by Jerry Meyers on July 23, 2010
Kevin Pho M.D. has written that a screening test incidentaloma can make healthy people ill. This is a theme that appears too frequently in the medical literature. When I previously addressed this issue in a prior Blog it did not then occur to me that the argument might be used to impair patients receiving recommended screening.
Medicine constantly searches for safer more specific screening tests to permit early diagnosis of treatable, but otherwise deadly diseases. Before a new strategy is introduced generally or prescribed in the care of a particular patient, considerable thought has been given to the sensitivity and specificity and cost of the method. Complications associated with a particular method are considered. Complications associated with such follow-up as may be employed in the pursuit of false positives is very much a part of the process. A nodule appearing on an imaging study doesn’t automatically require a biopsy or invasive form of follow-up. The distinction between findings that require follow-up and the particular kind of follow-up required is a matter of ongoing study, and it should be.
Earlier I addressed the idiocy of ignoring unexpected findings made on a diagnostic study. A chest x-ray is performed because pneumonia is suspected. The film when interpreted by the radiologist reveals a mass. Should one ignore the mass since that is not what was expected. The same logic could be employed to ignore a mass seen on a CT scan of the brain performed because of a recent head trauma. What is common to this point of view is the assumption that a physician’s initial assessment represents the universe of possibilities.
We once believed the earth was flat. Knowledge is acquired when we put aside assumptions that stand in the way of recognizing what is real.
What do you think?
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by Jerry Meyers on June 3, 2010
ANEMONA HARTOCOLLIS in a recent New York Times article describes outrageous behavior by the clinical director and medical director of Harlem medical center. Under the direction of these former hospital officers (they have since been fired and demoted, respectively) the cardiology department of the Medical Center permitted 4,000 echocardiograms performed on patients suffering from suspected cardiac problems to be read only by technicians. The tests supposed to be read by cardiologists were not submitted to any doctor for review. An investigation conducted by physicians from another medical center suggests hundreds of these patients may have suffered serious harm as a consequence of inadequately skilled technicians reviewing these tests instead of cardiologists. In an apparent cost cutting move, Harlem Medical Center had allowed their staff of cardiologists to be reduced. The cardiologists claimed the back log of echocardiograms requiring physician review accumulated at the rate of 2500 per year. The Harlem Medical Center cardiologists’ cries for additional staff went unheeded. Harlem Medical Center continues to deny that any patient suffered harm.
Certainly patients who trusted the Harlem Medical Center have been betrayed. Can anyone believe that similar problems are not occurring with some frequency elsewhere? The only real oversight is limited help that medical malpractice lawyers can provide victims after the fact. And yet trial lawyers are besieged in the Legislature of most states and by members of the Congress who are blind and deaf to the pleas of victims to not restrict the only tool available to most victims to uncover the truth and seek justice.
What do you think?
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by Jerry Meyers on April 30, 2010
Doctors knowingly fail to cooperate to make medicine safe because they would then be required to practice safe medicine, and be held accountable if they fail.
In the recent issue of Obstetrics and Gynecology,[1] Drs. Strunk and Queenan in their advocacy for an administrative compensation plan to replace the tort system in providing compensation for adverse medical outcomes, liken the performance of a physician to that of a professional golfer or bowler. Since a professional golfer does not always shoot par, and a professional bowler will not always have a perfect score, the authors reason similarly doctors should not be expected to have perfect results.
“To Err is Human”. But the fact that all humans are in some circumstance or at some points subject to err, does not mean that they should not be held liable for negligence. The authors claim without any offer of proof that the most important reason for adopting an administrative compensation model for adverse medical outcomes is that somehow such a system would improve patient safety and the quality of care. They also claim that there is such fear of litigation that it somehow impedes the investigation and analysis of adverse medical outcomes. A remarkable claim suggesting doctors are so self-absorbed they knowingly fail to cooperate in efforts to make the health system better because they assume cooperation will reveal that they agree something is unsafe and such agreement might have personal consequences. Certainly, if doctors were so affected by their egos, making them unaccountable for error would not convert them to patient centered saints.
There is and can be no evidence that litigation interferes with root cause analysis. What most interferes with analyzing how needless harms have occurred is the unwillingness of doctors or other healthcare providers to admit they have done something wrong. If a person has been careless and has hurt another that is wrong.
There was a time in this country when there was little litigation and there certainly were no malpractice suits available when there were doctors who continued to treat people with leaches long after their better informed brethren recognized the absurdity of such a practice.
The tort system particularly in Pennsylvania provides effective investigative tools, which in the hands of competent lawyers enable injured patients to determine with a reasonable degree of confidence whether an injury was avoidable or not.
Physicians object to the litigation system as they object to any system in which their conduct can be criticized. One need only examine the existing peer review mechanism and how they operate within hospital systems when no litigation has been threatened.
A Bogie occurs because a person trying as hard as they can is unable to complete a hole in the prescribed number of strokes. It does not occur because of negligence. It occurs because of a lack of required skill. If a golfer were to choose a putter to drive from the tee on a five par course, that would be negligence but only the golfer’s reputation would be at stake, not the life and welfare of a newborn. A bogie is not a matter of life or death.
[1] “Beyond Negligence,” Obstetrics and Gynecology, Volume 115, No.5, May 2010, page 896
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by Jerry Meyers on March 9, 2010
The March 8th New York Times publishes a remarkably insightful opinion piece by Atul Gawande. Gawande reminds us of a lesson learned long ago in a completely different professional context.
In 1935 the U.S. Army Air Corps held a flight competition for airplane manufacturers competing for the privilege of building the next generation long-range bomber. Boeing seemed, to those in the know, to be the obvious winner. It could carry five times as many bombs as the army had requested, it was fast and could travel almost twice as far as the existing equipment.
The competition was a disaster for Boeing. Moments after takeoff the plane crashed killing the pilot and two of the five crew members. After investigation it was clear that pilot error was the cause of the incident. The pilot was required to attend to four engines, retractable landing gear, wing flaps, trim tabs and propellers for each engine whose pitch had to be regulated with hydraulic controls. The pilot attending to all of these matters at the same time omitted to release a locking mechanism on the elevator and rudder controls. The contract went to Douglas Aircraft and Boeing faced financial ruin.
Fortunately, the army purchased a few of the Boeing aircraft as test planes. A group of test pilots came up with a brilliant and elegantly simple solution. They created a checklist which if followed would assure that each matter that needed to be attended would be attended to at the time and in the order necessary to assure that the pilot would not be confronted with having to recall all of the various interactions since the simplest omission could be fatal. These same pilots flew Boeing’s entry nearly 2,000,000 miles without a single accident. The army ordered 13,000 of the aircraft which became known as the B-17. This famous aircraft contributed to our victory in World War II.
The same lesson learned by the pilots who helped make the B-17 a safe aircraft have been resurrected sixty years later in an attempt to address preventable medical errors. Just as the original pilot who crashed the then experimental B-17 was overwhelmed by the many routine but essential things that needed to be done and done in a particular order, similarly physicians today face the same problem. Physicians are virtually assaulted by such a mass of information and important facts must not be overlooked, especially when to overlook a matter would be ruinous to a patient’s life.
Peter Pronovost, a critical care physician at John’s Hopkins Hospital was among the first, if not the first to give it a try. In 2001 he created a checklist designed to tackle just one recurring problem in medicine: line infections. He plotted the course one should take in order to avoid infections when putting in a venous or arterial line. 1. Wash hands with soap. 2. Clean patient’s skin with appropriate antiseptic. 3. Put sterile drapes over the entire patient. 4. Wear a sterile mask, cap, gown and gloves. 5. Put a sterile dressing over the catheter site once the line is in.
Note that these steps had nothing to do with attempting to articulate the surgical skills needed to safely place the line. Indeed, these steps have been known and taught for years. However, Pronovost had nurses in his ICU observe doctors for one month putting lines into the patients. In more than one-third of the patients the nurses observed that physicians omitted at least one step.
Pronovost was able in one year to reduce the ten-day line infection rate from 11% to 0.
What Pronovost observed is certainly a reality that we all confront. Mundane matters are easily overlooked especially in the middle of a medical emergency. Since Pronovost’s original work, other institutions have attempted similar undertakings.
Forward thinkers like Pronovost and others who followed, unfortunately are whispering in the midst of a storm. Gawande called Pronovost recently and reports a certain pessimism. According to Gawande, Pronovost told him, “At the current rate, it will never happen. The fundamental problem with the quality of American medicine is we fail to view the delivery of healthcare as a science. Once we acquire an understanding of the disease and find effective therapies for that disease, there seems little attention to assuring that the therapies are effectively delivered.”
We must not allow “The Art of Medicine” to be used as an excuse for individuality which is not a matter of informed choice but instead forgetful omission.
See related article concerning the Surgical check list
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by Jerry Meyers on February 9, 2010
Online Journal watch is a publication which surveys medical newly published medical literature and comments on various relevant medical issues. One of the January’s postings reported upon a study of patients being evaluated by cardiac CT scan. The study addressed, among other things, the value of utilizing information made available by reason of the study having been performed, though such information was not the reason for the scan being done.
The editors of Journal Watch published my remarks under the title captioning this post. For my remarks see Journal Watch .
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by Jerry Meyers on February 2, 2010
Natasha Singer, in her recent New York’s Times opinion piece suggests that saying you’re sorry is difficult in the health care industry. Indeed, her article addresses the pharmaceutical industry as well. It is interesting that this issue requires any discussion. We all learned as children the importance of apology in making right a harm resulting from our wrongful conduct. Moreover, that there might be adverse consequences associated with admitting wrongdoing was to be expected and was not ever deemed a justification for remaining silent.
It is remarkable that silence as a substitute for apology has become a standard of conduct for healthcare providers. They argue that if they apply to this that someone might try to hold them accountable for their conduct. In other words unlike what their parents told them as children, healthcare providers, who once knew that apology was the ethical and proper thing to do have come to believe that silence and obfuscation represent the ethical thing to do.
Remarkably, as pointed out by Singer, those medical centers such as the University of Michigan health Center have discovered honest apology makes they are victims feel good and reduces malpractice claims. The Michigan experience has been duplicated elsewhere. Honesty is not only the right thing to do but also represents a sound business practice.
One has to look elsewhere for the origin of the “conspiracy of silence” than fear of consequence. Arrogance is a better explanation.
What do you think?
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by Jerry Meyers on January 4, 2010
January 1, 2010 Journal Watch summarizes a remarkable article entitled “Investigation of incidental findings on cardiac CT.” The article was based on a study conducted at a Canadian institution where the investigators evaluated the incidence, clinical importance, and costs of these incidental findings.
It’s first important to note that these researchers used the word incidental as equivalent to the word, occult. In medical imaging, an occult finding is an unexpected finding that has clinical consequence. Such findings are made with great frequency and have dramatically improved the lives of many. For example, a chest x-ray searching for a rib fracture reveals a lung cancer mass which was otherwise completely unexpected. A CT scan of the abdomen performed because of a complaint abdominal pain reveals a dissection of the thoracic aorta.
The Canadian researchers are strangely troubled by the discovery of unexpected conditions. The test they are evaluating is cardiac CT. Imaging data obtained during a cardiac CT includes imaging information of structures or tissues outside the heart. in an examination of 966 consecutive patients who underwent cardiac CT during 12 months at a single Canadian institution, incidental findings were noted in 401 patients. 12 of the patients were found to have clinically significant conditions, many of them, life-threatening without treatment.
Even if one accepts the very conservative assessment that only 12 of the patients were found to have clinically significant conditions, that means that 3% of everyone who had a cardiac CT performed had a condition that might have seriously harmed or killed them if it had not been accidentally seen in this study.
The researchers do not see the benefit derived by the 3% as a bonus. They don’t question that all the patients benefited from having a cardiac CT. In fact, no one questions that this method of scanning provides an important and noninvasive method of evaluating patients suffering coronary calcification and arterial disease. However, 68 patients exhibited incidental findings such as nodules or cysts in the lungs or liver. There’s the rub.
Confronted with 68 patients of the 401 who had abnormalities deemed to be indeterminate (undetermined significance) researchers worry that the abnormalities found might lead some to conduct further testing or evaluation. The solution, as they see it, is to not format the data concerning non-cardiac tissue and structures. They want to ask patients to consent to keeping the non-cardiac information invisible. If they see no “evil”, they need speak no “evil.”
I think this is insanity. What do you think?
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by Jerry Meyers on December 2, 2009
For a comprehensive review of literature dispelling the myth that there is a big difference between high risk and low risk patients and screening for cervical cancer please read NUNS, VIRGINS, AND SPINSTERS’. RIGONI-STERN AND CERVICAL CANCER REVISITED, MALCOLM GRIFFITHS.
Put simply, over a long period of time a concept often explained and often repeated, acquires an authoritative stature it may not deserve . The concept’s very foundation may be faulty but the “test of time” is no test if, in all the retellings, the foundation is never reexamined.
In his article, Griffiths examines the much quoted proposition that low risk women do not require rigorous screening for cervical cancer. Who is at lower risk than a nun? It turns out this is a trick question because the risk of developing cervical cancer is about the same for a nun as an unmarried women and about half that of married women.
In the debate surrounding screening for cancer advocates of opposing positions tend to pick and believe evidence which agrres with therir respective positions. This is a debate in which women cannot afford to be driven by bias. They deserve the truth, their lives depend upon it.
For further information on cervical cancer and the importance of proper cancer screening see Meyersmedmal.com
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by Jerry Meyers on November 20, 2009
According to the American Cancer Society’s most recent estimate for 2009, 11,270 new cases of invasive cervical cancer will be diagnosed and 4,070 women will die from the disease.
Prior to 1955 cervical cancer was one of the most common causes of cancer death for American women. As a result of the development of the Pap smear screening test between 1955 and 1992, the cervical cancer death rate declined by 74%.
Since half of the cervical cancer cases arise in patients who have never had a Pap smear or whose last Pap smear preceded diagnosis of invasive cancer by more than five years, the problem is not that too many Pap smears are being done but that not enough Pap smears are being done.
Nevertheless, the guidelines for screening of Pap smears have resulted in fewer Pap smears being done. For a test that is misinterpreted when it shows abnormalities between 20 and 40% of the time, frequent repetition of the test is needed to assure one appropriate interpretation. Even when an appropriate interpretation of Pap smears is made and abnormalities are found which require treatment, the appropriate treatment is not given 10% of the time.
For a test associated with little cost, and which is essentially risk free, the pressure to limit the performance of even this test is clearly present.
Matthew Mintz, M.D. writes at KevinMD.com medical web blog on November 17, 2009, “Why Doctors are Doing So Many Unnecessary Pap Smears.” In his opinion piece, Dr. Mintz asserts that the Pap smear is a symbol of our healthcare system’s problems, yet the only evidence he quotes in support of this proposition is a study from the Annuals of Internal Medicine which demonstrates doctors are doing more frequent Pap smears on women than some guidelines recommend.
The fact that more Pap smears are being done does not mean that they are needless and they certainly are not harmful.
When even well-informed physicians can reach such wrong-headed conclusions it is not surprising that it is so difficult to fix the healthcare system.
Where is the alarm about the high rate at which Pap smears are wrongly interpreted as negative when in fact they show ominous changes?
Not all screening tests have been as successful as the Pap smear. The fact that we could have for example better screening tests for breast cancer than a mammogram does not negate the importance of women having an option to have a mammogram. We should be searching for better screening tests improving the performance of existing texts and not failing to screen with the tests available simply because the tests are imperfect.
With such controversy swirling about healthcare reform it is difficult to hear the truth in the midst of all the noise that is being made. Staying well informed and being skeptical is the safest approach to receiving appropriate medical care.
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by Jerry Meyers on November 20, 2009
November 16, 2009 the Washington Post reports new screening guideline issued by the U.S. Preventative Services Task Force now recommending against women receiving routine screening with mammograms for breast cancer prior to age 50.
Petitti, Chairman of the Task Force, asserts that the new recommendation will result in “just” 0.7 deaths for every thousand women who now will not be screened. His justification for this remarkable statement is that allowing these 0.7 women per thousand to die will prevent many from suffering the anxiety of a false-positive result. He goes on to say that 33 more women per thousand would be spared unnecessary biopsies. I wonder how many women would be willing to take a 3.5% risk of an unnecessary biopsy to avoid a .7 in 1000 chance of dying.
It is incredible that this Task Force apparently values a women’s life so cheaply.
I guess 0.7 deaths are hard to give a name. Perhaps they should have put it differently. For every 1,429 women who now will probably not be screened, one woman will die.
What do you think?
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