MDs Urged to Denounce Malpractice Site

Dan Lambe, executive director of Texas Watch, said the site is attempting to scare patients.

``This type of blacklisting runs counter to the Hippocratic Oath to the ethical and moral goals and obligations of medical professionals,'' Lambe said.

Dr. John Shannon Jones, a radiologist who created the database, could not be reached by The Associated Press for comment Friday. He told The Wall Street Journal that people who sue doctors are going to find their access to health care may be limited.

``That's a harsh thing to say, but this is a war,'' said Jones, who has settled two malpractice cases.

I understand it, but I cannot support it.

My colleague, Stef, wrote this important comment concerning my post on autopsies:

I would fault the NY Times article for failing to reference the autopsy review literature that supports the continued value of autopsies.

At least one or two papers a decade document the surprising effectiveness of autopsies at identifying clinically important (but unsuspected) diagnoses, despite our vaunted diagnostic technology. The most recent was published in JAMA (June, 2003) with Lee Goldman as senior author, reviewing 53 autopsy series articles published since 1966. Despite clearly documented improvements in premortem diagnoses over the decades, their data suggest that a contemporary US institution "could observe a major error rate from 8.4% to 24.4% and a class 1 error rate from 4.1% to 6.7%", where major errors involve the cause of death, and class 1 errors are such that the patient outcome would have been altered. Maybe some doctors prefer not to know about those missed diagnoses. I don't know for sure.

As a medical student pathology fellow at the original home of the "Black Crow Award," (an apocryphal legend about a contest in which a resident won a prize for obtaining the greatest number of autopsies, cf. House of Gods), I conducted about 17 autopsies. I scanned my notes from those cases this evening. Brief summary, of 15 adult autopsied, we found a fair number of unsuspected diagnoses and at least 1 or 2 that appeared materially related to the cause of death but were unsuspected by the physicians caring for the patient, a rate of Type 1 error which appears consistent with the findings of Goldman et al. At that particular hospital, housestaff came to a 20 minute autopsy conference once a week, and we reviewed the findings for them.

Beyond the turning up the occasional unexpected cause of death, the post-mortem examination does help physicians develop a clearer mental picture of the diseases we are called upon to diagnose indirectly, by hints and rumors.

These comments, while true, imply that we can extrapolate from these studies to all hospital deaths. That implicit assumption (which some may make explicitly) does not work.

We must remember that those patients who have autopsies are not representative of all hospital deaths. Most physicians push harder for autopsies when they do not really understand what happened to the patient. Thus, the probability of finding new information is enriched in the autopsied patients.

I favor autopsies in many patients. Usually I do not push for an autopsy in a patient who was terminal (i.e., receiving comfort care, managed by the hospice service). As this represents a large percentage of deaths on our services these days, we will have a lower autopsy rate than 50 years ago. I believe that many patients who had autopsies in the past do not receive them because we make more pre-mortem diagnoses, and thus treat patients appropriately, obviating the need for an autopsy. But then, I cannot prove that.

We have had excellent information on the pneumonia severity index in the past. This report re-emphasizes its usefulness. Tool Accurately Assesses Pneumonia Severity. If you want to use the index online, go here - Pneumonia Severity Index Calculator

In Texas, Hire a Lawyer, Forget About a Doctor?

For months, an obscure Texas company run by doctors has been operating a Web site, DoctorsKnow Us.com, that compiles and posts the names of plaintiffs, their lawyers and expert witnesses in malpractice lawsuits in Texas and beyond, regardless of the merit of the claim.

"You may use the service to assess the risk of offering your services to clients or potential clients," the Web site says.

For fees listed as low as $4.95 a month for the first 250 searches and thereafter 2 cents a search, subscribers are invited to search the database "one person at a time or monitor any sized group of individuals for litigious conduct." They can also add names to the database "from official and unofficial public records." Whether that could include a doctor's own files is not clear.

"They can sue but they can't hide," says the Web site.

So I ask, is this strategy akin doing a credit check, or is this an excuse to deny service. Some malpractice suits are legit.

I understand this strategy, but I do not think that I can personally endorse it. What do you think?

Go read our favorite surgeon (Bard Parker) - No Black Crow Award Here. I like his rant - of course we agree!

Interesting and well done study in today's NEJM. This report from Medscape describes the findings of a new COPD mortality risk index - Simple Grading System Predicts Mortality Risk in COPD

What the Body Knows

The NY Times has, in my opinion, used their editorial page irresponsibly (once again).

But autopsies have not declined because they're useless. In fact, most studies confirm that autopsies regularly turn up surprises, including mistaken diagnoses, undiscovered conditions and, in a small but steady number of cases, diagnosis and treatment errors that may have led to death. The numbers are not trivial. One study examined 1,000 autopsies between 1983 and 1988 and found that there were " `major discrepancies' between the autopsy findings and the clinical diagnosis" in 317 cases.

Autopsies have dwindled for a number of reasons. Hospitals were once required to perform them to be accredited, but that requirement ended in 1971. Insurance companies do not pay for autopsies. But the problem really lies in our attitude toward them. In recent years, families have become increasingly reluctant to authorize autopsies, and doctors too often believe that modern diagnostic tools like CAT scans and M.R.I.'s have made them obsolete. Yet underlying these reasons is another, more pervasive one: the risk of malpractice suits. An autopsy that uncovers an error in treatment also uncovers the potential for litigation. Never mind that it may improve subsequent diagnoses.

When our patients die, we frequently request autopsies, but rarely will the patient's family approve. I am probably naive or just not smart enough to consider that I could avoid malpractice through the deceit of not asking for an autopsy.

Most hospital deaths in 2004 are expected. Most dying patients are terminally ill.

Autopsies can give valuable information, but they are not as important an information source as they were in the 70s when I started training (nor as important then as they were in the 30s). I suspect that the NY Times editor has watched one too many episodes of CSI. Most autopsies show a few surprises, but rarely many that would change outcomes.

I favor getting more autopsies. They are instructive and help us understand medicine. They offer new important information less frequently than in the past.

The NY Times editors have, as I said before, overhyped this issue. But I must give them credit, they have taken a bold stance. Perhaps they understand our motivations better than we do. Thus I will finish this rant with an existential thought (yes I am still listening to the tapes) - does anyone really know our motivations for our actions - even ourselves? The NY Times editors have attacked the medical community because they believe that they can attribute motivation to us. I find that assumption arrogant.

Given the number of comments related to the MRSA article, I thought that I would provide a few thoughts.

MRSA refers to methicillin resistant staphylococcus aureus. For the non-physicians, that means that the old penicillin variants that we once use for staph infections (oxacillin, dicloxacillin, nafcillin) do no work to kill these staph. Staph infections commonly cause skin infections, like boils, but may cause even more serious infections.

Where did MRSA come from? Bacteria develop resistance by natural selection and mutation (the purest form of evolution). Bacteria naturally mutate. When we use antibiotics, we always have a probability that a mutant strain (starting with only 1 bacteria) will occur. If that mutant has resistance to the antibiotic, then it will multiply and become the prodominant infecting bacterial strain.

This process fits our understanding of natural selection perfectly. Unfortunately, staph infections spread easily between patients. Thus, once a mutant is selected and grows, it becomes capable of infecting other patients.

Some bacteria more often develop resistant strains (i.e., they mutate more often). Staph does mutate often.

Even with appropriate antibiotic use, the biology almost insures that resistance will develop. Over the past decade MRSA first became a problem in intensive care units, then hospital wards, and now the general community.

The cow is out of the barn. We now assume that staph are resistant (unless we prove otherwise with cultures and sensitivity testing).

Understanding how staph became methicillin resistant reemphasizes our need to use antibiotics prudently. They are great and powerful aids to treating serious infections. Whenever possible we need to use the most specific antibiotics possible. However, even with perfect antibiotic usage, we will still develop resistance organisms - genetics and evolution drive the development.

Continued research into the mechanisms of resistance will enable us to "defeat" the resistance - at least for a period of time. We can blame the emergence of resistance on many people and antibiotic uses. Our obligation though is to use antibiotics intelligently for clear indications. This will slow the emergence (not stop the emergence) of resistance and give research the opportunity to develop the next generations of antibiotics. We have an ongoing struggle against bacterial, viral and fungal infections. We can win battles, but will always lose some battles also.

This comment is placed with the wrong rant. Therefore I will quote the entire comment and respond.

Well there you go.

The "experts" believe the average citizen is too dumb to make healthcare decisions.

Let Daddy Government do it for you.

Or we will let the government delegate to self-appointed "experts" to decide for the people.

With government and agencies like AHRQ, heck with Hillary and her crowd...this is not about providing the most medical care, most appropriately, to the most people. People like Hillary don't care about the "little people". This is about their raw political power. They want to take your money and tell you how THEY will spend it on your behalf. The LAST thing they want is to let people decide for themselves, especially when so much money is at stake.

As has been said before, their fear is not that MSA's will not work.

The fear in government and their dependent private organizations like AHRQ......is that MSA's WILL work.

First I must defend AHRQ. AHRQ (Agency for Healthcare Research and Quality) is an important research agency. They have a meager budget (relatively) and deserve a larger budget since they fund studies which actually help us understand what works and what does not work in health care.

The article quoted an individual from AHRQ. He has an opinion with which I disagree. That does not invalidate the agency.

However, the commentor makes a very insightful point. We have advanced in medicine to patient focused decision making. Back in the 70s when I trained we generally functioned paternalistically. We rarely sought patient input into our decision making. Rather we told patients what to do.

Sharing decision making represents a major advance in health care. If we follow that logic, then HSAs extend that concept. We who favor HSAs see them as a way for patients to more actively participate in their medical care.

These plans increase patient's responsibility for their health care. As a physician I expect that patients will expect me to understand costs and explain advantages and disadvantages of differing strategies. As a patient, I should make medication decisions based upon knowledge of alternatives - especially generic alternatives.

Economically these plans should do much to control health care costs. They do require a belief in patients. That is a very libertarian concept.

Methicillin resistant staph will soon be the only staph that we see. Routine antibiotics just will not work against many minor abscesses anymore. Bacteria Run Wild, Defying Antibiotics

"Staph infections are such a common problem that the emergence of infections resistant to common antibiotics has important public health implications," said Dr. Daniel B. Jernigan, an epidemiologist at the federal Centers for Disease Control and Prevention.

But the infections are so common that they are not reportable to the local or federal public health authorities. Because of this, detective work to explain the appearance of the new resistant staph in this country and track its progress is just beginning.

The resistant staph was first recognized in the United States among children in Chicago in the mid-1990's. In 1999, the disease control centers reported that four children in the Midwest had died of infections with the new staph. Three of them had initially been treated with the wrong antibiotics.

In the last several years, clusters of infections with the resistant staph have been reported in jails and prisons in states around the country, including California, Texas, Pennsylvania and Georgia. Clusters of skin infections have also been reported among athletic team members and military recruits.

Clearly, we treat all suspected staph infections as MRSA until culture results prove otherwise. This has become the most prevalent and therefore the most important resistance problem.

Hospitals hang on to money-losing medical practices

A major problem in medicine stems from who gets paid and how much. Currently, the front line physicians (family docs, general internists) are struggling financially. They make significant money for everyone else in the health system. Some hospitals understand economics enough to support these groups.

Medical practices owned by hospitals or integrated delivery systems reported a median net loss of more than $82,000 per full-time physician in 2002, according to a survey published by the Medical Group Management Assn.

The report says the loss was 9.5% more than in 2001, when groups posted a median loss of just more than $75,000 per physician. The report highlights a trend that has been apparent to health systems for several years. Hospitals were selling practices back to physicians or anyone else that would take them more than four years ago because they already had been deemed a drain on finances.

Still, some hospitals have managed to mold thriving medical practices, while others have decided the losses are worth it to have a physician network.

"The philosophy is, 'We will make money off their referrals, even if we don't make money off their practice,' " said Janet Houser, PhD, associate professor of health services administration at Regis University in Denver.

Would it not make more sense for our system to reward these important physicians financially? We all know the answer to that rhetorical question. So why do we pretend that we cannot afford to pay these physicians?

Beat the clock: The new challenges to residents

Resident programs are taking the limits seriously, said David Leach, MD, executive director of the Accreditation Council for Graduate Medical Education, which accredits all residencies. But, he said, it is how they approach the task that makes the difference in the kind of education residents receive.

"There are early adopters and innovators who have shown you can improve patient care and [meet duty-hour limits]," he said. "The majority have shown you can do this, but in making do they've not redesigned clinical care as much as reacted to the requirements. In a few of our citations, programs have met the requirements but have weakened patient care and resident education."

The ACGME has reviewed 500 to 600 programs since July 2003 and has issued 79 citations related to duty-hour violations, Dr. Leach said.

Residents aren't completely happy with the new constraints either.

"You have to realize that the larger health care system is broken," Dr. Leach said. "Residents have lived in the cracks of that broken system for a long time, and they've been told that the system can and will kill your patient, and you need to make sure that doesn't happen. Residents have depended on vigilance, knowing that the system can't be trusted. Now we've reduced the availability of the residents, and they're worried. They want to stay [at the hospital] because they can't trust the system."

Here in our program, we are doing quite well. I have had to insist that interns leave a few times. They have a difficult dilemma. After admitting for 24 hours, then rounding for 3 hours, they only have 3 more allowed hours. If a patient has an interesting study scheduled, they really hate leaving until they know the results. They rarely want to stay for patient care (our system manages that quite nicely) but rather for their own education. So we have to say, sorry you must go home.

In talking with attendings at other institutions, they express the opposite problem. They have told me that their residents do not seem to take as much responsibility for their patients as residents formerly did.

The 24 + 6 rule is so arbitrary and without supporting data as to engender scorn from almost all of our residents and interns. How can we teach evidence based practice when our accredition body makes decisions without evidence?

But these are the rules and we do the best we can. I am proud of our residents who remain committed to outstanding patient care. They have developed a system which adheres to the most important principle - outstanding patient care - yet allows reasonable work hours. They are not always happy about the rules (and some will ignore the rules regardless of what the attendings say). Most important, our residents worry about the patients first, and the rules second. I think that should be the focus of ACGME evaluations.

HSAs (Health Savings Accounts) immediately push observers into one of two camps. Libertarians and free market economists believe that they will lead to better rationing of care - patient directed rationing. Others argue that patient care will suffer because patients do not understand enough to ration logically. Consumer-driven health care: Bush, GOP back HSA expansion

Businesses large and small are looking for ways to preserve employee health benefits without breaking the bank. Many have latched onto the concept of consumer-driven health care, which shifts more of the responsibility for health-spending choices onto the patient.

"We see a 15% reduction in drug spending right out of the chute within five to six months and a 6% reduction in physician visits," said Mike Parkinson, MD, chief medical officer for Lumenos, an Alexandria, Va.-based health insurance company offering consumer-driven plans across the country.

"You know that 20% to 25% of doctor visits are unneeded; 30% to 35% of all health care is ineffective or inefficient. How better to get at [that waste] than front-loading the consumer who says I want to get the care I want when I want it and from whom I want it," he said.

Consumer awareness of price and quality information will drive competition among physicians seeking to offer the highest value services, Dr. Parkinson said. Many physicians like consumer-driven plans because they emphasize preventive and behavioral services that support doctor-prescribed treatments and make for healthier patients, he said.

That is the argument in favor of HSAs. Others remain skeptical.

"What these plans are asking [patients] to do is to ration their own care," said Dwight McNeill, an expert in quality measurement and improvement at the Agency for Healthcare Research and Quality.

"The question now is, do consumers, as rationers or deciders of their own health care, have better or more useful information to make these decisions than doctors did" in managed care, he said. "The answer has to be, no, ... consumers just aren't ready for it, and they don't have appropriate information."

Gathering information on the efficiency, quality and value of health care services and procedures will take more time and money, McNeill said.

Republican lawmakers remain unconvinced by arguments that patients cannot make their own health decisions. Many want to move forward with legislation designed to encourage the trend.

People make bad economic decisions daily. This occurs through our economy. Those who favor HSAs (including this ranter) believe that patients will change their focus when asking for health care options. Most patients will listen to recommendations and be more likely to accept less expensive medications, rather than the newest medication advertised on television.

Our current system clearly does not work. We should collect data to understand the impact of HSAs. I have had them for several years - and am a major proponent.