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Injury and Trauma

The Wrong Way to Help Veterans

At MCNtalk we found this Op Ed piece in The New York Times to be particularly poignant. Firstly, it reminds us, as we enter the tenth year of armed conflict, of the very real and tragic cost of war. It is after all our war, and on our behalf that people — Americans and Afghanis both — are suffering: “If all goes according to plan, by the end of the year, 10,000 American soldiers in Afghanistan will be home with their families — and their memories. As many as 20 percent of them will suffer from post-traumatic stress disorder, anxiety or depression, while suicide rates have reached tragic new highs among veterans.”

Additionally, for MCN it reminds us of the human, and very complicated, side of the IME business, that of determining causality and disability: “After all, gauging the prognosis of mental injury in the wake of war is not as straightforward as assessing a lost limb. What’s more, it is very difficult to predict the pace and extent of a patient’s progress when the odds of success also depend heavily on non-medical factors: the veteran’s own expectations for recovery, availability of family and social support, and the intimate meaning the patient makes of his or her distress, wartime hardships and sacrifice.”

And reminds us in the IME business of what we don’t do for claimants—provide direct treatment: “Instead, Veterans Affairs should adopt a treatment-first approach. The sequence would begin with treatment, move to rehabilitation and then, if necessary, assess a patient for disability status, should meaningful functional deficits persist.

“At the same time, veterans too fragile for employment while in intensive therapy and rehabilitation—which, for some, could last up to a year—should receive financial support. Not disability payments, mind you, with their specter of permanent debilitation; call it a ‘recovery benefit’—as generous as total disability, but temporary.

“With some exceptions, it is both realistic and important to instill the expectation in veterans that they will get better and find a comfortable and productive niche within the community and family. The road home from war is already an arduous one — the mental health system shouldn’t make it any longer than it already is.”

And of course we  found this piece to be refreshing because the author not only outlines a problem, she attempts to find a solution while neither ignoring nor minimizing the factors involved. Read more…

Panel urges crackdown on excessive MRIs

As noted in this Seattle Times article, an influential independent congressional advisory group is urging lawmakers to crack down on doctors who order too many MRIs for seniors, setting off a battle with physicians and patient groups that argue that Medicare beneficiaries might suffer significant delays in treatment.

The recommendation by the Medicare Payment Advisory Commission, or MedPAC, would require some physicians who order a lot of MRIs, CT scans, nuclear-medicine studies and other imaging tests to obtain pre-approval from Medicare.

In its latest report, sent to Congress this week, MedPAC takes aim at doctors who order these tests inappropriately and concludes that Medicare costs for such tests are surging partly because physicians are buying their own high-tech equipment. When they can perform diagnostic tests in their offices, they pocket the profits.

How much do imaging costs impact Medicare? Imaging is one of the fastest-growing Medicare costs, rising from $6.5 billion to $11.7 billion from 2000 to 2009, according to federal figures. Industry groups say the use of imaging services declined from 2008 to 2009, but MedPAC disputes that data and counters that usage is on the rise. While a 1989 law prohibited physicians from referring patients to testing centers in which they had financial interests, it didn’t stop them from performing tests in their offices.

As a side note to this article, MCN does not own any X-ray or imaging facilities and must approve such studies when performed by consultants. Imaging and X-rays are needed in fewer than 5% of orthopedic and related IMEs performed by MCN. If you find that a particular IME physician or provider orders studies at a higher rate, questions are warranted. Does the provider have a financial interest in testing facilities or equipment and is the study truly necessary to render a credible report?

Read more…

When Doctors Are Called to the Rescue in Midflight

Ever wonder what happens when there’s a medical emergency mid-flight? According to this article in the New York Times, the answer to that question will vary quite a bit depending not just on who’s on the flight (“Is there a doctor in the house?) but on what’s actually in the plane’s emergency medical kit varies a great deal.

The F.A.A. requires that flight attendants undergo CPR training and that all United States airlines carry emergency medical kits and automated external defibrillators, but there’s no standard as to what’s in the kits nor how frequently they’re stocked.

Since the earliest days of commercial aviation, airlines have coped with medical emergencies in flight by calling on physicians who happen to be passengers. And as more people travel by air, the number of emergencies has risen accordingly.

“Passenger health is becoming more and more of an issue, because of increased life expectancy and more people flying with pre-existing conditions,” said Dr. Paulo Alves, a vice president at MedAire, a company that provides crew members with medical advice from physicians on the ground.

MedAire, which advises more than 60 airlines around the world, managed about 19,000 in-flight medical cases for commercial airlines in 2010. Although few were life-threatening, 442 were serious enough to require diverting the plane — and 94 people died onboard.

The numbers reflect a fraction of the actual number of in-flight emergencies. The Federal Aviation Administration does not track in-flight medical episodes, and airlines are not required to report them.

Airborne calls for medical assistance pose a singular challenge for physicians, who find themselves suddenly caring for a stranger whose history they don’t know, often with a problem well outside their specialty, in a setting with limited equipment but no shortage of onlookers scrutinizing their every move.

The lack of standardization was criticized in a recent article in The Journal of the American Medical Association. The paper argued not only that the medical kits should be standardized, down to the number of latex gloves, but also that a method for reporting incidents should be consistent among all airlines.

“Aviation is held up as this paragon of safety, yet here’s this nasty thing that happens with no standard for reporting,” said one of the article’s authors, Dr. Melissa Mattison, associate director of hospital medicine at Beth Israel Deaconess Medical Center in Boston. “We know more about animals that die on airplanes than we do about people.”

Despite the pressures, the haphazard nature of the work, the lack of compensation and the risks, physicians continue to reach up and answer the call. In a world of insurance forms, rushed office visits and ubiquitous technology, many count such emergency calls among the purest expressions of their Hippocratic oath.

“You feel good about trying to help someone, and that’s the most important thing,” said Dr. Ingrid Katz, an infectious disease specialist at Brigham and Women’s Hospital in Boston. “But don’t expect anything. It’s solely for the benefit of the person in need.” Read more…

Hospitals Overhaul ERs to Reduce Mistakes

Often chaotic and overcrowded, with scant data available about new patients, the emergency room is among the top hospital departments responsible for malpractice suits—and diagnostic errors account for 37% to 55% of cases in studies of closed claims.

The average payments and legal expenses for ER cases have more than doubled over the past two decades, according to the Physician Insurers Association of America, a nonprofit trade association whose members cover about 60% of emergency physicians.  This Wall Street Journal article explores pilot programs in different hospitals across the United States working to make corrective changes in emergency room procedures.

Changes include adopting new triage systems to ensure doctors and nurses jointly see at-risk patients soon after they arrive, requiring physicians and nurses to huddle to make sure no information is overlooked, and using time-outs at discharge to prevent patients with unresolved problems from leaving the ER.

Some interesting points to note, emphasizing the impact emergency room care and costs have upon health care in the United States:

  • Insurance broker Aon Corp. estimates malpractice suits arising from emergency-room incidents in 2009 alone will cost hospitals $1 billion.
  • While emergency-room errors often happen because a doctor misjudges symptoms, in almost all cases of missed or delayed diagnoses essential pieces of information weren’t available at the time the doctor made a decision, according to Dana Siegal, program director of risk-management services for Crico/RMF Strategies, whose parent company insures hospitals affiliated with Harvard University. Crico/RMF is working with 16 hospitals on a project to improve communication between doctors and nurses. Mannequins will be used to simulate various emergencies, and participants discuss what could have been done differently.
  • The changes to emergency-room systems come as ERs face a growing work load. In a survey released last month, the American College of Emergency Physicians said 80% of its members are reporting increased visits to emergency rooms and more than 90% expect increases next year.
  • David Seaberg, president-elect of the group, says a growing shortage of primary-care physicians is driving many patients to the ER.

Read more…

Spine Surgery, Medical Advances, and an Aging Population

A condition known as spinal stenosis is one of the top reasons older Americans seek surgery for lower back pain, and the number of people afflicted with the disorder is expected to grow as the population ages. A recent study in the Journal of the American Medical Association (JAMA), as detailed in this Wall Street Journal article, looked at the situation.

Some orthopedic doctors are concerned the procedure has gotten more complicated than it needs to be as some surgeons combine traditional stenosis therapy with other procedures that fuse vertebrae. The more complex surgery can be beneficial for some patients, especially those with more than one spinal disorder. But it also raises the cost of treatment and increases the chances of complications, including stroke and death, recent research shows:

  • The number of complex spinal surgeries has grown at a rapid rate:, now accounting for 19.9 per 100,000 surgeries from 1.3 per 100,000.
  • Although patients suffering only stenosis and not other spinal conditions were less likely to receive the combined procedures, these patients still accounted for as many as 50% of the complex surgeries.
  • The higher rate of complex procedures increased hospital costs for surgery by 40%.
  • The complication rate of those cases also was higher at 5.6% compared to 2.3% for the simpler, decompression surgery.
  • Hospitals stays were on average two days longer for complex surgery.
  • Average per-patient hospital charges were $80,888, compared with $23,724 for the simpler surgery.

Why the rate of increase? An aging population is inherently going to mean an increase in the number of spine surgeries in general, as vertebra naturally degenerate over time. However, the rate of increase currently happening is far greater than that transition would call for.

“Many factors are at play, but I think the finances play an important part,” says Richard Deyo, a professor of evidence-based medicine at Oregon Health & Science University in Portland, Ore., and lead author of the JAMA study. “There are some prominent surgeons who have strong financial connections to device manufacturers.”

Christopher Bono, an orthopedic surgeon at Brigham and Women’s Hospital in Boston, says the JAMA article doesn’t explain why the surgery numbers are increasing other than “insinuating that it is because of marketing and surgeon greed.” He says there could be other reasons for the increase “such as better corrections of deformities.”

“It has not been shown that the more complex surgery is better [for patients with simple stenosis], but people are willing to have it done,” says Eugene J. Caragee, an orthopedic surgeon at Stanford University School of Medicine, who has written on the topic in medical journals. “The marketing is relentless,” he says. Read more…

Sex, Lies and Videotape – and the Internet


We hesitated a bit before posting this. It is not often that we can see a combination in one event that includes the perils of the Internet, workers’ compensation, dishonesty, and perhaps human greed combined with ignorance.

We find these cases interesting on a social level. Typically the amount of money misappropriated in cases like this of probable malingering is in the tens or hundreds of thousands; an amount that would result in criminal charges if a person walked into their employer or someones else’s house and stole it. But in the case of clear and convincing evidence that an individual is faking injury or extent of injury, denial of subsequent benefits or as in this case, payback of prior payments seems more common. What is the difference between this situation and theft and why is prosecution not the norm?

While the majority of claims are valid and respond to appropriate treatment and rehabilitation, cases of fraud and malingering when they occur are costly and troublesome, and underscore at times larger social issues. This case also underscores the value of searching for information about claimants that are not under their direct control in the medical context. Historically this involved surveillance, but as this case demonstrates, the Internet – typically social networking sites, often provides a wealth of intentional or unintentional self-disclosure.

How Valid Are Pain Validity Tests?

Sprained ankle

We recently ran across an article citing a company that has reportedly devised a test to determine if pain is real. Here is the article, “Pain Validity Test Gets 30 Workers’ Compensation Claimants Back to Work Immediately.”

Here is the company that offers the test: http://veritassupporttesting.com. We have no experience with the test and would welcome comments from those who have reviewed or used it. It sounds like an interesting concept, but whether it meets scientific and clinical scrutiny is not clear to us.

New Puzzle: Why Fewer Are Killed in Car Crashes

A dramatic decline in highway fatalities in the U.S. since 2005 is a piece of good news that’s also a bit of a mystery.

Is it the result of better vehicle safety technology? Less stupid, reckless behavior? Smarter strategies for easing teens into the responsibilities of driving? Or just an unexpected positive side effect of a slumping economy?

A new study by two University of Michigan researchers — as explored in this Wall Street Journal article — of detailed federal crash statistics from 2005 to 2008 suggests all these reasons could be behind the reduced death toll.

Making Pain in the Back Less of a Pain in the Neck

A study published in the British Medical Journal has found a direct relationship between faster recovery times and the use of integrated care.

The key words here are “integrated care,” which really means adjusting the injured person’s workplace and having them in a guided excercise routine.

The workers that got the care returned to work an average of 120 earlier than the workers that didn’t, which is a substantial difference both in days and cost. While changing the workplace to suit the injury can also help, the monitored exercise is most definitely the factor tipping the scales toward faster recovery.