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The Grunt Doc reports that he is encountering a new strategy when Nursing Home patients are transferred to his care. They come with the list of medications but no record of when these dosages were last administered to them.
When they’re my patients I now ask for a faxing of the patient’s MAR from the nursing home with the removed information included, because it is, you know, part of the medical record, and may well be useful in the diagnosis and treatment of the patient. A patient often sent in with “AMS” (altered mental status) as the one-line explanation for the transfer, and the patient is on several (usually more than a dozen) medications, at least a third of which could cause an altered mental status. It would, in that case, be nice to know if they got their regular, let alone their PRN (as needed) sedative(s), as well as all their other medications.
The kicker is, since I cannot determine when their medications were administered (because the times were cut off of the copies sent to the ED), a lot of very useful information is now denied to me, the ED physician, and then most likely to the admitting team, since none of us can say who got what medication, and cannot account for their altered mental status. (I’m using AMS as the example here, but there are other complaints that could be medication related).
This intentional removal has happened often enough ( from different nursing homes and at different ED’s) that it’s clearly part of an organized effort on the part of Nursing Homes. I’m at a loss to think of a single innocent reason why this practice would have started. When I’ve called personally to have the information faxed (for patient care, the reason they sent the patient to the ED) the Nursing Home nurses routinely say that “It’s policy”, and then sometimes send the information, and sometimes they don’t.
The comments at the post contain some pretty heated discussion about nursing homes and their quality. I don’t know that this is really a story about medical malpractice and tort reform issues as much as it is simply about medical malpractice. Obviously, there is a group that is concerned about liability, but I don’t know if it is because of unreasonable lawsuits or because some nursing homes are cutting corners. Check out the conversation and decide what you think.
In other news, the medinnovationblog posts an entry reporting that a clinic has named a doctor a “CXO,” or Chief Experience Officer.
The Cleveland Clinic has named Dr. Bridget Duffy as its first chief experience . a new role aimed at making sure each patient has a high-quality expererience that meets their medical, physical and emotional needs.
As a leading healthcare provider, we must exceed the expectations of those we serve, offering compassion, showing empathy and passion for patient-centered initiatives,” said Dr. Toby Cosgrove, the Clinic’s chief executive, in a written statement.
Duffy, who most recently was a health-care consultant and advisor in San Francisco, is known nationally for building health-care environments that treat the whole person, humanize the delivery of medical technology, and support the role of doctors and nurses as leaders in patient care.
I think this is good to the extent that it shows doctors trying to increase communication. A lack of communication can lead to litigation. It also might be needed to keep everyone focused on patient care rather than getting by. Internal quality control is a good thing. Given the expense that such a new officer might involve, I hope this isn’t simply due to medical malpractice pressures that are more severe than they ought to be.
Panda Bear, MD recently blogged about how he and other hospital staff deal with notorious hypochondriacs. I’m pasting some of it here without endorsing all the sarcasm (in other words, be offended by him, not me!).
In one month I have had Mary as a patient four times. I have also noticed her roaming restlessly through the department on days when some other resident had the bad luck to pick up her chart. I would not be exaggerating if I said that she has been a patient in our department thirty times this year and the Lord only knows how many times at other Emergency rooms in the area. She is a huge consumer of emergency services and no one dares tell her to pound sand when she presents with one bogus complaint or another because one day, after crying wolf for her whole life, she is really going to be sick and if she dies the usual compassion fascists will descend on us like self-righteous harpies.
Thus do we regularly ignore common sense and, putting on our best kabuki faces, take every episode of chest pain, abdominal pain, shortness of breath, and near-syncope completely seriously pretending that we have not spent hundreds of thousands of the taxpayer’s dollars ruling out everything except drug addiction. It would be more cost effective if we just gave her perscriptions for all the oxycontin she wanted provided she limited her visits to once a month. Instead we enact the the traditional Kabuki drama where she assumes the role of a patient and we pretend to be her doctors. We stamp and posture, reciting our ritualistic lines while she demurely assumes the character of someone we actually can treat. Five acts later we discharge her, plus or minus a six-pack of vicodin, depending on how badly we want to get her out of the department.
File this under getting what you pay for. Putting asided the usual policy wonkery, the real problem of American medical care is the complete absence of common sense. Mary is not unique. She is just a very visible symbol of a society that is ridiculously risk averse and consequently ridiculoulsy over-doctored. In a perfect world, someone would meet her at the door and say, “No. You are not getting drugs here.” If she departed chastened from our door and died…oh, let’s just say from a perforated bowel… a reasonable jury, assuming the case ever went to trial, would decide that it was a darn shame but understandable given her pattern of abusing emergency services.
Sarcasm aside, it seems reasonable to me that this risk-aversion is not rational and points to a problem with litigation. I notice others have noticed that overuse of the medical system is a problem. “Our health care system is plagued with under-use, overuse and misuse,” Hillary Clinton has claimed.
With due respect for the Senator, I’m not a big fan of having some sort of centralized director trying to come up with guidelines for what counts as “overuse.” But it would be nice if we could make liability rational enough that doctors would be able to follow common sense judgments rather spend money on unnecessary medicine. Panda goes on to hold up “the typical cardiac work-up” as an example of overuse.
A young male with no risk factors for heart disease should not need a complete cardiac work-up when he presents with chest discomfort as it is almost certainly going to end up being musculoskeletal pain, reflux, or anxiety. And yet the patient inevitably gets the whole enchilada including an expensive stress test and occasionally an admission if he is deemed to be unrealiable for follow up (because if he is told to return in the morning for his stress test, forgets, and dies three years later it is our fault).
Read the whole thing and tell me if you agree with his basic point that, “Because of the highly litigious nature of American society, there is no incentive to exercise common sense.”
Because it is not paranoia if everyone really is out to get you.
Here is a story that might be especially important to our Illinoise doctors. It appears that some are lobbying to get around the lawsuit caps put in place for medical malpractice cases back in 2005.
One of the measures, signed into law last month, allows plaintiffs in wrongful death cases to seek damages for grief, sorrow and mental suffering. Previously in such cases, Illinois law allowed families to collect only for economic damages and some other specific categories, but not for grief.
The Illinois Trial Lawyers Association said 23 other states already allowed damages for grief and mental suffering.And Illinois Sen. Kwame Raoul, D-Chicago, who sponsored the original bill, said Illinois’ restrictions were unfair – families couldn’t seek damages for emotional distress, but pet owners could.
“It’s outrageous,” Raoul said. “I can’t think of any survivor of a loved one or somebody’s child not being able to talk about grief and sorrow.”
But critics of the law say it could amount to an end-run around medical malpractice caps passed in 2005, which limited non-economic damages, such as for pain and suffering, to $500,000 against doctors and $1 million against hospitals. The caps were an effort to stem a growing tide of doctors leaving the state because of high insurance rates.
Plaintiffs now potentially could file separate malpractice and wrongful death lawsuits and collect on both, essentially allowing them to avoid the caps set in the malpractice law.
That could stick doctors and hospitals with higher legal bills, said Ed Murnane of the Illinois Civil Justice League, who said the new law just gave trial lawyers another way to cash in.
“We’ve taken and pushed that pendulum back to the plaintiff side way past the middle once again in Illinois,” said Sen. Kirk Dillard, R-Hinsdale, who said the law wiped out efforts to make the legal system more fair.
I doubt opposing compensation for grief is going to be a popular position. But if it eventually translates into higher medical costs in Illinois, everyone will suffer. It would be helpful if some middle ground could be taken, where families are compensated in a manner that is reasonable.
I’ve blogged about how medical malpractice allegations and problems can sometimes be the result of poor communication. With that in mind, I thought the Medical Quack’s post on how a growing number of hospitals are posting patient reports about surgery on the web might be a positive development for preventing medmal litigation. “Hospitals are now posting surgery results and potential outcomes on their web sites. Excellent way for both the physician and patient to be informed up front on the potential outcome.” She points to a story headlined on the CBS News website: The Patient’s Prerogative, Hospitals Are Posting Surgical Results Online To Inform Those Considering Going Under The Knife:
After weeks of pain, Chuck Prigge is deciding whether to have back surgery, and he’s making his decision online.
His hospital, Dartmouth-Hitchcock Medical Center in New Hampshire, puts surgery results on the Internet.
Chuck can see that 62 percent of Dartmouth’s back surgery patients achieve symptom relief and that 85 percent would choose surgery again…
Prigge is leaning in favor of surgery because of what he learned online.
“I think it’s an honest way to go, to be able to tell what experiences people have had,” he said.
A 62 percent success rate tells him that not everyone gets perfect results. But thanks to an information revolution, at least he knows the odds.
If this gives more power to patients to decide on what happens to them, it seems to me it could only help avoid unnecessary litigation.
If you have any interest in medical malpractice, and medical malpractice insurance, you cannot only read doctors, or insurance providers. You have to read trial lawyers who take medical malpractice cases. Thus, I notice from one attorney blog that,
SURGICAL ERRORS ON THE RISE
Of course, this by itself doesn’t mean much. “With the increasing number of surgical procedures being performed in the United States, it’s not surprising to also see an increase in surgical errors.” So, it is possible that surgical safety is improving, for all I know.
The blog post provides a list of common mistakes in surgery. But what I find most telling is the statement, “Even the most experienced and skilled surgeons can commit a surgical error.”
It seems to me in making the case for tort reform, one needs to really point this out. My guess would be that, in the midst of the understandable emotional turmoil and other pain, patients who get an attorney might be prone to assume that there was some extra negligence or apathy that a doctor must be guilty of. But this may simply not be the case. Surgeries are dangerous. Do we understand that? Or do most people assume that surgeries are normally unproblematic? If they do, this might explain why medmal claims can get so high in court cases.
I suspect, if you’re a doctor or nurse, you already know about the common mistakes. But, if you need to refresh your memory, take a look at the list of errors.
…since, after all, this is a medical malpractice blog. But this somewhat old post caught my eye and led me to search and find yesterday’s NYT article on OxyContin.
The $634.5 million in penalties and fines that the maker of the painkiller OxyContin and some of its executives agreed to pay to resolve a false marketing charge represents 90 percent of the profits it initially made from the drug, according to court documents filed by federal prosecutors.
The company, Purdue Pharma, agreed to the penalty, one of the largest ever paid by a drug company in such a case, after an affiliate, Purdue Frederick, and three current and former executives pleaded guilty last month to criminal charges that it had misled doctors and patients when it claimed the drug was less likely to be abused than traditional narcotics.
As the MedSkool blogger tells it, the reason for the massive fine had to do with miscommunication.
while the FDA approved the Purdue claim that the time released formula might decrease the addictive potential of OxyContin compared to other opiate analgesics, Purdue went out and played up that as a fact. And in some cases just blatantly lied about the evidence for such a claim.
He raises though an interesting point. The salesmen presented a theory as a fact. That was wrong. But why did the executives plead guilty? “There doesn’t appear to be evidence during this time that Purdue knew the abuse potential of OxyContin and was hiding it.” Furthermore, the abuse involved snorting the drug as powder, something the labeling warned against (not to mention common sense). Just “how far do we want to go in criminalizing business practices?”
Thus, from the earlier story (emphasis added),
The three top former and current Purdue Pharma executives pleaded guilty to criminal misdemeanor charges of misbranding, a charge that does not require prosecutors to show knowledge or intent on the executives’ part. However, the three individuals ran Purdue Pharma during the period in question.
Those executives are: Michael Friedman, the company’s president, who agreed to pay $19 million in fines; Howard R. Udell, its top lawyer, who agreed to pay $8 million; and Dr. Paul D. Goldenheim, its former medical director, who agreed to pay $7.5 million.
In a separate statement, Purdue said: “Mr. Friedman, Dr. Goldenheim (while at Purdue) and Mr. Udell neither engaged in nor tolerated the misconduct at issue in this investigation. To the contrary, they took steps to prevent any misstatements in the marketing or promotion of OxyContin and to correct any such misstatements of which they became aware.”
So it appears to me, that because people abused a drug in a way that the company warned against that someone has to pay. Now the later story gives us assurances like,
In their response to Judge Jones’s questions, prosecutors, along with disclosing the 90 percent figure, explained why they had agreed not to recommend incarceration for the executives.
They stated that they believed that the conviction of the officials would serve as a deterrent to other pharmaceutical industry executives. And they noted that the individuals’ deals were part of the overall agreement with the company.
“Each corporate official will bear the stigma of being a convicted criminal,” Mr. Brownlee stated in that filing.
The three men are Michael Friedman, the company’s president; Howard R. Udell, its top lawyer; and Dr. Paul D. Goldenheim, its former medical director.
Some parents of teenagers and young adults who became addicted to OxyContin or died in overdoses in which it was a factor are expected to urge Judge Jones to reject the plea deal, saying they believe that the executives should go to prison.
These deaths are horrible and tragic, but it looks as if they resulted by directly ignoring warnings and that there has been no knowledge or intent proven on the part of the people who some would like to see jailed. And therefore, this looks like a sign of a rather less than impartial legal environment.
I can’t help but wonder if regular doctors face the same sort of thing, and if medical costs are rising for everyone because of this.
I just saw this at the injuryboard.com blog:
According to the facts in the lawsuit, in June 2003 Dr. Vaidya treated Dr. Westmoreland for removal of a stent from his urterer. During the procedure Dr. Westmoreland maintains he experienced pain and repeatedly told Dr. Vaidya to stop. Dr. Westmoreland also claims the procedure took 15-20 minutes when it should have only taken 15 seconds. Dr. Westmoreland alleges he has developed a variety of aliments including Peyronie’s Disease because of Dr. Vaidya.
Of course, I have no idea how much of this is true, if any of it is. That’s for the courts to decide. What makes this case interesting is that the plaintiff did not (and perhaps was not able to) follow required procedures for a medical malpractice case in West Virginia.
The suit was dismissed in October, 2006 when the judge ruled that Plaintiff failed to follow the requirements of the Medical and Professional Liability Act of 2003 in filing a certificate of merit. In both of his original suit and appeal, Plaintiff Westmoreland stated that the 14 urologists he consulted with 10 declined to sign the certificate and the remaining two wanted a fee of $40,000.
(Obviously something is wrong here. I’m not sure where the remaining two doctors disappeared to. Perhaps 14 is a typo for 12).
I wonder how this worked. Did the majority of doctors decide that the case had no merit or did they just not want to get involved? Or did the two who demanded payment not care about the merits of the case or did they think the patient was in the right but wanted the money before they would publicly admit to it? Whatever happened, the Supreme Court of West Virginia was not impressed. On June 6, they announced they would hear the case.
The problem, as I see it, is that we aren’t going to be able to make much headway in reducing medical costs (and thus, the availability of medical services to people who need them) if reform laws are simply set aside by the courts. I note that the West Virginia Record, the state’s legal journal, agrees with me. They commented before the decision was made that the Court was in danger of “gutting one of the most common-sense and widely supported provisions of our state’s Medical and Professional Liability Act (MPLA).”
At issue is what’s known as the “certificate of merit” requirement. It holds that in medical malpractice lawsuits, lawyers must first get an independent medical specialist to “certify” their case has legitimacy before proceeding. The concept is to protect doctors and their insurance rates from inexperienced lawyers aiming to pot-shot their way to a quick-and-dirty settlement.
That was the problem back in 2001 when lawsuits had driven liability insurance rates so high that Wheeling was without neurosurgeons and ambulances were being re-routed to Pittsburgh. Beckley had no obstetricians, and specialists were hard to find even in places like Charleston or Huntington. One national magazine dubbed West Virginia “Tort Hell” — or “Tort Heaven,” depending upon where you sat. Doctors who weren’t running for the border were staging mass rallies in white coats, begging the politicians for relief.
Certificates of merit were part of the package. Many respectable members of the plaintiff’s bar supported the idea, as it keeps out the fly-by-night buffoons striving to give them a bad name. The concept caught on: liberal Democrats John Kerry and John Edwards (a medical malpractice lawyer himself) even made certificates of merit part of their campaign platform in 2004.
But in his appeal to the Supreme Court, Dr. Westmoreland holds they are unconstitutional. He argues that obtaining a certificate of merit is too expensive. Requiring one, he says, restricts citizen access to our courts.
Well, it’s either that, or we’re de facto restricting citizen access to our hospitals.
Seeing that we don’t have an inalienable right to health care nor to filing a lawsuit (despite what lawyers claim), it’s the people’s prerogative to prioritize. It’s up to us to pick and choose — do we want more lawyers? Or more doctors?
In 2001 and 2003, West Virginia chose loudly and clearly. It would take some nerve for but a handful of judges to usurp that.
This is all debatable, of course, but I think there is a lot of evidence that the editorial’s portrayal of a stark choice between affordable litigation and affordable healthcare is a reasonable one. The abundance of new doctors in Texas, and the shortage of mammogram readers, both argue for this understanding of what is at stake.
I wasn’t intending to say anything more about the importance of doctor-patient communication. But Kevin, a primary care physician and blogger pointed out this morning that “How you do it matters.”
He links a story about a recent study that shows a divergence between what patients want for reassurance and what doctors typically give them.
According to the story, researchers are claiming, “Doctors should know that when meeting a new patient for the first time there is no second chance to make a good first impression.”
Almost all patients want to be greeted by name when seeing a doctor for the first time and want to shake hands, a survey of patients found. But while handshakes are common, doctors often never utter the patient’s name, the researchers said. “Greetings are just a small slice of the visit, but they can have a lasting impact,” study leader Gregory Makoul of Northwestern University Feinberg School of Medicine said in a telephone interview. “It’s the first impression that can really set the tone for the rest of the encounter and for the doctor-patient relationship.”
It is important to look for nonverbal cues and make a patient feel comfortable on that first encounter. Another report summed up the findings,
They surveyed 415 adults about their expectations and preferences for being greeted by doctors and found:
- Just over 78 percent wanted doctors to shake their hands, while about 18 percent did not.
- More than half (50.4 percent) wanted their first names used during greetings, about 17 percent preferred their last name was used, and nearly a quarter (23.6 percent) wanted doctors to use both their first and last names.
- Just over 56 percent of patients wanted doctors to introduce themselves using first and last names, 32.5 percent wanted doctors to use their last name, and about 7 percent wanted doctors to use their first name.
The researchers also videotaped 123 new patient visits with 19 different doctors. They found that:
- Doctors and patients shook hands about 83 percent of the time.
- In 50.4 percent of visits, doctors did not mention patients’ names at all.
- Doctors used their first and last names when introducing themselves in 58.5 percent of the meetings, and did not introduce themselves at all in about 11 percent of the visits.
If all ti takes is a handshake and reading and remembering a name, I suspect that is a small price to pay to avoid the sort of problems that lead to miscommunication and sometimes to an attorney.
Liability from a patient not following orders?
InsideSurgery’s Grand Rounds included InsureBlog’s post on Andrew Speaker, the flying TB sufferer.
Advised against flying.
So what does he do?
He takes a trans-Atlantic flight, then a circuitous route back home to avoid compliance with orders from the CDC to remain in Italy.
The man, however, told the Atlanta Journal-Constitution that doctors didn’t order him not to fly and only suggested he put off his long-planned wedding in Greece.
Oh, that’s different.
They never TOLD him NOT to fly, only advised against it.
Let’s see.
They told him he had a potentially deadly form of TB that is resistant to the usual treatment protocol. So what does he do?
He boards a plane, with the potential to infect others.
This makes me wonder if his claim (“they never told me…”) would be enough to launch a liability suit if anyone else gets sick.
A possible source of miscommunication and a solution.
I’ve blogged a couple of times about the importance of communication (here and here) in preventing unnecessary conflict between medical workers and patients. I noticed a post from the Impacted Nurse I thought both showed a source of misunderstanding (and, therefore, increased risk), as well as a way to try to correct it.
We occasionally have patients or their relatives complain that the nurses seem far too jovial.
That we are laughing and joking around during the shift, displaying total insensitivity to the suffering of those patients around us.
I thought his explanation for how medical staff have to find ways to deal with what is all around them was a great example of how to avoid misunderstanding. Read it for yourself.
(Hat tip: Grunt Doc)
At the same time, it wouldn’t hurt for all of us to think of how we come across to other people. Hospital culture makes sense to many within that culture, but–by definition–it will seem strange to new patients and their loved ones. This will be experienced on top of any fear they feel about the reason for their hospitalization. In addition to the simple obligation we all have we all have to try to be aware of one another’s needs, it seems pretty obvious that any alienation or offense that arises from this sort of misunderstanding could lead to unnecessary litigation due to a simple barrier in communication.
A few days ago I put my amateur free market economist hat on, and recommended that everyone listen to a Budweiser commercial. Following a tip from the medskool blog, I passed on news that Texas is dealing with a sudden influx of doctors and it was possible this was the result of tort reform.
In my view, this is just common sense. People will tend to gravitate toward work where it gets easier rather than harder. Living under the threat of lawsuits that you are convinced may be used against you even when you do a good job is a hard thing. Thus, doctors are, all things being equal, going to prefer being doctors in a place where they are protected from such lawsuits. I would confidently predict this was happening even if nothing had been reported.
But, we are not all comfortable with a priori economics. People want a lot of evidence before they agree to a general principle.
Well, here’s some evidence of the same economic forces working in the opposite direction. According to alternet, there are a growing number of vacancies in jobs requiring mammogram reading. Even though mammograms are lifesaving and there is a high demand for such readers it is still hard to find them. Not only are positions vacant, but also teaching fellowships are going unused. Finally, mammogram facilities are closing.
In short, radiologists are afraid of being sued, and there’s evidence that they have more reason to worry than providers in other areas of medicine.
Missed breast cancer is the most common basis for medical malpractice lawsuits in the United States, according to the Physician Insurers Association of America, a trade group of medical malpractice insurance carriers.
And it’s among the most expensive kind of malpractice cases. In a seven-year period ending in 2002, PIAA members spent almost $200 million on breast cancer malpractice cases. That was $30 million more than was spent during the previous six years.
But, experts say, the problem is not inept radiologists, although there are certainly some of those.
Instead, the problem is a misconception about the effectiveness of mammography.
The story goes on to explain how each woman is different and detecting anomalies is extremely tricky.
So, while in Texas tort reform means more doctors coming to serve Texans. In the mammography practice, high probabilities of an unavoidable lawsuit mean fewer doctors in that area.
