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Tag Archives: Defensive Medicine

Bloated Healthcare Costs: Are Emergency Physicians to Blame?

By Birdstrike M.D.   In an article entitled, ”Why the ER Admits Too Many Patients,” Dr. Michael Kirsch tries to explain that Emergency Department admissions are inflated due to Emergency Physicians acting in their own self-interest.  Many Emergency Physicians have read this and taken offense, feeling that his assertions point unfair blame on them for a significant portion of excesses in medical care and costs.  I share this visceral reaction in part, but such a reaction blurs some very important points worth examining.  Let’s give the benefit of the doubt for a moment, that the author may in fact be pointing the blame not at Emergency Physicians personally, but at a broken “system” instead. First, he claims that due to fears of potential lawsuits, Emergency Physicians when in doubt, cautiously err on the side of admitting a patient and ordering tests, rather than discharging them with minimal work up.  How any Emergency Physician can deny that this happens baffles me, as almost every one I’ve ever known will say in private they think about, and are motivated to avoid the threat of lawsuits (except for possibly a few in the handful of states with strong tort reform).  Physician surveys seem to support this, with at least one showing >90% of physicians across multiple specialties admitting to such.  This speaks to the greater issue of defensive medicine and the need for tort reform, and should not be seen as an indictment of Emergency Physicians.  Tort reform is an issue where the American people just plain need to decide.  Do they want to keep their cake uncut, or to eat it?  You absolutely cannot cling to the pipe dream of reducing unnecessary medical testing and expensive overly-cautious admissions while holding true to the good old-fashioned American past time of suing the pants off of a doctor who sends a patient home, only to have something unexpected go wrong.  Decide: Do you want, A-Doctors to send you home, cancel your test, and throw caution to the wind when you might be sick to save costs for the “greater system,” and give up the right to sue if something goes wrong, or, B-Do you want to retain the right to sue in court for hundreds of thousands of dollars (or even millions) if you have a bad outcome and have doctors admit you when in doubt and order every test (expensive or not) that they think they need to keep that from happening? You cannot have both A and B.   For the most part, and in most states in the land, the American people, their elected politicians and the plaintiff’s attorneys that support them, have already decided in favor of option B.  The right to sue has always come out on top (in most states) and there’s no sign that’s about to change any time soon.  To those who will respond with “science,” “data” and articles claiming the threat of medical malpractice doesn’t alter doctors’ practices or inflate healthcare costs, don’t bother.  Most physicians are not interested in hearing evidence or “data” to show oxygen isn’t needed for breathing, or that 2+2 isn’t 4, either.  There are some things we as doctors know to be self-evident.  To the extent that one blames such a drive to err on the side of admitting patients on a dysfunctional medical malpractice system, is the extent to which he is correct.  To the extent one points the finger specifically at Emergency Physicians, who have no choice in this day and age but to admit patients with the utmost of caution when in doubt, is the extent to which ...

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FDA’s Latest Deadly Drug: Codeine

Get ready for more governmental regulation of opioids and maybe even some black box warnings added to the prescribing information for c0deine-containing drugs … just for everyone’s safety, of course. According to this FDA Special Bulletin on Safety Information, three pediatric deaths and one case of respiratory depression were documented in the medical literature after children took codeine-containing compounds. The etiology for the deaths was allegedly because the children had a variation in their cytochrome P450 enzyme that caused the codeine to break down faster into morphine, high levels of which, according to the FDA, “may be fatal.” If your child or your patient is an “ultra-rapid metabolizer” of codeine, he or she could DIE. The FDA also published a “Drug Safety Communication” that disclosed the studies on which its recommendations were based. One case cited by the FDA as “proof” that codeine can kill you involved a 2 year old child with sleep apnea who underwent tonsillectomy and adenoidectomy and who died three days after surgery. At autopsy, the child had elevated levels of codeine and morphine in his system, had aspirated food particles, and also had bilateral pneumonia. No mention of how much codeine the patient’s parents gave the child, only of the dose that was prescribed. No mention of how bilateral pneumonia or aspiration in a young child can be deadly. The researchers concluded that the elevated morphine levels “may” have contributed to the child’s death. The FDA wants you to believe that there was a causal connection there. Another article cited by the FDA was from the same authors who now found three additional cases of children who died after having tonsillectomy/adenoidectomy and were prescribed codeine. I didn’t purchase the article, but I also am assuming that there were no controls for dosing of the medication, only for prescription of the medication. In other words, I doubt that the researchers would be able to tell whether the parents accidentally just gave the child too much medication as opposed to whether some genetic variant caused higher than normal blood levels of the medication at normal doses. I also did a PubMed search for “children codeine p450” and also “pediatric codeine p450“. There was one Canadian case report of a mother who was an “ultra rapid metabolism phenotype” whose breastfed child had fatal opioid intoxication after the mother used codeine. There was another case report from Canada of a 5 year old girl who died from hydrocodone overdose when she was taking both clarithromycin for an ear infection and valproic acid for seizures. The medications decreased metabolism of the drug and she also had a genetic defect that decreased the metabolism of the drug. None of the other articles that I found mentioned pediatric death due to an interaction between opioids and cytochrome P450. Now, based on 4 deaths out of likely hundreds of millions of codeine prescriptions, the FDA is “currently conducting a safety review of codeine” and is recommending that doctors use low doses of codeine for patients in pain or that doctors just use another medication completely for children in pain. The FDA also recommends that caregivers monitor patients for signs of opioid toxicity. These recommendations are already in the prescribing information for Tylenol with Codeine. Oh, and the FDA also notes that doctors can always perform “FDA approved” genetic testing to see if children have the gene responsible for rapid metabolism of codeine. I can’t help wonder what motivation the FDA has to issue this warning about 4 deaths in tens or even hundreds of millions of prescriptions that were hypothesized to have been caused ...

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A Nameless Faceless Killer

By BirdStrike M.D. 1) A 40-year-old female sees her family physician for burning chest pain after she eats hot peppers. She had it only once while exercising. Her family physician sends her to the emergency department and she gets admitted for chest pain. Rather than going home with treatment for her GERD, she ends up dead. This never should have happened, but the family never learns what really killed her. 2) A 33-year-old father of 3 dies on a hospice ward, bloated with steroids, on tube feeds with a tracheostomy. He was stricken down too young, his family is told, by a rare form of brain cancer. It was an unlucky fluke, they are told, but that is not the only reason. 3) A 7-year-old boy dies in the Pediatric ICU. His family is stunned, shocked and devastated. How could this have happened? The family is told he died from an ingrown toe-nail infection that spread to his blood stream and caused a severe form of sepsis. “It could happen to any of us.” They do not know that the breeding of this superbug was fed by a nameless killer. 4) A 16-year-old girl is on a CT scan table nervously giggling. Fifteen minutes later, she goes into cardiac arrest. A short time later, a solemn nurse informs her family that the patient has died from an allergic reaction. But her cause of death is something more insidious. Each of these patients had a different doctor, but a similar contaminant. Much like a baseball slugger whose home run swing at a 100 mph fastball is thwarted when a camera flash from his biggest fan causes him to blink; the doctors were thrown off of their game. The culprit: Defensive Medicine. In each case presented, the doctor had a very rational fear of being sued for either making a mistake or even for doing everything right. During the last moment in the rapid-fire decision-making process, each doctor had a “flash in the eye.” In each case, the result was a swing and a miss. Over and over, and over again in hospital wards, emergency departments, operating rooms, and doctors’ offices in America doctors are being told they must rule out every possibility or be sued. The ones who suffer are the patients, often tragically so. Why? Rather than trusting their instincts, the treating physicians are instead asking themselves, “What could a medical malpractice attorney possibly say I should have done?” While this may seem like a dangerous way to practice medicine, often the doctors have very little choice but to do so.  Consider the stories behind the cases presented above:

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More on Perfect Medicine

Someone forwarded my the link to this story about a Connecticut woman who filed a multi-million-dollar lawsuit against a hospital and emergency physician for failing to diagnose pulmonary emboli which ultimately killed her husband. According to the article, the patient went to Stamford’s Tully Hospital emergency department complaining of flank pain. The emergency physician performed a CT scan on the patient’s abdomen “without performing further testing” and then discharged the patient home. Nine days later, the patient returned to the emergency department in critical condition with blood clots in both lungs. He died the following day. It is hard to comment specifically about the case without knowing more facts. However, in general, pulmonary emboli are notoriously difficult to diagnose. We do a lot of chest CT scans looking for them, and a vast majority of the time the chest CT scans come back normal. Of course, after the negative result is known, then everyone accuses you of ordering an “unnecessary test” to look for a pulmonary embolism, but that’s another topic for later discussion. So in a patient who comes to the emergency department complaining of flank pain, a blood clot in the lungs is probably not going to be near the top of any reasonable physician’s differential diagnosis list. Flank pain is usually due to kidney problems and the kidneys are in your abdomen at about the level of your belly button. The pulmonary emboli that kill people lodge in the central parts of the lungs, in the center of the chest just to the sides of the heart. See the diagram. The thing that really bothered me about the article was that the plaintiff’s attorney, Craig Yankwitt, from the Stamford law firm of Silver Golub & Teitell, was quoted as saying: “They were simply not permitted to discharge without ruling out whether he was suffering from a life-threatening condition.” This is ridiculous confabulated unsubstantiated calumny. And the purpose of this calumny is to try to bolster the retrospective claim that Mr. Yankwitt will try to use to make millions of dollars: “Had they performed the additional testing, Mr. Hermann would still be alive.” There is no rule that a physician or hospital is “not permitted to discharge” a patient without ruling out whether the patient is suffering from a life-threatening condition. To require so would demand perfection in medicine: Doctors are not allowed to miss any life threatening conditions ever, regardless of how obscure or tangential the complaint. Think about if this really were the case. You come to the emergency department with pain when you urinate and a little bit of blood in your urine. Sounds like a simple UTI … but wait, we are “simply not permitted to discharge you without ruling out whether you are suffering from a life-threatening condition.” Your could have a pulmonary embolism. That is a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until a pulmonary embolism has been ruled out. We’ll have to do a CT scan of your chest before you can be discharged. Kidney cancer is also a life-threatening condition. Add a CT scan of the abdomen and pelvis to the list of tests. And you *could* be suffering from brain cancer. That’s a life-threatening condition. According to Mr. Yankwitt, you can’t be discharged until that potential life-threat is ruled out. May as well do a whole body CT scan and get it over with. But wait, you *could* also be suffering from leukemia. That’s a life-threatening condition. We’ll need to get an oncology consult for a stat bone marrow biopsy just to “rule out” that life ...

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Healthcare Update — 12-02-2010

Also see the satellite edition of this week’s update over at ER Stories. Problems with Canadian health systems getting worse. “We’re trying to get a Size 13 foot into a Size 8 shoe.” Emergency department overcrowding increasing due to lack of available beds. The president of the Edmonton Emergency Physicians Association described the situation as a “potential catastrophic collapse” of emergency medicine. Edmonton plans to decrease hospital emergency department crowding by moving patients out of the emergency departments sooner once the hospitals meet certain criteria such as the ED being 110% full or there are more than 35% boarding patients in the emergency department. Five times this past year, Dr. Raj Sherman’s 73-year-old father almost died after waiting hours on a stretcher in an ambulance parked outside the hospital waiting for a bed. As a parliamentary assistant on health, he decided he had had enough and blasted the government, the Alberta Health Services chairman, the former health minister, and Premier Ed Stelmach. As a result of his statements, he has been fired from his government position. California emergency physicians sue to keep the state from cutting reimbursement – and win. Medicaid insurance versus Medicaid access. Yes, they have insurance, but one patient had to drive 2.5 hours to see an orthopedist that would accept her insurance. He fitted her with a brace and sent the patient for physical therapy. Now the “insurance” won’t pay for the brace. Plans that are running Medicaid managed care plans are viewed as “managing costs, not managing the care.” When patients can’t get the care they need, where will they end up? Emergency department waiting rooms. Six California hospitals fined because employees inappropriately accessed patients’ medical information. How do we change the system to prevent this from reoccurring? Malpractice judgments and settlements in the news: $16.2 million Chicago settlement for neurosurgical injury after patient sustains a brainstem herniation. $6 million Wisconsin settlement in birth injury case where patient born with cerebral palsy. Largest verdict in Belize history for child who was delivered 2 weeks early due to miscalculation in gestational age and premature Caesarian section. Maine preparing to repeal its universal health care plan due to funding issues. The Governor elect states that the state has paid $160 million to cover 3,400 eligible residents. The outgoing governor disagrees with the numbers. Girlvet has another intriguing post about those warning labels on cigarettes. If cigarette packs are required to have graphic pictures on them, why aren’t beer cans required to have graphic pictures of DWI accidents? Why doesn’t McDonalds have to put graphic pictures of obese people on their bags? A real life “Catch Me If You Can.” Fake doctor works in Fayetteville, NC emergency department for 3 weeks before getting caught. SWAT team descends on hospital as Florida gunman fires shots in hospital cafeteria and then barricades himself inside hospital room. Canadian man has diabetic “seizure” while visiting his wife and newborn daughter. Instead of bringing him to the emergency department, the hospital calls an ambulance and paramedics bring the man to the emergency department where he is later released. Now there’s the little matter of that $400 ambulance fee that he’s being charged – even though he never set foot in an ambulance. One reason that some medical providers are reluctant to disclose errors: 25% of patients stated that they would file a medical malpractice lawsuit if they were told about a medical error. Many actions considered “medical errors” have no effect on patient outcomes. Giving a medication five minutes after the time it was ordered is a medical “error”. Giving ice chips to ...

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New Defensive Medicine Survey

“Every word that I write on every form is crafted with the idea that a malpractice attorney will challenge me to defend my practice.” Just one of the quotes in the survey about defensive medicine published by Jackson Healthcare. The survey of more than 3000 physicians showed that 92% admitted practicing defensive medicine and that, based on physician responses, the annual estimated cost of defensive medicine in the US each year is $650 billion to $850 billion – accounting for $1 out of every $4 spent on US health care. You probably shouldn’t believe any of the statistics or quotes from physicians in the survey, though. Trial lawyers have a much better idea about why physicians order so many tests and why defensive medicine has no impact on the availability of health care in our system.

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