September 22nd, 2009 by Happy Hospitalist in Better Health Network, Opinion
Tags: Body Of Opinion, Costs, Healthcare reform, Medical Malpractice, Responsible, Standard Of Care
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What’s wrong with using standard of care as the threshold of medical negligence? I walked you through a case, point by point, as to how the failure to diagnose cannot be considered negligence and why the process of the differential diagnosis must be protected from the fear based legal system we operate in.
When the differential diagnosis became a legal driven process, we physicians lost our ability to offer cost effective, clinical driven medicine. We became front seat drivers in the world’s largest Ponzi scheme known as the Medicare National Bank. A
99 trillion dollar black hole of defensive medicine.
What is it about the threshold of standard of care that makes it irrational? Why is that the standard for negligence? And what exactly is it? In six years of clinical hospitalist practice, three years of residency and four years of medical school, I have never taken a lecture, never seen a presentation, and never read a book about the mystical standard of care. In fact, I find myself grasping to comprehend exactly how to define its very existence.
The great legal resource,
Wikipedia, defines standard of care as
The requirements of the standard are closely dependent on circumstances. Whether the standard of care has been breached is determined by the trier of fact, and is usually phrased in terms of the reasonable person. It was famously described in Vaughn v. Menlove (1837) as whether the individual “proceed[ed] with such reasonable caution as a prudent man would have exercised under such circumstances.”
It goes on to define that reasonable caution as the
Bolam Test
Bolam v Friern Hospital Management Committee [1957] 1 WLR 583 is an English tort law case that lays down the typical rule for assessing the appropriate standard of reasonable care in negligence cases involving skilled professionals (eg doctors): the “Bolam test”. Where the defendant has represented him or herself as having more than average skills and abilities, this test expects standards which must be in accordance with a responsible body of opinion, even if others differ in opinion.
I see a problem with what the standard has become. If everyone in my community orders a head CT for drunks with altered mental status, that represents an action by a responsible body of opinion. Does it mean it’s the right opinion? It does not. When the body of opinion has been contaminated by a persistent and progress fear of litigation, the standard defies the evidence, and itself creates irrational bars of achievement that can never be sustained. The responsible body has itself become irresponsible.
If we are to be a science driven profession, we must be allowed to maintain our integrity, without the fear of legal retribution for failing to uphold the irresponsible responsible body of opinion. Our standards are no longer based on science. When everyone orders the CT scan in drunks with altered mental status, the standard itself has become unreasonable.
Yet the marked deviation of the standard of care from the science of care marches on.
I have argued that standard of care is a local phenomenon. It is what ever the local community of professionals says it is, as they are the responsible body of opinion. The standard for evaluating a pulmonary embolism in downtown Chicago is not the same as the standard in rural New Mexico as it is in the jungles of Africa.
A lawyer previously responded that the local community should not set the standard. They argued that the standard should be a national, or perhaps an international evidence based standard. If science is science, there is no reason to believe that evaluating a pulmonary embolism in the United States should be any different than it is in the jungles of Africa. The most important factor in medical decision making if often not the science but the way the science is practiced on a local level.
The
standard of care in
McAllen, Texas is not necessarily the same as the standard of care at the Mayo Clinic. Is the cost difference legally driven or is it money driven at the local level? I suspect the contribution from both is enormous. Some argue that we should practice as Mayo practices. Mayo may be cheaper, but it isn’t cheap. I would argue that even under their payment model as a large salaried multispecialty organization with economies of scale, the ability to practice defensive medicine still thrives. Who says what costs $8,000 in McAllen but costs $5,000 at Mayo couldn’t be done for $2,000 if the victory against defensive medicine was won? I suspect it could, if physicians weren’t held to irrational standards by the unreasonable
reasonable body of opinion.
If the standard in McAllen is to do a heart catheterization on everyone with chest pain, that is what the community has decided. If the standard of care at Mayo is to do a cardiac stress test, that is the standard at Mayo. If the standard in the African jungles is to do a history and physical, that is the standard in the African jungle? What is the right standard?
The right standard is the one that doesn’t get you sued.
Now, are all three standards of care based on science? No. They are based on what the community of physicians has decided should be done. There will always be a large disconnect between evidence based medicine and clinical medicine. It is not reasonable to do a CT scan to evaluate a pulmonary embolism in the jungles of Africa if that is not the standard, even if the evidence suggests otherwise. Clinical factors should always drive the medical decision making.
Some have argued the standard of care should be founded in evidence based guidelines and not local practice expectations from responsible bodies of opinion. Rarely are guidelines clinically relevant in the hundreds of decision trees physicians make every day in their diagnostic processes. Guidelines are based on studies with limited populations of patients whose neatly defined age groups have packaged disease processes. The realities of clinical medicine make many guidelines unworkable and unreasonable.
My post here is an example of the limited value of guidelines in the differential diagnostic process. Not only are the guidelines often not relevant, they are often contaminated by medical societies and other big businesses with a money driven agenda and stealth conflicts of interest.We must also remember that most guidelines are not based on science but rather based on
expert opinion. All physicians are experts in their scope of practice and their opinions should therefore carry the same weight as the opinions expressed on academic based guidelines. Those that believe national standards should exist to drive standard of care practices across the vast clinical spectrum lack an understanding of what it means to be a physician.
Some lawyers wish to believe that having X, Y, and Z data points means doing A, B and C. Some wish to believe that failure to do so represents negligence as a responsible body of opinion would have done so.
I have never been introduced to this responsible body of opinion. I have no way of speaking for their recommendations. We have local culture driving decision making. We have limited national guidelines often corrupted by external influences. We have a legal system, who’s negligence is based on responsible bodies of opinion, opinions which have been established by fear driven medicine.
So what exactly does it all mean? When I order a lab or a test or a procedure or an x-ray to make my clinical decision making, I don’t sit there and think to myself, “What is the standard of care?”
I think to myself, “What is my expected action or reaction from doing this? What am I trying to accomplish?” I have never been introduced to this elusive responsible body of opinion. I have never been invited to a luncheon. This responsible body has never asked me out for a drink. I have never gone on a date with this body. I have navigated through ten years of clinical medicine and I have never once been formally introduced to this all knowing body of opinion.
By establishing the threshold of negligence as a vague responsible body of opinion, a concept which few physicians have studied, few physicians can quantify and few physicians trust, we have built exactly what the medical-legal-industrial complex has prepared for us: A high volume, high supply, high demand, high cost fear driven reality that we all pay for with out of control health care inflation.
If you think Mayo care is cheap, the time has come to consider that even the highest quality, lowest cost centers in this country could reduce their utilization of health care resources by 1/3, 1/2 or more if the fear of civil retribution for failure to diagnose was taken off the shoulders of passionate and devoted physicians from all fields of training and they were allowed the freedom to employ their differential diagnosis skills in a manner consistent with scientific inquiry and not a legal driven fear.
The longer we deny the fear, the quicker the end will be here.
*This blog post was originally published at A Happy Hospitalist*
September 21st, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
Tags: Blood Loss, Broken Bones, Fractures, Orthopedics, Splints, wilderness medicine
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This is the next post based upon a presentation given at the Wilderness Medical Society Annual Meeting held in Snowmass, Colorado from July 24-29, 2009. The presentation was about trauma and orthopedics. It was delivered by Douglass Weiss, MD of Teton Orthopaedics in Jackson Hole, Wyoming.
Utilizing some fabulous images, including those of Lanny Johnson, Dr. Weiss made some important points. Many of these are familiar to seasoned medical practitioners, but they merit repeating. First, when approaching a victim, always attend to the “ABCs” first – airway, breathing, and circulation (including bleeding) – so that a life can be saved. Then, if possible, take into account other injuries, including those of bones – save the limb, save the joint, and restore function.
Here are two good pointers. First, your field evaluation of the victim may be the only complete one, so do your best to examine the entire victim, and also to document in writing what you discover. Examine and establish the airway, listen for breath sounds, observe chest movements, feel for pulses and observe skin color, etc. Within the constraints of the situation and environment, “expose” the victim in order to evaluate bony and other injuries. The, move on to the “secondary” survey, which will include examination of the neck, back, pelvis, arms and legs, looking for swelling, bruises, scrapes, cuts, bleeding and deformities. If you feel inappropriate motion (e.g., broken or dislocated bones or joints), be prepared to apply splints.
Always try to roll the patient (using a logroll technique if necessary) to examine the victim’s back.
For the benefit of doctors reading this post, remember that if a fracture is identified, suspect an injury to the joint above and below the fracture, and be sure to splint these for the comfort and protection of the victim.
The application of splints is an art form, so should be practiced prior to your expedition. Any limb that is obviously deformed or that demonstrates excess motion (where there should be none) should be immobilized immediately. If a helper(s) is available, use assistance. Be sure to pad all splints very well to avoid pressure injuries to the tissue underneath. Depending on the rescue, the splint may be in place longer than you anticipate.
If a broken bone (fracture) is “open” (the bone has poked through the skin), then apply a wet (preferably normal saline or disinfected water) dressing and apply a splint. If you have an all-purpose antibiotic (e.g., cephalexin, amoxicillin or ciprofloxacin) and the victim is capable of purposeful swallowing, administer a dose.
Fractures of the pelvis generally imply that a very significant force was applied, so they carry a high risk for associated life threatening injuries. The victim should be evacuated as soon as possible. It is commonly taught that a broken femur (the long bone of the thigh) can cause bleeding in excess of a liter into the limb. This can be dangerous, so these injuries should be promptly splinted, preferably with a pre-fashioned or improvised traction splint.
Compartment syndrome occurs when tissue pressures within inelastic soft tissue compartments of the limbs (commonly the forearm or lower leg exceed perfusion pressure, that is, the pressure necessary to allow blood to circulate freely through the tissues and provide energy and remove waste products. Symptoms include extreme pain, loss of pulses, pale skin color, weakness or paralysis of the muscle, and numbness and tingling. If the pain is severe and the skin feels tight, a compartment syndrome may be developing. If a compartment syndrome is felt to be impending or present, keep the limb elevated and seek immediate medical attention, because an operation may be required to open the compartment and release the pressure before the onset of permanent tissue damage.
Thanks to Dr. Weiss for his contribution to wilderness medicine education.
This post, Tips For Evaluating Injured People In The Outdoors, was originally published on
Healthine.com by Paul Auerbach, M.D..
September 21st, 2009 by DrWes in Better Health Network, Opinion
Tags: Federal Government, Fee, Medical Devices, Price Transparency, Tax, Transparency
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Here’s a dumb thought: If you want to save costs on medical devices to the federal government, require a tax fee concessions of $4 billion dollars from the medical device companies to fund a health care overhaul.
Now either that $4 billion will get added to the cost of devices (and the patient/insurer’s tab) or the device companies will decide that they must pay the fee to maintain their current pricing.
Government pressures hospitals and doctors by paying less, so hospitals keep the heat on medical device makers to lower costs so they can make their margins.
It all sounds good, right?
But according to one analyst, it seems device makers would rather pay the fee than make their prices transparent:
But the mechanism for how devices companies might pay matters more than what they pay, according to Morgan Stanley analyst David Lewis. “A ‘flat tax’ is preferable, in our view, to targeted industry fees as our larger concern is the creation of more infrastructure intended to catalyze pricing transparency,” he said.
And so, with the fee, the government pays itself while the medical device prices continue to remain inflated.
Why do the patients always seem to lose with these government-mandated scenarios?
-Wes
*This blog post was originally published at Dr. Wes*
September 21st, 2009 by Emergiblog in Better Health Network, Health Policy, Opinion
Tags: Abuse, Costs, Emergency Medicine, Finance, Fraud, Funding, Healthcare reform, Nursing, Obama, Waste
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Well, I lead a double life but it isn’t out dancing in formal wear!
“There is time for only fleeting thoughts about that dance you’ll attend during off duty hours.”
There isn’t even time for that.
Besides, who attends a dance during on duty hours?
Well, I guess the most important thing is that our hands are “soft, smooth and free from redness” because “your patients like it and your date expects it”.
Oh yeah?
The day they use a hand sanitizer thirty times in a shift and wash their hands another twenty, they can talk to me about soft hands.
********************
My husband won’t watch football with me because I tend to get hyped up and throw things at the TV when I get upset.
That explains why there were Notre Dame pom poms and a Cleveland Browns jersey at the base of the set this weekend.
I also like to talk back at the President when he is speaking on TV. Usually it’s things like “Say WHAT?” or “Give me a break!” “Get. A. Clue!” is usually a good one. This last speech, the one to Congress about health care, was no exception. My first comment came a bit into the speech when I noted a few times that “I haven’t heard a single thing I disagree with yet” and “he’s right on that point”.
I was afraid hubby was going to need smelling salts.
But I’m like, “let’s hear how he is going to pay for this…let’s hear him out”.
And then I heard it.
And then he lost me.
*****
There were two comments that I could not let go. I looked them up in the text of the speech to make sure I had heard them correctly.
“…we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system a system that is currently full of waste and abuse.”
“The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud…”
Hundreds of billions of dollars? Billions? With a capital “B”?
Waste. Abuse. Fraud.
This means that in order to pay to the proposed health care reform, we have to find enough waste, abuse and fraud to cover expenses.
*****
But I have some questions.
What is the definition of “waste”? To the extent that “waste” means inefficient bureaucratic practices that use up monetary resources, I can get on board with that.
Abuse? What kind of abuse? Using the system inefficiently, like calling an ambulance for a stubbed toe? Remember, the President is using the term “abuse” to represent a potential income stream for the new system, so it would have to encompass behaviors that spend money that should not be spent. Money is spent on patient care, so is he talking about patients abusing the system?
And then there’s fraud…
That’s a crime, folks.
Hundreds of billions of dollars in waste and fraud?
The President must think that there are an awful lot of criminals in the health care system.
So what’s my point?
*****
My point is this: funding for the new proposed health care system (see “most of this plan…”, above) is based on finding waste, abuse and fraud.
What happens when all the waste is taken out, all the abusers are stopped, the fraudsters jailed and the system needs more funding? Does that not make it imperative that we keep finding waste and abuse and fraud? Does that not mean that what constitutes waste, abuse and fraud must be constantly expanded to make up for rising costs?
This can’t be good.
I am in total agreement that our system can be streamlined, big time.
And maybe we could find enough money in waste, abuse and fraud to make it pay for itself, but I doubt it.
If we could do that, wouldn’t we have done it already with Medicaid and Medicare? The budgets for both are getting slashed on a regular basis. Drop the waste, abuse and fraud in those programs and then come back and tell me how much better their budgets are.
If we can’t do it in an existing government-provided system, how on earth do you expect us to believe it can be done on a larger scale?
*This blog post was originally published at Emergiblog*
September 20th, 2009 by Nancy Brown, Ph.D. in Better Health Network, News
Tags: Parenting, Pediatrics, Premature Death, Psychiatry, Psychology, Risky Behavior, teens
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There was a very interesting article in Reuters Health in June that has stayed with me all summer, and I finally decided to share it with my readers – in hopes that writing about it will help me quit thinking about it!
The data for this study came from more than 20,000 teens involved in the 1995 – 2002 National Longitudinal Study of Adolescent Health, a nationally representative school-based survey done with students in 7th through 12th grades.
The results from this disturbing study suggested that about 15% of teens believed they were likely to die prematurely, which predicted increased involvement in risky behavior and poor health outcomes during young adulthood. The question apparently asks if teens think there is at least a 50/50 chance that they will die before the age of 35, and the students who believed they would die prematurely were more likely to report illicit drug use, suicide attempts, fight-related injuries, police arrests, unsafe sexual activity, and a diagnosis of HIV at subsequent data collection points.
I guess I am not sure what to do with this information. On one hand, it suggests that all of the adults in teenagers’ lives – parents, teachers, coaches, doctors, neighbors, and family members – should pay attention to what teens think about premature death, calling for more communication, which I am supportive of, but how exactly would this subject come up?
I do not think asking how long they expect to live is the answer, but instead I do believe that adults can focus more on staying connected with teens and promoting optimism and hope in youth. I do not believe this means not talking about youth in meetings, but actually spending time with those youth where they spend their time, teaching them skills, sharing a sense of accomplishment, and making a physical and meaningful connection with each of them. Every teen needs to have multiple adults they can talk to and spend time with, especially during times of stress or interpersonal conflict.
Listening to teens talk about their friends, their futures, and their insecurities is a window into their expected life course, and being present enough to hear comments reflecting a “why bother” attitude may be the key! Please listen to your teens and help them feel positive about themselves today!
This post, Many Teens Believe They’ll Die Prematurely, was originally published on
Healthine.com by Nancy Brown, Ph.D..
