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The Practice of Medicine

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…

Administration Wants Tighter Painkiller Rules

MCNtalk has blogged about OxyContin and other powerful prescription painkillers in the past few months (“Oxycontin Express,” March 11; “Fight Over a Fix for Florida Pill Mills,” February 25) with a focus on the situation in Florida. Pill mills have flourished in Florida, especially in Broward County, in recent years. Weak standards governing who can set them up, a lack of oversight by state agencies and the absence of a prescription-monitoring program have contributed to the problem, said Sherry Green, chief executive of the nonprofit National Alliance for Model State Drug Laws.

To address the situation, as the New York Times notes, the Obama administration said last week that it would seek legislation requiring doctors to undergo training before being permitted to prescribe powerful painkillers like OxyContin, the most aggressive step taken by federal officials to control both the use and abuse of the drugs.

In the last decade, the abuse of pain medications like OxyContin has remained at epidemic levels, and medical experts have expressed concern that the legitimate use of the drugs may also pose patient risks. For years, the question of whether doctors should be trained as a condition of prescribing such medications has been fiercely debated. Read more…

Patients Are Not Consumers

Paul Krugman, (Nobel Prize for Economics, 2008),  in a New York Times Op Ed piece, has a few things to say about perspectives on health care. Some excerpts we found interesting:

Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as “consumers”? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.

What has gone wrong with us?

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values. Read more…

Interns at the Operating Table

In this New York Times article, Dr. Pauline Chen, M. D. notes that patients and their families are often wary of having interns in their loved ones’ operating rooms. A common attitude, she writes, runs along the lines of, “It’s not that I don’t like these young doctors. I just don’t want one practicing on my husband.”

As Dr. Chen further notes, “I’ve never developed an adequate response. A part of me understands these concerns. As talented and as earnest as residents can be, it’s true that they are still learning to operate. At the same time, I’m also fully aware that I am the doctor I am because other patients once allowed me to participate in their operations and care.”

So how well-founded are such concerns? In March the Journal of the American College of Surgeons published the results of a study on how well patients come through when a surgeon-in-training is involved in the operation. Analyzing the results of more than 600,000 operations at more than 225 hospitals across the country, researchers found that:

  • resident involvement was indeed associated with slightly higher complication rates and longer operating times
  • those complications were not necessarily serious
  • patients who had trainees participating in their operations also experienced decreased mortality rates
  • once one complication occurred, those patients with residents involved in their care were more likely to recover and less likely to fall prey to the so-called domino effect of complications, where one leads to another and ultimately to death

Read more…

Amid War on a Mystery Disease, Patients Clash With Scientists

In addition to providing an update on chronic fatigue research, this article in the Wall Street Journal summarizes some interesting points about the larger question of how illnesses are defined and the interplay between that and treatment research. As MCNTalk noted several weeks ago (What’s in a Name? For Illnesses, it’s Fodder for Debate) treatments may vary depending upon a physician’s diagnostic measurements. In a posting earlier this week (Gene Work Yields New Treatment For Lupus) MCNTalk further explored dilemmas raised by a condition’s definition.

Points to ponder:

  • The Internet has given patients the ability to organize and rapidly disseminate medical information—and rumors as well. Patient advocacy groups are increasingly powerful, involved in central endeavors such as funding research and collecting samples critical to experiments.
  • In the case of chronic fatigue treatment, Stuart Le Grice, head of the National Cancer Institute’s Center of Excellence in HIV/AIDS and cancer virology, is skeptical about XMRV’s role in the disorder. He is sympathetic to patients but he insists that science can’t be rushed. Desperate patients who want immediate answers risk diverting attention from essential research. “There’s a danger of deflecting us from what we really want to do,” Dr. Le Grice says.
  • There has never been any consensus on what causes the syndrome. Many doctors believe that there can be different triggers, including viruses and genetic vulnerability. There are still some doctors who believe the condition is psychiatric, a stance many patients believe has discredited them and slowed down efforts to find treatments.
  • The clashes between patients and scientists come as science in general becomes more polarized, according to a study published in the Journal of Risk Research last year. Researchers found that when scientists’ conclusions conflict with a community’s cultural values, people don’t accept the scientific consensus. “The phenomenon we are looking at is a cultural war over facts,” says Dan Kahan, director of the Cultural Cognition Project at Yale Law School, who co-authored the study last year.

Read more…

Gene Work Yields New Treatment For Lupus

As noted in the Wall Street Journal, the Food and Drug Administration approved the first new drug for lupus in more than 50 years, a milestone in the effort to mine data from the human genome to discover and develop new medicines. This development is important for a variety of reasons which highlight various situations within the world of how illnesses are defined and treated. Specifically the article notes that:

  • There’s a huge range in the number of people suffering from Lupus, depending upon how the disease is defined: Estimates of how many Americans are affected range from 161,000 to 1.5 million.
  • One version of the drug entered clinical trials in 2000.  So little was known about how to evaluate a new lupus drug, however, that it took the company, outside experts and the FDA took a year to design clinical trials that would determine whether Benlysta helped patients or not.
  • Benlysta, the drug in question, is one of the first drugs discovered based on mapping of genomic data to make it through to FDA approval.
  • The price of the drug will be about $35,000 a year per patient, which the company said was in the range of other biologic therapies used to treat similar diseases.
  • Clinical studies also showed those receiving Benlysta suffered more deaths and serious infections compared with patients not on the drug. (Patients using Benlysta will receive a medication guide that will outline the risks associated with the product.)
  • Before Benlysta, the FDA last approved drugs to treat lupus in 1955.
  • Nine out of ten people with Lupus are women.

Read more…

Hospitals With Robots Do More Prostate Cancer Surgery

Hospitals that buy surgical robots end up performing more prostate cancer operations, suggesting that technology has become a driving force behind decisions about men’s cancer care, new research shows.

The study, published in the journal Medical Care and explored in the New York Times, is the latest report to suggest that how men are treated for prostate cancer appears to be influenced by a variety of factors, including the technology and marketing goals of hospitals and doctors, rather than scientific evidence on benefits and risks.

The new study, conducted by researchers at New York University and other institutions, was a fairly large one, tracking surgical robot purchases at 554 hospitals, along with the treatment given to more than 30,000 men given a prostate cancer diagnosis from 2001 to 2005.

Interesting notes:

  • Buying a robot led to an average increase of 29 operations a year per hospital.
  • Hospitals that own a surgical robot may be that the technology helps a hospital lure potential surgical patients away from the competition.
  • The data also suggest that once a hospital obtains a robot, patients who might be candidates for non-surgical options are more likely to be steered toward robotic surgery instead.
  • A surgical robot used for prostate cancer costs $1 million to $2.25 million, according to the N.Y.U. study. In addition, hospitals spend $140,000 annually for a service contract and $1,500 to $2,000 per patient on disposable instruments.

The researchers found that treatment patterns varied markedly across the clinical sites studied, and those differences could not be explained by measurable factors like severity of disease or patient age. Read more…

Revisiting IME Ethics and standards

Revisiting IME Ethics and standards

As founder of MCN and a practicing physician, I am proud of what we do as a company and hold high expectations for ourselves, our consultants and indeed our clients. I write this note with a bit of trepidation, but I have never been known as one to shrink from issues.

What I am addressing is by no means the norm in many or most cases, but there are ethical situations that should not be part of our industry, even at the smallest level. Please review this post in the spirit that it is meant – to improve what we do. Please don’t shoot the messenger. But by all means, feel free to comment on this posting, or privately to me.

It has been almost two years since a major expose in the New York Times regarding certain practices in that region.  For those who wish to read this series, please visit:

http://topics.nytimes.com/top/reference/timestopics/subjects/w/workers_compensation_insurance/index.html this page has all the links. Here are links to the individual articles over 3 days:

http://www.nytimes.com/2009/03/31/nyregion/31comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/01/nyregion/01comp.html?ref=workerscompensationinsurance

http://www.nytimes.com/2009/04/02/nyregion/02comp.html?ref=workerscompensationinsurance

To my knowledge the matter to a large degree “blew over” in that I am not aware of any significant regulatory or other outcomes on this issue or sanctions against the company featured, though I have heard that they have changed names.

I believe that it may be time to revisit standards in performance of IMEs, especially in regions of the country where we have observed that certain practices that we regard as improper and indefensible may indeed continue to be practiced by certain consultants and IME companies. Not asking, for example, how it can be that they receive and accept examination reports at price points, length and quality that would not be possible elsewhere in the country.  All clients deserve the highest quality standards from those they rely upon for important services, which in the case of IME’s means unbiased, thorough, evidenced-based assessments performed by engaged and dedicated consultants.

With recent disruption in the industry, including a very large consolidation of a number of smaller companies, it is our hope that those who oversee large numbers of IMEs will endorse some or all of the points we are raising, and take appropriate actions in their own companies to insure integrity in all exams. Likewise all doctors who examinations must perform at the highest medical standards and not allow a lower standard for IME’s.

The basic principle is to do right by clients, claimants and society. And since we facilitate medical examinations, let doctors do their jobs properly and insist that high standards be followed and maintained.

Clients who order exams generally receive quality exams, but they should still ask questions if they see possible issues, and use common sense. Doctors who do exams, whocan’t or won’t practice in a way that treats each claim and claimant as individuals, with respect and dignity, give the process enough time, write original reports where critical thinking is employed, and remember why they entered (or should have entered) the profession, should not do exams. There are certain acts that MCN finds unacceptable. We believe all involved in the business should feel likewise and take appropriate measures to ensure that substandard performance does not occur. In no particular order they include:

Exams that are too brief: We believe that a reasonable rule of thumb is that an IME should take no less than 30 minutes— and often much longer—to perform. We generally schedule an hour in our own facilities, sometimes a bit less, but never more than two an hour, and we question at times whether this is optimal. The time must allow for review of appropriate records, a history from the claimant, a focused and appropriate physical or mental status examination, and an original report. We have observed with our own eyes the extreme of the company cited in one of the articles I liked cited above scheduling 12 exams in an hour, with an expectation of perhaps 4 no shows and therefore approximately 8 exams to be done. This timeframe is simply impossible. Further, I think that it is also impossible to do 4 proper exams in an hour. Attempting to cut corners on time does not work; it leads to claimants who feel rushed and not heard, reports that are shoddy, and conclusions that are inarticulate if not inaccurate.

Use of Boilerplate in substantive content areas: The history, examination and conclusions must be original. Templates can provide a framework to follow or serve as an introduction or disclaimer. But the words used in an exam should be original. Measurements should be real and reflect human variation. Normal findings if quantified should reflect a range of normal. While a 90 degree flexion for example, might be normal, normal flexion will be vary from 90 degrees, while still in a normal range. So the number would be expected to not be 90. Yet I have observed reports where normal variation appears absent. No two exams should ever look the same in language when it comes to the history, examination or conclusions.

Reports that are too brief: I am not prepared to state how long an exam should be, but can state with a high level of comfort that an assessment of a complex injury with records to review, a history to cite and an examination and assessment to record generally ought to be more than 2-3 pages.

Ghost-writing of reports or examination performance: It is the physician’s job, and his/her’s alone, to take the history, review records, perform a substantive examination and issue the final report. And it should be the physician contacted for the exam who completes this work. It may not be delegated. While rare, we have seen instances where this is not followed, despite clear guidelines on the matter. The physician must not sign their name on the work of others. While it may be the practice of a particular physician to delegate certain practice tasks, that is not the standard in IMEs, and certainly not something to be imposed upon an unaware client or IME company.

Ordering unnecessary tests, especially when personal or corporate gain may be involved: It is no secret that society has been looking very carefully at real or perceived conflict of interests in medical services. Fortunately our clients call us and ask for exams and we don’t drive the demand. But we do expect that consultants make a determination as to whether a particular study is needed. Interestingly, when it comes to typical orthopedic type examinations, we find that the common frequency of ordering of studies in situations where testing is not on site is less than 5%. However we have learned that in situations where physician practices or certain IME companies have X-ray equipment on site, the incidence of use increases to approximately 35%. This is a massive variable and suggests that something may be amiss. The only indication for a study should be if it is necessary for a quality report. Often it is not, or prior studies are more than adequate. If a consultant is ordering common films uncritically, or clients see this taking place, questions should be asked. We believe that clients should consider exercising the option of requiring approval for studies, to insert a bit of friction in the process, especially if X-rays appear to be a norm with a particular setting, consultant or company.

Think about the New York Times test: The homily that one should never do something that they would not mind seeing on the front page of the New York Times holds true. And as you can see above, aberrant behavior in our field made the front page two years ago. Or to frame this in another manner, don’t do anything in our businesses or tolerate practices that we would not subject our immediate family members and best friends to. Some of what I have observed over the years would suggest that if this were the case, some people really dislike their friends and families, to allow certain practices to not only take place, but persist.

Some of these practices have been defended on the basis that questionable claims and claimants may justify them. To this I only can shake my head. Yes there are questionable claims and claimants but this in no way justifies lowering our standards of dignity and respect for what we do as physicians and companies.

Other justifications have included the belief that this is what the client wants and that they are price sensitive and therefore a hurried approach, done cheaply and below standard is therefore acceptable. I don’t believe that clients want claimants to be mistreated, and while price may be an issue, clients realistically understand that quality does carry a price and one can’t cut corners in key areas and achieve a defensible and acceptable product. I believe there may be business risk in the long-term if questionable practices are tolerated. Also, the practice of medicine is the province of physicians, and just as a client would not tell a doctor how to provide treatment, the client hopefully should rely upon ethical and trained physicians to be the final arbiter on examination performance and quality.

The consequences of inattention to ethical medical examination practices creates an uneven playing field in the provision of IME’s; those who do quality work and those who don’t. Some IME provider will take a pass on work at a price that could only be provided sub-optimally. Fortunately we at MCN and many of our ethical competitors are blessed with great consultants and clients who value integrity in the work they do and the examinations they expect. We as a company will continue to strive for the highest standards of integrity. We invite all consultants, clients and competing companies to set similar bars of expectation.

In closing, I invite a dialogue, comments, even respectful challenges to these ideas. We also may have missed some additional issue and areas bearing attention. Please raise them.

Brian L. Grant, MD

Chair and Medical Director, MCN

What’s in a Name? For Illnesses, it’s Fodder for Debate

A study of chronic fatigue syndrome, published last month in The Lancet, has highlighted how competing case definitions for illnesses and syndromes can lead to confusion rather than clarification — what you see depends on who’s doing the looking — and has stoked a fierce debate among researchers and patient advocates on both sides of the Atlantic as noted in this New York Times article.

“If you recognize something is happening, you need a case definition so you can count it,” said Andrew Moss, an emeritus professor of epidemiology at U. C. San Francisco and an early AIDS investigator. “You need to know whether the numbers are going up or down, or whether treatment and prevention work. And if you have a bad case definition, then it’s very difficult to figure out what’s going on.”

Once a disease can be diagnosed reliably through lab tests, creating an accurate case definition becomes easier. But when an ailment has no known cause and its symptoms are subjective — as with chronic fatigue syndrome, fibromyalgia, and other diseases whose characteristics and even existence have been contested — competing case definitions are almost inevitable.

What does this mean for the patient? Well, quite a lot. As the article notes, treatments could easily vary depending upon which diagnostic measurements a physician were using. In the case of chronic fatigue, some researchers believe that the syndrome is  a psychological condition and patients would benefit from exercise. Other researchers, however, are deeply convinced it is a viral disease and note that the exercise therapy advised by the Lancet study can cause major relapses in people with chronic fatigue syndrome — a claim supported by some patient surveys. Read more…