DC Medical Malpractice & Patient Safety Blog

Diabetes is an affliction of modern life. Americans have abundant and relatively inexpensive food. We have a lack of interest and/or time for exercise. We are predisposed toward a high incidence of the disease and its devastating consequences.

Diabetes is a disorder of the metabolism. Its signature—high blood sugar—is the result of the body not producing enough insulin or the cells not properly using the insulin that is produced. It is nasty business: Diabetes can deprive people of their sight, their limbs, their lives.

There are three types: Type 1, commonly called juvenile diabetes because it presents early in life, requires insulin injections because the body just doesn’t make enough. Type 2, commonly called adult-onset diabetes, results from resistance to insulin—the body doesn’t use the hormone properly. Gestational diabetes occurs among woman without a history of diabetes but whose pregnancies raise their blood sugar; it can predispose them toward Type 2 diabetes.

Although genes play a role, adult-onset diabetes often results from lifestyle choices. As such, it’s the type that responds best to both medical and personal interventions. You’ve probably heard claims that many Type 2 diabetics who clean up their dietary act and get regular exercise can control, if not beat, this dread disease.

Maybe. But doctors at the American board of Internal Medicine analyzed which interventions had the biggest effect on diabetes patients, and they concluded that the best practice for diabetic patients involves significant physician involvement.

By comparing interventions—those that are managed by physicians (prescribing medicine for high blood pressure, for example) and those that are controlled by patients (eating a proper diet), they found that if the entire population of all U.S. patients diagnosed with diabetes met aggressive targets for lowering blood pressure, LDL cholesterol and blood glucose levels—all goals that must be monitored by doctors—they would have a 16 percent increase in quality-adjusted life-years and a nearly 23 percent reduction in 15-year mortality.

“Managing diabetes and preventing its associated morbidities require active physician-patient partnerships,” they concluded.

Diabetics who want to lead normal lives must take responsibility for understanding their disease and managing it to the best of their ability. But the team-based approach to treating diabetes clearly seems superior.

Another study, as reported on MedPage Today, supports this view. As stated in the Annals of Family Medicine, these researchers concluded that the involvement of nurse care managers working with patients and primary care physicians was associated with improved control of not only diabetes, but also depression and heart disease.

Even the most motivated diabetic can mismanage his or her medications, can struggle with adhering to rigid regimens and is subject to associated disorders—nearly 2 in 10 diabetes patients suffer from depression. The study examined a program called TEAMcare, a collaboration among a nurse care manager, physicians and patients that increased initiation of various types of medication, rates of treatment adjustment and self-monitoring by patients,

"Results of this trial suggest that improving specific patient and clinician behaviors (close monitoring of disease control parameters and timely treatment adjustments to achieve individualized goals) can improve disease control and quality of life among patients with multiple conditions and complex healthcare needs," the researchers wrote.

As MedPage noted, it’s difficult to exercise good disease control for patients with multiple chronic diseases because they often have multiple doctors, complex treatment regimens and a higher risk of harmful drug interactions. Depression exacerbates these challenges.

So if you or someone close to you has diabetes, read about standards of medical practice for diabetes here on our site. Make sure all of your care providers are aware of what you’re doing apart from their particular focus. Are your primary care doctor and endocrinologist doctors aware of your nutrition and exercise habits? Do your doctors and pharmacists have current records of all the medications you’re taking and are they aware if you’re struggling to adhere to their respective prescriptions? Are they aware if your depression is sapping the energy you need to exercise?

Diabetes is complicated. It takes a village to treat it.

Although the consequences of medical malpractice are often clear, devastating and sometimes irreparable, malpractice is not always the result of a mistake a doctor or hospital makes during treatment of disease or disorder. Sometimes, the problem lies in the communication of information, or failure to communicate.

A recent study published in JACR – Journal of the American College of Radiology – concluded that the risk of a malpractice lawsuit can increase when the notification of diagnostic test results breaks down between a referring doctor and a treating doctor.

Let’s say a primary care doctor refers a patient to a surgeon. Standard medical practice is for the surgeon, or treating physician, to ensure that the primary care doc is given the results of examinations and/or diagnostic tests if they yield an urgent or unexpected finding. And, commonly, even if they don’t. After all, a primary care doctor knows the patient best, and is considered the “gatekeeper” of a patient’s overall health-care profile and treatment.

The JACR study showed that in recent years, clinicians have ordered dramatically greater numbers of diagnostic examinations. Between 1996 and 2003, malpractice payments related to diagnoses increased by approximately 40 percent. “Communication failures, the authors said, “are a prominent cause of action in medical malpractice litigation. … [C]laims payments increased at the national level by an average of $4.7 million annually. …[C]laims data for 2004 to 2008 indicate that communication failures played a role, accounting for … 7 percent of the total cost.”

These numbers, the study suggests, might reflect the fact that people assume medical data is being reliably communicated among caregivers when sometimes it isn’t. It might reflect the remarkable growth of diagnostic testing, which generates a lot more test reports, some of which are invariably not going to be sent to every caregiver a patient sees. Whatever the reason(s), researchers concluded, “If notification reliability remained unchanged, this increased volume would predict more failed notifications.”

The researchers advise the implementation of “semiautomated critical test result management systems” to improve notification reliability, workflow, patient safety, and, in the event of a lawsuit, to provide legal documentation.

We advise that any patient who undergoes an examination or diagnostic test—X-ray, CT scan, MRI, lab work, etc.—administered by a doctor other than his or her primary caregiver request that a copy of the report and/or results be sent to the primary caregiver. And any other specialist who has participated in the patient’s care for this particular problem. Call your doctor(s) a week or 10 days after the specialist has your results to ensure they have received them.

And as always, we recommend that patients get copies of any test reports themselves. That is the ultimate preventive measure against communication failures.

We’re big believers in “evidence-based” medicine. Most recently, we questioned the fuzzy-science circumstances surrounding the death of Steve Jobs. But a recent article in The Atlantic by Megan McArdle reminds us that, sometimes, the art of medicine should play as large a role as that of science and that, ultimately, striking that balance requires the patient and the doctor to communicate well.

McArdle has lived with a thyroid condition for many years that requires periodic blood tests to determine how well that gland is functioning. For a long time, a normal thyroid was deemed to register between 0.5 and 5 for Thyroid Stimulating Hormone (TSH). But several years ago, the American Association of Clinical Endocrinologists Association of Clinical Endocrinologists lowered that threshold to between 0.3 and 3.

McArdle’s TSH levels were at the edge of the new, narrower range, and she had many of the symptoms associated with “underactive” thyroid—hair loss, fatigue, hoarseness, constantly feeling cold. (Overactive thyroid symptoms include insomnia, nervousness, heart palpitations, increased risk of bone fracture and a host of unpleasant and health-threatening problems.)

Her problem was that the numbers, the science, didn’t indicate how bad she was starting to feel.

The treatment for an underactive thyroid (hypothroidism) is a drug—thyroid hormone. And, like all drugs, it’s not without risk, so practitioners prescribe the lowest dosage possible to avoid them. As McArdle eloquently puts it, “There are real risks to taking too much thyroid hormone—it can cause heart palpitations and increase your risk of fractures. Unfortunately, too little thyroid hormone can leave you fat, bald, constipated, and depressed.”

Conservative TSH guidelines err on the side of hypothyroidism, McArdle writes, because “being hyperthyroid can kill you, while being hypothyroid just, well, makes you fat, bald, constipated, and depressed.” As long as TSH levels are under 5, many doctors believe, you are being treated appropriately, no matter how you feel.

Many primary care doctors have yet to adopt the more stringent levels recommended by the endocrinologists association, McArdle says, and even those whose patients’ blood tests show the new normal of 3 sometimes suggest these overweight, sluggish, cold people should just overcome their vanity or go to the gym more often.

“I can understand why doctors want to stick to the number: it is objective, while ‘I'm tired and kinda blue’ is not,” McArdle writes. “And presumably, you will get idiot patients who want to be thinner than is natural for them, and will lie about their symptoms in order to be prescribed dangerous levels of thyroid hormone.

"But this is not much comfort to the thyroid patient struggling to get enough energy to make it through the day.”

Which brings us back to the limitations of “evidence-based” medicine and the need for respectful, constant communication between patients and their doctors. “Evidence-based medicine works best on things that are very easy to measure, like blood levels.” McArdle says. “It is very easy to tell whether a statin reduces blood cholesterol levels. It took a lot longer to tell whether it actually reduced heart attacks.

“The more we rely on a central board to make decisions for huge numbers of people, the more tempted we are going to be to rely on metrics which can be collected, aggregated and mined for data. Where does that leave the thyroid patient with ‘normal’ blood levels . . . and a collection of vague, frustrating—but nonetheless very real--symptoms?”

McArdle found an endocrinologist willing to treat her more aggressively than mere numbers indicated to many of his colleagues. Three weeks after beginning her hormone regiment, she wasn't so cold any more and her voice lost its scratchiness.

“I don't want to come out against evidence-based medicine; we should always be trying to figure out what works and what doesn't,” she writes. “But I do question what constitutes evidence. Will evidence-based medicine push us even more towards looking at numbers rather than listening to patients?”

If you believe your care provider has caused serious harm by negligence or malpractice, consult an attorney about legal relief. But that’s using a machete, and sometimes the job requires a butter knife.

If you have a medical procedure – surgery, a screening test – whose outcome is not what you were led to expect, or has made you worse off, there are several ways to lodge complaints. Many of these options recently were spelled out in an article in the Los Angeles Times.

Often, as simple a gesture as writing a letter can have the desired effect, especially if your primary objective is to have your problem acknowledged. If you’ve expressed concern, for example, about enduring, post-procedure pain that hasn’t been addressed, a letter to your doctor seeking the name of another practitioner who can evaluate your symptoms, review the procedure that caused them and suggest how to treat it can be a wake-up call.

As The Times reported, a doctor no longer interested in treating a patient is legally required to notify him or her in writing. The doctor also is obliged to provide references to another physician, and instruct the patient or new provider how to access the records relevant to your treatment.

If you’re trying to get, say, a surgeon, to accept responsibility for an adverse outcome, Dr. Michael Carome, deputy director of the Health Research Group at Public Citizen in Washington, D.C., outlines what to do. “Failure to do so,” he said in The Times, “amounts to patient abandonment, an infraction that would justify an investigation by the state medical board.”

Most state medical boards – the agencies responsible for licensing medical practitioners, monitoring their behavior and imposing discipline – have similar provider requirements. Jennifer Simoes of California’s Medical Board said that a patient should file a complaint if he or she “believes the quality of care that they received was poor or not the standard of care they should have received."

Other state agencies also are appropriate places to report medical mistreatment and misadventure, such as state insurance commissions, which monitor health-care coverage by private insurers. Complain to your insurance company via letter, and copy your state insurance commission.

Medical societies, which range from all-encompassing organizations such as the American Medical Association (AMA) to groups whose membership is limited to certain medical specialties, such as the American Academy of Orthopedic Surgeons (AAOS), are concerned about their reputations. It’s in their best interest to ensure their members are responsive to patient needs and complaints.

To find a state medical society, visit the AMA’s website and click on the “Patients” tab to link to the Medical Societies Directories.

If your problem relates to a surgery or procedure performed in a hospital, file a complaint with that facility’s patient advocate and, if it has one, the ombudsman. Many hospitals are accredited by the Joint Commission, about which we recently wrote. It’s an independent, nonprofit organization that accredits and certifies U.S. health-care organizations and programs.

The Joint Commission also accepts patient complaints, and its Office of Quality Monitoring uses consumer complaints to help assess if a hospital meets its accreditation standards. In The Times’ story, Michael Kulczycki, executive director of the Joint Commission's Ambulatory Care Accreditation Program, said of patient complaints, "We would focus on the continuity of care and appropriate follow-up to the patient."

File complaints at http://www.jointcommission.org. Click on Report a Complaint About a Health Care Organization in the Action Center box on the home page. After reviewing a complaint, the Joint Commission can present your issue to the hospital and ask it to review the doctor’s actions to see if additional action is necessary.

Medicare patients have additional avenues to voice complaints. Contact your regional Medicare Quality Improvement Organization (QIO), which reviews medical care and helps consumers who complain about the quality of their care. Locate a QIO near you at http://www.ahqa.org. Click on QIO Locator.

As always, you have legal rights to safe and responsible medical care. Don’t be reluctant to exercise them if you’re not getting the attention, professional courtesy and resolution you believe you deserve. As Carome said in The Times, "Ultimately another way physicians are held accountable is through litigation."

You can find out more about non-lawsuit options for making a complaint about a doctor, nurse, hospital or other health care provider by reading the Health Care Advocates' Power Kit on Patrick Malone's law firm website. It contains addresses of all the relevant agencies and tips on how to make an effective complaint.

The per-capita U.S. expenditure for health care is twice that of the average industrialized nation, and it’s growing at an undsustainable rate. One reason for that grim reality, says a survey of doctors in the Archives of Internal Medicine, is that a considerable amount of health care is unnecessary. Patients, they say, get too much care.

You can’t read a big-city newspaper without encountering stories about people without adequate medical insurance going without medical care. But folks being overtreated? Not so much.

Nearly half of the of the 440-some respondents believe their own patients receive too much care, and just more than half believe the amount of care is just right. Nearly 3 in 10 said they were practicing more aggressive medicine than they would like.

They gave three primary reasons for their indulgent care:

• concern over malpractice lawsuits (that is, if you overtreat, accusations that your care was wanting lose their punch);


• clinical performance measures (that is, you have to “prove” your worth); and


• inadequate time to spend with patients (that is, if you don’t have time for people, give them tests and treatments to fill the void of communication).

The study concluded that “physicians are open to practicing more conservatively,” and that “physicians believe they are paid to do more and exposed to legal punishment if they do less. Reimbursement systems should encourage longer primarly care physician visits and telephone, email and nursing follow-up, rather than diagnostic intensity.”

In an accompanying commentary to the study, Dr. Calvin Chou sees “a kind of trained helplessness” in the physicians’ responses. They practice aggressively because they have no recourse.

Chou suggests that doctors address the problem through communication and by avoiding burnout.

His reflection mirrors our feelings. As far as avoiding burnout, well, we’re not career counselors, but we do understand the value of communicating with patients. Larding unnecessary tests and treatments into patient care is like giving kids expensive toys and too much sugar when you don’t have time sit down and go over their homework. It’s a replacement for time, and it’s not without side effects.

We also believe the concern about malpractice lawsuits causing defensive medicine is off target. When patients sue for not having been tested enough, it's because a simple test was available that could have headed off the catastrophe which then occurred.

There's no "defensive medicine" in ordering the right test, and it's perverse to suggest that a doctor might only order a valuable test on a patient because of the threat of being sued if he doesn't.

We've written about this topic before on this blog here and here.

Choosing a medical caregiver, like any good consumer behavior, involves comparison shopping.

Mindful of the restrictions of your health-care plan, cost, geography and/or time, choosing a psychological therapist is no different from choosing any other medical provider. In some ways, it’s even more important to have a good match between doctor and patient, because for most people, the mind is the most difficult body part to open to scrutiny.

Writing on PsychCentral.com, clinical psychologist Charles H. Elliott offers therapy shoppers several tips to ensure a good marriage between therapist and patient.

A range of factors can undermine the therapeutic relationship. Maybe the therapist reminds you of someone you dislike or with whom you have an uncomfortable history. Maybe you don’t even know why it just doesn’t feel right.

It doesn’t matter, Elliott advises, whether or not you can identify a reason for a rocky relationship. The fact that you’re uncomfortable is reason enough to question whether a practitioner is the right one for you. If he or she isn’t, you’re not getting the best care.

After a couple of sessions, ask yourself these questions in order to assess if the match seems to promise a successful outcome:

• Do I feel at ease in discussing almost anything with my therapist that I feel is important?


• Do I feel safe when I’m talking with my therapist?


• Does it seem like my therapist understands and truly hears what I have to say?


• Does my therapist look interested in what I have to say?


• Do my therapists’ reactions to what I say feel nonjudgmental and uncritical?


• Does it feel like my therapist cares about me and my problems?

The one exception is if you have relationship problems in general, and struggle to feel safe talking even with close friends or family. That’s a tip that communication/relationship issues should be part of the therapy itself.

In theory, people support the presence of trainees for medical procedures. But when it comes to personal practice … not so much.

So says a study in the Archives of Surgery, which examined patient perceptions and willingness to participate in resident education. More than 8 in 10 patients consented to having an intern participate in their surgical procedure, and more than 9 in 10 consented to the presence of a resident. But when presented with a real situation of trainee participation, not even 1 in 5 said OK.

More than half of the survey respondents said that knowing that their operation was a trainee’s first would affect their consent negatively.

As explained on MedPage Today, in the 1980s surgeons thwarted proposed legislation to mandate “informed consent” when trainees were involved in a patient’s procedure. The docs had argued that such patient consent referred only to the “responsible” surgeon who provides supervision and oversight. Today, the study’s researchers noted, it’s still common practice not to inform patients of trainee participation.

In an accompanying commentary to the study, Ali Salim, M.D., wrote “"As part of [the informed consent] discussion, it seems obvious that patients would want the extent of involvement of surgical trainees during a surgical procedure to be disclosed, but current ethical and legal requirements for informed consent for care by trainees have not been well elucidated."

"To my knowledge,” Salim wrote, “no specific requirement or guidance exists regarding disclosure of the extent of participation of surgical trainees."

If that just seems wrong, the writers concur that full disclosure of trainee participation would affect their education negatively, because patients might refuse permission for them to participate in their care. More than 8 in 10 survey respondents indicated they wanted to be informed about trainee participation.

So here’s the quandary: Medical students can’t learn how to be good doctors without hands-on training, and although patients understand that, they don’t want to be the individual guinea pigs. The authors suggested that patients should be better educated about the nature of a teaching hospital and the benefits for patients to have trainees participating in procedures. But they remain wary about full, mandatory informed consent.

"We believe that broad calls for routine mandated disclosure should be carefully planned and analyzed prior to implementation to avoid any adverse effects on surgical training," they concluded.

Putting the care back into medical care is the aim of a $42 million grant from a couple to the University of Chicago. Sometimes trivialized as "bedside manner," the issue of compassion and caring is central to what so many of us patients see as the lost piece of modern medical treatment.

The new Bucksbaum Institute for Clinical Excellence will be led by Dr. Mark Siegler, a medical ethicist and general practitioner who inspired the gift from Carolyn and Matthew Bucksbaum. Dr. Siegler's words are borrowed for the headline on this blog piece. His distinguishing attributes include listing his cell phone number on his business card, making house calls, and treating his office staff as colleagues and not underlings.

Read more about the caring movement in medicine in the New York Times.

Pharmaceutical companies love dish about doctors and patients almost as much as they love drug profits. One source of information they like to plunder to expand their markets is doctors’ prescribing histories. These “who,” “what,” “why” reports are one component of so-called “data mining” that has gotten much attention lately as a sometimes sneaky way to unearth potentially sensitive information.

The companies buy the reports from prescription drug intermediary (PDI) agencies that, as explained in an article in the New England Journal of Medicine, collect the prescription records from pharmacies and link them to physician information purchased from the American Medical Association.

Pharma sales representatives crunch the numbers in order to refine their sales pitches when they visit doctors’ offices. Critics of this process, known as “detailing,” claim that it:

• raises costs by increasing the use of brand-name drugs;


• jeopardizes patient safety through wider uses of drugs that haven't been studied appropriately; and


• compromises the privacy of doctors and their patients.

As the NEJM writers note, several states have passed laws to curtail detailing and restrict PDIs from providing prescribing information that identifies physicians. One PDI/pharma effort challenged a law in Vermont that prohibited pharmacies and PDIs from selling/licensing/exchanging prescriber-identifiable prescription information and from permitting its use for drug promotion. The case ended up in the U.S. Supreme Court on the claim that it unconstitutionally restricted free speech.

How information that is supposed to be private between a doctor and a patient can qualify as free speech seems preposterous on its face, but the court ruled in favor of the commercial interests in a long and carefully parsed finding that Vermont was biased against detailers and their free speech.

The authors of the NEJM article looked at both sides of the issue. “If laws like Vermont’s were to become widespread,” they wrote, “they would undercut pharmaceutical companies’ ability to detail physicians effectively, with the probable consequence that detailing would be greatly reduced. Although this outcome might well reduce the cost of prescription drugs, it would also reduce the amount of information that doctors receive. … detailing can have educational value. For all its problems, detailing — like its troublesome cousin, direct-to-consumer advertising — is probably of some benefit to patients.”

They explain that PDI databases are used to benefit public health as research material, and if PDIs were deprived of data-mining income, they might not invest in keeping such complete records. They also explain that landmark legislation to protect patient privacy remains strong. “[T]he Court defended the patient privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, noting that HIPAA imposed a general ban on disclosure except in ‘a few narrow and well-justified circumstances.’ Although the Court did little to define the boundary between unconstitutional laws such as Vermont’s and sacrosanct ones such as HIPAA, it is clear that some restrictions on data sales will, if tailored finely and fueled by strong governmental interests, survive.”

The writers suggest that data-mining prohibitions could survive judicial scrutiny if they:

• broaden the ban so as not to finger only drug marketers; and


• sharpen the focus on privacy issues.

In other words, the authors found reason for hope that this one decision does not establish an impenetrable precedent for commerce to boost drug costs, pose a threat to public safety and invade private files.

Of course, doctors can always close their doors to sales reps, but that’s more pipe dream than likelihood. Because even if doctors are as loath to open their files to Big Pharma as the industry is hungry for the information, and even if doctors know that a sales pitch is less than objective, they still can learn something new, and they value the free samples.

If you’re concerned about this issue, and your doctor prescribes a drug:

• Ask if there is a generic option, and if it’s suitable for you.


• Ask if he or she embraces the AMA’s Physician Data Restriction Program (PDRP), which allows doctors to withhold prescribing data from sales reps but still share it for research purposes. According the NEJM, only 4% of physicians have signed on, probably because “the AMA’s financial interests cut against strongly promoting the program.”


• Tell him or her that you’re uncomfortable with your drug history being shared, and request that he or she not entertain pharmaceutical sales calls.

If you believe the stereotype, surgery isn't a warm and fuzzy medical specialty (that would be family doctors), it's a cold, clinical engineering-like pursuit. And a surgeon is more likely to be known as "the knife" than "the smile."

The head of one major transplant center, however, would like to rearrange the stereotypical furniture. Says Andrew Klein, M.D., "Operating rooms are social environments where everyone must work together for the patient's benefit. When a surgeon, who is in the position of power, is rude and belittles the rest of the staff, it affects everything."

Klein and Pier Forni, Ph.D., authors of an article about civility and medicine in the Archives of Surgery, said an operating room is a crucible of stress that can manifest in bad personal behavior that isn't good for anybody. They acknowledge that scientific studies are reinforcing perceptions that outcomes improve when the surgical team cooperates.

As reported in MedPage Today, Klein and Forni found that rancor and the rudeness it engenders may be tied to heart disease and depression. They point to one study that deemed that "high-risk" uncivil behavior in the surgical suite increased the risk of postoperative death and complications.

The incivility extends beyond the OR and so do its side effects. In one study, 96% of nurses for the Department of Veterans Affairs' reported witnessing disruptive physician behavior. A survey by the Institute for Safe Medication Practices showed that 75% of nurses sought a co-worker's help to understand a confusing physician's order because they didn't want to interact with the doctor themselves. Seven percent of the nurses blamed doctor intimidation for medication errors.

In their article, Klein and Forni lobby for surgeons and OR teams "to lead a civility initiative in healthcare." That includes reviewing hiring criteria for surgical employees to look beyond the traditional standards of "accomplishments, knowledge, training, and productivity" in the hope of identifying ways in which prospective candidates can be assessed for how they function in a social environment.

We're thankful that there appears to be a growing awareness of the value of the "what you learned in kindergarten" approach to a collegial work environment. See: Testing for Life-Saving Communications Skills in Young Doctors

"The temptation to ignore warning signs that a surgeon will not play well in the sandbox with peers and co-workers is seductive when large clinical practices and (National Institutes of Health) funding are at stake," Klein said.

Like other workplaces, the writers suggest, hospitals should develop a code of conduct for medical and administrative staff. They also champion the idea of cultivating relationships at work, because a culture of caring fosters loyalty.

If your doctor, your nurses, your patient advocate cooperate and have empathy for each other's professional roles and responsibitlities, your care will improve. Ask if the hospital where you are scheduled to be treated has a code of conduct. As a patient, you should not tolerate rude behavior among the people caring for you. If you don't think someone on your care team is being treated properly, speak up. It's the right thing to do for her, and the best thing for you.

Article first published as Does Being Polite Save Lives in the OR? One Surgeon Says Yes on Technorati.

Only someone who suffers from asthma can understand the panic that comes with a sudden attack that feels as though you’re suffocating. Many such victims reach for an inhaler to dispense the drug albuterol, which provides lung relief.

Now, a new study published in the New England Journal of Medicine confirms not only the drug’s benefit, but a whole lot more -- about how caring can enhance treatment.

It found that asthma patients given a placebo (inert drug, aka fake treatment) or no treatment felt better despite measurable differences in lung function improvement as compared with those receiving drug treatment.

One of the study’s authors, Ted J. Kaptchuk, associate professor of medicine at Harvard Medical School, described for WebMD the elegance of the research: "Disease is what doctors search for--the underlying physical thing they can detect with labs and imaging and can express in hard numbers," he said. "Illness is what a patient experiences. ...There is a difference between what doctors find and what patients experience."

What the asthma study demonstrates is that making patients better requires treating illness as well as treating disease. Thirty-nine asthma patients stopped taking the drugs prescribed for their condition. Then they randomly underwent four different regimens during which lung function was tested regularly. They were:

• treatment with an albuterol inhaler;


• treatment with an inhaler with no active drug (a placebo);


• treatment with bogus acupuncture (the device appeared to puncture the skin like acupuncture needles, but didn’t); and


• no treatment.

As expected, the albuterol treatment registered improved lung function by 20%. And not unexpected was that the placebo treatments improved lung function somewhat--7%. It was interesting that patients who got no treatment also improved by 7%.

But truly surprising was how patients reported their condition. Asked how much better they felt, they said 50% better with the albuterol; 46% better after fake acupuncture and 45% better after using the inert inhaler. The latter two positive reports could be attributed to the “placebo effect,” which is often seen among study subjects who don’t know that they’re not receiving the real McCoy. But even after knowingly receiving no treatment, they said they felt 21% better.

As lead study author Michael E. Wechsler, M.D. told WebMD, "with this study we saw that part of taking care of the discomfort … is being there. …There is definitely some mind-body interaction in asthma that relates to the shortness of breath that patients feel."

People who study the placebo effect draw a distinction between objective medical outcomes (in this study, lung function) and the subjective medical outcomes of patient-based feelings (in this study, less shortness of breath).

They hope to raise consciousness that, sometimes, medical research dismisses subjective results to overwhelmingly favor objective results. But the artful practice of medicine addresses the reason for the suffering as well as the suffering itself.

That said, it would be foolish to ignore the whole picture painted by the asthma study. Treatment with a proven drug clearly resulted in superior lung function. And without the availability of that treatment, people will experience preventable asthma attacks. The goal is for patients to receive medical treatment and medical care.

As if the doctor-patient relationship isn't one-sided enough, the subservience patients often feel can be made even worse when you must wait way beyond the appointed time for your consultation.

For some patients, time is money, and for all patients whose doctors assume the doctor's time is more important than yours, extended waiting is disrespect. One study last year pegged the average wait time at doctors' offices in the United States at 24 minutes.

Everyone understands that medicine is fraught with emergency, and sometimes a physician simply must accommodate an unexpected patient. But some doctors are never on time; for them, running late is business as usual.

Others are told by superiors and insurance companies to book consultations at 15- or 20-minute intervals; if one patient has more than one problem, or a complication arises that requires 30 minutes' time, every patient after her will be seen late. So, does the doctor cut off the appointment in order to maintain the schedule, or does she meet the medical need at the risk of making everyone else late?

As doctors are increasingly besieged with paperwork demands and lower fees from Medicaid and Medicare, is it fair for patients to expect prompt service? Apart from making a scene, is there recourse when your 10 a.m. appointment begins just before lunch?

Some patients, according to several recent reports including one on CNN, are turning rude behavior into financial penalty. They're invoicing tardy physicians for time spent cooling their heels in the waiting or exam room. And physicians are paying.

Not too long ago, doctors would have scoffed at the idea of reimbursing patients for time spent waiting. But some told CNN they give patients money or a gift, sometimes even without being asked.

"I love this!" Dave deBronkart, co-chair of the Society for Participatory Medicine, told the network. "It's magnificent that some physicians are valuing patients' time. It's a commitment to designing a practice that truly serves patients."

Others ... not so much. One woman left her doctor's office at 8:40 when the gynecologist hadn't shown up for her 8:00 a.m. appointment. Encountering the doctor in the parking lot, the patient asked about the delay. "The doctor told me she had a little one and she was never in the office until ten to nine," she remembers. "I asked her why she scheduled appointments at 8 a.m., and she said to give the patients time to do paperwork. I was so mad I was shaking. I never went back to her."

DeBronkart blogged at E-Patient Dave when he waited 45 minutes for an X-ray. He told CNN that the head of the radiology practice later called and acknowledged the need to change how they scheduled patients.

Some physicians have seen the patient-waiting light, and are doing their best to ensure it isn't red. MedPage Today reported about one who offers Starbucks gift cards and text messages patients if he's running behind. Another, who practices boutique medicine, books only about 10 patients per day for at least 30 minutes each and charges a $125 annual fee per family for the convenience. If he is late, he pays $25.

The MedPage story makes clear that it's easier for some practices, such as surgery, to run more efficiently than a primary care office. Offices at greater risk of being late can address the problem and possibly mollify patients by:

• offering wireless Internet;


• ensuring good cell phone service, and providing space where waiting patients can talk privately;


• texting, emailing and/or calling patients if they're running late.

One patient who tries to turn waiting time into work time is concerned that if billing tardy doctors becomes fashionable they will start charging everyone more. They should focus on prevention, he says.

As a patient, you can minimize your likelihood of a shortened fuse from a longer wait by:

• scheduling your appointment at the beginning of the day or right after lunch;


• locating doctors with demonstrable on-time practices via an organization such as Ideal Medical Practice, which identifies superior practices; and


• putting a value on your time and invoicing your doctor for an unreasonably long wait.

Want to go to medical school? How well do you listen? How well do you work in a team? Those issues are now being tested by the nation's newest medical school in screening applicants.

This is not just a matter of touchy-feely. Preventable deaths and malpractice have been proven to happen all too often when arrogance trumps smooth teamwork and easy communication among members of medical teams.

But testing communication skills is not so easy. So in the new testing regime created by the leaders of Virginia Tech Carilion medical school, medical school applicants are given a series of quick, speed-dating type interviews where they have to show how they respond to real world scenarios that require good communication and teamwork skills.

Gardiner Harris has a fascinating account in the New York Times about the new program. A key quote from the article brings home its importance:

A pleasant bedside manner and an attentive ear have always been desirable traits in doctors, of course, but two trends have led school administrators to make the hunt for these qualities a priority. The first is a growing catalog of studies that pin the blame for an appalling share of preventable deaths on poor communication among doctors, patients and nurses that often results because some doctors, while technically competent, are socially inept.

The second and related trend is that medicine is evolving from an individual to a team sport. Solo medical practices are disappearing. In their place, large health systems — encouraged by new government policies — are creating teams to provide care coordinated across disciplines. The strength of such teams often has more to do with communication than the technical competence of any one member.

Chances are, you or a family member has been the beneficiary of a freebie from the doctor’s office, and we don’t mean a cherry lollipop when the kids got their tetanus booster. We’re talking drugs, often of the prescription variety, that a pharmaceutical representative has left after a marketing visit to the doctor’s office. "Samples," they're called.

We've covered the dangers and the hidden costs of "samples" for both doctor and patient previously in this blog, Today's topic is a little broader: the many tentacles of the pharmaceutical industry that reach into the doctor's office and that can affect the care you and your loved ones get. More specifically, there is a possible pay-for-play attitude that’s harder for doctors to resist as medical costs continue their upward thrust and doctors say they feel increasingly marginalized.

In “Doctor Compensation and Industry Influence,” writer Ed Silverman notes that “The ongoing controversy over financial ties between physicians and the pharmaceutical industry centers, of course, on concerns that medical practice may be unduly influenced,” and that doctors are indignant that people could believe their medical judgment would be influenced by swag. But many doctors are unhappy with their compensation, citing costly and lengthy education and training, stressful and protracted relations with insurance companies, rising malpractice insurance premiums and patients armed with an Internet medical degree and questions about diagnoses and treatment.

There’s a lot going on here, and although much of doctors’ dissatisfaction is righteous, it’s unfair for them to expect patients to:

be sympathetic about the costs of an education they chose to pursue;
suffer their ill will in the face of greedy or incompetent insurance companies; and
simply accept that mistakes will be made and that retaining legal counsel is disloyal and unfair.

And it’s just flat-out arrogant and dismissive for physicians to prefer patients who never ask questions, who aren’t invested in their own health care and whose default is to defer to the guy in the white coat because he’s over-educated and underpaid. That’s not good for the patient or, ultimately, the practice of medicine.

A recent survey by Medscape, “Do doctors earn enough?”, generated a robust response within the medical community, and not necessarily for the numbers report (orthopedic surgeons and radiologists earn the most--$350,000 median income—and pediatricians the least-- $148,000 median), but for the ancillary issues.

Responding to the survey in “Mo money mo problems,” physician Sean Pannick drew a line of clarity for parties on both sides of the worth issue: “Doctors should look at their income and ask themselves--and their patients--whether it fairly reflects the quality of their work. Patients, on the other hand, also need to be mindful of the financial component to the doctor-patient relationship. They may not know (or want to know) that money matters when it comes to doctors, who often profit more from a series of tests and procedures than a simple clinical assessment. Conversations in the consulting room already mask a number of hidden agendas, and the issue of renumeration (sic) is another one that lurks beneath the surface.”

Absent a truly malfeasant practitioner, the quality of care a patient receives from his or her doctor probably isn’t influenced markedly by occasional, reasonable attention from members of the medical industrial complex with something to sell. But it might be affected by the efficiency of ordering a test over the harder work of having a conversation.

It is your duty to yourself and your loved ones to get the best possible care, and that means asking questions. If you wonder if your doctor has gotten paid to represent a medical product or service, ask. If you have read something on the Internet that might relate to the problem you’re presenting in the exam room, broach the subject. If your doctor is too busy, distracted or feeling too undercompensated to engage, it’s time to go doctor shopping.

It’s bad enough when a treatment goes so wrong a patient has to sue to get financial compensation for the physician’s malpractice, but what if the physician has no liability insurance and the judgment can’t be collected? For Georgia residents, this no longer poses a problem, because under a new law that may be the first of its kind in the U.S., physicians must disclose whether or not they are covered by medical liability insurance.

According to the law, which was signed by Georgia Governor Nathan Deal last month, physicians are required to inform the Georgia Composite Medical Board if they are insured. The board will make the information available on its website as part of a physician's public profile. In addition, doctors also must disclose whether they are covered by insurance when asked by patients. If the physician declines to inform his patients, the result could be disciplinary action by the board.

"The patient has a right to know if a physician carries malpractice insurance," says Rep. Ben Watson, MD, who sponsored the measure. "This is part of how a patient can judge a physician."

The Medical Association of Georgia, which represents physicians in Georgia, supported the bill. The vast majority of Georgia’s nearly 18,000 physicians have liability insurance.

The Georgia law may be the first of its kind to add "insurance coverage" to the list of public disclosures required of physicians. Last month, the Illinois Assembly passed a similar bill, but it has yet to be signed into law.

Source: American Medical News

Every patient and every doctor know that delivering bad news is something that physicians sometimes have to do. But too many doctors don't realize that the way they communicate can cause terrible and needless emotional injury.

A flat, heartless delivery of bad news can make patients feel abandoned and devastated. A touch of compassion, on the other hand, may not extend a patient's life by a single day, but does make them feel that they are still part of the community of the living.

Patient advocates say that Compassion is one of the four C's that patients have a right to expect. (The others are: Competence, Communication and Convenience.)

William Branch, an internist and professor at Emory University School of Medicine in Atlanta, has conducted studies for two decades to determine if physicians can be taught to be more compassionate.

Dr. Branch maintains that “our healthcare system does not lack compassion,” and that compassion can be taught, though not in a single training session.

In research conducted at five medical schools in 2009, Branch studied two sets of faculty members on their compassion skills as evaluated by their medical students and residents. The students watched the faculty members interact with patients, and they scored those interactions plus the quality of their direct teaching of caring skills.

One faculty group underwent a two-year program that combined experiential learning of skills such as role modeling along with reflective exploration of values through writing narratives and other activities. The other group had no intervention. The study found that the compassion-training group rated significantly more compassionate with their patients.

However, just as it can be taught, compassion also can be lost. A 2008 study of 419 medical students showed that women had twice the empathy scores of men and that scores declined at the end of the third year, when students had begun regular exposure to patients during clinical rotations — exactly at the point where they needed more, not less, empathy. But this trend can be prevented; another study of 209 students at the Robert Wood Johnson Medical School found that empathy was maintained among third-year students who received specialized training.

Source: Washington Post

You can read Dr. Branch’s research paper in Academic Medicine here.

Physicians, researchers, drug makers and regulators should pay more attention to patients’ first-hand reports of their symptoms while they take medicines because their information could uncover safety problems and guide treatment and research, a cancer researcher says.

In an article in the New England Journal of Medicine, Dr. Ethan Basch, an oncologist who treats men with prostate cancer at Memorial Sloan-Kettering Cancer Center in New York, writes that direct reports from patients are rarely used during drug approval or in clinical trials, and, when patients’ comments are sought at all, they are usually filtered through doctors and nurses, who write their own impressions of what the patients are feeling.

In addition, physicians and nurses “systematically downgrade the severity of patients’ symptoms” and sometimes miss side effects altogether. One result is “preventable adverse events” — for instance, suicidal thoughts in young people taking antidepressants, or severe constipation in people taking a drug for irritable bowel syndrome, both of which might have been detected earlier if symptoms had been systematically tracked.

Basch first studied people who receive chemotherapy, comparing symptom reports by patients with those from doctors and nurses and found that for every problem — fatigue, nausea, appetite loss, vomiting, diarrhea, constipation — patients reported it earlier and more often than did doctors and nurses.

The tendency to downplay symptoms may be based on the doctor’s knowledge that a patient is in the early stages of an illness and could be much worse. Or the doctor may be making mental comparisons with other patients who are sicker.

Sometimes, the downgrading may reflect wishful thinking by doctors, who may think that a certain drug will help patients and don’t want to take them off it.

Mistakes and distortions in reporting symptoms can be compounded in studies, where one researcher collects the information, another retrieves it from the chart and enters it into the study record, and still others evaluate it. The results can be like playing broken telephone.

He recommends that patient symptoms should be rated separately by patients and their physicians, particularly before and after new medications are approved and brought to market.

Source: The New York Times

You can read the original article in the New England Journal of Medicine here.

A panel of experts set up to probe the effectiveness of opioid treatment agreements has decided not to support the universal utilization of these arrangements, also known as pain agreements or pain contracts.

Pain agreements outline the risks and benefits of opioid therapy, explain what is expected of the patient, educate the patient about how to store the drugs and help the patient distinguish between acceptable and unacceptable drug-taking. Physicians who provide pain management to patients with chronic pain may require such agreements to avoid liability issues if patients misuse their medications.

However, critics say the agreements can result in a more adversarial physician-patient relationship (because the physician can “fire” the patient if he or she doesn’t adhere to the terms of the “contract”).

The real problem, many critics maintain, is the lack of pain specialists. As a result, primary care physicians, many of whom lack appropriate training in pain management, may take the path of least resistance and overprescribe pain medications at the request of patients.

The panel of physicians and pain-policy experts, which was convened by the Center for Practical Bioethics, a Kansas City, Mo.-based think-tank, concluded it could not support the universal utilization of pain contracts at this time due to “the lack of data about the benefit of pain agreements/contracts, concerns about increasing disparities and further stigmatization of pain patients, and other possible unintended consequences, coupled with the importance of preserving the integrity of medicine from inappropriate outside influence.”

Source: American Medical Association News

For more information and analysis of the panel’s conclusions, click here.

Research shows that a surgeon who has been working for 24 hours is impaired as much as a drunk person in thinking and motor function. So should patients have a right to know if their doctor has been up all night?

Yes, say a group of sleep researchers, who argued for full disclosure of sleep deprivation in a recent article in the prestigious New England Journal of Medicine.

No, responded the American College of Surgeons, whose leaders say it should be up to the individual surgeon to decide if he or she is too tired to operate -- or if the surgeon needs to tell the patient before heading to the OR.

The debate shows that surgeons and hospital administrators are just beginning to consider some basic issues of fatigue and patient safety that in other contexts -- piloting airliners and driving large trucks on interstate highways -- have long been settled.

Surgeons understandably don't want to be subject to the welter of bureaucratic rules that truck drivers and pilots deal with. And patients might not like it either if a surgeon was required to announce that he would be starting their surgery but another doctor would come into finish it because the time would stretch beyond the first doctor's hour limit.

But some sensible limits could easily be put in place. For one, the opportunity for a surgeon to work inhuman hours is created by hospitals who let a surgeon sign up for overnight call, which often results in working all night in the OR, and let the same surgeon schedule elective non-urgent cases for the next day.

Why would a surgeon do this in the first place? The lure of money, as a number of commenters on the New England Journal of Medicine website candidly admitted. Which raises a problem with the American College of Surgeons' idea that surgeons should be left to their good judgment on when and when not to operate. Anyone who schedules back-to-back call nights with elective cases is not showing good judgment in the first place.

Another issue for patient safety is the surgeon who is well rested but inexperienced, for not having gone through sleepless nights filled with surgical cases. Residency training programs are now starting to limit young surgeons to 16-hour days, which many surgeons say is going to result in a generation of rested but green doctors.

The right of informed consent gives at least one answer to the conundrum. Every patient has a right to know what any reasonable patient would want to know going into a surgery. And since we would all pause before submitting to the knife with a surgeon smelling of alcohol, the same right should apply to the less obvious danger of the sleep-deprived surgeon. If a doctor wouldn't want a family member to undergo surgery with that glassy-eyed doctor, then the same right should apply to all patients.

This means patients should be told, and should be given the option of rescheduling or bringing in a fresh replacement to operate. This will be inconvenient for hospital schedulers and may cause some surgeons to lose income. But patients will ultimately be safer for it.

And if hospitals want to minimize patients getting upset for having their plans upended at the last minute, all they have to do is adjust their call schedules to make these up-all-night dilemmas a rare event.

Article first published as Should Patients Have a Right to Know When Their Surgeon Has Been Up All Night? on Technorati.

Doctors and nurses bring different values, different training, and different snapshots of patients to the process of care, so it's no wonder they can disagree. Often the disagreements are not about technical issues but about basic human values where there is no clear right and wrong.

Theresa Brown, R.N., has an excellent column in the New York Times about how she agonized when a terminal cancer patient cried out in protest against the painful chemotherapy treatments he was getting. The doctor pushed the patient to carry on the treatment, and so the patient agreed, only to die shortly later with extra pain from bleeding in his bladder that the aggressive treatment had caused.

When she was criticized by another physician for speaking out against what she saw as unnecessary and unwise care, here is how she responded:

So is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship? I don’t think so. Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor.

And while my physician colleague said that nurses only see a snapshot, that picture is often one the doctor does not see.

Later, I had another chance to talk to the doctor who raised this issue in the first place. I told him that I was planning to write about our discussion of the role of doctors and nurses. “Yes,’’ he said. “We never got to finish our conversation.”

So we finished it. He shared difficulties he’d had with nurses criticizing treatment decisions when they had only known the patient for a few hours. I nodded. Then I said that physicians can have blinders on, too, and he nodded as well.

In the end he said, “The point is, it needs to be a conversation.” And we both agreed on that.

But when in doubt, I will err on the side of aggressive advocacy for my patients. Nurses have a professional obligation to make sure that patients receive the best care possible and to insure that all care given in hospitals is safe. For better or for worse, patients who come into our hospital are the responsibility of the nurses, even if the patient has been admitted by a doctor of her own choosing. A good nurse will share his or her opinions with the medical staff — sometimes loudly — because that’s part of our job, even if we ruffle a few feathers in the process.

I agree that there has to be a conversation. But I think the central actor in the conversation is the patient, or if the patient is incompetent, then the family. We lawyers call this "informed consent." But it's really about the fundamental human right to determine what is done to our own bodies.

A new patient safety organization has launched a range of online tools and other resources to reduce abuse of opioids by identifying the risks associated with their use. The materials from the CARES Alliance (Collaborating & Acting Responsibly to Ensure Safety) include several “safe-use” programs, tools and educational materials for patients, caregivers and healthcare providers.

They were developed using Failure Mode and Effect Analysis (FMEA), a scientific methodology that identifies where problems occur in the use of pain medications and the underlying causes of those problems. The FMEA research identified 79 areas where problems occur in the use of opioidsand 290 potential causes of those failures.

Tools now available include clinical materials and risk assessments for physicians, safe-use guides for patients and general education for all groups. The organization also plans to develop additional tools based on the research.

Jeffrey Gudin, MD, a pain management and addition specialist at the Englewood Hospital and Medical Center in Englewood, N.J., says that healthcare professionals need to do a better job of assessing our patients' pain medication needs and of communicating the risks of the medications they prescribe.

"Through the resources of the C.A.R.E.S. Alliance, patients, caregivers and health professionals will have access to information, tools and resources to help them better understand these risks and better ensure that the medications are used properly by only those for whom they are prescribed," he says.

The alliance, which is sponsored by Covidien, the largest producer of prescription pain medications in the U.S., also will work to ensure that patients suffering from chronic pain have access to necessary medications.

Source: Medical News Today
You can obtain tools and other resources here.

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.

My law firm's website has more about VBAC and other types of birth injuries here and here.

An article by Jane Brody in the New York Times, "When Your Looks Take Over Your Life," draws attention to a tragic mental health issue called "body dysmorphic disorder."

These are people who are obsessed about a "flaw" in some aspect of their bodily appearance, and who sometimes subject themselves to repeated rounds of cosmetic surgery to "cure" this problem. And of course the surgery never works because the problem is much deeper than the skin. A malpractice lawsuit is not the answer for these patients, as I explained in a comment on the New York Times' "Well" blog:

As a malpractice attorney who represents patients, I have been consulted several times by potential clients whom I later realized had body dysmorphic disorder. When they called for the appointment, the story on the telephone was that they had been grotesquely disfigured by a cosmetic surgeon, often with repeat surgery. Then when I met them, I would not be able to see anything wrong with their appearance, even when they pointed it out to me.

One man in his mid-20s had had his nose operated on three times by the same surgeon. All I could see was that one nostril was slightly larger than the other. He was talking about needing to have yet another surgery. I politely urged him to see a psychiatrist first, and told him I could not represent him in any legal action against the surgeon.

My personal belief is that an ethical cosmetic surgeon would decline to operate on anyone with obvious signs of body dysmorphic disorder (if for no other reason than that this will be a hard-to-please patient), but a willing patient with the means to pay for the surgery can be persuasive for some surgeons, it seems. (Witness Michael Jackson.)

The legal system does not have good answers for these patients. A lawsuit would only perpetuate the patient's idea that their appearance can be "fixed" and that it's the doctor's fault for not doing so. Still, my heart goes out to people with this disorder especially when they subject themselves to a fruitless round of surgeries. They definitely need counseling.

Read more comments on the Well blog here.

A new website has tools for learning how to speak up effectively when you've had a bad health care experience. That can be anything from being on the wrong end of someone's rudeness to being the victim of a serious malpractice event. The website is called The Assertive Patient. Click here for the link. It comes out of Massachusetts but has good resources for patients everywhere.

The website has a good diagram here that shows the steps involved in getting resolution to a bad experience, especially if it's in a hospital. You start with talking with the providers involved and if they are non-responsive, the hospital will have some sort of patient advocate or ombudsman or quality assurance officer or "risk manager" (many different terms cover the same thing). If this doesn't work, formal complaints to regulatory bodies are the next step, or talking to a lawyer.

The final chapter in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, also gives a step-by-step approach to getting to the bottom of poor quality care. And you can get the same information at my law firm's website, by filling out the form to download our free Injury Fact Kit.

Almost nothing is worse in medicine than a cold-hearted delivery of bad news that sucks all the hope out of a patient's lungs. And almost nothing is better than an honest dialogue between doctor and patient that explores the hopes and fears of a patient faced with a very serious condition, in a way that allows for hope in some form to continue to exist. Because we know that when all hope ends, life does too.

Dr. Chris Feudtner, a bioethicist at Children's Hospital of Pennsylvania, has a sensitive essay on this topic in the New England Journal of Medicine. He titled it "The Breadth of Hopes."

His idea is that all of us have a range of hopes that are necessary to carry on with daily life; some are fanciful and others are very concrete and specific.

Doctors need to nurture hope while helping patients redefine what it is they hope for. Even hoping for a miracle in the face of an incurable disease is not necessarily something that doctors should scoff at. As he writes:

Judging such a hope as either realistic or false misses the point; rather, we should judge ourselves as clinicians by the degree to which we can help nurture our patients' collection of diverse hopes.

This is not to say doctors should encourage unrealistic Pollyanna thinking by patients.

Dr. Feudtner hopes to develop better tools to help patients and families in the emotional end of coping with disease. He concludes: "as clinicians, we need to more carefully work through what separates the appropriate management of hopes from their inappropriate manipulation, because whether we want the responsibility or not, we constantly interact with our patients' hopes."

Did you know that rupture of an Achilles tendon can be fatal? This common injury has one potentially fatal but preventable complication: a blood clot can develop in the calf while the leg is immobilized for healing of the injury, and if the clot gets big enough, it can travel to the heart and cause what is called a pulmonary embolism.

The Achilles tendon is the ligament that connects the calf muscles to the heel bone. When it ruptures, the patient must have the calf immobilized for several weeks. That can cause blood clots in as many as three in ten patients, because calf muscles when they flex act as a pump to help bring blood back toward the heart. Immobilized calf muscles allow the blood to pool in the deep veins of the leg and potentially clot.

Samuel Burton, a retired Coast Guard captain, died of such a clot, and a distinguished federal judge recently decided the death should not have happened. Judge Royce Lamberth, chief judge of the U.S. District Court for the District of Columbia, ruled that orthopedic surgeons at Walter Reed Army Medical Center had committed malpractice by failing to warn Capt. Burton when they were treating his Achilles tendon rupture about the risks of this blood clot and what he should do if he developed any of the symptoms of a clot.

When Capt. Burton died, his widow was shocked to learn from the medical examiner who performed the autopsy that two episodes of chest pain and shortness of breath, which Captain Burton had experienced in the weeks before his death, were signs of a potential pulmonary embolism. None of the doctors at Walter Reed had ever warned Captain Burton or his wife of this possible deadly complication and what to watch out for. She sued the government for medical malpractice under the Federal Tort Claims Act. After a trial, Judge Lamberth issued a verdict in favor of the widow, and he ordered the government to pay her $2,080,000. Judge Lamberth concluded that if the doctors had properly educated the patient and his wife, they were responsible people who would have appreciated the need to get to a hospital for treatment before it was too late. Both Captain Burton and his wife had assumed that his two episodes of pain and windedness were from deconditioning because he had resumed some physical activities after being off his feet for weeks.

The judge rejected Walter Reed's defense that since statistics showed that only about one in one hundred Achilles rupture patients died of pulmonary embolism, they didn't need to be warned about the risk.

Captain Burton's family was represented in their medical malpractice case by Patrick Malone & Associates.

Read the judge's decision here.

Two new books take up patient safety and quality of care issues from opposite perspectives, one a physician's, the other a patient's, and both have compelling lessons.

Lisa Sanders, MD is the New York Times Magazine "Diagnosis" columnist. Her book, "Every Patient Tells a Story -- Medical Mysteries and the Art of Diagnosis," starts with puzzles of sick patients and unknown diagnoses. We all love a good mystery, but this book is much more than a compelling mystery yarn. Through deftly told true stories, Lisa Sanders shows how correct medical diagnosis requires a combination of skills and right attitudes. As the book's title implies, careful listening to the patient comes first. A good physical exam is critical, and the worrisome part of the book is how this old-fashioned art is increasingly neglected in medical schools. Luck has a role too -- or maybe it's humility -- as the author gives several cases where happenstance seems to have helped find the correct diagnosis from a medical bystander, but that requires the ability to admit you don't have all the answers and to reach out for help. But perhaps most important: the empathy to persist toward the answer and the quiet time to contemplate the entire patient. This book will help young physicians do better and will help patients find the right doctors who will care about them.

Sorrel King is a Baltimore mother who lost her infant daughter in a medical catastrophe at Johns Hopkins Hospital. Her new book is "Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe." Sorrel King has already saved many lives with her tireless work to urge hospitals to listen carefully to what parents say about their sick children. It takes a special person to turn tragedy into something positive. I featured Sorrel and several other brave survivors of medical errors in my book: The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst. It's wonderful to see her now tell the full story of her daughter Josie and her inspiring crusade. I hope everyone can read this book and absorb its lessons.

Every hospital patient needs someone with them at all times to help prevent medical errors and keep them safe. That's a mantra I have advocated for years, and another example of why it's good advice comes with a riveting story in the Washington Post by health writer Sandra Boodman.

Ms. Boodman's article tells how a Washington area woman's advocacy in the emergency room and hospital helped lead to a correct diagnosis of baffling symptoms, and likely saved her sick daughter from harm. The article interviews Patricia Dawn about her 4-year-old daughter Brooke's illness, that was eventually discovered to be Kawasaki disease, an unusual heart condition.

Brooke got the right treatment in time, but only because of her mother's persistence. Mrs. Dawn refused the recommendation of the emergency room doctors to take her daughter home at 2 a.m. when she wasn't feeling any better but they had run out of things to do. At her insistence, her daughter was hospitalized, and an infectious disease specialist eventually figured out that the red lips, red eyes, fever longer than five days, and swollen lymph node in the neck all were signs of Kawasaki, which affects about 2,000 American children a year.

It was also at the family's suggestion that the infectious disease doctor was brought in who made the correct diagnosis.

The story underlines the importance of having a good advocate present at all times with a patient in the hospital. Even a lay advocate can see when symptoms aren't improving and can insist on action.

I discuss this subject in depth in Chapter 12 of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

I took a deposition a few days ago that underlined for me why we need to have public report cards on primary care doctors so that patients can separate the mediocre practitioners from the really good ones. I wrote an article explaining the idea. Read my entire piece on Huffington Post, which I called "One Good Reason to Get Mad About Health Care."

That question was asked in a New York Times column by Dr. Pauline Chen, and her column prompted a number of thoughtful comments by both doctors and patients. Clear communication is a critical element to good diagnosis, and that puts burdens on both doctors and patients.

Some of the comments on the column which I found most helpful:

I think the most important thing to avoid missed diagnosis is to improve the communication between doctors and their patients. It is especially important to encourage patients to be pro-active and be involved in their care. For example, I give my patients copies of all their test results when they come to visit and encourage them to read them and ask questions if they do not understand specific terms (and they frequently do). I tell all my patients not to assume anything; “If you call to find about test results and no one return your call, do not assume that they are ok. Please call again and make sure that you speak to someone.”

As a cancer specialist in a referring center, many of my patients ask whether they had their cancer for a long time, and whether an early diagnosis was missed. I perfectly understand the concerns. However, it is my experience that patients who are involved in their own health care and are well informed, usually have less chance of having missed diagnosis than those who blindly trust the system and passively participate. Blaming never resolves any problems. It is more tragic if one (patients or doctors) did not learn from their mistakes.
— Anas Younes, M.D.

And this one from a doctor in training:

I appreciate the 2nd half of the article, particularly highlighting the social characteristics of the patients most likely to not follow up with something they should have. However, in contrast to the comments above, I believe that it is always the physician’s responsibility to make sure that he/she and the patient are on the same page. I say this as a physician-in-training, and as a patient as well.

Patients are sick, scared, and, for the most part, worked pretty hard to get through the clinic door. it is the physician’s responsibility to understand the patient’s perspective, and act accordingly. We need to understand their disease as they understand it, even if we don’t agree with it.

All too often, we ignore or fail to appreciate the power differential latent within the patient-physician relationship. If a physician authoritatively tells a patient to schedule a mammogram or colonoscopy, it takes a strong patient to go against that edict. However, when the patient doesn’t follow up in the way we want him/her, it is our fault for failing to understand their position. Within each encounter, we need to strive for a truly shared decision-making model. If we solicit the patient’s thoughts, feelings and concerns about the plan we have for them, they will be on board with the plan, because it’s their plan too.

Granted, this is a tall order, However, it is our responsiblity as physicians to ensure that the patients we see are on board with us. Now certainly there are some patients and some reasons why a person may not follow-up when they say they will, but, from my experiences, a patient chooses not to follow-up when he/she hasn’t been part of the decision-making process.
— Alex

Patients who want to communicate effectively with their physicians and be joint participants in the care plan should take a look at my system for going to the doctor's office, in Chapter 3 of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst." The system is "Make a List, Leave a List, Take a List," and it involves putting in writing all our worrisome symptoms before the visit, leaving that list with the doctor, and making sure to take home a list of the action plan. This helps focus both you and the doctor on what is important and helps cut way back on the potential for miscommunication which is the source of so much misdiagnosis and missed opportunities for cure.

Whether or not a patient should get an expensive imaging scan or some other elaborate and expensive test is not always clearcut. But what should be clearcut is that doctors should not have a thumb on the scale when they're balancing harms versus benefits. The balancing ought to be focused entirely on what's in the patient's best interest. The news story about what happened when a group of urologists in Iowa ordered a new CT scanner for their office sheds light on this conflict of interest issue.

According to the article by Shankar Vedantam in the Washington Post, the doctors at Urological Associates in Iowa were ordering fewer than one dozen CT scans per month for their insured patients in the months before their office bought its own CT scanning machine. That number jumped to 55 scans per month soon after the doctors got their own machine and started getting direct insurance payments for its use.

Defenders of the doctor-owned machines say it's more convenient for patients not to have to go to some other building for their scan. That's no doubt true -- if the scan is really needed in the first place. The problem is that self-interest colors the doctor's calculation, whether subtly or blatantly.

You might say "so what," but no test is without its downside, and excessive radiation from unnecessary CT scans can ultimately cause cancer in some patients -- as many as one in one hundred cancers are traced to radiation exposure. Not to mention bankrupting our health care system in the meantime.

Congress is considering outlawing the practice of what is called "self-referral," referring the patient to a test on a machine that the doctor owns. At the least, Congress should make it mandatory that doctors disclose any self-interest they have in testing, so that patients can take it into account in deciding whether they want the test.

I discuss doctor conflicts of interest in Chapter 9 of my new book, "The Life You Save." Chapter 9 is called "The Second Opinion: Always Your First Choice." It explains why you the patient need to understand if your doctor may have some ulterior influence on his or her thinking, and how it's always a good idea to get a second opinion before undergoing any major procedure.

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.

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."

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.

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.

There's a new/old take on the importance of primary care doctors to obtaining the best quality medical care. It's called the medical home, and it doesn't mean house calls, but it does mean that the patient has a medical "home" -- a team of providers, led by a primary care doctor, who coordinate the patient's care and know everything that is going on with specialists, testing and followup.

This is new because it's being rejuvenated as a way to cut costs and get higher quality care; it's old because the term was coined by the American Academy of Pediatrics in 1967. Jane Brody reports on this in her personal health column in the New York Times.

The medical home concept is supported by all the medical societies who represent primary care doctors. Unfortunately, over the last few decades, insurance reimbursements have been slanted toward performance of tests and not the painstaking work of listening to the patient, thinking through the patient's problem, and recommending a course of care.

Getting a top primary care doctor is one of the "Necessary Nine" steps for quality care outlined in my book: "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Evidence continues to pile up for why patients need to read their own medical records. A new study finds it is distressingly common for primary care practices, especially big ones, to fail to inform patients about abnormal test results.

The study was published in the Archives of Internal Medicine and was reported by Nicholas Bakalar in the New York Times. The study was also featured in Tara Parker-Pope's "Well" blog at the Times, which features a number of horror story comments by readers.

Overall, the study found seven times out of 100, abnormal test results were not conveyed to patients. In two large primary care practices, one in four abnormal test results were never mentioned to the patient.

Bottom line: Patients who don't hear back the results of their testing can never assume that no news is good news. People need to ask for a copy of their test results from either the doctor's office or the lab where the test was done.

Getting and reading your own medical records is Step One in the nine-step system I recommend for getting the best medical care, in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Medicine continues to take small but encouraging steps to move out of the 19th century in communications with patients. The latest: an experiment at Boston's Beth Israel Deaconess Hospital to let patients read on a secure website the notes that doctors write about them at the end of each visit.

As reported in the Boston Globe by Liz Kowalczyk, the project will last a year and will include detailed questionnaires to see how doctors and patients react to these "open notes."

Sometimes the notes a doctor writes after seeing a patient are more blunt than the message the patient might hear in person, for example, a discussion in the office about the patient's obesity or use of narcotic pain relievers.

Patrick Malone's new book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," advises patients to always read their own medical records -- even if the facts they contain may be a little "raw." The upside to reading your own record is to improve your own understanding of what the doctor's advice was, to help correct errors or omissions in what the doctor wrote, and to otherwise make you the patient a more vital participant in your own health care.

A New Yorker article by Dr. Atul Gawande, a surgeon, focused on why McAllen, Texas has higher medical costs than just about anywhere in the country. Dr. Gawande concluded that much of the problem could be traced to the very aggressive, intervention-oriented style of medicine practiced there -- all stemming from the fee-for-service payment system that rewards the doctors who practice intensive, high-cost care. His article achieved new prominence this week when President Obama told White House aides and members of Congress that after reading the article, he decided "This is what we've got to fix."

The President was quoted on that by Senator Ron Wyden in an article in the New York Times by Robert Pear.

Aggressive, high-cost medicine has never been proven to make anyone healthier or live longer. Why do the McAllen doctors order so many tests and procedures? Because they make more money from our fee-for-service system. The answer is to reorganize care so that doctor don't have a built-in conflict of interest where they prosper economically the more stuff they order. But that reorganization is easier said than done. Dr. Gawande rightly looks to models like the Mayo Clinic, where doctors are on salary. Read more about this on Dr. Bob Wachter's health care blog.

One interesting sidelight to Dr. Gawande's article is that he nails the old bug-a-boo of the medical industry: so-called "defensive medicine" in which doctors supposedly order lots and lots of tests not out of any perceived medical necessity but out of fear of being sued for malpractice. A group of McAllen surgeons tried this explanation out on Gawande, but he rightly pointed out to them that Texas has some of the strongest tort reform in the country, so he was skeptical.

He didn't mention, but might have, that other states like California, which in the 1970s made it almost impossible to sue for malpractice except for the most egregious cases, have enjoyed no medical cost savings that anyone has been able to count. Health care economists have proven that what explains disparities in medical costs is high numbers of specialists in a community and correspondingly low numbers of primary care doctors.

That Congress is just now discovering the realities of medical economics, which have been published in study after study over the last three decades, is itself pretty scary.

It sounds like every patient's medical fantasy: Easy access to your doctor 24/7, same-day appointments, thorough and unrushed examinations, little to no time in the waiting room. The only downside is expense: To get this kind of personalized care from a primary doctor, you have to pay an annual fee, and forget about insurance covering it. And you will still need insurance to cover hospital stays and specialists.

Is this ultra-personalized health care, which is called "concierge medical practice," worth it? Many patients think so. Even those squeezed by the recession are often finding room in their budgets for the annual fee for a concierge doctor, even as they cut down on restaurant dinners and other non-essentials.

According to a report by Kevin Sack in the New York Times, leaders in the field of concierge care say they see no impact of the recession in the steady growth of their practices. Dropout rates from the practices are holding steady.

It's estimated there are about 5,000 concierge doctors in the United States, a small fraction of the 240,000 internal medicine doctors in the country. One of the largest groups is called MDVIP, which started in Florida and now has 300-plus physicians in its network. Each MDVIP doctor is limited to 600 patients, who have to pay an annual fee of $1,500 to $1,800. The limit on the number of patients lets the doctors see far fewer patients in a typical day.

The advantage for patients is having a medical expert on hand who knows your body intimately and can sometimes detect subtle danger signs before a full-blown crisis develops.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, finding a top primary care doctor is one of Patrick Malone's key "steps" to finding the best medical care. If it takes extra money to get that relationship, and you can afford it, signing up with a concierge medical practice can be money well spent.

Nobody wants to go home from the hospital only to be readmitted within a few weeks. But that revolving door is very common in conditions like heart failure, where the patient's heart muscle doesn't pump effectively after it has been weakened by heart attack or other heart disease.

The open secret of the hospital industry is that the financial incentives of Medicare and private insurers are tilted toward keeping that revolving door going. Hospitals that actually invest money in following patients after they leave the hospital to try to keep them healthy find that they lose money on this follow-up care. Reed Abelson of the New York Times wrote a report describing how progressive hospitals that have tried to keep their patients from readmission have lost millions of dollars in the process. Those include the Park Nicollet Health Services in Minnesota and Catholic Healthcare Partners in Cincinnati.

One lesson from this story is that patients don't have to wait for medical payment reform to get better care and avoid the revolving door. If you or someone in your family has heart failure, here are the early warning signs that symptoms may be worsening and a doctor or nurse should be called:

* Weight gain. Patients need to weigh themselves every day. Sudden weight gain often means a buildup of fluids caused by the heart not pumping effectively.

* Shortness of breath. Fluid buildup often is most apparent in the lungs and is signaled by being out of breath.

* Ankle swelling. Another place where fluid buildup can be spotted early.

A phone call to the nurse can result in an adjustment of medication that may ease the problem. If that doesn't work, a visit to the doctor's office might be in order. The goal is to intervene before a crisis develops and you have to be rushed to the hospital in an ambulance.

If your doctor already has a system in place that helps you monitor yourself at home, that means you have a top-quality doctor. If you have a hard time getting such a monitoring system going with your doctor, then it might be time to switch to someone who is more responsive.

Patrick Malone discusses how to find a top primary care doctor in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst

An Institute of Medicine report released on April 28, 2009, denounces the adverse effects that the health care system suffers from the free gifts regularly pumped into hospitals, medical schools, and doctors’ offices, writes New York Times’ Gardiner Harris. The report strongly advises doctors to stop accepting the gifts. The report says that accepting gifts would “create conflicts of interest, threaten the integrity of their missions and their reputations, and put public trust in jeopardy.”

When doctors accept gifts from drug companies – which may be money, drug samples, office supplies or food – they change their prescribing habits. This change may or may not be conscious, but the “reciprocity instinct” that prompts people to return a favor is part of human nature that has been recognized by psychologists and anthropologists. And when this happens, the patients are the real victims: their doctors may prescribe new drugs that are yet to be tested for their safety or effectiveness, or drugs that patients can easily replace with diet or lifestyle changes.

In his new book, The Life You Save: Nine Steps to Finding the Best Medical Care – and Avoiding the Worst, Patrick Malone discusses steps patients can take to avoid being victims of such conflicts of interest. He also explains how an average patient can dissect statistics on drug performance to determine if a particular drug is really as effective as it’s marketed to be.

Getting a loved one home from the hospital is always a relief for both patient and family, but the weeks immediately after hospital discharge are fraught with peril, as many families don't discover until the patient has to be readmitted for a new problem. This is especially common with Medicare patients: an alarming one in five Medicare patients are back in the hospital within thirty days, and one in three are readmitted within ninety days. Fully half of the non-surgical patients who have to be readmitted in the first month after going home had no followup visit with any doctor during that same month. That means the patients were basically set adrift to fend for themselves. These numbers come from an analysis published in the New England Journal of Medicine, as reported in an editorial in the New York Times.

Leaders in the health care field freely admit that hospital readmissions come about from poor discharge planning and inadequate communication with family members about what they need to do to keep the patient healthy. The president of the American Hospital Association said in a letter to The Times about the editorial: "Most unplanned readmissions can be traced back to our fragmented delivery system, and to the lack of social support programs for many elderly and sick patients."

What is the answer?

Family members who are assigned by hospitals to take care of a loved one at home need to be very clear on what they are supposed to do. Do not let a family member be dumped on your lap without a clear, written list of everything they need, including medications, therapies, and appointments for return visits. Family members need a lifeline they can call on when things don't seem to be going right.

The leaders of our health care system are talking about extending Medicare benefits so that nurse managers can coordinate the transition from hospital to home, or teams of caregivers can conduct house calls on recently discharged patients. These are promising ideas, but what is needed right now is for anyone who has a family member coming home from the hospital to speak up and insist on clear instructions and advice. Being forceful and clear can help the caregivers help you to make sure there is a well thought out plan and that you can realistically carry it out.

Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has a chapter on how family members can become effective patient advocates when they have someone in the hospital. The chapter includes a list of key checkoff points that you need to understand when a loved one is discharged to your care. You need to have at a minimum:

* A written set of discharge instructions.

* A specific appointment with the doctor in charge for a followup visit.

* A list of bad things to watch out for, and the contact person to relay this information to.

* Written lists of all medications that need to be taken, when and how; plus all therapies that need to be done with similar detailed instructions.

One of the true pioneers of modern medicine is Dr. Thomas Sarzl, who performed the first liver transplant and who developed many of the procedures that have made transplantation a safe lifesaving treatment for thousands of people.

Dr. Sarzl is still active at age 83. He was interviewed recently by another transplant surgeon, Dr. Pauline Chen, for her column in the New York Times.

From his many years of experience, Dr. Starzl gave three nuggets of advice to patients, which I am reprinting because I think he is right on target:

"As for the patients," he told Dr. Chen, "I would give this advice — I followed it myself. That is to get a practitioner of general medicine to take care of you, somebody who is not a narrow specialist. And have that person take care of yourself and the people you care for most, your family. The second is to be constantly learning so you can be informed and have some judgment about advice you are given. And then the third item would be to get a second opinion if some really significant thing happens that requires drastic therapy. Those decisions are so important that I think you should get a second opinion if you come to a point where you need the treatment required for cancer or transplantation or catastrophic indications."

My new book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," makes some of these same points. For example, Step Three of my "nine steps" says: "Team up with the best primary care doctor you can find." And Chapter 9 is titled: "The Second Opinion: Always Your First Choice."

One of the less common forms of cancer, oral cancer was diagnosed in about 35,300 Americans last year and caused the death of 7,600 people. Although oral cancer is one of the easiest to detect and diagnose, the five-year survival rate is only 59%, and more than 60% of cases are diagnosed in the late, incurable stages – which may be a result of people not regularly visiting their dentists or not asking to have visual exams, reports Laurie Tarkan of the New York Times.

The most effective way to screen for oral cancer is to carefully look for it. The dentist or dental hygienist should examine the cheeks, the gums, the floor of the mouth, the area behind the teeth, the palate and the tonsil area (pulling the tongue forward), and should feel the lymph nodes of the neck. Such visual exams are found to reduce mortality by 34% in a study done in India. Emerging on the market are alternative tests and devices that may be more sensitive than the traditional visual exams. However, no decisive study has been done to prove that the more expensive tests are necessarily better.

Dentists encourage patients to get a thorough visual exam every year, and they recommend it not only to the high-risk groups (smokers and heavy drinkers) but to every adult, because oral cancer has recently been linked to oral HPV, which is transmitted through oral sex.

An international research team has shown that death and complication rates from surgery can be dramatically improved by using simple checklists to make sure that safety measures are taken before, during and after each operation.

The research project, involving nearly 8,000 patients at eight hospitals around the world, was done as part of the World Health Organization's program called Safe Surgery Saves Lives. The results were published in January 2009 in the New England Journal of Medicine.

When the surgical teams at the hospitals used the checklists, they found that death rates were cut in half and non-fatal complications by one-third.

The nineteen items on the surgical safety checklist include basic items like verifying that the team has the correct patient and the correct surgical site, making sure the pulse oximeter (which measures oxygen in the blood) is working, making sure antibiotics have been given within one hour before the start of the surgery to prevent infection, and confirming that x-rays needed for the case are on display in the operating room. One other item on the checklist is to have all members of the surgical team introduce themselves by name and role; this is intended to give permission to lower-status team members to speak up at a later time if they notice something wrong. Click here for the entire checklist from the WHO (which is part of the United Nations).

The Patrick Malone law firm has prosecuted many lawsuits against hospitals where these basic preventive steps were not done and their absence led to tragedy. Examples include non-functioning pulse oximeters, surgery done on the wrong body part, and failing to prepare for known possible risks like heavy bleeding.

Patrick Malone discusses steps that patients can take to make sure their surgeons follow safe practices in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, available at Amazon.

When a doctor knows that his patient would receive better care elsewhere, should he inform the patient and send him to another provider? While this question is yet to be settled among bioethicists and physicians themselves, authors of an article published recently in the journal, Public Library of Science Medicine, think doctors have an ethical obligation to tell patients that better care is available to them, according to the New York Times’ Denise Grady.

Research has shown that facilities that perform high volumes of a certain procedure do it better than those that perform the procedure less frequently. The difference is substantial, especially in surgeries of pancreatic and esophageal cancer, although “the experience of the surgeon and the whole medical team [is] important in any major cancer surgery.”

Only a few courts around the country have decided whether doctors have a legal duty to inform patients that another doctor might have more skill and experience performing a planned surgery. One of them is Maryland's highest court, the Court of Appeals, thanks to a client of Patrick Malone named Billy Boone who suffered brain damage after an ear surgeon punched a hole into Mr. Boone's brain.

Mr. Boone's case shows that surgeons' skills make a difference in much more than cancer surgeries. The Maryland Court of Appeals decided that Boone had a legal right to know that his surgeon did not have extensive experience doing the ear surgery that Mr. Boone underwent.

Mr. Boone had an outpatient surgery in January 2000, to remove a benign growth from the mastoid cavity behind his left ear. Dr. Seth Goldberg, an ear nose throat surgeon, performed this surgery, called a mastoidectomy. Seventeen years before, Mr. Boone underwent the same procedure, in which another surgeon drilled out the same mastoid to remove a cheesy growth of skin debris called a cholesteatoma. Unknown to Boone, the surgeon had become lost at one point during the procedure and drilled a hole in the skull just above the mastoid, near the bottom of the brain's temporal lobe. But nothing happened to his brain, which was protected by the tough fibrous shell below the skull called the dura. Years later, when Dr. Goldberg prepared for the new surgery, he took some CT scan pictures of the bone anatomy and saw the pencil-sized hole in the side of the skull.

Dr. Goldberg's surgery seemed uneventful, but after Boone went home, he developed a short-term memory problem that ruined his ability to do carpentry; worse, he developed a problem controlling his temper that unleashed itself at stressful moments on whoever happened to be nearby. Later, his neurologist explained to the jury that Boone's outbursts could be traced to injury in the limbic system that modulates emotional response.

A CT scan showed that a hole had been poked from the pre-existing skull defect into Boone's brain. A small pocket of air could be seen in the temporal lobe, surrounded by a pool of blood. But it wasn't just air in the brain – it was something slightly denser than air, likely surgical gelfoam which could have made its way there only if Dr. Goldberg had pushed it in to try to stop bleeding after he punched the first hole.

The key moment for Mr. Boone came not in the surgery but a month before, when he sat down with Dr. Goldberg to go over the planned operation. Goldberg never volunteered the key information: that with the hole in the skull from the prior surgery, his surgery would be that much more difficult, could even result in an injury to the brain, and Mr. Boone might benefit from consulting with someone who regularly did "revision mastoidectomies," the technical term for this second go-round. A general ENT doctor who advertised his specialty in facial cosmetic work like nose jobs – he named his professional corporation the "Aesthetic Facial Surgery Center of Rockville" – Goldberg only had done occasional revision mastoid surgeries. His operation on Boone proved he wasn't up to the job. On the witness stand, Goldberg admitted he hadn't discussed with Boone the hole in the skull, the chance of brain damage, or the availability of sub-specialists called neurotologists. For Billy Boone, the jury's vote in his favor, and the Court of Appeals' affirmance of the award, gave him some vindication. For other patients, his win makes it easier to demand the information you need to make a sensible selection among surgeons. Of course, if you asked Billy Boone, he would trade in legal vindication for a healthy brain any day. It's too late for him, but not for the rest of us.

(Click here for more information on the Boone case, and follow this link to Mr. Patrick Malone's closing argument.)

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

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

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

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

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

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

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.