order, so when they order these so-called defensive tests purely to protect themselves, they commit insurance fraud.

Of course, if there's any chance the test may help the patient by revealing a treatable problem, then the test was necessary and doesn't fall into the category of insurance fraud or defensive medicine. Yet many doctors seem to think it's only the extra threat of being sued for not ordering the test that pushes them over the line to ordering it.

The Wall Street Journal's Katherine Hobson wrote up the new survey on her health blog, which appeared in Archives of Internal Medicine, and drew some interesting comments from readers. One patient told his own story:

* Gerald wrote:

I have read comments here with interest. I have had a doctor tell me he was ordering a test on me more out of a fear of being sued, and that it “was probably not necessary.” I was shocked. I said, “Doc, you are telling me that if I have a brain tumor, and die, that is not a serious enough risk for me to have an MRI, UNLESS YOU COULD BE SUED FOR IT!” I had some severe headaches.

The doctor turned red with embarrassment, and perhaps shame. He apologized and said he did not realize what he was saying. He could only be sued if turned out to have a serious medical problem that could have been prevented by the test. He was admitting that my life was not enough motivation for the test, but if he could be sued for the lost of my life; then it was good motivation for the test.

The survey was not scientifically rigorous. As reported by the WSJ:

Researchers say that 91% of the 1,231 doctors who responded to their survey “reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits.”

The "belief" by a survey respondent that some doctors order tests only to protect themselves is a far cry from admitting that one personally does this.

Another commenter, who identified himself on the WSJ blog as Rod Tucker Esq., wrote:

Every survey such as this one should require that the doctors give their names and specific examples of the tests they had done which they did not feel were necessary. Then their patients could ask why they were forced to undergo these often harmful and usually painful tests and why they were forced to pay for unnecessary acts by the doctor. The insurance company could also refuse to pay because the test was by definition unnecessary.

No person in business (doctors get paid for their work and are by definition in business) has the right to demand that they get to mess up and not be responsible to the innocent person they hurt. So instead of trying to give doctors a free pass how about we treat them like everyone else and ask the cost of a test and decide for ourselves if it is necessary, just like we do when we buy anything else.