DC Medical Malpractice & Patient Safety Blog

A young health care journalist named William Heisel has put together a fascinating Google map of the United States highlighting case after case of state licensing boards going easy on doctors who abuse drugs, send fraudulent bills or engage in other misconduct. Check it out here.

For the latest news on Mr. Heisel's blog about dangerous doctors, see this story about a psychiatrist who has been welcomed to Maine by the licensing board there despite a checkered history including a fraud conviction, drug abuse, a competence inquiry, and some forgetfulness to mention much of this on his licensing application.

Piecing the story together about a doctor who has traveled from state to state, with multiple disciplinary actions, takes practically a Pulitzer Prize level journalistic inquiry.

Mr. Heisel rightly raises the question about why these publicly funded state licensing boards are so secretive and slow to divulge information even when they have taken concrete action. Among the boards he criticizes: Maryland, where the licensing board says only that the doctor once worked there. This is in keeping with the experience of malpractice lawyers like me who know that the Maryland Board of Medicine is slow to act and won't tell consumers much even when it has. (I discuss this in more depth in a chapter on "dangerous doctors" in my book: The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst.

Whose interest are these medical boards serving?

Two nurses who were fired from their hospital for alerting state authorities to a dangerous doctor have now been fully vindicated -- except for one thing.

The nurses won a $750,000 settlement of their lawsuit against the Winkler County (Texas) Memorial Hospital and the local authorities who criminally prosecuted them for their complaint to the state medical board about the doctor. Read details here.

The west Texas hospital has been fined $15,850 by the state health department for its role in firing the two nurses, who worked in quality assurance at the hospital and had a duty under the state nursing practice act to turn in the doctor.

The doctor himself, Rolando G. Arafiles Jr., has now been charged in an administrative complaint by the state licensing board with endangering at least nine patients in recent years and with other violations of good medical care. You can read the official complaint here.

The only thing left: nurses Anne Mitchell, RN, and Vickilyn Galle, RN, who live in Jal, New Mexico, still haven't been able to find a new job since their illegal firing, according to their lawyer, Brian Carney. And the physician? Dr. Arafiles still works every day at the Winkler County Memorial Hospital.

Recent news reports suggest that getting only part of your colon scoped for precancerous lesions might be a good enough way to prevent colon cancer. But the real story is that whatever test you get, there is a wide variation in the quality of the colon examinations that doctors do, and out of hurry or poor training, some doctors miss a lot of lesions that should be taken out.

So if you want to have a safe, effective -- and potentially life-saving -- exam, you need to do some simple doctor screening to make sure the doctor is right for you.

The good news is it's not that hard. Research has found that two simple questions will bring out what you need to know to assure that all the trouble you're going through to get your colon examined will be worthwhile.

Before I lay out the questions, some quick anatomy to make this easy to understand:

The food we eat passes through the stomach and then through nearly thirty feet of small intestine before hitting the large intestine, or colon. The place where the small intestine joins the colon is called the ileocecal valve. It connects the ileum, the final part of the small intestine, to the cecum, the first part of the colon. The cecum is also where your appendix dangles off the end of the colon. In most people, the cecum and the appendix are in the right lower section of your abdomen. Intestinal contents travel from there vertically, in the ascending colon, up your right side toward the liver. The colon then turns 90 degrees to cross your belly from the right to the left. This section is called the transverse colon. Then the colon turns south in the descending colon, which runs down the left side of your abdomen. Finally it moves sideways one more time, in the sigmoid colon, which then reaches the rectum and the anus.

A colonoscopy uses a flexible telescope inserted through your anus to travel the entire length of the colon, to where it ends at the cecum. Most of the visual inspection by the doctor is done while the scope is being pulled back from the cecum to the exit at the anus.

A sigmoidoscopy, by contrast, only inspects the first foot or so of your colon. In some people, that's enough to find most precancerous growths. But in many, it's not. African-Americans, for example, have a higher rate of colon cancer in the further reaches of the colon beyond where the sigmoidoscope looks.

So the smart choice is to go with the full colonoscopy, even though the bowel preparation you have to undergo is more burdensome. That's the recommendation of the American Gastroenterological Association, the doctors' group that specializes in the intestines.

Now for the two questions to get the best chance of a good colon exam:

First, ask the doctor:

What is your detection rate of precancerous polyps?

(These are technically called adenomas). The rate should be at least 20 percent -- or 25 percent in men patients and 15 percent in women patients. A lower rate means the doctor is very likely missing precancerous lesions that are waiting to turn into cancer -- when the whole purpose of the colonoscopy is to find them and snip them off before they go bad.

The second question for the doctor:

What is the amount of time you typically take to inspect the entire length of the colon?

This answer should be at least six minutes. It takes that long to adequately inspect all the nooks and crannies.

Both these questions get at the same issue. You want to minimize the chance that a hurried examination will give you a clean bill of health by mistake.

How often does that happen? Frightfully often. In research published this year, the rate of colon cancers in people who had had a colonoscopy within the previous five years was ten times higher when the doctors who did the colonoscopy had a detection rate of ten percent or less, compared to doctors who had a detection rate of twenty percent or more.

Dr. Douglas Rex of Indiana University has written guidelines for his fellow gastrointestinal doctors about how to do an adequate colon exam. Dr. Rex is an advocate for careful comparison shopping by patients. In an article he wrote for fellow practitioners, he estimated that the doctors with the lowest detection rates are missing 75 to 90 percent of precancerous growths in the colon.

That's a huge number. But patients can do their part to make sure their colon cancers aren't missed by asking these simple questions before they undergo a colonoscopy.

Mary Ellen Mannix lost her baby son James to an unexplained event in a hospital intensive care unit. It took persistent digging by her lawyer to work through the cover story of the providers who cared for James. Here is an excerpt from Mary Ellen's book, "Split the Baby: One Child's Journey through Medicine and Law."

The testimony of James's bedside nurse is highlighted in this sample, introduced by Mary Ellen:

From the moment I was told my baby "had a serious and sudden event", I had one question "What happened?"

I asked everyone while I was at the hospital and after we left. We never got an answer. Until I "tripped" upon a lawyer who wanted to help. The following post highlights the deposition of James's bedside nurse about the night of October 4, 2001. It was traumatic to have to learn via litigation. When a patient or family member asks a question(s), it is because they do indeed want an honest answer. Not a lawsuit. Medical malpractice litigation is however the only route though which some injured patients and families may have to get answers. As a result, this is all public information that if shared purposefully can help stop this from happening to another newborn, young child, mother, physicians, nurse, Heart family.

The pediatric cardiac intensive care unite nurse began with her first entry into James’s flowchart: “At 19:30 the baby awoke, heart rate decreased, requiring hand ventilation to bring the heart rate back up with a mask, and medications were given to achieve that goal.”

She was ready. Her bedside manner and sense of empathy for a patient had been checked at the door. James's lawyer,Jim Beasley, Jr., who also held his medical degree, slowed her down to go left from right, point to point.

“My initial heart rate was 138 and it had changed by the time I finished writing to 107. I have an arrow indicating that it was beginning to decrease,” the nurse testified.

Read more at Mary Ellen Mannix's blog site here.

One question I asked myself while reading: How could such a traumatic event have left this nurse with absolutely no recall of what had happened? Is amnesia one defense to unacceptable mistakes?

Medical errors and malpractice events cost the U.S. economy $19.5 billion in 2008, according to a recently released study commissioned by the Society of Actuaries.

Of the approximately $80 billion in costs associated with medical injuries, about 25% were the result of avoidable medical errors, the study says.

Lost productivity due to related short-term disability claims cost $1.1 billion, while $1.4 billion was lost due to increased death rates among individuals who experienced medical mistakes.

The study also found that:

• There were 6.3 million measureable medical injuries in the U.S. in 2008; of the 6.3 million injuries, the SOA and Milliman estimate that 1.5 million were associated with a medical error.

• The average total cost per error was approximately $13,000.

• In an inpatient setting, seven percent of admissions are estimated to result in some type of medical injury.

• The measurable medical errors resulted in more than 2,500 avoidable deaths and more than 10 million excess days missed from work due to short-term disability.

The study also identifies the 10 medical errors that are most costly to the U.S. economy each year. Approximately 55 percent of the total error costs were the result of five common errors:

• Pressure ulcers • Postoperative infections • Mechanical complications of devices, implants, or grafts • Postlaminectomy syndrome -- back surgery • Excessive bleeding complicating a procedure

Source: Fierce Healthcare

To view the complete report, click here.

Primary care physicians, such as family practitioners and general internists, have the highest number of heart-attack-diagnosis-related malpractice claims and the highest average lawsuit payments of any physician specialty.

According to the study by the Physician Insurers Association, which evaluated paid malpractice claims related to heart attacks since January 1985, family physicians faced the highest number of claims (160 of 423 defendants). Internal medicine physicians, who faced the second highest number of claims, had to pay the highest average indemnity payment of any specialty group ($252,100).

What are these doctors doing wrong to miss heart attacks?

In cases involving diagnostic errors, the physician ordered an EKG in 59% of cases. No diagnostic study of any kind was performed in 28% of cases. In more than half the cases in which an EKG was performed but the physician did not make the correct diagnosis, the EKG was either misinterpreted or the results were not conveyed to the physician quickly enough.

The study noted that 277 of the 304 providers sued for diagnostic errors did not correctly diagnose the heart attack at all, and of these, 220 did not even refer the patient to another provider.

The most common initial diagnosis made in error by providers was that of a gastrointestinal complaint, followed by musculoskeletal pain; angina; a respiratory ailment, such as bronchitis, peneumonia or asthma; and anxiety. The study alleges that 77% of patients died as a result of the diagnostic and treatment errors.

In addition, of the 154 claims for treatment – as opposed to diagnostic – errors, 109 involved allegations related to both treatment and diagnostic issues, with patients in 22 of the 154 cases reporting they received no treatment at all.

Twenty-seven member insurance companies participated in the study, reporting a total of 349 paid cases related to heart attack.

Source: hereExpertstalking.com.

For years, patient safety experts have known that medical devices, like tubes that deliver food and drugs to hospitalized patients, need to be designed so that predictable mix-ups don't hurt patients. If a tube is safe if it goes through the nose to deliver food to the stomach, it should not be possible to hook up the same tube to a line that delivers medication to a blood vessel, since that could kill the patient.

But this basic safety philosophy -- which permeates other high-risk industries like aviation and nuclear power -- still hasn't penetrated the medical industry, as a new report in the New York Times documents in distressing detail.

Partly to blame is the U.S. Food and Drug Administration, which could set up uniform rules that would bar as unsafe any medical devices where fatal mix-ups could be easily made by hurried nurses or other caregivers.

The way the agency does its work is the problem. When the FDA has tried to act on a case-by-case basis with an application from a manufacturer for a new product, efforts by FDA safety reviewers to solve the problem have been met with cries from the new manufacturer that it is being unfairly singled out.

Efforts to have industry-wide regulations have met with years of bureaucratic delay and industry resistance.

Here's a quotable quote from former FDA official Dr. Robert Smith:

“F.D.A. could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die.”

A new study from the American Medical Association about malpractice lawsuits has an eye-catching statistic: Six out of 10 physicians 55 and older have been sued, according to the AMA. But is it really true?

"Even though the vast majority of claims are dropped or decided in favor of physicians, the understandable fear of meritless lawsuits can influence what specialty of medicine physicians practice, where they practice and when they retire," AMA Immediate Past President J. James Rohack, MD., said in a statement. "This litigious climate hurts patients' access to physician care at a time when the nation is working to reduce unnecessary health care costs."

Patient safety advocates called the report misleading. "Their data, as well as other studies, show that a small percentage of physicians are responsible for the vast majority of malpractice claims," according to Ray De Lorenzi, spokesman for the American Association for Justice, which represents lawyers who represent patients in lawsuits against doctors and hospitals.

Research has shown that "the vast majority of claims are meritorious and involve real errors," and those types of errors are not declining, De Lorenzi said. "This reinforces why lawmakers must focus on the 98,000 people that die every year from preventable medical errors, not eliminating the rights of injured patients," he said.

That figure was popularized by a 1999 Institute of Medicine report, which cited research stating that such medical errors kill between 44,000 and 98,000 people each year.

The new AMA study analyzed data from 5,825 physicians who responded to the AMA's Physician Practice Information survey, which examined costs of medical practice and associated factors from 2007 to 2008. Among the report’s highlights:

* Only 5% of medical liability lawsuits make it to trial. However, defendants won 90% of these cases.

* 42.2% of physicians were sued, with 22.4% sued twice or more.

* General surgeons and obstetrician-gynecologists were most likely to be sued (both 69.2%), while pediatricians (22.2%) and psychiatrists (27.3%) were sued the least.

Source: American Medical News
You can view the report from AMA Policy Research Perspectives, entitled "Medical Liability Claim Frequency: A 2007-2008 Snapshot of Physicians" here.

Hospitals that want to reduce their exposure to malpractice lawsuits from patients might want to take a hard look at a new study about a radically new strategy: Being honest with patients when errors have happened.

The usual hospital strategy in the face of a malpractice event is to deny everything and hope the patient and the family go away quietly, then when a lawsuit is filed, defend it to the hilt. But they do things differently at the University of Michigan Health System (UMHS), and it's a win-win for both patients and the hospital.

Since 2001, the University of Michigan Health System (UMHS) has fully disclosed and offered compensation to patients for medical errors. Under this model, UMHS has claimed to proactively look for medical errors, fully disclose found errors to patients and offer compensation when at fault.

The study -- newly published in the Annals of Internal Medicine -- compared liability claims before and after the “disclosure-with-offer” program was implemented between 1995 and 1997 and assessed the number of new claims for compensation, number of claims compensated, time- to-claim resolution and claims-related costs.

After full implementation of a disclosure-with-offer program, the study found that the average monthly rate of new claims decreased from 7.03 to 4.52 per 100,000 patient encounters. Likewise, the average monthly rate of lawsuits decreased from 2.13 to 0.75 per 100,000 patient encounters.

Median time from claim reporting to resolution decreased from 1.36 to 0.95 years, wrote the authors, who also reported that the average monthly cost rates decreased for total liability (rate ratio, 0.41), patient compensation (rate ratio, 0.41) and non-compensation-related legal costs (rate ratio, 0.39).

However, the researchers acknowledged that the study “design cannot establish causality” and noted that malpractice claims generally declined in Michigan during the latter part of the study period. As a result, “the findings might not apply to other health systems, given that UMHS has a closed staff model covered by a captive insurance company and often assumes legal responsibility,” the researchers said.

Source: Annals of Internal Medicine
You can view the full text of the study here.

That's all that a sick friend needs to hear from you. Two sentences. Nine words. Too often, what they hear instead is silence -- you don't know what to say, you're afraid to say the wrong thing, and so the friend winds up feeling abandoned in a time of need. Or, just as bad, friends will weigh in with unsolicited advice, or insensitive comments.

The best thing to do is to be present. And to listen. And respond.

More thoughtful comments and experiences from patients can be found in the NY Times blog piece on "When friends disappear during a health crisis."

Medical malpractice lawsuits are so frequently blamed for the high cost of medical care that when another, actual cause (not apocryphal, like lawsuits) of expensive medicine comes around, it's almost hard to believe. Exhibit A: End of Life care. This is the single most expensive segment of Medicare -- the last 30 days of someone's life, when aggressive practitioners throw everything they've got at an elderly patient's failing body to see if a miracle might result.

It's also a time of life that is virtually immune from malpractice suits. Few if any lawyers would take a case that argued the doctors were insufficiently aggressive, and Grandma might have lived a few more months.

The practitioners are not aggressive solely because they're paid to be, although it cannot hurt. Families in denial often egg doctors on to do everything possible technologically, when what the dying patient needs is peace, comfort and a chance to be with one's relatives.

Here's a story onend of life care, courtesy of one of our favorite blogs, The Pop Tort.

CT perfusion scans, often done on patients suspected of having a stroke, produce beautiful, detailed pictures of the human brain undergoing oxygen deprivation and tissue damage. But they don't do anything to advance treatment, according to candid radiologists. This adds a new layer to the story of massive radiation overdoses with these tests at some institutions with undertrained technologists and undertested machines.

Dr. George Lantos, an associate professor of radiology and neurology, Albert Einstein College of Medicine in the Bronx, explained it this way in a letter to the New York http://www.nytimes.com/2010/08/09/opinion/l09radiation.html?_r=1&ref=opinionTimes in response to the recent investigative piece on overdoses around the country:

One important point not emphasized in the article is that this is a case where diagnostic capability far exceeds accepted effective therapy. To date, the only widely used drug in acute stroke therapy is the clot-dissolving agent tissue plasminogen activator (tPA), approved by the Food and Drug Administration in 1996. The only imaging test required for the use of tPA is a computed tomography (CT) scan, done without the use of intravenously injected contrast material.

The purpose of the CT scan is to exclude brain hemorrhage, the presence of which frequently can’t be determined by physical examination alone. CT perfusion exams discussed in the article are very informative, giving precise, detailed images of the degree of nourishment of brain tissue and where such nourishment may be decreased during a stroke.

The problem is that there is no F.D.A.-approved therapy that uses the information from perfusion scans in the setting of acute stroke. Even the injection of the iodinated contrast material for this test is an “off label” application as far as the F.D.A.-approved package insert is concerned.

My stroke neurologists and I have decided that if treatment does not yet depend on the results, these tests should not be done outside the context of a clinical trial, no matter how beautiful and informative the images are. At our center, we have therefore not jumped on the bandwagon of routine CT perfusion tests in the setting of acute stroke, possibly sparing our patients the complications mentioned.

Dr. Lantos's letter highlights a frequent problem for expensive American-style medicine: imaging technology runs ahead of effective treatments. This is true for several other kinds of CT scans, such as "virtual colonoscopies" done with CT scanners, and similar scans done on the heart's arteries. In all these cases, careful questioning of the doctors will usually reveal that the results of the test will NOT change treatment one way or the other. The scans just yield nicely detailed images. For treatment, however, one has to look directly into the colon with a telescope-type device, or directly into the heart's arteries with a catheter.

The whole set of letters on this issue in the Times are worth reading.

One from the American College of Radiology talks about how mandatory adoption of the ACR's voluntary testing and accreditation program would go a long way toward reducing inadvertent overdoses.

Another talks about yet another aspect of unregulated, unnecessary radiation: from CT scans done in dentists' offices.