User login
Success with team care
I was not surprised by the flood of letters I received from readers* in response to last month’s editorial (“End EMR tyranny!” J Fam Pract. 2013;62:173). Mixed in among the gripes and groans was a well-reasoned response from a family physician who not only is coping with EMRs (and the seemingly endless other demands on an FP’s time), but has found a way to prosper.
That doctor’s “secret”? Like other physicians who are thriving with EMRs, he has someone else do most of the data entry.
“Team care” is the popular term used to describe what is essentially a redistribution of work. (To learn more, visit www.familyteamcare.org.) Team care typically involves assigning at least 2 medical assistants (MAs) to each physician, along with an RN or LPN whose time is often divided among 2 or 3 doctors. One of the most important features of team care is that an MA serves as a scribe, updating the patient’s medical history and entering presenting symptoms in the EMR before the physician even enters the room. The MA remains in the room while the physician examines the patient, entering orders and physical findings, and remains there after the physician is done to close the visit, issue instructions, and ensure that the patient has the prescriptions or orders for tests that he or she needs.
The result? The physician is freed of the 2 to 3 hours per day that EMRs add to the workload of doctors who do not have scribes, and relieved of numerous other administrative functions.
During my tenure at the Cleveland Clinic, we initiated team care at one of our practices. After 9 months, the FP at the helm had increased his patient flow by 40%. Yet he walked out of the office by 5:30 every evening, with all of his charts completed and all of his phone and e-mail messages answered. And his quality measures and patient satisfaction scores did not decline one bit. In fact, he saw an upward tick on both counts.
This, too, doesn’t surprise me. For years, fellow FPs have told me they spend 30% to 50% of their time on tasks that could—and should—be delegated to office staff. When we all figure out how to offload nonmedical duties to nonphysicians, FPs can get back to doing what most of us love to do and do best—looking patients in their eyes, taking time to understand their problems, and deciding together which tests and what treatment plans will do the most to improve their lives.
*We’ll publish some of these responses in the Letters column in the June issue.
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
I was not surprised by the flood of letters I received from readers* in response to last month’s editorial (“End EMR tyranny!” J Fam Pract. 2013;62:173). Mixed in among the gripes and groans was a well-reasoned response from a family physician who not only is coping with EMRs (and the seemingly endless other demands on an FP’s time), but has found a way to prosper.
That doctor’s “secret”? Like other physicians who are thriving with EMRs, he has someone else do most of the data entry.
“Team care” is the popular term used to describe what is essentially a redistribution of work. (To learn more, visit www.familyteamcare.org.) Team care typically involves assigning at least 2 medical assistants (MAs) to each physician, along with an RN or LPN whose time is often divided among 2 or 3 doctors. One of the most important features of team care is that an MA serves as a scribe, updating the patient’s medical history and entering presenting symptoms in the EMR before the physician even enters the room. The MA remains in the room while the physician examines the patient, entering orders and physical findings, and remains there after the physician is done to close the visit, issue instructions, and ensure that the patient has the prescriptions or orders for tests that he or she needs.
The result? The physician is freed of the 2 to 3 hours per day that EMRs add to the workload of doctors who do not have scribes, and relieved of numerous other administrative functions.
During my tenure at the Cleveland Clinic, we initiated team care at one of our practices. After 9 months, the FP at the helm had increased his patient flow by 40%. Yet he walked out of the office by 5:30 every evening, with all of his charts completed and all of his phone and e-mail messages answered. And his quality measures and patient satisfaction scores did not decline one bit. In fact, he saw an upward tick on both counts.
This, too, doesn’t surprise me. For years, fellow FPs have told me they spend 30% to 50% of their time on tasks that could—and should—be delegated to office staff. When we all figure out how to offload nonmedical duties to nonphysicians, FPs can get back to doing what most of us love to do and do best—looking patients in their eyes, taking time to understand their problems, and deciding together which tests and what treatment plans will do the most to improve their lives.
*We’ll publish some of these responses in the Letters column in the June issue.
I was not surprised by the flood of letters I received from readers* in response to last month’s editorial (“End EMR tyranny!” J Fam Pract. 2013;62:173). Mixed in among the gripes and groans was a well-reasoned response from a family physician who not only is coping with EMRs (and the seemingly endless other demands on an FP’s time), but has found a way to prosper.
That doctor’s “secret”? Like other physicians who are thriving with EMRs, he has someone else do most of the data entry.
“Team care” is the popular term used to describe what is essentially a redistribution of work. (To learn more, visit www.familyteamcare.org.) Team care typically involves assigning at least 2 medical assistants (MAs) to each physician, along with an RN or LPN whose time is often divided among 2 or 3 doctors. One of the most important features of team care is that an MA serves as a scribe, updating the patient’s medical history and entering presenting symptoms in the EMR before the physician even enters the room. The MA remains in the room while the physician examines the patient, entering orders and physical findings, and remains there after the physician is done to close the visit, issue instructions, and ensure that the patient has the prescriptions or orders for tests that he or she needs.
The result? The physician is freed of the 2 to 3 hours per day that EMRs add to the workload of doctors who do not have scribes, and relieved of numerous other administrative functions.
During my tenure at the Cleveland Clinic, we initiated team care at one of our practices. After 9 months, the FP at the helm had increased his patient flow by 40%. Yet he walked out of the office by 5:30 every evening, with all of his charts completed and all of his phone and e-mail messages answered. And his quality measures and patient satisfaction scores did not decline one bit. In fact, he saw an upward tick on both counts.
This, too, doesn’t surprise me. For years, fellow FPs have told me they spend 30% to 50% of their time on tasks that could—and should—be delegated to office staff. When we all figure out how to offload nonmedical duties to nonphysicians, FPs can get back to doing what most of us love to do and do best—looking patients in their eyes, taking time to understand their problems, and deciding together which tests and what treatment plans will do the most to improve their lives.
*We’ll publish some of these responses in the Letters column in the June issue.
End EMR tyranny!
Although electronic medical records (EMRs) were initially touted as a means of greater efficiency and streamlined workload, physicians are now required to use them not only to document patient care, but to enter all orders, medications, referrals, appointments, medical updates, and billing codes. It should come as no surprise, then, that a new survey by AmericanEHR Partners finds physician satisfaction with EMR systems on the wane (www.americanehr.com/about/news/).
If the EMR burden is bringing you down (and “meaningful use” is making it worse), you’ll be interested in what Dan Sweeney, a family physician of 27 years, had to say on the matter. He wrote the following “Declaration of Physician Independence” on a day when 2 of his long-time patients said they would not be returning; the wait time at his practice (more than an hour and a half that day) had simply become too much.
When in the course of medical practice it becomes clear that patient care and physician and patient satisfaction are at all-time lows, it is time to declare an end to unrealistic burdens that hinder our ability to provide compassionate patient care. We are expected to serve 2 masters: our patients and our EMRs. But we cannot serve both. We can complete the EMR during a visit (and forego adequate patient counseling). Or we can interact humanely with our patients—listening to their stories, answering their questions, and ending each visit with thorough instructions—and spend 2 hours each evening finishing documentation (leaving little time for our families).
I therefore declare:
- Completion of the EMR will no longer be the primary focus of my time with patients. I will attend to appropriate EMR functions during patient encounters, reviewing relevant information and completing tasks as appropriate. This will be accomplished with the aid of voice recognition software and transcriptionists.
- I will schedule adequate time for each patient.
- I will no longer succumb to the pressure to add more patients to my already overbooked schedule.
To make these declarations financially feasible, Dr. Sweeney continued:
Family physicians will provide medical homes for our patients and be paid based on the number of people we care for and quality care standards, not by piecework. Relative value units will be banished forever as the measure of our productivity and our worth as physicians.
Provocative stuff.
So where do you stand on EMRs? Have you found other ways to spend quality time with patients, fulfill the myriad EMR requirements, and maintain a fulfilling family life? Have you written declarations of your own? Let us know what steps you’ve taken to end EMR tyranny. E-mail me at the address below.
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
Although electronic medical records (EMRs) were initially touted as a means of greater efficiency and streamlined workload, physicians are now required to use them not only to document patient care, but to enter all orders, medications, referrals, appointments, medical updates, and billing codes. It should come as no surprise, then, that a new survey by AmericanEHR Partners finds physician satisfaction with EMR systems on the wane (www.americanehr.com/about/news/).
If the EMR burden is bringing you down (and “meaningful use” is making it worse), you’ll be interested in what Dan Sweeney, a family physician of 27 years, had to say on the matter. He wrote the following “Declaration of Physician Independence” on a day when 2 of his long-time patients said they would not be returning; the wait time at his practice (more than an hour and a half that day) had simply become too much.
When in the course of medical practice it becomes clear that patient care and physician and patient satisfaction are at all-time lows, it is time to declare an end to unrealistic burdens that hinder our ability to provide compassionate patient care. We are expected to serve 2 masters: our patients and our EMRs. But we cannot serve both. We can complete the EMR during a visit (and forego adequate patient counseling). Or we can interact humanely with our patients—listening to their stories, answering their questions, and ending each visit with thorough instructions—and spend 2 hours each evening finishing documentation (leaving little time for our families).
I therefore declare:
- Completion of the EMR will no longer be the primary focus of my time with patients. I will attend to appropriate EMR functions during patient encounters, reviewing relevant information and completing tasks as appropriate. This will be accomplished with the aid of voice recognition software and transcriptionists.
- I will schedule adequate time for each patient.
- I will no longer succumb to the pressure to add more patients to my already overbooked schedule.
To make these declarations financially feasible, Dr. Sweeney continued:
Family physicians will provide medical homes for our patients and be paid based on the number of people we care for and quality care standards, not by piecework. Relative value units will be banished forever as the measure of our productivity and our worth as physicians.
Provocative stuff.
So where do you stand on EMRs? Have you found other ways to spend quality time with patients, fulfill the myriad EMR requirements, and maintain a fulfilling family life? Have you written declarations of your own? Let us know what steps you’ve taken to end EMR tyranny. E-mail me at the address below.
Although electronic medical records (EMRs) were initially touted as a means of greater efficiency and streamlined workload, physicians are now required to use them not only to document patient care, but to enter all orders, medications, referrals, appointments, medical updates, and billing codes. It should come as no surprise, then, that a new survey by AmericanEHR Partners finds physician satisfaction with EMR systems on the wane (www.americanehr.com/about/news/).
If the EMR burden is bringing you down (and “meaningful use” is making it worse), you’ll be interested in what Dan Sweeney, a family physician of 27 years, had to say on the matter. He wrote the following “Declaration of Physician Independence” on a day when 2 of his long-time patients said they would not be returning; the wait time at his practice (more than an hour and a half that day) had simply become too much.
When in the course of medical practice it becomes clear that patient care and physician and patient satisfaction are at all-time lows, it is time to declare an end to unrealistic burdens that hinder our ability to provide compassionate patient care. We are expected to serve 2 masters: our patients and our EMRs. But we cannot serve both. We can complete the EMR during a visit (and forego adequate patient counseling). Or we can interact humanely with our patients—listening to their stories, answering their questions, and ending each visit with thorough instructions—and spend 2 hours each evening finishing documentation (leaving little time for our families).
I therefore declare:
- Completion of the EMR will no longer be the primary focus of my time with patients. I will attend to appropriate EMR functions during patient encounters, reviewing relevant information and completing tasks as appropriate. This will be accomplished with the aid of voice recognition software and transcriptionists.
- I will schedule adequate time for each patient.
- I will no longer succumb to the pressure to add more patients to my already overbooked schedule.
To make these declarations financially feasible, Dr. Sweeney continued:
Family physicians will provide medical homes for our patients and be paid based on the number of people we care for and quality care standards, not by piecework. Relative value units will be banished forever as the measure of our productivity and our worth as physicians.
Provocative stuff.
So where do you stand on EMRs? Have you found other ways to spend quality time with patients, fulfill the myriad EMR requirements, and maintain a fulfilling family life? Have you written declarations of your own? Let us know what steps you’ve taken to end EMR tyranny. E-mail me at the address below.
Colon cancer screening comes too late . . . A drug reaction with lasting consequences . . . More
Colon cancer screening comes too late
AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.
PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.
THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.
VERDICT $500,000 Massachusetts settlement.
COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!
A drug reaction with lasting consequences
AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.
After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.
At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.
PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.
THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.
VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.
COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.
A colonoscopy, then hepatitis C
AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.
PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.
THE DEFENSE No information about the defense is available.
VERDICT $675,000 New York settlement.
COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.
Colon cancer screening comes too late
AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.
PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.
THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.
VERDICT $500,000 Massachusetts settlement.
COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!
A drug reaction with lasting consequences
AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.
After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.
At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.
PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.
THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.
VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.
COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.
A colonoscopy, then hepatitis C
AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.
PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.
THE DEFENSE No information about the defense is available.
VERDICT $675,000 New York settlement.
COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.
Colon cancer screening comes too late
AFTER 14 YEARS OF TREATMENT by her physician, a 73-year-old woman with a medical history that included chronic obstructive pulmonary disease and major depression underwent her first colonoscopy. It revealed colon cancer. The patient died about a year and a half later.
PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.
THE DEFENSE The physician claimed that the patient had declined his recommendations for colon cancer screening many times and that she had failed to return stool samples from a home test kit he had given her. The physician’s medical records, which began in 2001, didn’t reflect his screening recommendations. Earlier records had been destroyed in 2007 in accordance with office policy.
VERDICT $500,000 Massachusetts settlement.
COMMENT Do you routinely document refusal of preventive services by your patients? If not, you, too, may fall victim to a plaintiff’s attorney!
A drug reaction with lasting consequences
AN ALLERGIC REACTION to trimethoprim/ sulfamethoxazole caused skin changes in a 44-year-old woman. Nevertheless, her physician prescribed another regimen of the drug 4 years later. This time, the patient had a full-blown allergic reaction, characterized by red, scaly, weepy skin and elevated liver enzymes, among other symptoms.
After several emergency department visits and a hospital admission, the patient was transferred to the burn unit of a regional medical center, with a presumed diagnosis of Stevens-Johnson syndrome (SJS). After evaluating the patient, however, the director of the burn unit concluded that her symptoms were not severe enough to be SJS; he attributed them to a simple drug reaction and had the patient moved to a medical/surgical floor.
At some point, she developed peripheral sensory neuropathy in her hands and feet. The parties involved disagreed about when the neuropathy began and what caused it.
PLAINTIFF’S CLAIM The patient should not have been transferred to the medical/surgical unit; the higher level of care provided on the burn unit would have prevented the peripheral neuropathy. The patient received inadequate nutrition, which contributed to her injuries.
THE DEFENSE Because the patient didn’t actually have SJS, the medical/surgical floor was the appropriate place to treat her. The patient received proper skin care and nutrition. The patient had complained of numbness and tingling in her hands and feet before she was hospitalized, indicating that the drug-related neuropathy had existed before admission to the regional facility.
VERDICT Defense verdict following confidential settlement with the physician who prescribed trimethoprim/sulfamethoxazole.
COMMENT When prescribing any antibiotic, always confirm that the patient isn’t allergic to it. Have your nurses and medical assistants help you maintain accurate medication and allergy lists in your office chart or electronic medical record.
A colonoscopy, then hepatitis C
AFTER UNDERGOING A COLONOSCOPY, a 44-year-old man was diagnosed with hepatitis C. He claimed that the infection had been transmitted by the anesthetic used during the procedure.
PLAINTIFF’S CLAIM The anesthesiologist drew the anesthetic from a multiple-dose vial that had been used during previous procedures; proper sterile techniques weren’t followed.
THE DEFENSE No information about the defense is available.
VERDICT $675,000 New York settlement.
COMMENT I thought this practice had stopped 20 years ago. Review your office procedures and make sure it doesn’t happen. Don’t use single-dose, single-use vials for more than one patient—ever.
Catching up with the evidence
Early last year, the US Preventive Services Task Force (USPSTF) and the American Cancer Society, among other medical groups, jointly issued guidelines for cervical cancer screening.1 In November, the American College of Obstetricians and Gynecologists followed suit,2 and the Canadian Medical Association jumped on the bandwagon early this year.3
For the first time, all agreed that no Pap smears are needed for women younger than 21 years; no testing for human papilloma virus (HPV) is necessary for women younger than 30; and for low-risk women, combined Pap smear and HPV testing can safely be done every 5 years, instead of every 3.
This is not the first time the USPSTF has told the public that less cancer screening is better. Remember the furor that accompanied its announcement that mammograms were no longer routinely recommended for women ages 40 to 49 and the downgrading of PSA screening to a D (not recommended) rating?
There is mounting evidence that more is not better in many aspects of health care. Research has shown, for example, that there is little relationship between dollars spent and quality of care for Medicare beneficiaries,4 and studies by the family physician-led Ambulatory Sentinel Practice Network have long since established that more CT scans of the head (J Fam Pract. 1993;37:129-134) and more D&Cs (J Am Board Fam Pract. 1988;1:15-23) do not lead to better outcomes. And I’ll never forget the patient—a sturdy farmer referred by a pulmonologist for cardiac catheterization—who was found to have normal coronary arteries but died of an arrhythmia on the cath table.
I doubt that we can convince our patients that less is best for cancer screening, as well as many procedures. But we can practice shared decision making, taking the time to talk to patients about the pros, cons, and trade-offs of tests and treatments and to elicit their preferences (which often differ in surprising ways from what we might guess). This approach, particularly when it’s paired with easily understood patient education material, is likely to result in fewer unnecessary—and potentially harmful—tests and treatments.
1. ACOG announcement. March 14, 2012. Available at: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations. Accessed February 12, 2013.
2. ACOG Practice Bulletin No. 131: screening for cervical cancer. Obstet Gynecol. 2012;120:1222-1238.
3. Canadian Task Force on Preventive Health Care. Guidelines. Recommendations on screening for cervical cancer. January 2013. Available at: http://www.cmaj.ca/content/185/1/35.full?sid=9cf0e8c7-74ae-45de-8c3a-80dca60bc136. Accessed February 19, 2013.
4. The Dartmouth Institute for Health Policy and Clinical Practice. Health care spending, quality, and outcomes: more isn’t always better. February 27, 2009. Available at: http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf. Accessed February 21, 2013.
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
John Hickner, MD, MSc
Editor-in-Chief
jfp.eic@gmail.com
Early last year, the US Preventive Services Task Force (USPSTF) and the American Cancer Society, among other medical groups, jointly issued guidelines for cervical cancer screening.1 In November, the American College of Obstetricians and Gynecologists followed suit,2 and the Canadian Medical Association jumped on the bandwagon early this year.3
For the first time, all agreed that no Pap smears are needed for women younger than 21 years; no testing for human papilloma virus (HPV) is necessary for women younger than 30; and for low-risk women, combined Pap smear and HPV testing can safely be done every 5 years, instead of every 3.
This is not the first time the USPSTF has told the public that less cancer screening is better. Remember the furor that accompanied its announcement that mammograms were no longer routinely recommended for women ages 40 to 49 and the downgrading of PSA screening to a D (not recommended) rating?
There is mounting evidence that more is not better in many aspects of health care. Research has shown, for example, that there is little relationship between dollars spent and quality of care for Medicare beneficiaries,4 and studies by the family physician-led Ambulatory Sentinel Practice Network have long since established that more CT scans of the head (J Fam Pract. 1993;37:129-134) and more D&Cs (J Am Board Fam Pract. 1988;1:15-23) do not lead to better outcomes. And I’ll never forget the patient—a sturdy farmer referred by a pulmonologist for cardiac catheterization—who was found to have normal coronary arteries but died of an arrhythmia on the cath table.
I doubt that we can convince our patients that less is best for cancer screening, as well as many procedures. But we can practice shared decision making, taking the time to talk to patients about the pros, cons, and trade-offs of tests and treatments and to elicit their preferences (which often differ in surprising ways from what we might guess). This approach, particularly when it’s paired with easily understood patient education material, is likely to result in fewer unnecessary—and potentially harmful—tests and treatments.
Early last year, the US Preventive Services Task Force (USPSTF) and the American Cancer Society, among other medical groups, jointly issued guidelines for cervical cancer screening.1 In November, the American College of Obstetricians and Gynecologists followed suit,2 and the Canadian Medical Association jumped on the bandwagon early this year.3
For the first time, all agreed that no Pap smears are needed for women younger than 21 years; no testing for human papilloma virus (HPV) is necessary for women younger than 30; and for low-risk women, combined Pap smear and HPV testing can safely be done every 5 years, instead of every 3.
This is not the first time the USPSTF has told the public that less cancer screening is better. Remember the furor that accompanied its announcement that mammograms were no longer routinely recommended for women ages 40 to 49 and the downgrading of PSA screening to a D (not recommended) rating?
There is mounting evidence that more is not better in many aspects of health care. Research has shown, for example, that there is little relationship between dollars spent and quality of care for Medicare beneficiaries,4 and studies by the family physician-led Ambulatory Sentinel Practice Network have long since established that more CT scans of the head (J Fam Pract. 1993;37:129-134) and more D&Cs (J Am Board Fam Pract. 1988;1:15-23) do not lead to better outcomes. And I’ll never forget the patient—a sturdy farmer referred by a pulmonologist for cardiac catheterization—who was found to have normal coronary arteries but died of an arrhythmia on the cath table.
I doubt that we can convince our patients that less is best for cancer screening, as well as many procedures. But we can practice shared decision making, taking the time to talk to patients about the pros, cons, and trade-offs of tests and treatments and to elicit their preferences (which often differ in surprising ways from what we might guess). This approach, particularly when it’s paired with easily understood patient education material, is likely to result in fewer unnecessary—and potentially harmful—tests and treatments.
1. ACOG announcement. March 14, 2012. Available at: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations. Accessed February 12, 2013.
2. ACOG Practice Bulletin No. 131: screening for cervical cancer. Obstet Gynecol. 2012;120:1222-1238.
3. Canadian Task Force on Preventive Health Care. Guidelines. Recommendations on screening for cervical cancer. January 2013. Available at: http://www.cmaj.ca/content/185/1/35.full?sid=9cf0e8c7-74ae-45de-8c3a-80dca60bc136. Accessed February 19, 2013.
4. The Dartmouth Institute for Health Policy and Clinical Practice. Health care spending, quality, and outcomes: more isn’t always better. February 27, 2009. Available at: http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf. Accessed February 21, 2013.
1. ACOG announcement. March 14, 2012. Available at: http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations. Accessed February 12, 2013.
2. ACOG Practice Bulletin No. 131: screening for cervical cancer. Obstet Gynecol. 2012;120:1222-1238.
3. Canadian Task Force on Preventive Health Care. Guidelines. Recommendations on screening for cervical cancer. January 2013. Available at: http://www.cmaj.ca/content/185/1/35.full?sid=9cf0e8c7-74ae-45de-8c3a-80dca60bc136. Accessed February 19, 2013.
4. The Dartmouth Institute for Health Policy and Clinical Practice. Health care spending, quality, and outcomes: more isn’t always better. February 27, 2009. Available at: http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf. Accessed February 21, 2013.
Delayed MI diagnosis ends in disability, huge ($126M) verdict … more
Delayed heart attack diagnosis ends in disability and a huge verdict
DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).
An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.
In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.
Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.
PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.
THE DEFENSE The dissection during surgery caused the patient’s injuries.
VERDICT $126.6 million New York verdict.
COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.
Inadequate INR monitoring implicated in woman's death
A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.
The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.
At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.
Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.
PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.
THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.
VERDICT $386,648 net California verdict.
COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.
Delayed heart attack diagnosis ends in disability and a huge verdict
DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).
An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.
In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.
Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.
PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.
THE DEFENSE The dissection during surgery caused the patient’s injuries.
VERDICT $126.6 million New York verdict.
COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.
Inadequate INR monitoring implicated in woman's death
A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.
The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.
At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.
Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.
PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.
THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.
VERDICT $386,648 net California verdict.
COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.
Delayed heart attack diagnosis ends in disability and a huge verdict
DESPITE FEELING ILL ON AWAKENING, a 50-year-old woman went to work, where she suffered crushing chest pain radiating down her left arm and up to her jaw. Her coworker (and husband at the time) recognized the symptoms of a heart attack and drove her to the emergency department (ED).
An electrocardiogram (EKG) performed more than 4 hours later was read as not indicating a heart attack. The patient was given pain medication and an antianxiety drug because she had a history of anxiety. She spent the night at the hospital, lying on a gurney in a hallway at times.
In the morning, her husband called his own cardiologist, whose office was across the street from the hospital. The cardiologist came to the ED and immediately arranged to have the patient transferred by ambulance to the intensive care unit at another hospital.
Upon arrival, the patient was immediately sent to the hospital’s cardiac catheterization lab, where a heart attack was diagnosed. She underwent immediate surgery, during which she suffered dissection of an artery. Because of damage to her heart, she couldn’t return to work.
PLAINTIFF’S CLAIM The patient lost 70% of her heart’s pumping capacity and would require a heart transplant eventually. A cardiologist should have evaluated the patient immediately upon her arrival at the first hospital; the EKG done at that hospital was misread. On the catheterization film taken before surgery at the second hospital, the front portion of the patient’s heart was motionless.
THE DEFENSE The dissection during surgery caused the patient’s injuries.
VERDICT $126.6 million New York verdict.
COMMENT I do some malpractice case review and have seen 2 cases just like this one. If it sounds like a horse (myocardial infarction), it is a horse until proven otherwise. I’ve heard of men in their 40s seeking urgent care, being diagnosed with dyspepsia, and dying within 2 days.
Inadequate INR monitoring implicated in woman's death
A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.
The patient’s international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.
At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.
Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.
PLAINTIFF’S CLAIM The defendants didn’t monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.
THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.
VERDICT $386,648 net California verdict.
COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight. Use a registry and double checking system. Be sure you know who is responsible during care transitions.
Don’t call me a provider
There is a severe shortage of doctors in the United States, and it’s not because we are training too few physicians. It is because, shortly after graduation, doctors all morph into “providers.”
This strange transformation was called to my attention about 10 years ago by a family physician from Wisconsin. He was quite indignant about being called a provider, and I decided I should be, too. I didn’t spend 4 years in medical school and 3 in residency training to become a provider; I am a family physician and my patients want a family doctor—not a family provider.
(For history buffs, the word “provider” first appeared in a PubMed title in 1971, in an article titled “Home care, new provider approaches – physical therapy.”1 Not about doctors at all.)
About 4 years ago, the provider issue resurfaced when an ad caught my attention. Driving to work one morning listening to the radio, I heard a local garbage collector advertise his services—and urging listeners to contact one of his “providers” to obtain the company’s services. I am sure he runs an excellent business and his providers do an important job, but I do believe there is a fundamental difference between collecting garbage and taking care of people’s health care needs.
In health care, the word provider has made its way into the lexicon, and it’s not just outsiders who use it. I frequently hear doctors referring to other doctors as providers.
Why did we become providers? The answer is simple: Health insurers foisted the title upon us. They wanted a generic term to encompass all those who provide health care services for billing purposes. Because they reimburse physicians, chiropractors, physical therapists, nurse practitioners, physician assistants, occupational therapists, and more, they found it more efficient to lump all of us into one category.
Frankly, I think this is demeaning to all health care professionals, not just physicians. What about medical assistants, nurses, and lab techs? Why should they be lumped into one category when their training is quite different from one another?
Please join me in banishing the word “provider” from your vocabulary when you’re referring to doctors, physician assistants, nurse practitioners, or any other health caregivers. As a department chair, I don’t allow it to be used in any departmental discussions.
And while I doubt that we can change the insurance industry’s use of the word, we can be more cognizant of our own word choices. Let’s use the word that reflects who we are: doctors.
Reference
1. Blood H. Home care, new provider approaches - physical therapy. NLN Publ. 1971;(21-1432):79-81.
John Hickner, MD, MSc
Editor-in-Chief
hickner@uic.edu
John Hickner, MD, MSc
Editor-in-Chief
hickner@uic.edu
John Hickner, MD, MSc
Editor-in-Chief
hickner@uic.edu
There is a severe shortage of doctors in the United States, and it’s not because we are training too few physicians. It is because, shortly after graduation, doctors all morph into “providers.”
This strange transformation was called to my attention about 10 years ago by a family physician from Wisconsin. He was quite indignant about being called a provider, and I decided I should be, too. I didn’t spend 4 years in medical school and 3 in residency training to become a provider; I am a family physician and my patients want a family doctor—not a family provider.
(For history buffs, the word “provider” first appeared in a PubMed title in 1971, in an article titled “Home care, new provider approaches – physical therapy.”1 Not about doctors at all.)
About 4 years ago, the provider issue resurfaced when an ad caught my attention. Driving to work one morning listening to the radio, I heard a local garbage collector advertise his services—and urging listeners to contact one of his “providers” to obtain the company’s services. I am sure he runs an excellent business and his providers do an important job, but I do believe there is a fundamental difference between collecting garbage and taking care of people’s health care needs.
In health care, the word provider has made its way into the lexicon, and it’s not just outsiders who use it. I frequently hear doctors referring to other doctors as providers.
Why did we become providers? The answer is simple: Health insurers foisted the title upon us. They wanted a generic term to encompass all those who provide health care services for billing purposes. Because they reimburse physicians, chiropractors, physical therapists, nurse practitioners, physician assistants, occupational therapists, and more, they found it more efficient to lump all of us into one category.
Frankly, I think this is demeaning to all health care professionals, not just physicians. What about medical assistants, nurses, and lab techs? Why should they be lumped into one category when their training is quite different from one another?
Please join me in banishing the word “provider” from your vocabulary when you’re referring to doctors, physician assistants, nurse practitioners, or any other health caregivers. As a department chair, I don’t allow it to be used in any departmental discussions.
And while I doubt that we can change the insurance industry’s use of the word, we can be more cognizant of our own word choices. Let’s use the word that reflects who we are: doctors.
There is a severe shortage of doctors in the United States, and it’s not because we are training too few physicians. It is because, shortly after graduation, doctors all morph into “providers.”
This strange transformation was called to my attention about 10 years ago by a family physician from Wisconsin. He was quite indignant about being called a provider, and I decided I should be, too. I didn’t spend 4 years in medical school and 3 in residency training to become a provider; I am a family physician and my patients want a family doctor—not a family provider.
(For history buffs, the word “provider” first appeared in a PubMed title in 1971, in an article titled “Home care, new provider approaches – physical therapy.”1 Not about doctors at all.)
About 4 years ago, the provider issue resurfaced when an ad caught my attention. Driving to work one morning listening to the radio, I heard a local garbage collector advertise his services—and urging listeners to contact one of his “providers” to obtain the company’s services. I am sure he runs an excellent business and his providers do an important job, but I do believe there is a fundamental difference between collecting garbage and taking care of people’s health care needs.
In health care, the word provider has made its way into the lexicon, and it’s not just outsiders who use it. I frequently hear doctors referring to other doctors as providers.
Why did we become providers? The answer is simple: Health insurers foisted the title upon us. They wanted a generic term to encompass all those who provide health care services for billing purposes. Because they reimburse physicians, chiropractors, physical therapists, nurse practitioners, physician assistants, occupational therapists, and more, they found it more efficient to lump all of us into one category.
Frankly, I think this is demeaning to all health care professionals, not just physicians. What about medical assistants, nurses, and lab techs? Why should they be lumped into one category when their training is quite different from one another?
Please join me in banishing the word “provider” from your vocabulary when you’re referring to doctors, physician assistants, nurse practitioners, or any other health caregivers. As a department chair, I don’t allow it to be used in any departmental discussions.
And while I doubt that we can change the insurance industry’s use of the word, we can be more cognizant of our own word choices. Let’s use the word that reflects who we are: doctors.
Reference
1. Blood H. Home care, new provider approaches - physical therapy. NLN Publ. 1971;(21-1432):79-81.
Reference
1. Blood H. Home care, new provider approaches - physical therapy. NLN Publ. 1971;(21-1432):79-81.
Arm them with evidence
Health care in this country is at the beginning of a major overhaul, and not just because of “Obamacare.” It is because medical care is getting too darned expensive, and patients, payers, and employers are fed up with the high cost. The good news for family physicians is that virtually everyone finally realizes that a strong primary care presence is essential for both successful cost containment and high-quality care.
But the people most able to bring about significant health care cost savings are not physicians at all. They are our patients. Those who eat properly, exercise regularly, don’t smoke, and drink alcohol in moderation typically need less medical care. For people who have chronic illnesses, good “patient self-management”—a pillar of the patient-centered medical home—makes it less likely that they’ll land in the hospital or ED, resulting in lower costs and better outcomes.
To be most effective, patient self-management must be based on solid evidence—just like any treatment.
But that’s not always the case.
Daily blood glucose checks used to be the standard of care for patients with type 2 diabetes. But it turns out this is a medical myth, improperly extrapolated from data on patients with type 1 diabetes. A number of excellent randomized trials have shown marginal benefit at best from routine self-monitoring for patients with type 2 diabetes. (The evidence is detailed in this month’s Clinical Inquiries.)
For many patients with type 2 diabetes, checking blood sugar weekly or even monthly is sufficient. (Others should do glucose checks several times a day to titrate insulin doses.) We could save millions by teaching patients to check their blood sugar only when it’s appropriate, thereby reducing the number of glucose monitoring strips they use.
Which brings me to another way we can improve patient self management: Treat each patient as an individual. That is family medicine—and medical care—at its best. It costs less than cookie-cutter medicine, and leads to better outcomes.
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
Health care in this country is at the beginning of a major overhaul, and not just because of “Obamacare.” It is because medical care is getting too darned expensive, and patients, payers, and employers are fed up with the high cost. The good news for family physicians is that virtually everyone finally realizes that a strong primary care presence is essential for both successful cost containment and high-quality care.
But the people most able to bring about significant health care cost savings are not physicians at all. They are our patients. Those who eat properly, exercise regularly, don’t smoke, and drink alcohol in moderation typically need less medical care. For people who have chronic illnesses, good “patient self-management”—a pillar of the patient-centered medical home—makes it less likely that they’ll land in the hospital or ED, resulting in lower costs and better outcomes.
To be most effective, patient self-management must be based on solid evidence—just like any treatment.
But that’s not always the case.
Daily blood glucose checks used to be the standard of care for patients with type 2 diabetes. But it turns out this is a medical myth, improperly extrapolated from data on patients with type 1 diabetes. A number of excellent randomized trials have shown marginal benefit at best from routine self-monitoring for patients with type 2 diabetes. (The evidence is detailed in this month’s Clinical Inquiries.)
For many patients with type 2 diabetes, checking blood sugar weekly or even monthly is sufficient. (Others should do glucose checks several times a day to titrate insulin doses.) We could save millions by teaching patients to check their blood sugar only when it’s appropriate, thereby reducing the number of glucose monitoring strips they use.
Which brings me to another way we can improve patient self management: Treat each patient as an individual. That is family medicine—and medical care—at its best. It costs less than cookie-cutter medicine, and leads to better outcomes.
Health care in this country is at the beginning of a major overhaul, and not just because of “Obamacare.” It is because medical care is getting too darned expensive, and patients, payers, and employers are fed up with the high cost. The good news for family physicians is that virtually everyone finally realizes that a strong primary care presence is essential for both successful cost containment and high-quality care.
But the people most able to bring about significant health care cost savings are not physicians at all. They are our patients. Those who eat properly, exercise regularly, don’t smoke, and drink alcohol in moderation typically need less medical care. For people who have chronic illnesses, good “patient self-management”—a pillar of the patient-centered medical home—makes it less likely that they’ll land in the hospital or ED, resulting in lower costs and better outcomes.
To be most effective, patient self-management must be based on solid evidence—just like any treatment.
But that’s not always the case.
Daily blood glucose checks used to be the standard of care for patients with type 2 diabetes. But it turns out this is a medical myth, improperly extrapolated from data on patients with type 1 diabetes. A number of excellent randomized trials have shown marginal benefit at best from routine self-monitoring for patients with type 2 diabetes. (The evidence is detailed in this month’s Clinical Inquiries.)
For many patients with type 2 diabetes, checking blood sugar weekly or even monthly is sufficient. (Others should do glucose checks several times a day to titrate insulin doses.) We could save millions by teaching patients to check their blood sugar only when it’s appropriate, thereby reducing the number of glucose monitoring strips they use.
Which brings me to another way we can improve patient self management: Treat each patient as an individual. That is family medicine—and medical care—at its best. It costs less than cookie-cutter medicine, and leads to better outcomes.
Death follows a normal EKG ...Kidney failure after multiple meds
Death follows a normal EKG
MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.
The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.
Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.
No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.
PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.
THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.
VERDICT $1.5 million Illinois verdict.
COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.
Kidney failure after multiple meds
A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.
PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.
THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.
VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.
COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.
Death follows a normal EKG
MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.
The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.
Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.
No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.
PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.
THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.
VERDICT $1.5 million Illinois verdict.
COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.
Kidney failure after multiple meds
A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.
PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.
THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.
VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.
COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.
Death follows a normal EKG
MID-CHEST DISCOMFORT, A COUGH, AND SWEATING brought a 59-year-old man to his primary care physician. The patient had normal vital signs and reported that belching relieved the chest discomfort. He had a history of severe coronary artery disease and had undergone angioplasty and stenting several years earlier.
The primary care physician performed an electrocardiogram (EKG), which was normal and unchanged from one done the year before. The doctor suspected bronchitis, but prescribed omeprazole because the patient had previously been diagnosed with gastroesophageal reflux disease. He ordered a chemical stress test to be performed within a month and a chest radiograph to be done if the patient’s symptoms didn’t improve.
Two hours after returning home, the patient called an ambulance. He told paramedics that he’d been having chest pain for an hour. While they were putting the patient into the ambulance, he went into cardiac arrest. Four defibrillation attempts en route to the hospital and additional resuscitation attempts in the ED failed; he was pronounced dead 3½ hours after leaving his physician’s office.
No autopsy was performed. The patient’s widow found the omeprazole bottle, with one pill missing, and fast-food hamburger wrappers on the kitchen table.
PLAINTIFF’S CLAIM The primary care physician should have sent the patient to the ED to determine whether the chest pain had a cardiac cause; the patient was suffering from acute cardiac syndrome when the doctor saw him.
THE DEFENSE The patient’s normal EKG and vital signs and the fact that belching relieved his chest symptoms indicated that the complaints did not arise from cardiac causes or require emergency assessment. The patient didn’t report chest pain at the office visit; the later cardiac arrest probably resulted from a sudden plaque rupture unrelated to the earlier chest discomfort.
VERDICT $1.5 million Illinois verdict.
COMMENT I hope most doctors won’t have to learn this lesson from their own experience. A normal EKG does not rule out acute ischemia in a high-risk patient with chest pain and sweating. Admit such patients immediately to a cardiac observation unit.
Kidney failure after multiple meds
A MAN WAS TAKING MULTIPLE MEDICATIONS: 3 blood pressure drugs prescribed by his primary care physician, an NSAID prescribed by another doctor, and sizable doses of BC Powder, an over-the-counter analgesic containing aspirin, salicylamide, and caffeine. After 4 years on this medication regimen, the patient’s kidneys failed.
PLAINTIFF’S CLAIM The primary care physician failed to properly monitor kidney function with blood and urine tests while his patient was taking the medications. Proper testing would have resulted in a diagnosis of kidney disease before the patient’s kidneys failed completely. In addition, the primary care physician failed to explain the risks and side effects of the medications to the patient.
THE DEFENSE The patient refused kidney function testing and did not follow medical advice. He consumed excessive amounts of alcohol against medical advice, did not tell the primary care physician about other drugs he was taking, and had allowed his supply of blood pressure medication to run out.
VERDICT $2 million gross verdict in Georgia, with a finding of 47% comparative negligence.
COMMENT This case offers several lessons: First, each BC Powder packet contains the equivalent of 2 aspirin. Second, chronic, high-dose NSAIDs can cause renal failure, especially in patients whose renal function is compromised by hypertension. Third, all patients with hypertension should undergo periodic monitoring of renal function.
Postelection culture clash?
It was the night after the election. I was trying to recruit Steve, a stalwart rural family physician, to join the Cleveland Clinic Department of Family Medicine. We met for dinner at the entrance to the Gamekeeper’s Taverne, and the culture clash was evident at the door. He apologized for coming in his work clothes—brown scrubs top and blue jeans—and I apologized for being in mine, a suit and tie.
We couldn’t help discussing the election results, and our views were 180 degrees apart. I am delighted that we do not have to start over with health care reform. Steve, who has been a private practitioner for 22 years and is fiercely independent, is highly wary of government intervention and “Obamacare.”
There’s no chance of recruiting him, I thought to myself.
That is, until we started talking about patient care. I related my experience as a rural family physician. He recited the vision and mission statements he had written for his practice, which sounded exactly like ours. We both ordered a glass of the Great Lakes Brewing Company Christmas ale. I took that as a good sign.
During dinner, Steve received 3 calls related to patient care, including one from a priest who had recently seen one of his elderly patients. He chatted easily with the priest and his patients. You could tell there was a mutual bond and that Steve is one terrific family physician.
I reminded Steve that the US health care system is getting way too expensive and that we need to deliver better value. He agreed. I told him our facility is eliminating unnecessary testing and treatments and coordinating patient care and is committed to providing high-quality health care no matter who is in the White House. Steve said he shared that commitment and told me about his vision: To create a family medicine group in his small town in which each FP has expertise in a different area, like geriatrics, sports medicine, and dermatology, so patients can get 90% of the care they need right on site. That’s a vision I’d buy into any day.
When we parted that night, Steve and I were still far apart in our views of health care reform, and he still wasn’t sure whether he could tolerate all the rules and regulations that he would face if he were to work in a large organization. But despite our differences in both politics and practice settings, we found ourselves equally committed to providing patients with the best possible care as we face a changing health care system in the years ahead.
Happy holidays!
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
John Hickner, MD, MSc
Editor-in-Chief
jfp@ccf.org
It was the night after the election. I was trying to recruit Steve, a stalwart rural family physician, to join the Cleveland Clinic Department of Family Medicine. We met for dinner at the entrance to the Gamekeeper’s Taverne, and the culture clash was evident at the door. He apologized for coming in his work clothes—brown scrubs top and blue jeans—and I apologized for being in mine, a suit and tie.
We couldn’t help discussing the election results, and our views were 180 degrees apart. I am delighted that we do not have to start over with health care reform. Steve, who has been a private practitioner for 22 years and is fiercely independent, is highly wary of government intervention and “Obamacare.”
There’s no chance of recruiting him, I thought to myself.
That is, until we started talking about patient care. I related my experience as a rural family physician. He recited the vision and mission statements he had written for his practice, which sounded exactly like ours. We both ordered a glass of the Great Lakes Brewing Company Christmas ale. I took that as a good sign.
During dinner, Steve received 3 calls related to patient care, including one from a priest who had recently seen one of his elderly patients. He chatted easily with the priest and his patients. You could tell there was a mutual bond and that Steve is one terrific family physician.
I reminded Steve that the US health care system is getting way too expensive and that we need to deliver better value. He agreed. I told him our facility is eliminating unnecessary testing and treatments and coordinating patient care and is committed to providing high-quality health care no matter who is in the White House. Steve said he shared that commitment and told me about his vision: To create a family medicine group in his small town in which each FP has expertise in a different area, like geriatrics, sports medicine, and dermatology, so patients can get 90% of the care they need right on site. That’s a vision I’d buy into any day.
When we parted that night, Steve and I were still far apart in our views of health care reform, and he still wasn’t sure whether he could tolerate all the rules and regulations that he would face if he were to work in a large organization. But despite our differences in both politics and practice settings, we found ourselves equally committed to providing patients with the best possible care as we face a changing health care system in the years ahead.
Happy holidays!
It was the night after the election. I was trying to recruit Steve, a stalwart rural family physician, to join the Cleveland Clinic Department of Family Medicine. We met for dinner at the entrance to the Gamekeeper’s Taverne, and the culture clash was evident at the door. He apologized for coming in his work clothes—brown scrubs top and blue jeans—and I apologized for being in mine, a suit and tie.
We couldn’t help discussing the election results, and our views were 180 degrees apart. I am delighted that we do not have to start over with health care reform. Steve, who has been a private practitioner for 22 years and is fiercely independent, is highly wary of government intervention and “Obamacare.”
There’s no chance of recruiting him, I thought to myself.
That is, until we started talking about patient care. I related my experience as a rural family physician. He recited the vision and mission statements he had written for his practice, which sounded exactly like ours. We both ordered a glass of the Great Lakes Brewing Company Christmas ale. I took that as a good sign.
During dinner, Steve received 3 calls related to patient care, including one from a priest who had recently seen one of his elderly patients. He chatted easily with the priest and his patients. You could tell there was a mutual bond and that Steve is one terrific family physician.
I reminded Steve that the US health care system is getting way too expensive and that we need to deliver better value. He agreed. I told him our facility is eliminating unnecessary testing and treatments and coordinating patient care and is committed to providing high-quality health care no matter who is in the White House. Steve said he shared that commitment and told me about his vision: To create a family medicine group in his small town in which each FP has expertise in a different area, like geriatrics, sports medicine, and dermatology, so patients can get 90% of the care they need right on site. That’s a vision I’d buy into any day.
When we parted that night, Steve and I were still far apart in our views of health care reform, and he still wasn’t sure whether he could tolerate all the rules and regulations that he would face if he were to work in a large organization. But despite our differences in both politics and practice settings, we found ourselves equally committed to providing patients with the best possible care as we face a changing health care system in the years ahead.
Happy holidays!
Inattention to history dooms patient to repeat it ... Persistent breast lumps but no biopsy ... more
When an atypical presentation is missed
A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.
The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.
The man died an hour later.
PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.
THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.
VERDICT $825,000 Virginia settlement.
COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).
Treatment delayed while infection spins out of control
VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.
The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.
PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.
THE DEFENSE The defendants who didn’t settle denied any negligence.
VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.
COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.
Inattention to history dooms patient to repeat it
HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.
About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.
PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.
THE DEFENSE No information about the defense is available.
VERDICT $1.5 million New Jersey settlement.
COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!
Persistent breast lumps, but no biopsy
ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.
When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.
Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.
PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.
THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.
VERDICT $750,000 Massachusetts settlement.
COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.
A red flag that was ignored for too long
A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.
Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.
After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.
The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.
PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.
THE DEFENSE No information about the defense is available.
VERDICT $875,000 New Jersey settlement.
COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.
When an atypical presentation is missed
A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.
The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.
The man died an hour later.
PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.
THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.
VERDICT $825,000 Virginia settlement.
COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).
Treatment delayed while infection spins out of control
VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.
The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.
PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.
THE DEFENSE The defendants who didn’t settle denied any negligence.
VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.
COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.
Inattention to history dooms patient to repeat it
HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.
About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.
PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.
THE DEFENSE No information about the defense is available.
VERDICT $1.5 million New Jersey settlement.
COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!
Persistent breast lumps, but no biopsy
ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.
When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.
Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.
PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.
THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.
VERDICT $750,000 Massachusetts settlement.
COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.
A red flag that was ignored for too long
A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.
Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.
After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.
The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.
PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.
THE DEFENSE No information about the defense is available.
VERDICT $875,000 New Jersey settlement.
COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.
When an atypical presentation is missed
A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.
The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.
The man died an hour later.
PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.
THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.
VERDICT $825,000 Virginia settlement.
COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).
Treatment delayed while infection spins out of control
VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.
The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.
PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.
THE DEFENSE The defendants who didn’t settle denied any negligence.
VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.
COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.
Inattention to history dooms patient to repeat it
HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.
About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.
PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.
THE DEFENSE No information about the defense is available.
VERDICT $1.5 million New Jersey settlement.
COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!
Persistent breast lumps, but no biopsy
ABOUT 3 YEARS AFTER GIVING BIRTH, a 38-year-old woman, who was still breastfeeding, went to her primary care physician complaining of pain, a dime-sized lump in her breast, and discharge from the nipple. The patient’s 2-year-old breast implants limited examination by the nurse practitioner (NP) who saw her. Galactorrhea was diagnosed and the woman was told to stop breastfeeding, apply ice packs, and come back in 2 weeks.
When the patient returned, her only remaining complaint was the lump, which the primary care physician attributed to mastitis. At a routine check-up 5 months later, the patient continued to complain of breast lumps. No breast exam was done, but the woman was referred to a gynecologist. An appointment for a breast ultrasound was scheduled for later in the month, but the patient said she didn’t receive notification of the date.
Metastatic breast cancer was subsequently diagnosed, and the woman died about 3 years later.
PLAINTIFF’S CLAIM The NP and primary care physician should have recommended a biopsy sooner.
THE DEFENSE The care given was proper; an earlier diagnosis wouldn’t have changed the outcome.
VERDICT $750,000 Massachusetts settlement.
COMMENT Failure to recommend biopsy of breast lumps is a leading cause of malpractice cases against family physicians. All persistent breast lumps require referral for biopsy— regardless of the patient’s age.
A red flag that was ignored for too long
A MAN IN HIS EARLY 30S consulted an orthopedist for mid-back pain. The doctor took radiographs of the man’s lower back and reported that he saw nothing amiss. When the man returned 3 months later complaining of the same kind of pain, the orthopedist examined him, prescribed a muscle relaxant, and sent him for physical therapy. The physician did not take any radiographs.
Four months later, the patient came back with pain in his mid-back and ribs. The orthopedist ordered radiographs of the ribs, which were read as normal.
After 18 months, the patient consulted another orthopedist, who ordered a magnetic resonance imaging scan and diagnosed a spinal plasmacytoma at levels T9 to T11. The tumor had destroyed some vertebrae and was compressing the spinal cord.
The patient underwent surgery to remove the tumor and insert screws from T6 to L2 to stabilize the spine. He wore a brace around his torso for months and had a bone marrow transplant. The patient couldn’t return to work.
PLAINTIFF’S CLAIM The tumor was clearly visible on the radiographs taken at the patient’s third visit to the first orthopedist; thoracic spine radiographs should have been taken at the previous 2 visits.
THE DEFENSE No information about the defense is available.
VERDICT $875,000 New Jersey settlement.
COMMENT Current guidelines recommend a red flags approach to imaging. This patient had a red flag—unremitting pain. When back pain persists unabated, it’s time for a thorough evaluation.