DC Medical Malpractice & Patient Safety Blog

In 2010, when he was hired as medical director of Bakersfield Family Medical Center (BFMC), a professional network, and then, a year later, at another, Communities Physician Network (CCPN), Dr. John S. McGee had a pristine, 20-year reputation in internal medicine. The physician networks are intermediaries among managed care plans.

McGee did well with his new responsibilities—in 2011 he got a boost in salary and benefits.

So why, in June 2012, was he was fired?

According to a lawsuit he filed against the medical groups’ corporate parent, "Despite Dr. McGee's highly successful performance as medical director, defendants continuously threatened and pressured Dr. McGee and his staff to disregard patient safety in order to further increase profits," as reported by the Bakersfield Californian.

The suit, according to The Californian, enumerates several instances of the physician networks putting a priority on profits over patient care. It alleges that McGee and other employees were pressured to increase the denial rate for out-patient service requests "without consideration of the nature of services requested and utilized or their medical necessity."

In April 2012, McGee and his staff met with a corporate administrator to discuss their concerns that changes made by nonphysician employees and managers to were "compromising patient care" and, the paper says, increasing the risk of disease and death.

Some of the concerns were:

• Managers canceled McGee’s order to transfer a patient for surgery and, instead, sent the individual to a facility that couldn’t provide the needed care, delaying by days the transfer to the facility ordered by McGee.


• Managers and nonphysician employees regularly delayed or denied transfers of pediatric patients to a local hospital and instead tried to send them to facilities with which the company had contracts in cities several hours away.


• Managers and nonphysician employees delayed requests for air-ambulance transport to distant facilities, even in life-threatening situations. In the rare cases when air-ambulance transfer was approved, McGee and his staff were berated for using it.

After that grievance-airing, McGee was summoned to a meet with administrators, criticized and told to fire an experienced nurse case manager who had participated in the earlier meeting. The order appeared to be retaliation for expressing patient care concerns, and intended to drive a wedge between McGee and his staff. In short, it looked like a threat of termination for anybody who advocated for patients if it compromised profits.

McGee’s complaint says that the networks’ CEO “repeatedly and regularly challenged the medical decisions made by Dr. McGee and his staff, and directly confronted and debated treatment with the companies' hospitalists, the member's treating providers, and even the patients themselves directly, based exclusively on financial considerations."

California law prohibits employers from retaliating against employees who lodge complaints about patient safety. McGee says that in violating this law, the medical groups put artificial limits on patient care. "Dr. McGee went to bat with for those patients and was terminated for it," his lawyer told The Californian.

John Metz, executive director for the health-care advocacy group JustHealth, has seen this sorry scenario before. Although he could not comment on McGee’s case specifically, he told The Californian that plenty of medical gatekeepers make treatment decisions based on the financial interests of providers and their executives, not on best medical practice.

"We've been seeing this for decades," he said.

It’s impossible to know the extent of patient harm as a result of this mercenary approach to medical care, but it surely is considerable.

For the first time since 1994, the American Psychiatric Association (APA) has approved a revision to its primary guide, the Diagnostic and Statistical Manual of Mental Disorders (DSM).

It’s the fifth edition of the manual, dubbed DSM-5, which is like the dictionary of mental disorders. Its definitions are the foundation of how mental disorders are treated -- and how and whether that treatment gets compensated by insurance companies. The book’s formal release is in May.

We wrote about how the new DSM is likely to address substance abuse in our blog earlier this year. As described on MedPageToday.com, more than 160 clinicians and researchers worked on the DSM-5, assisted by hundreds of other clinical investigators and thousands of comments from health professionals and the general public.

Significant changes since DSM-4 include an end to the system of "axes," which classify diagnoses into broad groups. Instead, diagnostic groups will be restructured so that disorders believed to be biologically related fall under the same headings. There’s also now a measure to indicate the severity of symptom.

If that seems rather science-y—that is, something that might make you ask, How does this affect me?—well, NPR has some ideas how theory will filter down into practice. There’s always controversy when the DSM is revised, and the DSM-5, NPR says, is the most controversial edition of all.

Until May, there’s only speculation about the exact nature of its changes. But, according to NPR, these are likely to be among them:

• Elimination of Asperger's Syndrome. It’s a popular diagnosis often used by mental health professionals to identify people with mild autism. Instead, look for a spectrum of autism, and people who would once have been diagnosed with Asperger's will instead be diagnosed as mildly autistic. Many people with Asperger's syndrome oppose this change.

  As posted on MedPage Today, a statement from the chief science officer for Autism Speaks said the group remained "concerned about the impact of the new DSM-5 criteria when they are used in real world settings. The field trials are somewhat reassuring that the criteria are working well, but these trials are based on a relatively small number of children. We still have very little information about the impact of the DSM-5 on diagnosis of autism spectrum disorder in young children and adults."

  The group is concerned that autistic kids might be classified out of that diagnosis to a lesser one. As the statement continued, "We want to make sure that no one is excluded from obtaining a diagnosis and accessing services who needs them."

  As explained on NPR, if the disruptive behavior of a child is deemed to be a disorder — like attention deficit hyperactivity disorder (ADHD) or autism — schools pitch in with subsidized services. If not, kids can be seen simply as troublemakers, and can be penalized for behavior they might not be able to help.

• Advent of a new childhood disorder called disruptive mood dysregulation disorder. This proposal is the result of many clinicians believing that too many children were being categorized as having bipolar disorder and prescribed anti-psychotic drugs. The hope is that the new diagnosis will mean fewer kids are overdrugged and that diagnoses of bipolar diminish.


• Revision of the concept of bereavement. DSM-4 warned psychiatrists away from diagnosing major depression in people who had recently suffered the death of a loved one because grief in the face of loss was seen as a normal — not abnormal — response. Such a response is not illness, but an appropriate human experience. But telling psychiatrists that people who are grieving shouldn't be diagnosed as depressive, as one expert said, "excludes a bereaved person from being diagnosed with depression, if they have a depression, and no one wants to do that, either."

  If it seems like hair-splitting, NPR suggests that there’s a broader lesson: the expansion of behaviors considered abnormal, such as when shyness becomes "social phobia," and restlessness becomes ADHD.

Such is the torturous terrain of the human mind. As Dr. Roger Peele, secretary of the APA observed on NPR, "It's important that people not see the DSM as a bible, that they respect it but don't worship it."

The researchers, Peele said, worked hard to make the manual as good as they could figure, but its wisdom is really just their best guesses about how to think about mental disorders and, by extension, treat them.

The New York Times' Benedict Cary wrote an excellent piece this week summarizing the various controversies surrounding the new DSM and how they were worked out.

For many people, the word “melanoma” often prompts the same response as the word “snake”— fear and, if announced as a personal warning, panic.

Indeed, the worst form of skin cancer can be deadly if ignored or treated improperly. Several years ago we sued a dermatologist whose dereliction in treating a patient with moles led to his death. But like so many other kinds of cancer, many people are harmed because their symptoms or their disease is overtreated by fear-mongering surgeons. This was the case in a story published in the Archives of Internal Medicine called “What the Surgeon Should Have Said to My Patient with Thin Malignant Melanoma.”
The writers, two medical doctors, explained how the patient presented with a colored lesion on his shoulder. A simple biopsy revealed a stage 1A malignant melanoma which, on a relative scale, is a small, early-stage cancer. This one was 0.5 mm deep. It had no ulceration nor evidence of palpable lymph nodes, either of which should have raised more questions. The surgeon, who specialized in oncology, played the fear card in encouraging the patient to have a procedure known as a sentinel node biopsy.

According to the authors, he said, “It is up to you, but you have a risk that there is spread into your lymph nodes. It has been shown that patients with nodal disease operated on at an early stage do better than those having total lymph node resection at a later stage when an enlarged lymph node is palpable. By doing this procedure, I could save your life.”

A sentinel node biopsy involves injecting a radioactive substance, dye or both near the tumor. Then the surgeon uses a probe to locate the lymph node(s) containing the injected marker—that’s the “sentinel.” The affected nodes are removed and analyzed for the presence of cancer cells. The point is to see where cancer cells are likely to spread from the primary tumor.

As noted in a companion story in the same publication, performing sentinel node biopsy on patients with early-stage melanomas is not considered best practice. But nearly 1 in 10 such melanomas are overtreated with such invasive procedures. About 30,000 of these melanomas are diagnosed every year, so thousands are overtreated in this way.

The risks of sentinel node biopsy include:

• infection;


• hematoma (swelling of clotted blood caused by a break in a blood vessel wall);


• nerve damage.

In addition, the procedure can cost about $15,000.

Patients in the only scientifically sound study on sentinel lymph node biopsy had lesions that measured at least 1.2 mm. The death rate from malignant melanoma was nearly identical in the group with sentinel lymph node biopsies compared with those whose lymph nodes were biopsied only if enlarged. But patients with microscopic disease did better than those with lymph nodes that were enlarged and palpable.

The journal writers note that it’s wrong to compare outcomes of patients with palpable nodes with those who have normal-sized lymph nodes, because the latter group’s disease is at an earlier stage, and when it’s discovered incidentally is usually less aggressive. In short, it’s possible that their positive sentinel nodes might not progress because of the body's natural immunity. “The unambiguous finding of this trial,” the writers reported, “is that there was no advantage of sentinel node biopsy over observation.”

The surgeon in this case not only was too eager to practice his skills, he was malfeasant; he neglected to discuss treatment options with his patient and their possible side effects weighed against their benefits.

According to the journal authors, the surgeon should have said, “A wide excision alone [cutting around the lesion] gives you an excellent chance of cure. No studies have shown that sentinel node biopsy will improve your chances, and we do not know if you would benefit from the discovery of microscopic lymph node disease.”

If you want to more about melanoma and how to assess the value of treatment options, link to the website LifeMath.net, which tries to make sense of “the enormous number of fundamentally discrete events that occur among the many molecules, genes, and cells of which we are comprised.” Click on the cancer and melanoma tabs.

Here's a discussion on our firm's web site about the vital issue of "informed consent" in medicine.

Too many people are being exposed to life-threatening infections because clinicians fail to follow safe practices when administering medicine by injection or infusion.

According to a recent study in Medical Care, the journal of the American Public Health Association, at least 130,000 patients were put at risk between 2001 and 2011 for pathogens including hepatitis and HIV.

As the Centers for Disease Control and Prevention (CDC) noted in response to the study, “In this age of high-tech care, it is difficult to imagine that these types of basic infection control breaches still happen.”

The study showed that exposure to dreaded viruses was the result of reusing syringes, reusing and mishandling medication vials, containers and insulin pens and narcotics theft.

Specifically, the CDC says that disease transmission occurs most commonly from:

• using the same syringe to administer medication to more than one patient, even if the needle was changed or the injection was administered through an intervening length of intravenous (IV) tubing;


• accessing a medication vial or bag with a syringe that has been used to administer medication to a patient, then reusing contents from that vial or bag for another patient;


• using medications packaged as single-dose or single-use for more than one patient (single-dose or single-use vials are labeled as such by the manufacturer);


• failing to use aseptic techniques when preparing and administering injections to prevent contamination (aseptic refers to the manner of handling, preparing and storing of medications and injection equipment such as syringes, needles and IV tubing).

Under the direction of the CDC, the Safe Injection Practices Coalition (SIPC) has compiled a multimedia toolkit for clinicians to educate themselves and their staffs. It’s part of the One & Only (“One Needle, One Syringe and Only One Time”) public health campaign to raise consciousness about injection safety.

Because many health-care providers apparently aren’t aware of how to inject patients safely (or are simply not paying attention), consumers should be assertive about safety when receiving a shot.

If you are a patient receiving an injection or infusion, make sure that the person administering it:

• does not use the same syringe for anyone else, even if the needle is changed or it’s being injected through an intervening length of IV tubing;


• does not breach a medication vial, bag or bottle with a used syringe or needle;


• does not use medications packaged as single-dose or single-use for anyone else;


• always uses aseptic techniques in preparing and administering the injection.

If you are not in the same room where the medication was prepared, if you were unable to observe that safe injection practices were employed, ask. If the answer is unclear or insufficient, refuse the medicine and request that it be newly prepared while you observe.

In 2011, a jury in Las Vegas, Nevada found two drug companies liable for damages to victims of hepatitis C infection because they knowingly sold multi-use vials of the anesthetic proposal to a clinic that used the drug in an unsanitary way. The infections could have been prevented with single-use vials. The plaintiffs were represented in that case by Rick Friedman, co-author with Patrick Malone of the "Rules of the Road" books for plaintiffs' lawyers.

Maybe the national conversation about the rationing of health care finally is moving to a more thoughtful plane. Maybe, instead of incendiary language, half-truths and mistruths, Americans, with the help of the medical establishment, are beginning the think rationally about rationing.

As widely reported last week, a panel of physician groups representing the American Board of Internal Medicine Foundation officially recommends that doctors cut back on the routine use of 45 common medical tests and procedures, deeming them often unnecessary and thus more prone to cause harm than good.

As regular readers know, we’ve walked this path many times.

Rationing is neither a new idea nor, necessarily, a bad one. It all depends on context. Doctors and patients who communicate well ration care all the time. One example is “watchful waiting” in the case of a 70-year-old man with prostate cancer, for whom the practice of holding off on treatment in favor of monitoring the status of the disease makes sense unless and until the cancer grows to the point where it would be dangerous to let it continue. Often, these patients live a long life and die of something else, and treating the cancer would cause side effects much worse than living with the disease.

A patient with a sinus infection who wants her doctor to prescribe an antibiotic might be denied because sinus infections often are caused by viruses, which, unlike bacteria, don’t respond to antibiotics, and because even a bacterial sinus infection usually resolves on its own. So the “rationing” of prescription medicine is wholly appropriate in this case.

As medical costs spiral out of control, as insurance premiums match that ascent, rationing makes sense when such care won’t improve someone’s condition, or only incrementally, and with the potential for negative side effects.

As the New York Times explained, the panel, composed of nine medical specialty boards, recommended that doctors perform 45 common tests and procedures less often. It also said patients should question such services if they are offered. Eight other specialty boards, the paper said, are preparing additional procedures their members should perform far less often.

“The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients,” said The Times. “By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.”

Removing the discussion of overused and overpriced tests and treatments from the realm of politics and/or commercial interests (insurance and pharmaceutical companies) and staging it instead on a platform of science confers a welcome sense of authority. Of course, The Times adds, it also reflects the fact that insurers and other entities that pay these costs want to shift more of them to providers, including hospitals and physicians. So, sometimes, it’s in their best interest to rethink a treatment.

To promote critical thinking about what’s necessary and what’s habit, the nine medical boards have created Choosing Wisely in partnership with Consumer Reports. The educational initiative speaks to both medical professionals and patients.

According to the panel, among the overused tests that should be called into question are such procedures as EKGs performed during an annual physical examination when the patient has no symptoms of heart problems, and MRIs or X-rays whenever someone complains of back pain. For the complete list of the initial 45 tests and treatments, link here.

Of course, this isn’t the first time elements of the medical community have suggested reining in the desire to test, test, test. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, and the ongoing debate about the wisdom of regular and invasive prostate cancer tests (see our post here) have caused concern about government interference in personal health-care decisions and the rationing of treatment.

As The Times noted, “Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over malpractice lawsuits…. Clear, evidence-based guidelines like [these] will go far both to reassure physicians and to shield them from litigation.”

We’ve broached the topic of “defensive” medicine as well, concluding that malpractice lawsuits in the wake of a medical error are much less likely if the practitioner takes responsibility, apologizes and assists in rectifying a bad situation.

The solution to too many patients receiving too many tests and costly treatments isn’t about government control, restricting care from people who need it or protecting practitioners against lawsuits. It’s about the thoughtful use of medical resources and putting individual patients’ conditions into context to make informed instead of reflexive decisions. Call it rationing if you want; we call it wisdom.

In his article “Ten Medical Mistakes That Changed the Standard of Care,” Dr. Barry Bialek offered a lemons-to-lemonade account on CoverMd.com. In reviewing these sad tales, Bialek demonstrates how medical errors -- and the resolve to right a wrong -- can advance science and the notion of best practice.

Bialek provides some historical perspective as well. Western standards of care, he notes, date to Hippocrates more than 2,400 years ago. The origins of our contemporary understanding of best practices date only to 1910, with publication of the Flexner Report, a seminal document in which Abraham Flexner surveyed the state of medical education in the U.S. and Canada. At that time, only 16 of the 155 medical schools required more than a high school education for admission.

“The practice of medicine across the U.S.,” Bialek writes, “is much more standardized, thanks in large part to changes made by medical schools in response to the Flexner Report.” Among those changes are rigorous medical school admissions and clinician licensing. In addition, standards of care are (mostly) based on science.

Here are Bialek’s 10 tales of teachable mistakes.

1. In 1976, Dr. Jim Styner, an orthopedic surgeon, crashed his small plane into a Nebraska cornfield. His wife was killed and he sustained serious injuries, as did three of their children. The local hospital’s care was inadequate, even by the standards in those days. Later, Styner stated, "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system, and the system has to be changed."

Their tragic adventure spawned Advanced Trauma Life Support (ATLS) and changed the standard of care in the first hour after trauma.

2. Judy, 39, underwent a supposedly routine hysterectomy. But she died on the operating table, and an autopsy revealed that the anesthesiologist had placed a breathing tube not in her trachea, but in her esophagus.

Such a grave, simple anatomical mistake today is avoided because an anesthesiologist measures the patient’s carbon dioxide levels, which are much higher from the trachea than from the esophagus, with a CO2 monitor.

3. Sally’s labor for her first child was long, so her obstetrician administered Pitocin, a synthetic version of the hormone oxytocin, to speed things up. Unfortunately for the baby, the Pitocin prompted fetal distress that went unrecognized, and she suffered severe brain injury and cerebral palsy.

Today, fetal monitoring to test both uterine contractions and fetal heart rate is the standard. If fetal distress registers, it takes only 30 minutes for the baby to be delivered.

4. Bill was driving when he suffered a seizure and crashed his car into a tree, crushing both legs. Arteriography, an X-ray mapping of the arteries depicting the progress of an injected fluid, revealed that his right leg was salvageable, but his left leg was not. But the X-ray technician mislabeled the films and the orthopedic surgeon amputated Bill’s right leg.

Today, the surgical site is marked and multiple health-care providers interview each patient before he or she undergoes surgery.

5. Tom was 12 when his appendix burst. Three days after his appendectomy at a local pediatric hospital, his fever spiked anew. After one week, the surgeon performed a second procedure and found the cause—a surgical sponge had been left inside the wound.

Today, post-operative sponge and instrument counts are routine. In addition, threads visible on X-ray are woven into surgical sponges, so that such tools are readily apparent in post-operative X-rays.

6. As a young child, Betty had been given penicillin, turned blue and was rushed to the hospital. At 15, she contracted Strep throat, was given penicillin and died. No one had asked her about medication allergies.

Today, medical questionnaires always include a high-profile space for allergies.

7. Linda was in her first trimester of pregnancy, and not doing well. Nausea and vomiting had left her severely dehydrated and low on potassium. She was seen in a busy emergency department where the nurse made a simple mistake in arithmetic and added too much potassium to her IV. Within an hour, Linda was dead.

Today, clinical personnel don’t compound this medicine on the fly—potassium is added to IVs by the manufacturer and labeled.

8. Frank, 72, broke his right leg in a car accident. He recovered for a few weeks in a rehab facility in which the nurses didn’t know they were supposed to move him periodically, and he developed deep pressure wounds. They became infected, and Frank’s leg had to be amputated.

Today, caregivers know that pressure wounds are mostly preventable by regularly repositioning at-risk patients every two hours to enable blood flow to the skin.

9. Lillian was 68 and weighed 250 pounds when she underwent surgery to remove her gall bladder. The second day after surgery, she needed help walking to the bathroom. Her nurse, Millie, couldn’t bear the load, and they both fell, breaking Millie’s right arm and Lillian’s left leg.

Today, clinical personnel are taught proper lifting techniques, and they practice them.

10. Christy was 42 when her doctor discovered a large lump in her left breast. It would have been evident during Christy’s two previous annual exams, had those physical exams been complete. By the time it was diagnosed, the cancer had progressed beyond cure.

Today, breast self-exams are taught widely, and are routine in physical examinations. Mammograms are also standard care.

Bialek concludes his malpractice roundup by noting that the federal government and medical schools, acknowledging that all of the mistakes he recounted could have been prevented, have developed guidelines for prevention and treatment of many diseases. Chief among them is the Agency for Healthcare Research and Quality (AHRQ) from the Department of Health and Human Services. The website offers guidance to medical consumers as well as practitioners, including how to locate good quality medical care and reduce medical errors; how to compare medical treatments; how to navigate the health-care system; and how to assess insurance coverage.

We’ve discussed several of these topics in our monthly newsletters. If you think you or a loved one might have been the victim of medical malpractice, link to our Medical Malpractice A-Z page for guidance how to proceed.

Earlier this month, the U.S. Preventive Services Task Force (USPSTF) recommended against the routine use of the prostate-specific antigen (PSA) test for most men. A couple of years ago, the same federal agency concluded that routine mammography for most women in their 40s and 50s was counterproductive.

Both declarations incited passionate arguments on both sides of the issues.

So who are these fearless people whose job is to articulate health protocols with the potential to roil the waters of any medical specialty?

As readers will see from the list at the end of this piece, the members are distinguished doctors and other caregivers from around the country. Nary a faceless bureaucrat among them, contrary to what you hear from critics on the right.

Established in 1984, the USPSTF, according to its website, “was convened to rigorously evaluate clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations and preventive medications.”

Anyone can look at the wide range of topics the agency addresses by linking to the site, and see whether a given recommendation is active, inactive or in progress.

As described in the Los Angeles Times, “If the world of primary-care physicians had a supreme wizarding council that only weighed in on screening tests and pills promising to head off disease, it would be called the U.S. Preventive Services Task Force.”

Wizardry is certainly one way to cultivate order within the chaos that is health care in America, a thick, perpetually simmering stew of commerce, politics, perpetual motion and consumerism. Wizards can ferret out the influence of a Big Pharma "task force" of physicians paid to hawk their product. They can disarm grass-roots movements that have declared otherwise worthy medical treatments suspect because of coincidence instead of science.

USPSTF wizards are obliged to filter out the noise and focus on the scientific evidence about screening tests, preventive medications, counseling and anything else that holds promise to treat symptoms or disease.

As the L.A. Times notes, the USPSTF has opined about “medications that promise to prevent heart attack or stroke, cancer screening tests that claim early detection means better chances of survival, HIV/AIDS screening in which privacy concerns are paramount.”

Sixteen people compose the USPSTF, representing physicians, nurses, health psychologists, epidemiologists and statisticians with expertise in primary care and preventive medicine. Their backgrounds include clinical practice, organizations and academic institutions outside of the federal government. They are nominated by institutions or individuals for four-year terms that can be extended by one or two years. They have no financial or professional conflicts-of-interest that could color their assessment of a preventive measure's value, and anyone under consideration for the task force gig may be asked to provide detailed professional and financial information to ensure objective judgment. The U.S. Public Health Service ultimately grants membership.

As The Times says, the work is not glamorous, “but it is remarkably influential. Once a measure has been accepted for study (a decision made by the Health & Human Services Department's Agency for Healthcare Research & Quality), task force members review the findings of an entire body of published studies on that measure. Then, they issue grades that not only recommend for or against the measure's widespread use, but bluntly grade the quality of research that has been done.”

Most USPSPF decisions are aimed toward primary care physicians who need advice on which screening tests or preventive medications are worth ordering and prescribing to their healthy patients. But its sphere of influence has grown. If a health plan or an insurer is uncertain about whether to cover a screening or diagnostic test, or wants to shift the cost of a preventive medication to a patient, the recommendation of the task force is often the deciding factor. Professional societies see this small, but influential agency as a standard-of-care bearer.

Everybody, even a Godlike doctor, needs a mentor.

Here are the current members of the US Preventive Services Task Force. The list is courtesy of Healthnewsreview.org.

Virginia A. Moyer, M.D., M.P.H. (Chair) Professor, Pediatrics Baylor College of Medicine, Houston, TX Chief, Academic Medicine Service, Texas Children's Hospital

Michael L. LeFevre, M.D., M.S.P.H. (Co-Vice Chair)
Professor, Department of Family and Community Medicine
University of Missouri School of Medicine, Columbia, MO

Albert L. Siu, M.D., M.S.P.H. (Co-Vice Chair)
Professor, Geriatrics and Palliative Medicine
Mount Sinai School of Medicine, New York, NY

Kirsten Bibbins-Domingo, Ph.D., M.D.
Associate Professor, Medicine, Epidemiology, and Biostatistics
University of California, San Francisco, CA
Co-director, UCSF Center for Vulnerable Populations
San Francisco General Hospital

Adelita Gonzales Cantu, Ph.D., R.N.
Assistant Professor, Family and Community Health Systems
University of Texas Health Science Center, San Antonio, TX

Susan J. Curry, Ph.D.
Dean, College of Public Health
Distinguished Professor, Health Management and Policy
University of Iowa, Iowa City, IA

Glenn Flores, M.D.
Professor, Pediatrics and Public Health
University of Texas Southwestern, Dallas, TX
Director, Division of General Pediatrics
UT Southwestern Medical Center and Children's Medical Center of Dallas

David C. Grossman, M.D., M.P.H.
Medical Director, Preventive Care and Senior Investigator, Center for Health Studies, Group Health Cooperative
Professor of Health Services and Adjunct Professor of Pediatrics
University of Washington, Seattle, WA

George J. Isham, M.D., M.S.
Medical Director and Chief Health Officer
HealthPartners, Minneapolis, MN

Rosanne M. Leipzig, M.D., Ph.D
Professor, Geriatrics and Adult Development, Medicine, Health Policy
Mount Sinai School of Medicine, New York, NY

Joy Melnikow, M.D., M.P.H.
Professor, Department of Family and Community Medicine
Director, Center for Healthcare Policy and Research
University of California Davis, Sacramento, CA

Bernadette Melnyk, Ph.D., R.N., C.P.N.P./P.M.H.N.P.
Associate Vice President for Health Promotion, Chief Wellness Officer, and Dean
College of Nursing
Ohio State University, Columbus, OH

Wanda K. Nicholson, M.D., M.P.H., M.B.A.
Associate Professor, Obstetrics and Gynecology
Director, Diabetes and Obesity Core Center for Women's Health Research
University of North Carolina School of Medicine, Chapel Hill, NC

Carolina Reyes, M.D., M.P.H.
Medical Director, Maternal and Fetal Medicine
Virginia Hospital Center, Arlington, VA

J. Sanford (Sandy) Schwartz, M.D., M.B.A.
Leon Hess Professor of Medicine, Health Management, and Economics
University of Pennsylvania School of Medicine and Wharton School, Philadelphia, PA

Timothy J. Wilt, M.D., M.P.H.
Professor, Department of Medicine, Minneapolis VA Medical Center
University of Minnesota, Minneapolis, MN

... goes to Skip Lockwood, head of a prostate cancer advocacy group called Zero. When the US Preventive Services Task Force recommended against routine screening of men with the PSA blood test, Lockwood said the PSTF's advice "condemns tens of thousands of men to die this year and every year going forward..."

Prostate cancer kills about 30,000 American men a year, so if Lockwood is right, that means the PSA test would have prevented MOST of those deaths. If it was that obviously beneficial, why would so many doctors and health care leaders have such doubts? Last year, in a less publicized statement based on the same research studies, the American Cancer Society also pulled the plug on its advice for screening with the PSA test.

The fact is that fears of just this kind of over-the-top reaction caused the PSTF to delay its advice for two and a half years after definitive studies came out from Europe and the US showing that PSA testing just doesn't do the job of putting any measurable dent in the death rate from prostate cancer. The PSTF was cowed by the blowback to its last big recommendation: that the numbers don't justify routine mammograms for women in their 40s.

PSA testing has generated a billion dollar industry of urologists doing surgery on men, with high rates of impotence and incontinence in their wake. At the risk of making a bold statement in the opposite direction of Mr. Lockwood's, it's almost malpractice now to put men into routine prostate cancer screening when the odds are much greater for harm than help.

Even the inventor of PSA testing came out last year against its routine use in low-risk men. The test is best reserved for high-risk men who need monitoring after they've already had prostate cancer and need to know if it's coming back.

But don't try to confuse the advocates with scientific facts. They'd rather play on emotions.

Article first published as The Award for Most Fear-Mongering Health Care Statement of the Year ... on Technorati.

Hospitals are subject to clear standards and procedures for infection control, but germs don't care whether they live in an operating room or a medical office exam room.

The Centers for Disease Control and Prevention (CDC) do. It recently issued "Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care" for all manner of ambulatory care centers, including doctors' offices and outpatient testing and lab facilities.

Among the most basic practices such facilities should follow are:

• Develop and maintain infection prevention and occupational health programs.


• Assure sufficient and appropriate supplies necessary for adherence to standard precautions (hand hygiene products, personal protective equipment, injection equipment).


• Assure at least one individual with training in infection prevention is employed by or regularly available to the facility.


• Develop written infection prevention policies and procedures appropriate for the services provided by the facility and based upon evidence-based guidelines, regulations, or standards.

Patients generally are not aware, nor should they be, if their health-care providers have undergone the necessary training to adhere to these guidelines. But they're common sense, and if anything seems amiss when you visit your doctor--say, the nurse doesn't wash her hands before offering a thermometer--ask what measures are being taken to protect you from someone else's germs.

Ever since the U.S. Preventive Services Task Force suggested relaxing the rigid schedule for mammography testing in 2009, patients seeking a unified, authoritative voice on the topic have been rewarded with confusion. Probably because the medical community, too, is unresolved about who needs what kind of breast screening and when.

A study published this week in the Annals of Internal Medicine, is the latest participant in the discussion. It articulates as well as any previous research the notion that mammograms are situationally useful, and promotes the idea that such testing should be customized to each patient.

For women with a normal genetic profile, the timing and frequency of a mammogram, the researchers say, depend on the patient's:

• breast density;


• age;


• family history; and


• personal preference.

Age, history and, to a lesser degree, density, are not new factors in the tricky equation of when to have a mammogram, but personal preference? Since when does science ever acknowledge, much less respect, that what's preferable might also be good medicine?

Although the study researchers made clear that, apart from genetic mutation, breast density is the single-most important consideration in determining the suitability of relatively frequent screening, mammograms often result in false positives -- the suspicion that you have cancer when you really don't. That feeds a cycle of anxiety, unnecessary exposure to radiation, expensive follow-up procedures including surgery and physical discomfort. The artful conclusion here is that such a tangle of concern can undermine the utility of the procedure.

Because dense breasts (more muscle tissue, less fat) are the strongest risk factor for cancer, women with that anatomical profile should have mammograms more frequently. But after an initial screening at age 40 to establish a baseline reading and determine breast density, women lacking other risk factors--such as the two genetic mutations known to increase cancer risk--who aren't comfortable with such frequency, might be acceptably excused from it.

The American Cancer Society and the Task Force would disagree. The former recommends
that women screen initially at 40, and repeat the procedure every year or two thereafter. The latter recommended that women begin screening sometime between 40 and 49, depending on risk factors, and every two years after 50.

As usual, the best guidance for women seeking clarity is to establish and maintain an open line of communication with their physicians that results in a mutual decision about their treatment.

It’s the morning of your surgery, and you have been a paragon of preparation. Your advance lab work is complete, you’ve fasted for 12 hours, you arrived 10 minutes ahead of schedule and are poised to sign the final paperwork before being directed to pre-op. You present the advance health-care directive you prepared months ago to the intake clerk, and begin to fill in the consent form.

But wait. One provision says that the hospital has opted “not to honor” advance directives. Can it do that? If so, what’s the point of being such a responsible person in the first place?

Yes it can, and many medical institutions do under the laws of “conscientious objection.” But there are good reasons for filling out such a directive, and for medical facilities to have the flexibility to override them.

According to the Centers for Disease Control and Prevention, the most common types of advance directives are living wills and do-not-resuscitate orders. Overall, 28% of home health-care patients, 65% of nursing home residents and 88% of discharged hospice care patients had at least one advance directive on record.

Advance directives protect the wishes of patients unable to speak for themselves. Outside of the surgical theater, directives generally address conditions associated with the elderly and others such as persistent vegetative states that are not acute, but ongoing. During surgery, if something goes wrong, such as an adverse reaction to anesthesia or an unexpected organ failure, doctors need to respond quickly; their goal is to ensure the success of the surgery, and a completely binding advance directive can hamstring a reasonable effort to address a sudden problem. You don’t want someone able to correct a situation quickly and successfully to be prohibited from doing so by a document intended to address a more long-term issue.

But the time limits suspending a directive should be clear; medical providers, even if they aren’t bound by its terms during surgery, must be aware of them afterward. And if the surgeon or hospital refuses to honor your documented wishes during recovery, most states require them to make a reasonable effort to transfer you to providers who will.

Patients can protect their rights and enhance their surgical outcome by:

asking before surgery about the hospital’s policy on advance directives. If you don’t like it, look elsewhere for your procedure, but understand that most hospitals won’t comply with a directive during surgery;

understanding the time limits of the suspension—it should cease once you’re in recovery;

ensuring that you have an advocate with you who understands your wishes—a relative or friend who acts as your agent to make health-care decisions if you’re unable.

When you see a specialist, you expect to hear from an expert who will diagnose your condition and then recommend the appropriate treatment. But that may not be the case, especially if you’re dealing with gastroenterologists and your symptoms appear to resemble those of Barrett’s Esophagus, a condition in which the lining of the esophagus is damaged by stomach acid.

When gastroenterologists were asked in a survey to cite the criteria for diagnosing and managing Barrett’s, most gave answers that differed from published guidelines, suggesting overdiagnosis and an excessive burden on patients.

Barrett's can be a precursor to cancer of the esophagus. It happens with repeated episodes of reflux when stomach acid is expelled upward into the esophagus. Typically the lower part of the esophagus closer to the stomach becomes chronically inflamed. Heartburn is the usual symptom from these repeated episodes of reflux, or even difficulty swallowing.

Under a microscope, Barrett's is diagnosed when a biopsy from the esophagus shows that the normal cells have been transformed into "dysplastic" or precancerous cells. The cells look more like those seen in the colon than those that should be lining the upper part of the gastrointestinal system.

In the survey of 261 gastroenterologists presented last week at Digestive Disease Week in Chicago, 23% failed to name the only criterion for Barrett’s endorsed by the official American College of Gastroenterology (ACG) practice guideline, while more than half listed other criteria.

Furthermore, about a third said they perform follow-up exams in patients with non-dysplastic Barrett’s more frequently than the 3-year interval recommended by the ACG.

The ACG guideline defines Barrett's as a change in the lower lining of the esophagus of any length to a columnar-type mucosa, with biopsy confirmation as intestinal metaplasia. Although 77% of respondents correctly indicated that such a finding would be adequate for a diagnosis of Barrett’s, respondents could name multiple criteria and a substantial number endorsed one or more criteria not included in the ACG guideline including (1) irregular-appearing squamocolumnar junction with biopsy finding of intestinal metaplasia (47%); normal-appearing squamocolumnar junction with biopsy finding of intestinal metaplasia (22%); visible columnar-type mucosa above the gastroesophageal junction (17%) and irregular-appearing squamocolumnar junction without biopsy ( 3%).

The guideline also indicates that, for nondysplastic Barrett's esophagus, follow-up endoscopy should be performed every three years. This interval was seconded by 55% of respondents in the survey. Some 34% respondents indicated that they perform endoscopies in such cases every one or two years, while another 9% said their preferred follow-up interval varied, depending on the length of the dysplastic segment.

The survey also found that, compared with salaried physicians, those with "productivity-based incomes" were significantly more likely to perform endoscopies at 1- or 2-year intervals in nondysplastic patients.

Source: MedPage Today

Reference: “Poor compliance with guidelines in the diagnosis and management of Barrett's esophagus" DDW 2011; Abstract Sa1064.