Medical Malpractice

Some notes on medical malpractice:
There was recently an editorial discussing a wrongful death lawsuit being filed in Texas - an editorial that I feel deserves careful evaluation. The patient was a preschool aged girl who, sadly, was ultimately found to have meningitis. The physician involved was a senior emergency medicine resident (who has since graduated) at UT Southwestern. The initial diagnosis was ear infection.
Let’s look closer (at the case, and the article)...
The patient was initially seen at 2 in the morning for fever. At the time of her initial evaluation, her fever had improved from its peak of 101, but she continued to have a fast heart rate (not uncommon with many infections, although certainly a finding worth noting as it can indicate a more nefarious process) so the physician ordered labs (we’ll get to this in a minute) and gave her fluids. She was then discharged home on antibiotics for an acute ear infection.
Point #1: A resident saw the patient. While this is, indeed, a specialist-in-training, many 2nd year ER residents are good, if not great, clinicians. I would trust my family to any of the residents I train (and if not, our program won’t let them moonlight). Remember, ultimately, an ER means access and convenience. It doesn’t mean you get to see a neurosurgeon or orthopedist for your back pain, and not everybody is entitled to Dr. House M.D. for their difficult diagnosis; you get the doctor that is available - after all, that’s why you’re there, instead of at a primary care’s office. It wasn’t very long ago that many emergency rooms, especially in smaller towns, were staffed by a general practitioner (1 year of post-medical school training). In many cases, the doctor working in the hospital would run down to the ED, see a patient, and then run back upstairs to continue taking care of patients on the floor. The whole notion of a specialty trained physician in the ED is relatively new, and in many places, ERs are still staffed by various medical professionals (general practitioners, family practitioners, general surgeons, opthomologists, hemotologists, etc.).
Point #2: this presentation and management is very common; in fact, this happens nearly every shift in the ED, usually without the labs or fluids (if a kid can tolerate drinking, then that’s the best way for them to get fluids. Plus, it hurts less than an IV). Upper respiratory infections are exceedingly common, as are ear infections. Both usually go away in 7-10 days regardless of what you do. In fact, you are more likely to have an allergic reaction to an antibiotic than you are to get meningitis from an ear infection (though this wasn’t always true). Literally, if we did nothing for every kid with an ear infection, most (80+%) would be just fine (consider, it wasn’t epidemics of ear infections and meningitis that killed kids in the past - it was measles, pertussis, influenza, etc.). I’ve only given my own kids antibiotics twice, and both times I waited 10 days before I started them.
Point #3: Meningitis is rare - really rare, and even if the doctor does everything perfectly (early antibiotics, lots of fluids, etc.) there is somewhere between 10-30% change you will die. Of those who survive, there is a really high rate (nearly 1/2) of neurological complications - usually hearing loss, but a more rapid onset and more severe symptoms portends a worse outcome. Some diseases are just really, really bad, no matter what you do. Medicine is not Miracle.
Point #4: If we did a lumbar puncture on every kid that came in to the ED with a fever, we would still miss cases of meningitis, and the girl who died in this case very well may have been one of them. You see, this is where laboratory interpretation comes in. To begin, one of the accusations in this case was that the WBC was high, so the doctor should have known that she had a serious infection; however, this has been studied and shown to be worthless in diagnosing meningitis. For the statistically minded, the area under the curve for a WBC count (from the blood) was about 0.5, or the same as if you walked into the room, flipped a coin, and made a clinical decision based on the outcome. It quite literally has no predictive power here. If, clinically, a doctor is worried about meningitis, then the appropriate test is a lumbar puncture (a needle into the back). Now, this comes with some risk - headache, bleeding, introducing infection - and it also misses some cases - usually the early ones, and often the most dangerous ones. You see, to be simple, there are two ways a disease can progress: rapidly or slowly. For the slowly progressive diseases, you have time to make a diagnosis, and the outcomes are usually better. For the rapidly progressive diseases (e.g. over hours in this case), if you do a test too early, it will be normal, because the disease hasn’t “sunk in” yet; but by the time you see signs and symptoms of the disease, the patient is already very sick and you’re behind the eight-ball, so to speak. Unfortunately, there isn’t any way to figure out who is likely to have the bad stuff, and who has the less bad stuff, other than just waiting.
To offer a real-life example, there was a similar lawsuit years ago against an emergency physician who, astutely, noted neck pain in a patient with abdominal pain - that’s right, the kid presented with abdominal pain - and got the parents to agree to a lumbar puncture on their smiling, well appearing son. By technical criteria, the tap was negative and the kid looked well (he improved with fluids), and so he was discharged. He died the next day of meningitis. So this initially well-appearing young boy, who presented with abdominal pain, died within 24 hours of a disease that he was tested for, and tested negative for. Despite this, the physician was sued for what I consider to be excellent care (in fact, he should be commended for doing a lumber puncture on a child with abdominal pain - I think most of us would have felt so silly even suggesting this that we never would have mentioned it).

This brings me to the state of modern medical malpractice.
Malpractice hypothetically does (or was created to do) two things: “hold physicians’ feet to the fire,” so to speak, by creating a penalty of sorts should they perform badly (and, as a corollary, it would hopefully prevent bad doctors from practicing), and also to provide some recompense for people, or families, who had suffered at the hands of medicine.
The reality of medical malpractice is that it does neither. Malpractice insurance nearly always covers any losses a physician would have sustained, and it is exceedingly rare that a “bad” physician fails to find employment, despite a claims history (although their employment may be limited). Other than causing a great deal of stress to the physician being sued, malpractice suits often do nothing other than sow discord. If you are thinking that maybe it improves a physician’s practice, I can assure you it does not. It may make them more defensive, but studies, and my personal experience, would suggest that defensive medicine is far more expensive and causes more problems by overtesting and overdiagnosing diseases (in other words, now medicine is directly hurting people rather than diseases).
You might be thinking that at least people who were harmed get some financial recompense - after all, many of these lawsuits settle, or get decided, for hundreds of thousands, if not millions of dollars. Unfortunately for those individuals, and this argument, over 90% of all malpractice money goes to lawyers, courts, and expert witnesses.  It is a rare case that ultimately provides any significant amount of money for the individual harmed. Furthermore, just because someone “wins” a lawsuit does not necessarily mean that they were actually harmed by their medical care. Not everyone who suffered at the hands of medicine will sue (in fact, most don’t), and many who do file suit never had a legitimate complaint to begin with (though they may have had a good sob-story). Ultimately, the “standard of care” is what a jury decides, not what is, in fact, best practice; and even the standard of care/best practice has often been shown, in the long run, to be harmful (think anti-arrhythmic drugs after a heart attack - used to be the standard of care, later found to increase the risk of death). Even when physicians do make mistakes, how fair is it to insist on perfection, every time, all the time? In my opinion, an honest mistake is different than negligence.
Lastly, how unfortunate are those who suffer because of the slings of fortune rather than the honest mistake of a well-meaning doctor? Alas, there is no-one to sue. Our system is set up to exploit the honest mistake, the unintentional oversight (which we all do occasionally) equally with the truly negligent physician.
Overall, I think that our current system punishes physicians without regard for their skill level, increases costs, and pits patients and physicians against one another, rather than allying them with one another.
While I do understand that this was a bit long, I think it is exceedingly important, and worth reflecting on for all of us; after all, a recent report listed medical error as the 5th leading cause of death in the U.S., so it will likely affect all of us in some way.

Texas Wrongful Death Lawsuit - Preschool meningitis

Abdominal Exam: are we just wasting our time?

To start with a difficult admission: I have a fairly long history of doing a poor abdominal exam, despite being very interested in this bedrock of the physical examination. In fact, I love the physical exam, in theory; but I have recently found that, in practice, I have been sorely lacking in both technique and the willingness to perform up to my knowledge.
How this came about:
I was recently working in a small emergency room with a group of non-emergency-trained physicians. Old school guys. A bit behind on the newest information, but overall not bad physicians. I went in to see a woman complaining of abdominal pain, got an appropriate history, and then performed my abdominal exam. Maybe a little questionable, but overall a benign exam. I went to chat with one of the docs about her and he went in to do his abdominal exam. Acute abdomen. CT scan showed florid diverticulitis. She was admitted to the hospital for IV antibiotics.
The very next day, a middle-aged woman came to the ED complaining of, what else but lower abdominal pain. I decided to test myself. After taking her history - relatively unimpressive (resolving abdominal pain, currently about 2/10 and more "achy" than really "painful") - I began with my "old" (I now refer to as "crap") abdominal exam. Benign in the truest sense of the word. Then I did a thorough exam. Acute abdomen with rebound tenderness localized to the right, lower quadrant and a strange variant of Rovsing's sign (palp in the LLQ made both LLQ and RLQ hurt). Suddenly suspicious of significant pathology, I ordered a CT and... acute appendicitis. She was wheeled off to surgery.
The real lessons I learned were to push hard - it may hurt more, but it also tells you more, and if you must, give the patient morphine first (it actually seems to bring out pathology rather than cover it up) - and do a real, honest-to-God rebound tenderness test - jerk your hand off the patient's belly (it really does make a difference). Furthermore, when evaluating for rebound tenderness, try in several locations. The lady with the appendicitis only reacted when I tested her RLQ. And the heel jar test does NOT necessarily correlate with peritoneal irritation. Both ladies had a negative heel jar but positive rebound tenderness.
It's too late to get into it right now, but I want to incorporate this with a discussion on the use of CT scans. The SMART EM podcast has a fantastic discussion of the risks of CT scans (I highly recommend it) that would go well with a discussion of the utility of an excellent physical exam. There was also a recent article concerning the use of serial abdominal exams rather than CT in the pediatric population for diagnosing acute appendicitis. Not to mention some excellent scoring systems (the one I am most familiar with is the Alvarado Score). I'll try to get back to this later.

MONA or just ONA?

The age old acronym of "MONA" used in the management of acute coronary syndrome has recently come under some criticism after a study published in 2005 in the American Heart Journal noted that patients treated with morphine had a higher mortality rate than those who did not recieve morphine. Two subsequent letters to the editor differed in their reception of this information (as good science would have it). So, what is the gist?

The study itself - "Association of intravenous morphine use and outcomes in acute coronary syndromes: Results from the CRUSADE Quality Improvement Initiative" - was a non-randomized, retrospective, observational trial. It enrolled patients presenting with non-ST-segment elevation acute coronary syndromes and ultimately noted an increased odds ratio of death of about 1.5. Considering its limitations, the study was well done and run through several re-assessments, including risk adjustment (i.e. comparing the sickest patients given morphine to the sickest patients not recieving morphine) and matching on propensity score for treatment (most basically, an attempt to minimize the influence of confounding variables). Ultimately, there needs to be a randomized control trial on the issue, but this is still concerning.

The letters to the editor (December 2005; American Heart Journal):

#1: Observation that morphine supresses ("paralyzes") cortisol production in the opioid-naive, potentially dropping levels as much as 75% or more within 3 hours. Occasional Addisonian crises. Notes that some reports suggest improved survival in MI patients treated with corticosterooids (I am personally not familiar with this information), possibly due to a replacement effect rather than the oft cited anti-inflammatory hypothesis.

#2: Although the original article cites a source that suggests morphine increases infarct size in animal models, this author notes that in his own lab, morphine reduces infarct size. He does note, however, that the effect is largely dose-dependent and time-dependent, showing no effect at higher doses and being effective only when given before and ischemic event and just before reperfusion, losing their cardioprotective effect when administered after reperfusion. How this compares to the other study that suggests that morphine not only does not work but is harmful, I haven't figured out yet. I'll update when I do.

Medical charting

It is customary, at least in the Emergency Department, to have selective hearing of sorts. A patient says, "I have low back pain." The ER doc asks the requisite, "do you have any problems with urinary incontinence or do you ever poop on yourself?" The patient replies, "well, I have peed on myself once or twice, but not in the last few days." The physician writes down, no urinary or fecal incontinence.

This is not unreasonable, as an affirmative response to either of the questions calls for a lengthy and expensive work up, steroid administration, and possible neurosurgery or orthopedic consultation, and this patient's back pain does not seem to be related to their urinary incontinence. However, a falsehood (of omission) has now been written on this patient's chart. And this is done dozens of times, by dozens of doctors every day. For practical purposes it probably makes little to no difference. Patients receive adequate emergency care regardless of whether or not their 2/6 systolic murmur was recorded on their chart; but, if ever a chart review for research is conducted, inaccurate information is obtained. If a physician tries to find correlated physical findings he may draw an empty net, as many of the findings may have been omitted.

But I can't blame the physicians. If given the choice between omitting information on the chart and saving myself from a possible lawsuit or writing down every tiny detail for future posterity and possibly having the shoes sued off of my feet, I would omit. Because every detail on a chart must be explained. If a chart has "+ urinary incontinence" in a patient with low back pain, a physician must have a good, a very good reason for not performing an MRI. It doesn't much matter if they've had urinary incontinence for 30 years. A lawyer will pin them to the ground. And until this changes, physicians will lie.

Health woes

A recent CNN article cited a survey that suggested that, due to the new 21% reimbursement cut, over 60% of physicians are planning on reducing their Medicare patient population, if not eliminating it entirely. Another article suggested that as many as 10-15% of general practitioners are planning on leaving the profession. Considering these figures, how is it that the government assumes that a national health care plan will fix our current crisis? With a significant majority of physicians already avoiding government-sponsored health-care plans and a growing number of physicians leaving the field entirely, who will provide the care for the millions of newly insured Americans?

Community

There is a great deal of talk about health care reform these days, most of it about the dollars and sense of the whole thing (pun intended). We debate the fiscal responsibility of a multi-billion dollar healthcare bailout, of sorts; we argue the potentials for abuse; we champion the necessity of cardiac catheters, dialysis, and other life-saving heroics and how everyone should have access to these "essentials." But never do you hear the ultimate truth of healthcare, which, incidentally, is a truth of society. Health is a community endeavor. As it happens, we live in an unhealthy society; our unhealthy society promotes unhealthy people.

Americans watch, on average, 34 hours of television per week. A third of the American population is obese, with another third overweight (even as skewed as the BMI system is, those numbers are terrifying). And how many people know more than 2 of their neighbors? From what I've seen, almost nobody. With all of that information, it is no wonder that the leading cause of disability in America is depression. We are spectators in a life that was meant for participation. We are unfulfilled, unsatisfied, and isolated. We are creatures that excelled at survival because of community only to exchange community for a lonely isolation. While this isolation allows us to avoid uncomfortable virtues like accountability and courage, it also allows us to sink into our own mediocrity. No one ever has to know.

The public arena discusses healthcare on a national level, but fails to recognize the community. We talk about costs on such a grand level that people lose touch with the visceral facts and forget that it actually costs real money and man hours to provide that care. A community, on the other hand, sees the figures and the people behind them. There is both an understanding of the cost, and an appreciation for the service. Furthermore, there is accountability. I, as a member of the community, find it much more aggravating if an acquaintance of mine doesn't take his medicine, or watch his weight, or stop smoking because I can understand on an intellectual, as well as emotional level how that will impact me and the rest of the community. It is our money and our resource. On the other hand, as things are, I simply brush off such behavior with the notion that the god-like government will handle it. After all, they have enough money, and they've taken care of it so far, so why not now? Is this fair? No. But I would argue that it is human nature.