Medical Malpractice News and Views


Welcome to our blog where we discuss current issues in medicine and law. We welcome your comments.

Developments in Type 1 Diabetes.

October 03, 2022

Nine years in and counting.  It has been nine years since my then 3 year old grandson was diagnosed with Type 1 diabetes.  At the time of his diagnosis, I assured his anxious parents that relief was on the horizon.  Medical science was working feverishly to find both a cure for Type 1 diabetes and mechanical treatments that would more closely replicate the natural processes of the pancreas and keep blood sugars in a normal range.  While medical science continues to work feverishly on these two fronts, a really good solution seems still to be just out of reach.

What is diabetes? | CDC

Success in treating Type 1 diabetes is a holy grail for many companies and researchers.  There are an estimated 2 million people living with Type 1 diabetes in the United States today.  Approximately 200,000 of them are under 20.  The incidence of Type 1 diabetes is increasing for reasons that are not entirely clear.  It is estimated that by 2050 there will be 5 million people living with Type 1 in the United States.  Selling insulin to these people is already a huge money maker for Big Pharma.  Developing a cure would bring untold riches to the successful companies.  Developing an insulin pump which can effectively replicate the function of the cells that produce insulin and regulate blood sugar levels would also be a huge money maker.

Type 1 diabetes is an autoimmune disease.  For some unknown reason, the body’s immune system decides that the cells which produce insulin are a foreign invader and attacks them.  Insulin is a hormone that is essential to the body’s ability to use glucose to produce the energy the body needs in order to operate.  When enough insulin producing cells are destroyed, the body does not have enough insulin to survive.  Sugars in the blood reach out of control levels and, if insulin is not provided from the outside, the patient dies.  A little over 100 years ago, there was no outside source of insulin.  A little over 100 years ago my grandson would be dead by now.

There are two somewhat competing avenues of research for the treatment of diabetes.  The first is biological and seeks to restore the ability of the body to make insulin.  This avenue faces substantial obstacles created by the very process that caused the diabetes in the first place.  Any new insulin creating islet cells transplanted into the patient will be attacked by the immune system as were the original cells.  At present, islet cells are taken from a donor pancreas but there are not enough donors to supply everyone.  Anyone receiving such a transplant must take immunosuppressants for the rest of their life to protect the transplanted cells and immunosuppressants present problems of their own.  In spite of the use of immunosuppressants, the average life of an islet cell transplant is about two years.

Researchers are experimenting with novel ways to obtain islet cells for transplant and to protect them from destruction by the immune system.  Notwithstanding their best efforts, they appear to be quite a ways away from the time when a successful therapy can be rolled out to the public.

The second avenue of research and treatment is more advanced.  It is mechanical in nature.  It seeks to create what has been called “the artificial pancreas.”  The FDA has approved and companies already sell insulin pumps, which automatically deliver small amounts of insulin over the course of the day.  There are also sensors on the market that measure blood sugar and report it directly to the pump.  At present, the FDA has been unwilling to approve a pump that can take the data from the sensor and, using an algorithm, determine on its own how much insulin to deliver and when.  The greatest concern is that the pump might malfunction and deliver too much insulin, which causes a condition called hypoglycemia, or low blood sugar.  If blood sugar drops too low the patient becomes unconscious and can die.

The other failing of today’s pumps is that, unlike the human body, they can only deliver insulin.  In a non-diabetic, the body senses blood sugars and delivers insulin as blood sugar rises.  If blood sugar drops too low, the body will release stores of glucose to maintain appropriate levels.  The ability to sense the need for and to deliver glucose is a great defense against dangerous hypoglycemia.  Today’s pumps do not deliver glucose and will not in the foreseeable future, although some talented programmers have hacked insulin pumps to allow them to independently regulate blood sugar levels using both insulin and glucagon.

There is constant progress in the research and development of a cure and in the creation of an “artificial pancreas.”  In fact, the Wall Street Journal recently reported on a new pump being given fast track status by the FDA.  The pump does not need to be told how much insulin to deliver but makes the decision on its own and monitors the blood sugar levels.  That device may be approved in the next year or two.

If you, like me, have a loved one with Type 1 diabetes, you will continue to watch the developments and hope for significant breakthroughs.

 

Posted in drug companies, health, Medical Costs, Medical Devices, Type 1 Diabetes |

Thanks to Health Insurance Health Care Is Getting Worse.

September 26, 2022

In the United States, we already pay more than any other developed nation for health care, but have poorer outcomes in major categories of care, such as infant mortality, life expectancy, obesity levels and rate of suicide, just to name a few.  Of course, there is one significant difference between us and the rest of the developed world; we are the only ones without universal health care.  This has two important consequences, which will continue to plague us and which will likely lead to a continuing decline in our quality of care.  First, many of our citizens do not have access to health care, until they are desperately ill and hospitals are required by law to accept and treat them.  Second, health insurance companies take a huge chunk out of our health care spending as their cost of doing business and profit; money that could be better spent providing care.

Daring Women Doctors: Physicians in the 19th Century | PBS

If you have health insurance and think that the plight of the uninsured is no concern of yours, you are sadly mistaken.  Adults and children without health care cost society a lot of money.  Preventable illnesses or medical conditions may keep lower wage workers off the job and injure productivity or put them on government-paid disability.  Preventable illnesses may keep children out of school or they may go to school and infect other children.  As noted above, when people get sick enough, hospitals must accept them as patients and treat them until their medical emergency is over.  Someone must pay for that treatment and it is not likely to be the uninsured patient.  The cost of their care is added to your hospital bill and mine.  Since we are going to pay for it anyway, we should be looking for ways to keep people healthy as it will cost us the least in the long run.

The profit motive does not belong in health care and yet it is front and center.  Under our health insurance system, doctors treat patients and then send bills to the insurance company.  Each treatment and condition must be coded for billing purposes.  Doctors offices employ teams of people, not to treat patients, but to handle coding, send bills, and resolve billing disputes with the health insurers.  The bureaucratic paperwork necessary to run our health system takes up billions of dollars each year, even before the health insurers take their profit.

The health insurance companies are in business to make money and, according to Wall Street, they are very good at it.  One of the ways they make money is by controlling the care doctors provide their insured patients.  If the health insurer does not think the treatment was medically necessary, it refuses to pay.  If it thinks the doctor spent too much time with the patient, it refuses to pay.  If it thinks that the treatment was not covered by the mish mash of provisions in its insurance policy, it refuses to pay.  Doctors should not be forced to make treatment decisions based on whether the health insurance company is going to agree that the patient needed that care.  Doctors should not be forced to deny or limit needed care for fear of not being paid.

The corrosive effects of our health insurance system are all around us and getting worse.  Doctors spend less and less time with patients because health insurers limit the amount they pay for an office visit.  Everyone in medicine knows that listening to the patient is the best way to figure out what is going on.  It is the very foundation of diagnosis.  If the doctor has no time to listen to the patient, misdiagnosis, the most common form of medical malpractice, is more likely to occur.  Patients do not receive the treatment they need when the doctor cannot take time to listen to the patient.

Another key to good care is the quality of the physician/patient relationship.  The more trust the patient has in the doctor the better.  The better the doctor knows the patient and her medical history, the better care the doctor can deliver.  Health insurance cares nothing for the physician/patient relationship.  If your employer or you change your health insurance company, you can probably say goodbye to your doctor as you will be forced to use a doctor in the new insurance company’s plan and your doctor may not be among those on the list.  If you choose to remain with your doctor, you can count on paying extra for out of network treatment.

The corrosion raises ethical questions for doctors.  Faced with the risk of underpayment or no payment, the doctor is tempted to fudge the coding in billings to increase the chances the insurance company will pay for a treatment the patient needs but for which the insurer would not pay, if it knew the true story.  Forcing doctors into this ethical dilemma is bad for the doctors and for their patients.

As long as our health insurance system remains in its present form, health care is going to deteriorate.  Costs will go up.  Co-pays and deductibles will increase.  Doctors will be squeezed more and more.

Our health insurance system is virtually immune from meaningful change or regulation.  The problem is national in scope and requires a national solution.  We have a Senate in which nothing gets done without 60 votes.  Health insurers are veterans of the lobbying wars.  They have lots of money and know how to spend it to make sure they have the votes to prevent any threats to their profits.  You might as well get used to health care that gets worse each year while at the same time costing more each year.

 

 

 

Posted in Doctors, Fee for Service, health, Health Care Costs, Health Insurers, Hospitals, Medical Costs, medical ethics, Misdiagnosis |

Some Doctor Reviews Are Fake.

September 19, 2022

Studies show that consumers search for and rely on reviews for nearly everything, including medical care.  We are all looking for that 5 star product or service.  Couple this with a thriving black market in fake reviews and you have a real problem.  Many sellers believe that it is a matter of life and death for them to have positive reviews and are willing to pay someone to provide them.  Doctors are not immune to these temptations.

Amazon Reviews: Thousands are fake, here's how to spot them

The problem of fake reviews of doctors, hospitals and other medical care providers is not new but it is getting worse.  There is ever greater pressure to have good reviews in order to drive patients to your practice or hospital.  Your competitors are posting 5 star reviews.  Can you afford to be left behind?  What if your patients don’t feel comfortable leaving reviews?  What if you can’t persuade enough of them to give you good ratings?  What if some of them give you an undeserved bad rating?  The solution many doctors have turned to is the service that sells fake 5 star reviews.

It is hard to tell just how many fake reviews are out there but everything suggests there are a lot of them.  The sites where these reviews appear have algorithms that look for signs of a fake review and either remove it or downplay it.  At the same time, the sellers of the fake reviews are learning how to make their reviews seem more authentic and to avoid being identified by the algorithms.  It is a constant game of cat and mouse and the consumer is caught in the middle.

It is not just fake 5 star reviews that are a problem.  There are also services out there that, for a price, will scrub the internet of any negative reviews.  So even if a doctor’s reviews are all legitimate and from real patients, if the negative ones are scrubbed, the doctor may look a lot better than she or he deserves to look.

So what happens when a doctor or hospital buys fake reviews?  Generally, nothing happens.  You can look long and hard and not find examples of doctors being disciplined for buying fake reviews.   You would think this type of dishonesty would bring medical board discipline but you would be wrong, at least based on the lack of action by the boards.

In some ways this is poetic justice.  Why are we relying on internet reviews when selecting a doctor or hospital in the first place?  Many doctors argue, and with good reason, that patients are not in a good position to evaluate medical care.  For many patients, a good outcome must mean that the doctor did a good job.  Conversely, for many patients, a bad outcome means poor medical care, even if the outcome was beyond the ability of the doctor to control.  Another example of the lack of reliability of patient doctor reviews is that patients rated doctors who freely prescribed opiates more highly than those who were more careful about prescribing these highly addictive medicines.

A similar problem exists in patient ratings for hospitals.  Medicare keeps track of many quality measures, such as hospital readmissions, infections, complications, cleanliness, deaths and so forth.  However, it appears that consumers are much more likely to look for and be swayed by on line patient reviews than by Medicare’s more reliable tracking.  To top it off, studies have shown that the single most important factor in patient hospital ratings is the quality of the food.  It is pretty foolish of us to value hospital food higher than the quality of the health care.  If you want good food, go to a nice restaurant.  If you want good hospital care, go to a hospital that scores well on Medicare’s quality standards.

There are some important lessons to learn from all this.  First and foremost, don’t rely on patient ratings of doctors or hospitals.  They may be fake but, even if they are real, they may not be reliable indicators of the quality of care you can expect to receive.  Second, go to trusted sources such as Medicare.gov and your state medical board.  Check the hospital’s rating with Medicare and check the doctor’s education, training and discipline history with the medical board.  You can’t guarantee a good outcome, even if you follow these steps, but you can give yourself the best chance to receive good medical care.

 

 

Posted in Arizona Medical Board, Doctors, Hospitals, medical ethics, Medicare |

The Private Autopsy.

September 12, 2022

Sadly, I see a lot of death cases.  Prospective clients come to me with questions about the death of a loved one.  Why did she die?  What happened to her?  Most often they want to know if her death was the result of a medical mistake.  One of the first questions I must ask is whether there was an autopsy or not.  If the answer is that there was not, there is usually nothing I can do to help that person or to answer their questions.

Autopsy - Wikipedia

Medicine is complicated.  Even in a young, previously healthy person who dies unexpectedly, there may be a lot of things going on with that finely tuned organism we call the human body that make it hard to determine exactly what went wrong and why the patient died.  As we age, the number of health issues increases.  It is rare for a person in their seventies not to have some chronic health problems.  These health issues may further cloud the question of what happened and why the patient died.

Even when the cause of death is obvious, the question of whether the death was the result of medical error may be very unclear.  While there is a great deal of debate over exactly how many hospital deaths in this country each year are the result of an avoidable medical mistake, there is no question that it is a large number.  I have seen some respected sources place the number around 250,000 annually while another places it at over 400,000.  These are staggering numbers.  If you are waiting for the hospital or the doctors to tell you that your loved one died due to an avoidable medical mistake, you will have a long wait.

In order to bring a successful medical malpractice death claim, the plaintiff must prove by a preponderance of the evidence (that is, a greater than 50% likelihood) that there was an avoidable medical error and that, had the error not occurred, the patient would have survived.  There are many hurdles to overcome in doing this.

The first hurdle is the medical record.  Under the best of circumstances, medical records do not tell the whole story.  There is no way to record every conversation, observation or thought.  There will always be gaps and questions.  Of course, the best of circumstances are not always present.  The medical records are prepared by the doctors and nurses who provided care for the patient.  Sometimes they are prepared at the time of the care and before anyone realizes that there is something wrong.  Even though incomplete, these records are likely to be accurate.  At other times, however, the chart entries are prepared after things have gone to hell.  These records can be suspect as there is a natural tendency for the doctors and nurses to make entries that excuse their conduct or cover it over.  When a patient dies of an avoidable medical error, it is highly unlikely the chart will even hint that may have been the case much less say so.

Another hurdle arises out of the complexity of medical care and human illness.  There may be a lot of room for legitimate disagreement about what happened and why.  There may have been tests that could have shed light on the issues but were not ordered.  There may be equivocal or contradictory test results or observations.

This is where the autopsy comes in.  A patient’s family cannot rely on the record, even if it strongly supports their claim about the cause of death.  The doctors and nurses making the chart entries may claim that they made a mistake about the cause of death or may say they now have more information and a different opinion.  They may simply be uncooperative with the family when the time comes to testify.

Even if an autopsy is performed by the hospital, the family’s needs may not be met.  The family needs a doctor who is willing to call them as she or he sees them concerning the cause of death and to cooperate with them, should they decide to bring a wrongful death claim.  A pathologist hired by the hospital may not fill the bill.  A pathologist who performs a private autopsy will be that doctor.

The important thing to remember is the element of time.  If an autopsy is to be performed, it must be conducted soon after the death by a qualified medical examiner who knows what to do.  This is a difficult time for families but, if there are questions, they must be recognized and the autopsy arranged promptly before the opportunity is lost.

Posted in Autopsy, disclosure of medical mistakes, Doctors, electronic medical records, Hospital Negligence, Hospitals, Lawsuits, medical charts, medical errors, medical ethics, Medical Malpractice, medical malpractice claims, medical malpractice lawsuits, medical mistakes, Medical Negligence, Nurses, plaintiff, Secrecy |

Read, Read, Read.

September 05, 2022

If you have a mobile device or have been on line for almost any reason, you have surely been confronted with a lengthy statement outlining the terms of your use of the whatever-it-is.  In order to use the whatever-it-is, you have to agree to accept those terms.  If you are like countless other Americans, you don’t read the text.  You just scroll down to the “Accept” box, click it and move on.  I am not here today to debate the wisdom of those decisions.  What I want to talk about today is the trend in many doctor or hospital waiting rooms of asking you to give up some of your right to the privacy of your medical records.

Health Data Privacy: Updating HIPAA to match today's technology challenges  - Science in the News

Under the HIPAA law, the privacy of your medical records and health information is protected against disclosure.  You, however, have the right to waive those protections and to disclose as much of your health information as you wish.  If you wish to tell others about your health, that is certainly your business.  What you don’t want to do, however, is to accidentally agree to waive your privacy rights.  That is happening in some doctor’s offices and hospital waiting rooms.

When we go to check in with the doctor or at the hospital waiting room, we are almost always given forms to fill out.  Some of them ask for information about our health and insurance status.  Others are forms describing billing practices, and information sharing practices.  We are asked to sign these forms and show our agreement to be bound by them.  Do you know what you are signing?  Do you know to what you are agreeing?

Some information sharing is necessary to support billing insurance companies for the services being rendered.  Some may be necessary to coordinate care among various providers.  These practices need to be disclosed by the provider you are seeing and approved by you.  What you need to be on the lookout for is an agreement to allow your data to be shared with people or companies that do not need it for the provider to do her or his job.

More and more often, doctors and hospitals are accepting money or other consideration from outside companies in return for the privilege of asking your permission to sell your data or to target you with advertisements for drugs or other services.  These outside companies note what medical conditions you have and choose advertisements that they think might get you to ask for a prescription for their medications or might get you to purchase products they make for your condition.  These outside companies cannot sell your data or send you advertisements like that without your permission.  They get that permission by including it in the jumble of forms you get when you check in.  They may be paper forms or they may be screens on an electronic device.  If you don’t read what you are given, you may have become a chump, who just gave up his privacy rights.

Unlike most of the permissions you give when you are using a device or are on line, you can say “No” to this one and still receive your medical treatment.  The privacy of your medical information is a big deal.  Once your information is out there, you never know how it may be used.  It may be used in a manner that affects your ability to get a job or to buy insurance or it may end up on line where everyone can see it.

The only way to protect yourself from this loss of privacy is to read what you are given.  Don’t be a compliant sheep who just assumes that all of this is routine and not worth spending the time to read what you are given.  Read, read, read and when you are sure you are not waiving your privacy rights, you can sign.  You can also decline, if you are being asked to give up your rights.  Either way, take a moment to protect yourself.  No one else is going to do it for you.

 

Posted in Doctors, drug companies, electronic medical records, health, Hospitals, medical ethics |

Some Medicare Advantage Plans Are Taking Us For A Ride

August 29, 2022

In 2003, Congress made a major change to Medicare.  In the hopes of reducing costs through privatization, it created what are called Medicare Advantage plans.  The idea was that private companies would be paid a fixed amount to provide Medicare beneficiaries with the health care for which Medicare would normally pay.  The amount the plan would be paid would depend upon a number of factors, including the cost of medical services in the area where the beneficiary lived and risk factors relating to the beneficiary himself or herself.  If the plan could deliver those services for less money that it received from Medicare, it made a profit.  The benefit for Medicare was that its costs for that patient were fixed.  Even if the patient needed thousands of dollars worth of unexpected care, Medicare was off the hook; the advantage plan paid for it all.

Medicare Advantage Riding High As New Insurers Flock To Sell To Seniors | Kaiser Health News

As anyone who has watched even a few minutes of television can attest, Medicare Advantage plans are in hot competition to persuade seniors to sign up with them.  As an enticement, some offer services Medicare does not, such as vision and dental coverage.  Some even offer to pay eligible beneficiaries a monthly amount to sign up.  In return for these extra benefits, the Advantage plans limit the options seniors enjoy under traditional Medicare.  I wrote about some of these limitations here.  Here is an excellent piece from Medicare about how much it costs to enroll in a Medicare Advantage plan and how the plans charge for various services as well as how they control costs.

Medicare Advantage plans have been very successful in persuading beneficiaries to sign up with them.  They have doubled their enrollment over the last ten years.  In 2021, there were 26 million enrollees (42% of all Medicare beneficiaries), who accounted for $343 billion, or 46%, of all Medicare spending.  You will note that, while only 42% are enrolled in plans, the plans cost Medicare 46% of its payouts.  That 4% difference amounts to almost $30 billion in 2021.

In my earlier blog post, I was not critical of the plans themselves.  It appears I was a bit hasty in my assessment that the plans were overall a good thing.  It appears some plans have been taking advantage of both Medicare and their customers.

As I noted above, one of the factors which goes into determining the amount of money Medicare pays to an Advantage plan is how sick is the beneficiary.  Each beneficiary’s health is converted to a risk score, which is used to set the amount of payment from Medicare to the plan.  Basically, the sicker the patient, the higher the amount Medicare pays to the plan to provide health care to that patient.

The plans are taking a disproportionate amount of money from Medicare by claiming that their patients are sicker than the average patient.  In some cases, this may be true but in others, the plans are misrepresenting the health of their customers.

Over and over again, Medicare has found what it believes to be aggressive attempts by Advantage plans to bill excessively on the grounds that their enrollees are very sick.  These excessive billing cases are difficult to prove because they involve the health of many, many individual patients and it would require a detailed analysis of each patient’s records to show misrepresentations and even then Medicare would have to prove intent to defraud.

It is not just small, fly-by-night companies that are involved in overbilling Medicare.  Recently, Medicare settled with a large plan in Northern California.  Medicare alleged that the plan had added fake diagnoses to the medical records of its patients.  The allegations against the plan were based upon information from a whistleblower, who had been employed by the plan to cull patient records looking for stray information that could be used to justify a claim that the patient was very sick.  Most of the fake diagnoses were of cancer or stroke or a fracture.  The plan, which did not admit guilt, nonetheless paid the federal government $90 million.

These fake diagnoses not only hurt our national treasury by siphoning off billions that could and should go to actual patient care, they also hurt the patients whose health records now show them as having serious illnesses that they don’t really have.  This will affect them when they seek life insurance or some other forms of insurance.  It can affect them, if they are injured in an accident and their health status becomes an issue.  It can affect them in their employment as many seniors continue to work after reaching the age of Medicare eligibility.

The point, of course, is that wherever there is money, greedy people will look for ways to help themselves to some of it.  Privatization is not a silver bullet that will always save us money.  Many times it is the private interests brought in to save the government money, who end up stealing from it.

 

Posted in Fee for Service, Fraud, General Health, Health Care Costs, Health Insurers, medical charts, Medical Costs, Medicare, Secrecy |

New Hope For Pancreatic Cancer Patients

August 22, 2022

Pancreatic cancer is one of the most deadly forms of cancer afflicting human beings.  85% of patients diagnosed with pancreatic cancer will live less than five years following their diagnosis.  Looking at it another way, although only 3% of all human cancers are pancreatic cancer, it accounts for 7% of all cancer deaths.  It is a bad cancer.  The lethality of pancreatic cancer is at least in part due to the fact that it is rarely discovered before it has grown and metastasized, that is, spread to other parts of the body.  Now, at last, there may be some good news on the horizon for pancreatic cancer patients.

Will a test to detect early pancreatic cancer ever be possible?

In a case report published in the prestigious New England Journal of Medicine, doctors report on the successful treatment of a woman with advanced pancreatic cancer, whose cancer had resisted all other forms of treatment.  In the new treatment, which the doctors involved called a “proof of concept” treatment, some of the patient’s own T cells were harvested.  T cells are white cells that are part of the human immune system.  They attack and destroy bacteria, viruses and any other foreign invaders identified by the immune system.  Unfortunately, pancreatic cancer cells are able to hide their “otherness’ from the immune system and therefore able to go about their nasty business without interference.

Oncologists and other cancer researchers have known for years that some cancers, including pancreatic cancer, have unique protein fragments on the outside of their cells.  These fragments are not found on normal cells.  Unfortunately, the fragments are not enough to catch the attention of the immune system.  For years, researchers have been trying to find ways to use the presence of these unique fragments to target cancer cells.

In the experimental treatment reported in the NEJM, the doctors used the latest techniques of gene therapy to modify the T cells they took from the patient.  They were able to train the T cells to recognize the protein fragments.  They then released the genetically modified T cells back into the patient’s body, where they attacked the pancreatic cancer cells.  The metastatic tumor cells that had invaded her lungs began to shrink to the point that it appears they are now dead.  Surgery, radiation and chemotherapy, which preceded the T cell treatment, had “cured” the cancer in her pancreas.

The beauty of the experimental treatment is that the T cells only attack cancer cells with the protein fragments.  Normal cells and tissue are left alone.  There are essentially no side effects.  This is in stark contrast to chemotherapy in which strong poisons are administered to the patient in an effort to kill the cancer cells without killing the patient.  As anyone who has undergone chemotherapy knows, its side effects are substantial and debilitating.

This therapy is an example of therapies that are targeted to the specifics of a particular patient.  Here, the patient’s own immune system was essentially trained to attack the pancreatic cancer cells.  These same T cells, if introduced into the body of another patient, might not have the same effect and would probably even be attacked by the new patient’s immune system, which would recognize them as invaders.

According to the NEJM report, this same experimental therapy was tried on another pancreatic cancer patient but was unsuccessful in saving her life.  The treating doctors are not sure why the treatment was successful in one patient but not the other.  They do note, however, that not all patients with pancreatic cancer have cells with the protein fragments on the outside and that is a possible explanation for the failure with the second patient.

There is a long way to go before this type of gene therapy becomes standard treatment for pancreatic cancer but the case reported shows that it can work and that a deadly cancer can be defeated.  There are a number of other cancers that carry the same protein fragments on the outside of their cells.  They are also candidates for treatment with this type of gene therapy.  Keep your fingers crossed.

Posted in Cancer, Doctors, health, Lung Cancer, Medical Costs, medical research, science news |

Medication Errors Are Easy To Make.

August 15, 2022

A few months ago I wrote about the Tennessee nurse who was criminally prosecuted for administering the wrong medication to a patient.  The medication resulted in the patient’s death and the nurse was convicted of negligent homicide.  One of the defenses offered by the nurse was that the mistake she made was in part the result of the hospital’s use of a computerized medication dispensing machine.  There had already been a number of problems with the device.  The nurse claimed that the hospital had not corrected the problems and that the dispensing machine contributed to the death.

Covid: Pfizer says antiviral pill 89% effective in high-risk cases - BBC  News

The computerized dispensing machines pretty much all work the same way.  The nurse types in the first couple of letters of the name of the medication she is searching for and the machine offers her a list of medications that begin with those letters.  The nurse clicks on the medication she wants and the cabinet delivers it to her.

In the Tennessee case, the nurse was to have administered Versed to the patient.  Versed is a mild sedative that was intended to calm the patient before the imaging procedure she was about to undergo.  The nurse typed in VE and the list generated by the dispensing machine included Vercuronium as well as Versed.  In her haste, the nurse clicked on Vercuronium, a powerful paralytic drug, and administered that to the patient instead of Versed.  The Vercuronium paralyzed the patient and stopped her breathing, but only after the nurse had gone on to care for another patient.  By the time someone came to take the patient to her imaging procedure, it was too late to save her.

Safety advocates say the machines should require more than two or three letters be entered before the computer generates a list of drugs from which the nurse can choose.  One machine in common use only requires one letter be entered before it generates a list of choices. Had the machine in Tennessee required at least four letters, it would not have offered Vercuronium as one of the choices for the nurse and this tragedy would have been avoided.

One of the largest manufacturers of computerized dispensing devices has created a software fix, which requires the nurse to type in five letters before a list will be generated.  It did this a couple of years ago but left it up to the hospital customer whether to apply the software fix to existing machines or not.  Many hospitals did not.  The manufacturer has announced that the fix will be installed in all its new machines beginning later this year but there is still no way to force hospitals that already have the machines to require five letters.

While there is no question that typing in five letters is less likely to result in the wrong medication being selected, there are some reasons why five letters can be a problem.  There are a lot of medications out there with complex names that can be difficult to spell correctly.  Add to the equation that sometimes the medication is needed immediately because of a life-threatening emergency and you can see the problem.  Under the pressure and chaos of the emergency, the nurse may fumble the data entry through a spelling or typing error and getting the medication out of the machine may be delayed in a situation when any delay can cause death or catastrophic injury.

Anecdotal reports by nurses state that, after an adjustment period during which there is a lot of frustration, they get used to entering five letters before they can get a medication out of the machine.  There is no question that requiring five letters before a list is generated will save lives and prevent many medication errors.  Since the death in Tennessee, at least five reports have been made of similar errors caused by the dispensing machine requiring only one or two letters to be entered before offering nurses a choice of medications.

As I have observed on many occasions in the past, our advanced health care system is complex.  It requires many skilled providers, who must clearly and accurately communicate with one another.  Machines, including the medication dispensing ones, must be programmed correctly.  There is so much opportunity for error that the wonder is not that errors occur but that there are not more of them.

 

 

Posted in Hospital Negligence, Hospitals, Medical Devices, medical errors, Medical Malpractice, medical mistakes, Medication Errors |

Women With Heart Disease Just Can’t Catch A Break.

August 08, 2022

Women get the short end of the stick in a lot of areas of life.  Health care is one of them.  Heart disease, the leading cause of death in men and women in the United States today, does not present the same way in men and women.    The differences between heart disease and its treatment in men and women are quite pronounced and a real problem for women.

Conquering Cardiovascular Disease | NHLBI, NIH

For many years the conventional wisdom was that women did not get heart disease like men did.  It was believed that they were somehow “protected” against heart disease by the female hormones they produce.  If that was ever true, it is no longer true today.  The rate of heart attacks among mid-life women (ages 35 to 54) has been increasing over the past twenty years while, over the same period, it has been decreasing in men.  The onset of menopause is believed to be a major driver of the increase in risk factors for cardiovascular disease among women.

But because of the perception that women don’t get heart disease like men, they don’t receive the same kind of preventive treatment that men receive that has caused the rate of heart attacks among men to decline.  Women are less likely to be put on a treadmill than a man with the same complaints.  They are also less likely than a man to receive a coronary angiogram, which is the gold standard when looking for the narrowed coronary arteries that cause heart attacks.  They are more likely to have their heart-related complaints attributed to some other cause.

What do you think of when someone says, “heart attack?”  If you are like most people, you think of chest pain.  While chest pain is the most common symptom of a heart attack, it is far from being the only symptom.  Even when a patient has chest pain due to a heart attack, it is not often like the movies where the person doubles over while holding his chest.  The chest pain caused by a heart attack can be no more than discomfort.  Chest pain can be completely absent.  Other symptoms of a heart attack may be arm pain, radiating or not, jaw pain, back pain, shortness of breath, fatigue, malaise, or indigestion.  Studies have shown that women having a heart attack are less likely than men to present with classic complaints of chest pain.

The fact that women don’t often have classic complaints of chest pain when having a heart attack has profound implications for their treatment and survival.  In the first place, women themselves don’t call for an ambulance as soon as men having heart attacks do.  They tend to wait longer before calling and often call a friend for advice before calling 911.  The reason for this delay is that women having a heart attack do not usually have classic chest pain and are therefore more likely to attribute the symptoms they are having to something other than a heart attack.  Denial plays a role for both women and men.  No one likes to think they are having a heart attack.

Women are not alone in attributing their symptoms to something other than heart disease.  Because they are not complaining of classic, crushing chest pain, the doctors examining women in the emergency department also tend to dismiss heart attack as the correct diagnosis.  Studies have found that women were not seen by a doctor in the ER as quickly as men with the same complaints.  They were less likely to be admitted to the hospital than a man with similar complaints and they were also less likely to receive diagnostic tests for heart attacks, such as an EKG.

Education appears to be the solution to these problems.  Women need to be educated about heart disease, their risk factors for it and how heart attacks present in women so they can recognize one, should it occur.  Doctors need to be educated about the increasing likelihood that a woman may experience a heart attack, the different symptoms of a heart attack in women and the importance of including women in studies of heart disease.

All patients should be polite but firm in insisting on a full evaluation any time they think they may be having a cardiac event.  I have seen too many cases of people in the middle of a heart attack sent home with reassurances that their problem is not cardiac in nature.  Many of those people died within hours of returning home.   Don’t let this be you.

Posted in Doctors, health, heart attack, Heart Attacks, Hospitals, Lawsuits, medical errors, Medical Malpractice, medical mistakes, Misdiagnosis, Obesity |

Doctors Behaving Badly.

August 01, 2022

Doctors are not immune to the mores of the society around them.  It seems that everywhere we look today, we see a coarsening of society.  Past generations may have cursed, but they didn’t do it all the time or loudly in public.  Certain subjects, which were not discussed in polite society, are all over television and the print media today.  Cases of road rage and public boorishness abound.  Doctors are following suit.

Doctor caught cursing at patient;... - Good Morning America

Poor behavior on the part of doctors comes in many forms.  According to surveys of doctors themselves, rude, bullying behavior in the office or hospital is the most frequently observed bad conduct.  Some doctors believe themselves a cut above the rest of us and certainly a cut above their patients.  They treat nurses and office staff, and sometimes even other doctors, with contempt.  They yell and call names.  They expect to be pampered and to have everything go smoothly and according to their wishes.  When the usual problems of daily life occur, they react badly.  If the bad behavior occurs in the office of the doctor who owns the practice, there is little anyone can do, except find another job or another doctor.  If it occurs in the hospital, other members of the staff or of the administration can call the misbehaving doctor onto the carpet.

Among the other forms of bad doctor behavior “on the job” are mocking patients behind their backs, being physically aggressive with staff, use of racist language and insults, being intoxicated, making inappropriate sexual advances to patients and staff, and lying about credentials.  All of these examples come from surveys of doctors asking about their colleagues and what they have observed.

Away from the job, doctors misbehave as well, although they have a little more latitude when they are on their own time and away from the office or hospital.  Even though it may occur “off the job” doctor misbehavior is a problem because it undermines the respect people have for doctors and weakens the physician/patient relationship.

Social media is a frequent site of “off the job” misbehavior for doctors as it is for many other citizens.  Much of this bad behavior takes place on Facebook, where the doctor may be and often is identified as a doctor.  Facebook misconduct includes racist language, insults, sending sexual images and images showing drug use.

Some doctors post videos of themselves interacting with unconscious patients.  Famously, the surgeon performing a procedure on comedienne Joan Rivers took a selfie of himself with the unconscious Ms. Rivers without her permission.  This might not have sparked the attention it did had she not died as a result of the procedure.

Some pictures or videos of patients do not blur their faces, which allows them to be identified and which destroys the privacy of their medical care.  If done without the advance consent of the patient, this is a serious breach of ethics and of the HIPAA rules.

Other instances of doctors behaving badly relate to criminal acts.  They may be criminal acts against patients, such as sexual assault or inappropriate touching.  These are especially problematic when the patient is unconscious and cannot appreciate and report the violation.

Criminal acts by physicians most often involve fraud against either health insurance companies or a government program, which pays for treatment.  The federal government regularly reports on doctors it has caught who submit bills for medical treatment that never happened or which was not medically necessary.  Sometimes these frauds reach into the millions of dollars and involve a network of doctors and other providers.

There is a phrase used in connection with keeping travel safe that applies here:  “If you see something, say something.”  Bad behavior that is ignored is not going to stop.

Posted in Doctors, Fee for Service, Fraud, Hospitals, medical ethics, Medicare, Nurses, Secrecy |