User login
Failure to spot CHF leads to heart transplant
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Failure to spot CHF leads to heart transplant
A 49-YEAR-OLD MAN SOUGHT TREATMENT AT AN URGENT CARE FACILITY after having shortness of breath every morning for 2 weeks. His heart rate was 119 beats/min, his blood pressure was 170/101 mm Hg, and he did not have chest pain. An electrocardiogram (EKG) was abnormal and chest x-ray showed fluid in the lung. The patient was diagnosed with pneumonia, prescribed antibiotics, and told to follow up with his physician. A follow-up chest x-ray 2 weeks later showed an enlarged heart and more fluid in the lung. A computed tomography scan indicated congestive heart failure and an EKG showed signs of a heart attack. The patient underwent a heart transplant and requires immunosuppressants.
PLAINTIFF'S CLAIM If the physician at the urgent care facility had noticed the patient’s enlarged heart, there would have been less heart damage, and the patient might have required a bypass, rather than a transplant.
THE DEFENSE No information about the defense is available.
VERDICT $1 million New Jersey verdict.
COMMENT When evaluating shortness of breath, always think lungs and heart until you have a definite diagnosis. Remember that neurological disease can present with shortness of breath, too. Consider amyotrophic lateral sclerosis, Guillain-Barré syndrome, and myasthenia gravis.
Infant suffers brain injury after delayed lab results
PARENTS BROUGHT THEIR 2-WEEK-OLD DAUGHTER TO THE EMERGENCY DEPARTMENT (ED) after she had missed several feedings and was short of breath. The ED physician ordered blood tests, but discharged the patient before receiving the results and told the parents to follow up with the infant’s pediatrician. Blood work subsequently revealed that the child had a Group B streptococcus infection, but by the time these results were communicated to the parents and treatment had begun, the infant had developed meningitis. She suffered brain injury, and was diagnosed with cerebral palsy.
PLAINTIFF'S CLAIM There was a delay in the diagnosis and treatment of the infant. Blood test results showing a bacterial infection were available the morning after discharge, but instead of notifying the parents, an additional blood culture was ordered to determine the type of bacteria present. The parents were then contacted 6 hours after the bacteria was identified as Group B streptococcus.
THE DEFENSE The defendants denied any negligence, although a nurse who cared for the infant claimed she had expressed concerns about the decision to discharge the patient.
VERDICT $7.15 million Maryland verdict.
COMMENT In newborns, the differential diagnosis for shortness of breath widens to include infection. In this case, I suspect the problem was a lack of tight follow-up, which can lead to bad outcomes—especially in newborns.
Shifting our focus to HIV as a chronic disease
Last month in our practice we had a patient with a positive HIV enzyme-linked immunoassay (ELISA) test and a negative Western blot. The patient’s doctor was astute, elicited a history of a recent viral-like syndrome, and considered the possibility of recent HIV infection, which further testing confirmed as the correct diagnosis.
It has been fascinating to watch the discovery of HIV/acquired immunodeficiency syndrome (AIDS) and the evolution of diagnosis and treatment since the inception of the epidemic in 1981. In 1981, I was practicing in a small town in Michigan’s Upper Peninsula, and I did not see a patient with HIV infection in my office until 1990. In 2014, with an estimated prevalence of 1.1 million HIV cases in the United States,1 family physicians are likely to come into contact with several patients with HIV every year. Practicing on Chicago’s south side in 2008, I diagnosed 2 teenagers with HIV. It was a heartbreaking reality.
The discovery of highly active antiretroviral therapy (HAART) has transformed HIV/AIDS from an acute, infectious specialty disease to a chronic primary care disease. Although the annual incidence of HIV in the United States has dropped precipitously from its peak of 130,000 in the 1980s to about 50,000 in 2010,1 the prevalence continues to rise as more people with HIV infection are living for many years. People with HIV who receive proper care do have a shortened life span, but not by many years, and they are highly likely to show up in our offices for treatment of not only chronic illnesses that accompany HIV but also common diseases such as hypertension, diabetes, and coronary artery disease. More and more patients with HIV are being managed in primary care settings, with infectious disease specialists acting as consultants.
Universal screening for HIV is recommended and becoming the norm, and the stigma for testing appears to be decreasing. The burdensome informed consent process has been streamlined in many states, making screening seem routine to patients. Family physicians must do their part to help control the HIV epidemic by screening, properly diagnosing new cases of HIV, and providing chronic disease and preventive care. To that end, I encourage you to read “HIV screening: How we can do better,” by Editorial Board member Jeffrey T. Kirchner, DO, FAAFP, AAHIVS.
REFERENCE
1. Centers for Disease Control and Prevention (CDC). Today's HIV/AIDS epidemic. CDC Web site. Available at: http://www.cdc.gov/nchhstp/newsroom/docs/hivfactsheets/todaysepidemic-508.pdf. Accessed June 23, 2014.
Last month in our practice we had a patient with a positive HIV enzyme-linked immunoassay (ELISA) test and a negative Western blot. The patient’s doctor was astute, elicited a history of a recent viral-like syndrome, and considered the possibility of recent HIV infection, which further testing confirmed as the correct diagnosis.
It has been fascinating to watch the discovery of HIV/acquired immunodeficiency syndrome (AIDS) and the evolution of diagnosis and treatment since the inception of the epidemic in 1981. In 1981, I was practicing in a small town in Michigan’s Upper Peninsula, and I did not see a patient with HIV infection in my office until 1990. In 2014, with an estimated prevalence of 1.1 million HIV cases in the United States,1 family physicians are likely to come into contact with several patients with HIV every year. Practicing on Chicago’s south side in 2008, I diagnosed 2 teenagers with HIV. It was a heartbreaking reality.
The discovery of highly active antiretroviral therapy (HAART) has transformed HIV/AIDS from an acute, infectious specialty disease to a chronic primary care disease. Although the annual incidence of HIV in the United States has dropped precipitously from its peak of 130,000 in the 1980s to about 50,000 in 2010,1 the prevalence continues to rise as more people with HIV infection are living for many years. People with HIV who receive proper care do have a shortened life span, but not by many years, and they are highly likely to show up in our offices for treatment of not only chronic illnesses that accompany HIV but also common diseases such as hypertension, diabetes, and coronary artery disease. More and more patients with HIV are being managed in primary care settings, with infectious disease specialists acting as consultants.
Universal screening for HIV is recommended and becoming the norm, and the stigma for testing appears to be decreasing. The burdensome informed consent process has been streamlined in many states, making screening seem routine to patients. Family physicians must do their part to help control the HIV epidemic by screening, properly diagnosing new cases of HIV, and providing chronic disease and preventive care. To that end, I encourage you to read “HIV screening: How we can do better,” by Editorial Board member Jeffrey T. Kirchner, DO, FAAFP, AAHIVS.
Last month in our practice we had a patient with a positive HIV enzyme-linked immunoassay (ELISA) test and a negative Western blot. The patient’s doctor was astute, elicited a history of a recent viral-like syndrome, and considered the possibility of recent HIV infection, which further testing confirmed as the correct diagnosis.
It has been fascinating to watch the discovery of HIV/acquired immunodeficiency syndrome (AIDS) and the evolution of diagnosis and treatment since the inception of the epidemic in 1981. In 1981, I was practicing in a small town in Michigan’s Upper Peninsula, and I did not see a patient with HIV infection in my office until 1990. In 2014, with an estimated prevalence of 1.1 million HIV cases in the United States,1 family physicians are likely to come into contact with several patients with HIV every year. Practicing on Chicago’s south side in 2008, I diagnosed 2 teenagers with HIV. It was a heartbreaking reality.
The discovery of highly active antiretroviral therapy (HAART) has transformed HIV/AIDS from an acute, infectious specialty disease to a chronic primary care disease. Although the annual incidence of HIV in the United States has dropped precipitously from its peak of 130,000 in the 1980s to about 50,000 in 2010,1 the prevalence continues to rise as more people with HIV infection are living for many years. People with HIV who receive proper care do have a shortened life span, but not by many years, and they are highly likely to show up in our offices for treatment of not only chronic illnesses that accompany HIV but also common diseases such as hypertension, diabetes, and coronary artery disease. More and more patients with HIV are being managed in primary care settings, with infectious disease specialists acting as consultants.
Universal screening for HIV is recommended and becoming the norm, and the stigma for testing appears to be decreasing. The burdensome informed consent process has been streamlined in many states, making screening seem routine to patients. Family physicians must do their part to help control the HIV epidemic by screening, properly diagnosing new cases of HIV, and providing chronic disease and preventive care. To that end, I encourage you to read “HIV screening: How we can do better,” by Editorial Board member Jeffrey T. Kirchner, DO, FAAFP, AAHIVS.
REFERENCE
1. Centers for Disease Control and Prevention (CDC). Today's HIV/AIDS epidemic. CDC Web site. Available at: http://www.cdc.gov/nchhstp/newsroom/docs/hivfactsheets/todaysepidemic-508.pdf. Accessed June 23, 2014.
REFERENCE
1. Centers for Disease Control and Prevention (CDC). Today's HIV/AIDS epidemic. CDC Web site. Available at: http://www.cdc.gov/nchhstp/newsroom/docs/hivfactsheets/todaysepidemic-508.pdf. Accessed June 23, 2014.
Impending stroke chalked up to carpal tunnel syndrome
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
Impending stroke chalked up to carpal tunnel syndrome
A WOMAN WENT TO HER PHYSICIAN COMPLAINING OF DIZZINESS, blurred vision, numbness, tingling in her hands and feet, and other symptoms. The physician diagnosed carpal tunnel syndrome. The patient visited her physician a second time, and a day later, suffered a stroke and died.
PLAINTIFF The patient specifically asked her physician if she was having a stroke and her physician told her No.
THE DEFENSE No information about the defense is available.
VERDICT $907,486 Kansas verdict.
COMMENT Certainly carpal tunnel syndrome is not sufficient to explain all of this patient’s symptoms—especially dizziness and blurred vision—but the details on this case are limited. If the patient did in fact express concern about a possible stroke, it was incumbent upon the physician to evaluate carefully and either diagnose that condition or rule it out.
Rather than coming too late, Rx for methadone came too soon
A 34-YEAR-OLD MAN ADDICTED TO OXYCODONE AND OTHER PAIN MEDICATIONS as the result of a work-related injury 10 years earlier sought treatment for his addiction from a family physician (FP) while visiting Kentucky. The patient also was abusing alprazolam. The FP administered a drug test but prescribed methadone, 180 10-mg pills, before receiving the results. The next day, the drug screen returned positive for multiple drugs, including opiates and cannabinoids. The FP’s staff tried to reach the patient, but was unsuccessful. The patient was found dead a few hours later after overdosing on a combination of methadone and alprazolam. Although 64 methadone pills were missing, the patient could not have taken all of them because only a therapeutic level of methadone was found in his system.
PLAINTIFF’S CLAIM The physician should have waited to receive the results of the drug screen before prescribing methadone. Drug Enforcement Administration guidelines allow prescription of methadone for addiction only if a patient is in withdrawal and in the process of being admitted to a treatment facility. There was no proof of withdrawal symptoms.
THE DEFENSE The treatment was reasonable and compassionate. The patient was at fault for abusing narcotics.
VERDICT $204,500 Kentucky verdict.
Could a proper history have spared this patient multiple surgeries?
A 13-YEAR-OLD CAME TO THE EMERGENCY DEPARTMENT (ED) with left knee pain and fever. He was diagnosed with a quadriceps strain and discharged. The next morning the patient still had knee pain and sought treatment from an FP, who diagnosed a sprained knee. At this visit, the patient’s temperature was normal. Three days later, the patient went to another ED with a high fever and knee pain so severe that he couldn’t walk. Blood culture revealed methicillin-resistant Staphylococcus aureus (MRSA) in the knee, which quickly spread. The patient was hospitalized and required 17 surgeries.
PLAINTIFF’S CLAIM The FP should have ordered blood work and recognized the signs of infection. MRSA had been present at least 4 days before it was diagnosed.
THE DEFENSE The patient did not have a diagnosable infection the day the physician saw him and his condition had progressed over the following 3 days.
VERDICT $2.1 million Illinois verdict.
COMMENT This case reminds me of the necessity of obtaining a history of the mechanism of injury for joint pain. Absence of a definite cause should have led to a wider differential diagnosis.
The times they are a-changin’
“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”
These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.
Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.1 Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.2 After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.
This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).3 Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.
For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.
“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”
These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.
Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.1 Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.2 After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.
This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).3 Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.
For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.
“... you better start swimmin’ or you’ll sink like a stone, for the times they are a-changin’.”
These song lyrics, written by Bob Dylan in 1963, could have been written to describe US health care in 2014. In this issue, Randy Wexler, MD and colleagues summarize many of the changes that are creating upheaval and opportunity for family physicians. The 2010 Patient Protection and Affordable Care Act (ACA) has been a disruptive innovation in many ways, and like it or not, it appears there is no way to turn back the clock. The ACA was only the beginning of change at the federal level, followed rapidly by mandates many of us love to hate.
Family medicine, however, was a decade ahead of the health care reform curve. Family physician leaders met in 2000 at the Keystone III conference and declared that the health care system was due for a makeover.1 Findings of the Future of Family Medicine 1.0 initiative were published in 2004, making a number of important recommendations for family physicians to survive and thrive.2 After 10 years, the American Academy of Family Physicians has launched the Future of Family Medicine 2.0 initiative to reexamine the roles and opportunities for family physicians in the evolving health care system.
This has not been an easy journey. Some of you have written to me about your struggles and your belief that health care in the United States is moving in the wrong direction. But many industrious and innovative family physicians are meeting the challenge by implementing new models, including the patient-centered medical home model and the direct primary care model (no insurance company invading the doctor-patient relationship).3 Go to the Patient-Centered Primary Care Collaborative Web site (www.pcpcc.org) to read success stories for inspiration.
For the sake of our patients and the US health care system, I hope there are enough of you out there leading the way toward systems that deliver high-quality service, better health outcomes, and lower cost. Write and tell us about the changes you are making to have a positive impact on health care in your community.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.
1. Green LA, Graham R, Stephens G, et al. Keystone III: The Role of Family Medicine in a Changing Health Care Environment: A Dialogue. Washington, DC: The Robert Graham Center; 2001.
2. Martin JC, Avant RF, Bowman MA, et al; Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 suppl 1:S3-S32.
3. Direct Primary Care Coalition Web site. Available at: http://www.dpcare.org. Accessed May 19, 2014.
40 years of helping family physicians refine their care
The Journal of Family Practice and I have grown up together. JFP turns 40 this year, and I complete my 40th year as a physician next year. JFP was the brainchild of family physician John Geyman, MD, who established the journal in response to the need for original family medicine research.
Reviewing the articles published in the first issue, I find many of the topics are just as important today as they were 40 years ago: “The family as our patient,” “The future of family practice in our medical schools,” and “An integrated system for the recording and retrieval of medical data in a primary care setting."
Preserved in JFP’s archives are the seminal works of many academic family medicine pioneers, including Maurice Woods, Jack Froom, Hiram Curry, Gayle Stephens, and Eugene Farley, and many studies of the Ambulatory Sentinel Practice Network, the forerunner of the American Academy of Family Physicians’ National Research Network. One of the most important landmark studies for family medicine, the Virginia Study, was published in JFP in 1976.1,2 It summarized more than half a million medical problems seen by family physicians caring for 88,000 patients in Virginia over 2 years.1,2 It remains the largest US database of family medicine encounters reported by family physicians.
JFP continues to publish original research, along with summaries of the scientific literature and evidence-based answers to common clinical questions. The National Library of Medicine has cataloged the journal’s rich history that, as of March 2014, includes more than 8300 articles.
One of the biggest leaps in JFP’s evolution has been the increased diversity of offerings on the journal’s Web site, jfponline.com. The Web site includes a multimedia library of audiocasts and how-to videos, online-exclusive articles, quizzes, sponsored continuing medical education (and non-CME) content, career opportunity listings, and of course, an archive of the journal’s articles.
JFP remains a top, evidence-based family medicine journal that benefits from the expertise and insights of its editorial board, extensive cadre of peer reviewers, and authors from across the country—and around the world. We remain committed to meeting the needs of you, the busy family physician. And this month, in recognition of our 40th anniversary, we present the winners of our writing contest. (See “The patient who changed the way I practice family medicine.”)
We hope you enjoy this anniversary issue of JFP and we look forward to serving you in the years to come.
1. Marsland DW, Wood M, Mayo F. Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. J Fam Pract. 1976;3:37-68.
2. Marsland DW, Wood M, Mayo F. A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract. 1976;3:25-28.
The Journal of Family Practice and I have grown up together. JFP turns 40 this year, and I complete my 40th year as a physician next year. JFP was the brainchild of family physician John Geyman, MD, who established the journal in response to the need for original family medicine research.
Reviewing the articles published in the first issue, I find many of the topics are just as important today as they were 40 years ago: “The family as our patient,” “The future of family practice in our medical schools,” and “An integrated system for the recording and retrieval of medical data in a primary care setting."
Preserved in JFP’s archives are the seminal works of many academic family medicine pioneers, including Maurice Woods, Jack Froom, Hiram Curry, Gayle Stephens, and Eugene Farley, and many studies of the Ambulatory Sentinel Practice Network, the forerunner of the American Academy of Family Physicians’ National Research Network. One of the most important landmark studies for family medicine, the Virginia Study, was published in JFP in 1976.1,2 It summarized more than half a million medical problems seen by family physicians caring for 88,000 patients in Virginia over 2 years.1,2 It remains the largest US database of family medicine encounters reported by family physicians.
JFP continues to publish original research, along with summaries of the scientific literature and evidence-based answers to common clinical questions. The National Library of Medicine has cataloged the journal’s rich history that, as of March 2014, includes more than 8300 articles.
One of the biggest leaps in JFP’s evolution has been the increased diversity of offerings on the journal’s Web site, jfponline.com. The Web site includes a multimedia library of audiocasts and how-to videos, online-exclusive articles, quizzes, sponsored continuing medical education (and non-CME) content, career opportunity listings, and of course, an archive of the journal’s articles.
JFP remains a top, evidence-based family medicine journal that benefits from the expertise and insights of its editorial board, extensive cadre of peer reviewers, and authors from across the country—and around the world. We remain committed to meeting the needs of you, the busy family physician. And this month, in recognition of our 40th anniversary, we present the winners of our writing contest. (See “The patient who changed the way I practice family medicine.”)
We hope you enjoy this anniversary issue of JFP and we look forward to serving you in the years to come.
The Journal of Family Practice and I have grown up together. JFP turns 40 this year, and I complete my 40th year as a physician next year. JFP was the brainchild of family physician John Geyman, MD, who established the journal in response to the need for original family medicine research.
Reviewing the articles published in the first issue, I find many of the topics are just as important today as they were 40 years ago: “The family as our patient,” “The future of family practice in our medical schools,” and “An integrated system for the recording and retrieval of medical data in a primary care setting."
Preserved in JFP’s archives are the seminal works of many academic family medicine pioneers, including Maurice Woods, Jack Froom, Hiram Curry, Gayle Stephens, and Eugene Farley, and many studies of the Ambulatory Sentinel Practice Network, the forerunner of the American Academy of Family Physicians’ National Research Network. One of the most important landmark studies for family medicine, the Virginia Study, was published in JFP in 1976.1,2 It summarized more than half a million medical problems seen by family physicians caring for 88,000 patients in Virginia over 2 years.1,2 It remains the largest US database of family medicine encounters reported by family physicians.
JFP continues to publish original research, along with summaries of the scientific literature and evidence-based answers to common clinical questions. The National Library of Medicine has cataloged the journal’s rich history that, as of March 2014, includes more than 8300 articles.
One of the biggest leaps in JFP’s evolution has been the increased diversity of offerings on the journal’s Web site, jfponline.com. The Web site includes a multimedia library of audiocasts and how-to videos, online-exclusive articles, quizzes, sponsored continuing medical education (and non-CME) content, career opportunity listings, and of course, an archive of the journal’s articles.
JFP remains a top, evidence-based family medicine journal that benefits from the expertise and insights of its editorial board, extensive cadre of peer reviewers, and authors from across the country—and around the world. We remain committed to meeting the needs of you, the busy family physician. And this month, in recognition of our 40th anniversary, we present the winners of our writing contest. (See “The patient who changed the way I practice family medicine.”)
We hope you enjoy this anniversary issue of JFP and we look forward to serving you in the years to come.
1. Marsland DW, Wood M, Mayo F. Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. J Fam Pract. 1976;3:37-68.
2. Marsland DW, Wood M, Mayo F. A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract. 1976;3:25-28.
1. Marsland DW, Wood M, Mayo F. Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. J Fam Pract. 1976;3:37-68.
2. Marsland DW, Wood M, Mayo F. A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract. 1976;3:25-28.
When in doubt about lab tests …
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
Last week I saw a 35-year-old man for follow-up on a positive rapid plasma reagin (RPR). He thought he had syphilis, but he had never had any syphilis symptoms, so I suspected the RPR was a false positive. Because I seldom encounter this situation, it was time for some “point of care” research. I checked an online reference and found that the fluorescent treponemal antibody absorption (FTA-ABS) test is highly sensitive and would be sufficient to rule out syphilis. The good news: His subsequent FTA-ABS was negative. But the situation left me wondering why the FTA-ABS had not been done automatically after the positive RPR.
The question, “What is the best test to rule in or rule out X?” comes up frequently for family physicians (FPs), and sometimes we are uncertain about ordering the best test and interpreting the results correctly. According to a recent national survey sponsored by the Centers for Disease Control and Prevention1—for which I was privileged to be the principal investigator—1768 FPs and general internists reported ordering diagnostic laboratory tests for an average of 31.4% of their patients per week. They were uncertain about the right test to order for 14.7% of these patients and uncertain about interpreting the results for 8.3%. That might not seem like a lot, but with more than 500 million primary care patient visits per year in the United States, this potentially affects 23 million patients each year.
We asked about problems with test ordering, too. I don’t think you will be surprised that physicians reported insurance company restrictions and costs to patients were the main barriers. They also reported difficulty with the variety of names for the same tests, which I certainly noticed when I moved from Cleveland Clinic to University of Illinois at Chicago. Not getting test results in a timely manner was a big problem, too, as was confusing report formats. In our electronic medical record, 90% of the lab report details things I don’t need to know and to get to the 10% I do need, I have to scroll or click.
In this issue, Tessier et al illustrate ways to avoid common lab testing pitfalls. I would argue that in addition to helpful articles like this one, we also need better electronic tools to help guide us when uncertain. Then again, the phone is still good technology; when in doubt, pick it up and call your lab.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
REFERENCE
1. Hickner J, Thompson PJ, Wilkinson T, et al. Primary care physicians’ challenges in ordering clinical laboratory tests and interpreting results. J Am Board Fam Med. 2014;27:268-274.
4 reasons to be optimistic about family medicine
I just returned from the Association of Departments of Family Medicine Winter meeting in San Diego. Despite the tight financial times many departments are experiencing, an air of optimism permeated the meeting. One Chair commented, “I don’t know about you, but this is the most exciting time I have ever had in my 35 years as a family physician.”
You may be asking yourself how he could say this when FPs are struggling to keep up with conversions to electronic medical records, “meaningful” use, the specter of the ICD-10 implementation, and other increasing government and insurance company requirements. Because I share his excitement, I’ll give you my 4 reasons for optimism in our specialty.
1. Family medicine has been discovered. We no longer take a back seat in the health care system. In fact, one Chair said, “It is our turn to drive the bus.” Insurers, large health care organizations, and our patients expect us to drive health care out of its current state of confusion and bloated costs into local and regional integrated systems that improve care and decrease costs. Dr. Chelley Alexander, Family Medicine Department Chair, University of Alabama College of Community Health Sciences in Tuscaloosa, led a terrific project in his state that engaged community health workers, social workers, primary care physicians, and hospitals in a collaboration targeting high-utilization patients. The project dramatically reduced hospital admissions and ED visits and improved patients' health care outcomes. This is one of many projects around the country led by FPs that have improved health care and decreased costs.
2. We have an opportunity to fill the gaps in physician manpower as general internists become hospitalists and specialists become subspecialists. For this reason, it is crucial for FPs to train and maintain skills in a broad scope of practice.
3. Applications to family medicine residencies are increasing1 and the candidates are strong. This recruitment season, I had the opportunity to interview applicants to our program at the University of Illinois at Chicago. Judging by the quality of the candidates, I am not sure I would have been successful in landing a spot!
4. FPs are in demand in the marketplace. Just look at the want ads for FPs in the various family medicine journals, including this one. Take your pick in an area of the country and look at the rising starting salaries.
To be sure, life is not easy as a family doc; but it never has been. We are FPs because the rewards outweigh the hassles (on most days). The health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.
1. Family medicine match rate increases slightly again in 2013. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/news-now/education-professional-development/20130315matchresults.html. Accessed February 18, 2014.
I just returned from the Association of Departments of Family Medicine Winter meeting in San Diego. Despite the tight financial times many departments are experiencing, an air of optimism permeated the meeting. One Chair commented, “I don’t know about you, but this is the most exciting time I have ever had in my 35 years as a family physician.”
You may be asking yourself how he could say this when FPs are struggling to keep up with conversions to electronic medical records, “meaningful” use, the specter of the ICD-10 implementation, and other increasing government and insurance company requirements. Because I share his excitement, I’ll give you my 4 reasons for optimism in our specialty.
1. Family medicine has been discovered. We no longer take a back seat in the health care system. In fact, one Chair said, “It is our turn to drive the bus.” Insurers, large health care organizations, and our patients expect us to drive health care out of its current state of confusion and bloated costs into local and regional integrated systems that improve care and decrease costs. Dr. Chelley Alexander, Family Medicine Department Chair, University of Alabama College of Community Health Sciences in Tuscaloosa, led a terrific project in his state that engaged community health workers, social workers, primary care physicians, and hospitals in a collaboration targeting high-utilization patients. The project dramatically reduced hospital admissions and ED visits and improved patients' health care outcomes. This is one of many projects around the country led by FPs that have improved health care and decreased costs.
2. We have an opportunity to fill the gaps in physician manpower as general internists become hospitalists and specialists become subspecialists. For this reason, it is crucial for FPs to train and maintain skills in a broad scope of practice.
3. Applications to family medicine residencies are increasing1 and the candidates are strong. This recruitment season, I had the opportunity to interview applicants to our program at the University of Illinois at Chicago. Judging by the quality of the candidates, I am not sure I would have been successful in landing a spot!
4. FPs are in demand in the marketplace. Just look at the want ads for FPs in the various family medicine journals, including this one. Take your pick in an area of the country and look at the rising starting salaries.
To be sure, life is not easy as a family doc; but it never has been. We are FPs because the rewards outweigh the hassles (on most days). The health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.
I just returned from the Association of Departments of Family Medicine Winter meeting in San Diego. Despite the tight financial times many departments are experiencing, an air of optimism permeated the meeting. One Chair commented, “I don’t know about you, but this is the most exciting time I have ever had in my 35 years as a family physician.”
You may be asking yourself how he could say this when FPs are struggling to keep up with conversions to electronic medical records, “meaningful” use, the specter of the ICD-10 implementation, and other increasing government and insurance company requirements. Because I share his excitement, I’ll give you my 4 reasons for optimism in our specialty.
1. Family medicine has been discovered. We no longer take a back seat in the health care system. In fact, one Chair said, “It is our turn to drive the bus.” Insurers, large health care organizations, and our patients expect us to drive health care out of its current state of confusion and bloated costs into local and regional integrated systems that improve care and decrease costs. Dr. Chelley Alexander, Family Medicine Department Chair, University of Alabama College of Community Health Sciences in Tuscaloosa, led a terrific project in his state that engaged community health workers, social workers, primary care physicians, and hospitals in a collaboration targeting high-utilization patients. The project dramatically reduced hospital admissions and ED visits and improved patients' health care outcomes. This is one of many projects around the country led by FPs that have improved health care and decreased costs.
2. We have an opportunity to fill the gaps in physician manpower as general internists become hospitalists and specialists become subspecialists. For this reason, it is crucial for FPs to train and maintain skills in a broad scope of practice.
3. Applications to family medicine residencies are increasing1 and the candidates are strong. This recruitment season, I had the opportunity to interview applicants to our program at the University of Illinois at Chicago. Judging by the quality of the candidates, I am not sure I would have been successful in landing a spot!
4. FPs are in demand in the marketplace. Just look at the want ads for FPs in the various family medicine journals, including this one. Take your pick in an area of the country and look at the rising starting salaries.
To be sure, life is not easy as a family doc; but it never has been. We are FPs because the rewards outweigh the hassles (on most days). The health care system and our patients want more of us, and now we are seeing signs that the system is willing to pay more for us, too.
1. Family medicine match rate increases slightly again in 2013. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/news-now/education-professional-development/20130315matchresults.html. Accessed February 18, 2014.
1. Family medicine match rate increases slightly again in 2013. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/news-now/education-professional-development/20130315matchresults.html. Accessed February 18, 2014.
New CVD guidelines put focus in the right place
There is a lot for primary care physicians to digest in the new hypertension and lipid treatment guidelines.1,2 And there is one very important thing that we can be happy about: the guidelines focus on POEM (patient-oriented evidence that matters) outcomes—reducing the risk of stroke, heart attack, congestive heart failure, and renal failure—rather than treating the numbers.
In this month’s audiocast on jfponline.com, Dr. Campos-Outcalt summarizes the new hypertension guideline. The Eighth Joint National Committee (JNC8), led by family physician Paul James, focuses on 3 important clinical questions: At what blood pressure should treatment begin? What is the treatment target? and What drugs should be used? The new guideline relies heavily on randomized trials and less on expert opinion than the prior JNC7 guideline. This new guideline simplifies management decisions to 2 treatment targets: <150/90 for patients 60 and older and <140/90 for everyone else. Lower targets for patients with diabetes and chronic kidney disease have been eliminated, based on a lack of evidence that tighter control leads to better outcomes.
Relaxing the systolic goal from 140 mm Hg to 150 mm Hg for patients 60 and older is a welcome and sensible change. I regret over-treating one of my elderly hypertensive patients who became hypotensive during a bout of diarrhea, fell, and fractured her hip. Permission to use 150/90 as a target for patients over age 60 is likely to save other senior citizens from hip fractures.
The new lipid guideline, which Dr. Campos-Outcalt reviews on page 89, has received mixed reviews due to the use of a new, unproven risk calculator and a somewhat arbitrary decision to use a 10-year cardiovascular event risk of 7.5% as the treatment threshold. The big plus of this new guideline, however, is the elimination of treatment targets, a concept that never has had strong scientific evidence. Deciding who to treat is more difficult, but follow-up is simplified—no more lipid-level monitoring.
I believe the strength of these new approaches is that they are firmly grounded in high-quality evidence from clinical trials and they are patient centered. Patients and physicians are encouraged to discuss the risks and benefits and make personalized, informed decisions about treatment choices. This gives doctors permission to more aggressively treat those who are most likely to benefit and to back off on aggressive treatment for those least likely to benefit.
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 18 Dec 2013. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 7 Nov 2013. [Epub ahead of print].
There is a lot for primary care physicians to digest in the new hypertension and lipid treatment guidelines.1,2 And there is one very important thing that we can be happy about: the guidelines focus on POEM (patient-oriented evidence that matters) outcomes—reducing the risk of stroke, heart attack, congestive heart failure, and renal failure—rather than treating the numbers.
In this month’s audiocast on jfponline.com, Dr. Campos-Outcalt summarizes the new hypertension guideline. The Eighth Joint National Committee (JNC8), led by family physician Paul James, focuses on 3 important clinical questions: At what blood pressure should treatment begin? What is the treatment target? and What drugs should be used? The new guideline relies heavily on randomized trials and less on expert opinion than the prior JNC7 guideline. This new guideline simplifies management decisions to 2 treatment targets: <150/90 for patients 60 and older and <140/90 for everyone else. Lower targets for patients with diabetes and chronic kidney disease have been eliminated, based on a lack of evidence that tighter control leads to better outcomes.
Relaxing the systolic goal from 140 mm Hg to 150 mm Hg for patients 60 and older is a welcome and sensible change. I regret over-treating one of my elderly hypertensive patients who became hypotensive during a bout of diarrhea, fell, and fractured her hip. Permission to use 150/90 as a target for patients over age 60 is likely to save other senior citizens from hip fractures.
The new lipid guideline, which Dr. Campos-Outcalt reviews on page 89, has received mixed reviews due to the use of a new, unproven risk calculator and a somewhat arbitrary decision to use a 10-year cardiovascular event risk of 7.5% as the treatment threshold. The big plus of this new guideline, however, is the elimination of treatment targets, a concept that never has had strong scientific evidence. Deciding who to treat is more difficult, but follow-up is simplified—no more lipid-level monitoring.
I believe the strength of these new approaches is that they are firmly grounded in high-quality evidence from clinical trials and they are patient centered. Patients and physicians are encouraged to discuss the risks and benefits and make personalized, informed decisions about treatment choices. This gives doctors permission to more aggressively treat those who are most likely to benefit and to back off on aggressive treatment for those least likely to benefit.
There is a lot for primary care physicians to digest in the new hypertension and lipid treatment guidelines.1,2 And there is one very important thing that we can be happy about: the guidelines focus on POEM (patient-oriented evidence that matters) outcomes—reducing the risk of stroke, heart attack, congestive heart failure, and renal failure—rather than treating the numbers.
In this month’s audiocast on jfponline.com, Dr. Campos-Outcalt summarizes the new hypertension guideline. The Eighth Joint National Committee (JNC8), led by family physician Paul James, focuses on 3 important clinical questions: At what blood pressure should treatment begin? What is the treatment target? and What drugs should be used? The new guideline relies heavily on randomized trials and less on expert opinion than the prior JNC7 guideline. This new guideline simplifies management decisions to 2 treatment targets: <150/90 for patients 60 and older and <140/90 for everyone else. Lower targets for patients with diabetes and chronic kidney disease have been eliminated, based on a lack of evidence that tighter control leads to better outcomes.
Relaxing the systolic goal from 140 mm Hg to 150 mm Hg for patients 60 and older is a welcome and sensible change. I regret over-treating one of my elderly hypertensive patients who became hypotensive during a bout of diarrhea, fell, and fractured her hip. Permission to use 150/90 as a target for patients over age 60 is likely to save other senior citizens from hip fractures.
The new lipid guideline, which Dr. Campos-Outcalt reviews on page 89, has received mixed reviews due to the use of a new, unproven risk calculator and a somewhat arbitrary decision to use a 10-year cardiovascular event risk of 7.5% as the treatment threshold. The big plus of this new guideline, however, is the elimination of treatment targets, a concept that never has had strong scientific evidence. Deciding who to treat is more difficult, but follow-up is simplified—no more lipid-level monitoring.
I believe the strength of these new approaches is that they are firmly grounded in high-quality evidence from clinical trials and they are patient centered. Patients and physicians are encouraged to discuss the risks and benefits and make personalized, informed decisions about treatment choices. This gives doctors permission to more aggressively treat those who are most likely to benefit and to back off on aggressive treatment for those least likely to benefit.
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 18 Dec 2013. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 7 Nov 2013. [Epub ahead of print].
1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 18 Dec 2013. [Epub ahead of print].
2. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 7 Nov 2013. [Epub ahead of print].
Vasovagal syncope, or something far worse?
Vasovagal syncope, or something far worse?
A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.
The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.
The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.
PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.
THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.
VERDICT $1.6 million Wisconsin verdict.
COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.
Failure to take full sexual history has devastating consequences
A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.
PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.
THE DEFENSE No information about the defense is available.
VERDICT $5.2 million Illinois verdict.
COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.
Vasovagal syncope, or something far worse?
A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.
The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.
The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.
PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.
THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.
VERDICT $1.6 million Wisconsin verdict.
COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.
Failure to take full sexual history has devastating consequences
A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.
PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.
THE DEFENSE No information about the defense is available.
VERDICT $5.2 million Illinois verdict.
COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.
Vasovagal syncope, or something far worse?
A 48-YEAR-OLD WOMAN with a history of syncopal events was brought to the emergency department (ED) by her daughter, following an episode in which the mother lost consciousness and vomited while driving. (The daughter was able to get the car safely to the shoulder of the road.) The episode occurred after the woman had eaten, and followed a week in which she’d experienced several episodes in which her left arm and chin briefly went numb. In fact, she experienced another chin/arm numbing episode while in the ED. The ED physician gave her a diagnosis of vasovagal syncope, instructed her to follow up with her primary care physician, and included “rule out transient ischemic attack (TIA)” on the discharge note.
The primary care physician subsequently established a differential diagnosis of “vasovagal vs hypoglycemia vs both or neurocardiogenic syncope” and referred the patient to an electrophysiologist, who concluded that she’d had a vasovagal syncope episode triggered by a gastrointestinal cause.
The patient continued to have arm/chin numbness but was unconcerned because her physicians didn’t seem worried. Months later, she sought treatment for low back pain, for which her primary care physician prescribed celecoxib; her numbness was not discussed with her physician. The next day, she suffered a stroke from an occluded right carotid artery. She had hemiparesis with little to no movement of her left shoulder, elbow, hand, hip, and ankle.
PLAINTIFF’S CLAIM The numbness and fainting were TIAs and an ultrasound should have been performed, which would have revealed the carotid artery occlusion and helped avoid the stroke.
THE DEFENSE The events the plaintiff experienced were not TIAs and there was no way to show whether, or to what degree, the carotid artery was occluded before the stroke. The plaintiff should have reported the continuing symptoms. Given that the patient had a long history of syncopal events—and a history of smoking—the diagnosis was reasonable.
VERDICT $1.6 million Wisconsin verdict.
COMMENT I think the lesson here is that physicians need to take focal neurological findings seriously and continue the evaluation until one has a reasonably certain diagnosis. The cause of this patient’s recurrent arm and chin numbness should have been pursued.
Failure to take full sexual history has devastating consequences
A MAN WITH A HISTORY OF ABNORMAL BLOOD TEST RESULTS sought treatment in the emergency department for extreme leg pain. He was given a diagnosis of sepsis and renal failure. A positive human immunodeficiency virus (HIV) test led to a diagnosis of acquired immunodeficiency syndrome (AIDS). The patient had been seeing his primary care physician for 10 years, but the doctor never asked about his sexual history. The patient survived, but suffers from AIDS-related kidney disease and must undergo peritoneal dialysis for the rest of his life.
PLAINTIFF’S CLAIM The physician should have tested for HIV much sooner to prevent the loss of kidney function. The physician’s questions were not specific enough to obtain proper information on whether the patient was having unprotected sex, if he had multiple partners, and what gender his partners were.
THE DEFENSE No information about the defense is available.
VERDICT $5.2 million Illinois verdict.
COMMENT I’m not sure the jury got this one right. Nonetheless, the Centers for Disease Control and Prevention now recommends HIV screening for all adults so it is worthwhile to offer it to all patients and to document refusal if a patient doesn’t want to be tested.
Lung cancer found belatedly despite multiple chest radiographs
Lung cancer found belatedly despite multiple chest radiographs
DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.
PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible.
THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.
VERDICT $2 million Virginia verdict.
COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.
Otitis media? Not likely
A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.
PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.
THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.
VERDICT $1.72 million Pennsylvania verdict.
COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.
Lung cancer found belatedly despite multiple chest radiographs
DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.
PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible.
THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.
VERDICT $2 million Virginia verdict.
COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.
Otitis media? Not likely
A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.
PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.
THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.
VERDICT $1.72 million Pennsylvania verdict.
COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.
Lung cancer found belatedly despite multiple chest radiographs
DURING AN ANNUAL PHYSICAL EXAMINATION by her primary care physician, a 68-year-old woman with a history of smoking for more than 30 years had an in-house chest x-ray. The physician didn’t have a radiologist read the radiograph or order follow-up imaging. The chest film was repeated the following year. A year after that, the patient developed pulmonary symptoms. A chest x-ray showed an abnormality. The doctor prescribed antibiotics for presumed bronchitis or pneumonia. When the antibiotics didn’t relieve her symptoms, he referred her to a radiologist, who reported a large lesion suggestive of advanced lung cancer. Subsequent films confirmed stage IIIB lung cancer. After 16 rounds of chemotherapy, the patient died at age 73.
PLAINTIFF'S CLAIM The doctor missed an obvious lung lesion on the first radiograph; missed the lesion, which had grown and metastasized, on the second x-ray; and misinterpreted late-stage metastatic cancer on the third radiograph as bronchitis or pneumonia. The chest radiographs should have been over-read, especially when they showed an abnormality. A cancer diagnosis at the time of the first chest radiograph would have allowed a 75% possibility of cure with surgery alone. By the time of the diagnosis 2 years later, a surgical cure wasn’t possible.
THE DEFENSE The lesion could be seen only on retrospective review of the radiographs. The first and second radiographs were consistent with pulmonary hypertension and didn’t necessitate referral to a radiologist or additional imaging. The patient had many comorbid conditions, including obesity, hypertension, and stenosis of the carotid arteries. She also had a family history of heart disease and COPD.
VERDICT $2 million Virginia verdict.
COMMENT This case illustrates that a simple test, a chest x-ray in this instance, has the potential for litigation if it isn’t interpreted accurately and followed up. Failure to appropriately follow up on test results is one of the 2 major patient safety issues for family medicine; the other is medication errors/drug interactions.
Otitis media? Not likely
A 3-MONTH-OLD INFANT was taken to the emergency department with a fever of 103°F. The ED physician discharged her with a diagnosis of otitis media and a prescription for amoxicillin. He didn’t document which ear was infected or what he observed in the affected ear. The following day, the infant was pale, cool to the touch, and lethargic. She was brought to her pediatrician, then transferred immediately to a local medical center, where she was diagnosed with pneumococcal meningitis, hypoxic brain injury, and hydrocephalus and hospitalized for nearly a month. She was subsequently taken to the hospital 10 times and evaluated by several specialists. The child died of respiratory complications linked to the infection almost 2 years after her initial hospitalization.
PLAINTIFF'S CLAIM The ED physician should have ordered a blood count and urinalysis to rule out bacteremia and meningitis. He should have scheduled a follow-up within 24 to 48 hours of the ED visit.
THE DEFENSE The doctor wasn’t negligent; he couldn’t have anticipated the infant’s clinical course. The bacteremia and meningitis developed after the baby left the hospital, and the causative pneumococcal strain was resistant to amoxicillin.
VERDICT $1.72 million Pennsylvania verdict.
COMMENT Does otitis media ever cause a fever of 103°F in a 3-month-old? Although no definitive studies exist, I doubt it. Otitis media is a closed-space infection like an abscess, and abscesses rarely cause fever. Furthermore, the physical findings of otitis media, although not recorded in this case, are highly unreliable in a 3-month-old. Attributing a fever of 103°F in a 3-month-old to otitis media is always a bad idea.