Patient Safety Blog

Nearly every week, we hear more evidence that American children are over-medicated, especially with drugs that affect mood and behavior. Most recently, a panel of experts has denounced the overuse of Risperdal, a powerful antipsychotic drug, for attention deficit disorder. The drug has too many side effects, including potential development of permanent muscle twitching, to justify its use in mild conditions like ADD for which other options exist, according to the expert panel convened by the Food & Drug Administration to advise it on labeling changes.

What is behind the explosion in use of antipsychotic drugs in children (besides Risperdal, they include Zyprexa, Seroquel, Abilify and Geodon) is a drumbeat of support from leaders in child psychiatry. But that leadership is tainted by their ties to the drug industry -- ties that frequently don't get mentioned in public when these same doctors are lecturing their colleagues and advising worried parents. One leader, Dr. Joseph Biederman, a child psychiatrist at Harvard, was revealed by a Congressional investigation to have accepted $1.4 million from manufacturers of antipsychotic drugs that he did not disclose to his university. Another psychiatrist leader, Dr. Charles B. Nemeroff of Emory, had to step down as chair of psychiatry after it was revealed that much of his consulting pay from drug makers, which totaled over $2.8 million in seven years, had been hidden from his university.

Now another influential psychiatrist has been exposed for his secret ties to the drug industry. He is Dr. Frederick Goodwin, former chief of the National Institute of Mental Health, who hosted a popular show on National Public Radio, "The Infinite Mind." Senator Charles Grassley of Iowa released data to the New York Times showing that Dr. Goodwin received $1.3 million from drug manufacturers from 2000 to 2007 for giving marketing lectures to other doctors. The money was never mentioned on his radio show, and NPR now says the show has been canceled and all reruns will stop soon.

According to the Times' Gardiner Harris, on one day in 2005, Dr. Goodwin received $2,500 from GlaxoSmithKline to give a talk about its mood stabilizer drug Lamictal at a Ritz Carlton resort in Florida. On his radio show broadcast the same day, Dr. Goodwin said that children with bipolar disorder who did not get treatment could suffer brain damage (a controversial prognosis) but he reassured his listeners that mood stabilizer drugs were a safe and effective way to treat the problem.

Senator Grassley has sponsored legislation to require drug makers to post publicly all the payments they make to doctor consultants. That would help the public to know whether the recommendations they see from doctors for medicating their children are truly unbiased or should be taken with a grain of salt.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Disclosure , Doctor-Patient Relationship , Medications

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Millions of people with normal cholesterol levels in their blood could be started on cholesterol-lowering statin drugs based on a new research study, but if patients understood the numbers behind the study, they might not move so fast to put statins in their medicine cabinet. Every patient can benefit from a closer understanding of how statistics work in medicine to push people toward treatments that they may or may not really benefit from.

The latest study involves people who were put on cholesterol-lowering statins because they had a high result on a blood test called C-Reactive Protein, even though the same people did not have high cholesterol.

As reported by Tara Parker-Pope in the New York Times' "Well" blog, here are the key numbers:

* The researchers reported an impressive sounding 50 percent reduction in heart attacks in the group treated with statins, as compared to patients in the same study who got a sugar pill (placebo) instead.

* But the real numbers of actual patients helped by the statins were only around nine in every 1,000 people treated -- less than one percent.

How do those numbers fit together? In the placebo group, 18 of every 1,000 patients suffered a heart attack or some other serious heart event during the study. In the group taking the statin drug, nine of every 1,000 patients had a serious heart event. That's how the researchers could report that the risk had been cut in half -- from eighteen to nine -- although the actual numbers of patients were few. Comparing eighteen to nine is called a relative risk ratio. Comparing 18/1,000 to 9/1,000 is called comparing the absolute risk. The absolute risk number is usually more meaningful.

Another important number for patients to understand in figuring out if a new medicine is for them is called the "number needed to treat." How many patients need to be treated with the new drug for one patient to benefit?

According to a New England Journal of Medicine editorial which analyzed the new study, 120 patients would need to be treated with statins over two years for just one of those patients to benefit.

That number might be enough to persuade some patients to take the drug. But it's a lot different than fifty percent. Bottom line: to make intelligent choices about treatments, patients need to understand how many patients like them are really expected to benefit from the treatment.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Disclosure , Doctor-Patient Relationship , General , Medications

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A recent medical malpractice lawsuit prosecuted by Patrick Malone & Associates for the victim of a delayed diagnosis of skin cancer highlights the need for annual skin checks by a qualified doctor. Anyone who is fair-skinned, sunburns easily, or has a lot of moles on their skin should see a dermatologist or a good primary care doctor for annual skin checks. These can be part of a routine physical exam. The doctor should measure and do sketches of the moles' location and appearance on your skin, or should take good photographs. A change in a mole is one of the key indicators of potential for malignant melanoma, a skin cancer which is deadly once it gets into the bloodstream but is 100% curable when still confined to the skin. Patients and their families often don't notice subtle changes in a mole -- getting bigger, changing color, etc. -- that health care providers can pick up.

In the legal case of Semsker v. Lockshin, a benign mole on the patient's lower back turned into a deadly melanoma over an eight-year period, during which time the mole's presence and change in size was documented by the dermatologist. The lawsuit alleged the dermatologist should have removed the mole two years before it finally was removed, when it had already invaded the patient's lymph nodes. Mr. Semsker died 14 months after the diagnosis.

In their defense of the malpractice lawsuit, the dermatology practice of Norman Lockshin, M.D., P.A., contended that they would have told the patient to get skin checks even more often than he was (every few years from either his primary doctor or his dermatologist), although this recommendation was not documented in their records.

Regardless, every patient needs to know about the dangers of melanoma and the need for regular skin exams. Exams should focus on the ABCDE's of skin cancer: A for Asymmetry of the mole; B for irregular Borders; C for variegated Color or unusual color in the mole; D for diameter greater than 6 millimeters, and E for Evolution or changes in the mole's size, shape or color.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Cancer , Communication , Doctor-Patient Relationship , Medical Error

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Tara Parker-Pope at the NY Times Well Blog has an article about how patients can cope with the vast flood of information (and misinformation) that is now available to them through the Internet.

Nowadays, people can look up their symptoms, self-diagnose certain conditions, find studies about the efficacy of various treatments, and find out what the medical community's consensus opinion is on a wide range of issues--all things that they once relied on doctors for.

Dr. Marisa Weiss, a breast oncologist quoted in the article, points out that doing independent research before a doctor's appointment has become mandatory because doctors have less and less time for patients. So it's in the patients' best interests to come in some idea of what's going on, so they can communicate what they've learned to their doctors and the appointment will proceed with more efficiency.

However, coping with so much information can be a puzzling experience. The article lists several helpful suggestions, such as considering what mental impact doing the research will have on you, exploring non-Internet sources, using your research as a supplement to your doctor rather than as a complete replacement, and other such useful tips. The whole thing is worth a read.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , Self-care

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Dr. Pauline Chen has an article about doctors, empathy and time crunches.

She notes that many doctors would like to express empathy to patients when delivering terrible news, but due to the load of cases they are dealing with, are afraid of spending too much time comforting one patient when there are others that need attending to.

She argues that expressing empathy takes less time than one might anticipate, especially if you use the right strategies: for instance, she recommends expressing empathy throughout a consultation instead of waiting until the very end, as some doctors tend to do.

The whole column is interesting and worth a read.

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Posted In: Communication , Doctor-Patient Relationship

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Forbes Magazine has an informative article on the frequency of hospitals making mistakes while caring for patients, pointing out that 1.5 million Americans fall victim to such errors every single year.

Some of these errors occur through sheer carelessness: for example, 100,000 people a year die from "superbugs," bacteria that are resistant to available antibiotics. Infections from these superbugs can frequently be prevented by hand-washing. Yet other errors are the system's fault and not the fault of any individual. They occur because of overcrowding and the consequent inability of doctors and nurses to spend sufficient time with each patient.

The article also cites an Auburn University study showing that hospitals administer the wrong drug one time out of five. The dosage of the drug is another common source of error. A famous recent example of a drug error is from last November when actor Dennis Quaid's newborn twins were given 1,000 times the intended dose of the blood-thinner heparin. Luckily the hospital detected the error before permanent damage was done.

What is the bottom line? There are no magical solutions, especially since most of these problems are systemic. As a doctor quoted in the article says: "If you're sick, the best way to avoid getting sicker is to take charge of your care." Asking questions and being unafraid to make demands is the most any individual patient, or their loved ones, can do to reduce risk of error.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Doctor-Patient Relationship , Medical Error , Medications , Standard of Care--Hospitals

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The Toledo Blade has a good article with stories from patients whose crucial treatments, ordered by doctors, have been denied or delayed by insurance companies.

It begins with the harrowing story of Randy Steele, who died after the kidney-liver transplant that could have saved his life was stalled by his insurer.

Even if patients do not die as a result of these repeated denials and delays, they often end up unable to follow their doctors' instructions and their health suffers seriously as a result.

The Blade conducted interviews with 100 physicians and did a survey of 920, which you can read more about by clicking the above link. The results of both the interviews and the survey show that doctors believe that insurers countermanding or stalling their orders is creating a crisis in health care. Of the survey's 920 respondents, more than 99 percent said that insurers had interfered in their medical decision-making.

Clearly doctors are more qualified to make medical decisions than insurance companies. Any health care system that allows a bureaucrat working for an insurance company to make these calls will inevitably end up creating the tragedies that this article describes.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Doctor-Patient Relationship , Insurance

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Tara Parker-Pope has a blog post about how doctors will treat women of childbearing age as "pre-pregnant," focusing on their reproductive capacities to the detriment of their overall health. Obviously reproductive matters are an important part of overall health and can influence many other medical conditions. But so can a lot of other common issues: neurological and psychological problems, drug-related issues, alcohol and tobacco habits, gastrointestinal issues, and so on all have a huge effect on a person's overall health. Yet these issues do not command the same attention from many doctors, who focus on the potential for a pregnancy rather than on the woman as a whole patient. As a consequence, the woman's health suffers.

The comments section of the post is enlightening and makes it clear that this is an issue many women face and are extremely angry about. There are also a few dismissive comments telling women to "get over it," displaying the ignorance and foolishness that enable these attitudes in the first place.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , Gynecology

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The NY Times Well blog has a podcast of Dr. John Hickner, professor of family medicine at the University of Chicago, discussing why patients should always call their doctors to follow up after having a medical test done.

We have previously discussed the issue of medical test results getting lost in transmission: the patient will expect the doctor to call if there is bad news, and will feel reassured if he or she hears nothing, while the doctor's office will wait for the curious patient to contact them, or will simply forget, and the patient "falls through the cracks." As a result, the patient may not hear about important test results.

The best way for patients to deal with this is to remember to call their doctors after testing and keep in mind that no news is not necessarily good news.

Another thing that patients can do is always ask the testing facility for a copy of the test results. Some laboratories and radiology offices resist this, but every patient has a right to their own records.

Serious injuries can happen to patients from delayed treatment due to these failures of communication, so it's important for patients to be pro-active about their test results.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , Medical Records , Testing

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A new study from the journal Quality and Safety in Health Care, and discussed in the NY Times Well blog, reveals common testing mistakes by primary-care doctors. Of course, the same kinds of errors can happen in hospitals and other health care settings.

Out of close to the 1,000 mistakes experienced by 590 patients, the following testing mistakes were the most common:

-13% involved ordering the wrong test or failing to order a test

-18% involved performing the right test, but doing it improperly

-25% involved delays in getting tests back from the laboratory, failure to get the tests back at all, or errors on the results report

-7% involved failing to follow up with patients after receiving results from the laboratory

-75% of the mistakes caused the patient to suffer (through delays in proper treatment, greater expense, physical pain or worsened overall health).

What can a patient do about this? A possible solution would be to carefully ask and write down what specific test your doctor has ordered for you. Ask when the results of the test are expected from the lab. Then make sure you call to follow up after the doctor's office should have received the results. Read the results report, if you can get hold of it, to see the name of the test and make sure that the results are for the same test that was ordered and performed. All of these things might help reduce your risk. Calling the doctor to follow up is probably the most important item on the list, as Dr. Lamberts says in his quotation in the linked NY Times blog post.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , Medical Error , Medical Records , Testing

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Tara Parker-Pope recently wrote two articles discussing fundamental rules for doctors and for patients.

The rules for doctors can be boiled down to respect for the patient's feelings and understanding that they did not come to the office in order to waste the doctor's time for the sheer pleasure of it. Dr. Robert Lamberts, who blogs under the name of "Dr. Rob," is the physician who initially invented the rules for doctors quoted by Parker-Pope. His original article can be found on his blog, Musings of a Distractible Mind.

Dr. Lamberts also wrote the rules for patients, which mostly focus on the importance of being honest and open with your doctor, maintaining the lines of communication between you and the doctor and finding a doctor you can trust.

Both lists are worth reading in their entirety.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Doctor-Patient Relationship , General

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It is instructive and interesting to read about Senator Edward Kennedy's treatment for his brain tumor.

The linked article describes the change in direction between May 20th of this year, when Kennedy's brain cancer was first disclosed and surgery was not discussed as a possible treatment, and two weeks later, when neurosurgeons performed a "successful" surgery on his brain.

Why the change? From the article:

Precisely why Mr. Kennedy’s treatment course changed is not known; he and his doctors are not talking to reporters.

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

As the article notes, Senator Kennedy called similar conferences of experts when one of his children was diagnosed with bone cancer and the other with lung cancer. He has been known to advise his colleagues in the Senate to use this method when dealing with an illness in the family.

Obviously, powerful senators can do things the rest of us cannot. Again, from the article:

Mr. Kennedy can tap leading doctors for answers in a way few patients could. His celebrity status aside, he has spent a career promoting insurance and other ways to improve the health of Americans. And he has had a track record of being thorough and diligent in researching medical options when relatives or friends have fallen ill.

Nevertheless, despite Kennedy's power and influence, there are ways in which the average person can imitate his example and seek second and third opinions on their medical care:

Several doctors not connected with Mr. Kennedy’s case said in interviews that they admired his resourcefulness in getting more opinions simultaneously. At the same time, these doctors said many average patients gained competent advice, without a command performance, by sending pertinent records to experts for their opinions.

Many patients search the Internet for medical information and ask that their scans and other data be sent electronically or by overnight services.

Then such patients visit, call or write the consultant.

The potential negative consequence of all this opinion-shopping is that people may focus on what they want to hear and disregard everything else. This is partly why the doctors quoted in the article strongly recommend actually meeting physicians whose advise you intend to take (rather than just sending records and receiving written responses). That way the physician can make sure your expectations are realistic and address your specific concerns.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Cancer , Communication , Disclosure , Doctor-Patient Relationship , General , Surgery

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Tara Parker-Pope recently had an article on how fewer and fewer patients trust their doctors.

About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.

The distrust and animosity between doctors and patients has shown up in a variety of places. In bookstores, there is now a genre of “what your doctor won’t tell you” books promising previously withheld information on everything from weight loss to heart disease.

What are the reasons for this new distrust? Several factors appear to be involved:

(1) Patients often don't understand what is going on with their health care because doctors and nurses are too rushed to explain things to them. Dr. Sandeep Jauhar, cardiologist and author of Intern: A Doctor's Initiation, is quoted in the article with a story of a patient who was transferred from one hospital to another with no explanation for why. He blamed a "broken system" for such failures to communicate.

(2) There has been greater coverage in the news of medical error, the power of the drug industry and the flaws in health care administration.

(3) The Internet makes information much more available, so patients can be informed skeptics. Drug companies also market directly to patients, so they come into the doctor's office with their own desires and opinions on what medications they should take. The upside to this is that patients have the information to challenge a doctor's errors. The downside is that many end up taking a drug commercial, for instance, at face value and will not listen to a doctor's reservations about the efficacy of a drug.

Again, from the article:

“Doctors used to be the only source for information on medical problems and what to do, but now our knowledge is demystified,” said Dr. Robert Lamberts, an internal medicine physician and medical blogger in Augusta, Ga. “When patients come in with preconceived ideas about what we should do, they do get perturbed at us for not listening. I do my best to explain why I do what I do, but some people are not satisfied until we do what they want.”

The whole article is worth reading. In addition, the article's page also has an embedded video clip of interviews with people discussing their attitudes to their doctors.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Communication , Disclosure , Doctor-Patient Relationship , General , Medications , Standard of Care--Hospitals , Testing

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