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Archive for September, 2011

Thursday, September 29th 2011

Malpractice Risk According To Physician Specialty

Background
The details of the medical malpractice environment have been studied in detail. The risks providers face of a claim, the risk factors for such, the results of such claims and the like. But previously the risks of claims, indemnity and such physicians of different specialties faced had not been published.

A new study by Dr. Chandra and his colleagues in the New England Journal of Medicine puts some numbers to the malpractice risk faced by various physician specialties.

Jena, Anupam B., Seth Seabury, Darius Lakdawalla, and Amitabh Chandra. “Malpractice Risk According to Physician Specialty.” New England Journal of Medicine 365.7 (2011): 629-36. Print.

The group is done some of the most extensive work on medical malpractice and even a cursory search of this block is likely to show links to many of their previous publications.

The full text of this article can be found on the NEJM website.

Design

  • Database of all closed claims filled between 1991 and 2005 from a large physician owned malpractice insurer
  • Insurer covered 40,916 unique physicians over that time period who self reported more than 200 medical specialties
  • Looked at all claims for each individual year for each specialty to calculate per annum risk
  • Broke claims into those with indemnity and without
  • For those claims with indemnity looked at mean and median payments for each specialty
  • Broke specialties into ‘high risk’ and ‘low risk’ and by Kaplan-Meier estimator gave estimations of cumulative lifetime risk of any claim and any claim leading to payment

Results
There was unsurprising considerable variability amongst specialties for risk for claim.

Procedure based specialties topped the risk of any claim with the annual risk for a neurosurgeon standing at 19.1%

There was more variability for mean and median indemnity payments. Perhaps not surprising specialties in which harm occured to younger patients had larger mean and median payments, even if the risk of claim was low. Pediatrics had the largest payments, topping more than $500,000.

There was also considerable variability, perhaps more difficult to explain, amongst specialties for the risk of a claim leading to an indemnity.

Critique

  • Although a large insurer, the study looked at data from but a single one
  • “Our model assumes that the probability of being sued was unrelated to the duration of coverage by the insurer”
  • “[Our model assumes] that the probability of being sued at a given age was independent of being sued at an earlier age (after adjustment for physician random effects)”
  • The mix of specialties may not be representative

Conclusion

It’s an interesting article and provides good data on risk by specialty. It also provides tangential insight into how physician behavior might be influenced by risk of suit. The author’s discussion of such might be the most interesting thing in the article in fact.

As in other surveys the risk of indemnity was relatively low. Nearly 80% of claims resulted in now payments in this sample. That has been one of the major points by opponents who find no basis for defensive medicine based on the malpractice ‘crisis’. However, as the authors speculate,

Although these annual rates of paid claims are low, the annual and career risks of any malpractice claim are high, suggesting that the risk of being sued alone may create a tangible fear among physicians.

The perceived threat of malpractice among physicians may boil down to three factors: the risk of a claim, the probability of a claim leading to a payment, and the size of payment. Although the frequency and average size of paid claims may not fully explain perceptions among physicians,1 one may speculate that the large number of claims that do not lead to payment may shape perceived malpractice risk. Physicians can insure against indemnity payments through malpractice insurance, but they cannot insure against the indirect costs of litigation, such as time, stress, added work, and reputational damage.

I’m in agreement. I would highly recommend a read of this article.

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Thursday, September 29th 2011

To Care For All

Medical professionals in Bahrain are being sentenced for treating wounded protesters during this years unrest.

Thirteen doctors and nurses who treated anti-government protesters during demonstrations in Bahrain earlier this year have been jailed for 15 years for crimes against the state.

The Physicians and Nurses Faced A Military Tribunal.

Their seems to be a systemic nature and focus on denying those who opposed the government healthcare services in Bahrain. Intimidation forced many medical NGOs, including Doctors Without Borders, out of the country during the unrest.

[W]hat human rights activists call a particularly odious aspect of the Bahraini protests: the government’s systematic effort to deny medical services to wounded protesters — partly by jailing or intimidating the doctors, nurses and paramedics who have tried to treat them.

Many medical workers in Bahrain are often too frightened to help protesters, activists say, and the wounded themselves are often too frightened to seek help, fearing they will be arrested.

At the height of the protests, led by the kingdom’s Shiite majority, seeking more rights from the Sunni monarchy, security forces commandeered the Salmaniya Medical Complex, Bahrain’s largest public hospital. Dozens of doctors and nurses who treated protesters were arrested.

In a report last month, Human Rights Watch said the crackdown included “attacks on health care providers; denial of medical access to protesters injured by security forces; the siege of hospitals and health centers; and the detention, ill-treatment, torture and prosecution of medics and patients with protest-related injuries.” It called the attacks “part of an official policy of retribution against Bahrainis who supported pro-democracy protests.”

Wednesday, September 28th 2011

Freedom From Pain

I like Al Jazeera, I think it does some really good reporting. They have a documentary series called People & Power which a couple of months ago ran a piece on pain control in the developing world.

The conclusion of the piece is really incredible. They find that the main obstacle to pain control for patients in most of the world is not costs or drug availability, it is the stigma of opiates and the war on drugs.

Overall, Freedom from Pain reveals that bureaucratic hurdles, and the chilling effect of the global war on drugs, are the main impediments to a pain free world. Patients will continue to suffer until global bodies actively work with countries to exclude medical morphine from the war on drugs, and change the blunt drug laws that curtail access to legitimate medical opiates worldwide. Uri Fedotov, the executive director of the United Nations Office of Drugs and Crime, admits in the film that the war on drugs is cutting people off from pain medication, but offers little in the way of concrete proposals for changing the status quo.

If you have the time it is well worth the 30 minutes to watch the piece.

Tuesday, September 27th 2011

More On Work Hours

Currently non-intern physician residents are limited to working 320 hours in any four week period, 24 hours of patient care in any one continuous setting and most have 4 days off in any four week period amongst other rules.

The history of medicine’s self governing bodies limiting resident physician work hours in a patient protection bid has a long history, as do my complaints about such.

But I thought it worth reiterating one of the major problems with these work hours. They can only be policed by individuals who are largely negatively impacted by their violation.

Say you’re a obstetrics/gynecology resident at a program that has some rotations that regularly violate the 80 hours/week (averaged). Let’s say you, and all the other residents in your program, report those violations. That is the only way that programs (and thus medical schools and the ACGME) learn about violations…they ask their residents to report them. Mix in some other things and before you know it your program is on probation from the ACGME and then, a few years later as the work hour violations continue despite best efforts, your program is shut down.

All in the name of patient safety. Only there is evidence, despite our best intentions, that restricting resident work hours has done nothing for patient safety.

And so now you are an out of work ob/gyn resident who can only blame yourself for self reporting those duty hour violations. Now you have to go out interviewing across the country to find another residency program, costing you potentially tens of thousands of dollars. It’s true that your funding for your resident position (your salary) can travel with you as you look for a new residency program and that the ACGME will almost universally provide a waiver to any program that accepts you to increase the size of their residency program and so your odds of finding another residency program to accept you are high, even if you’re in a competitive specialty. However, that isn’t guaranteed and there’s a small chance you may not find another ob/gyn residency to accept you. Even if you do it means packing up your family and your belongings, leaving your friends and moving cross country.

There’s some evidence that the majority of residents continue to routinely violate duty hour rules, largely without complaint. For one, I’m not sure they see the adverse effects of doing such. For two, knowing the light at the end of the tunnel they swallow the long work hours. And, for three, reporting those violations most negatively impacts the resident physicians themselves.

This isn’t a call for some dramatic shift in how we track resident physician work hours or for mitigating the effects of program violations on residents. This is a call for some return to sensibility and some loosening of the work hour restrictions in the first place.

A pipe dream but I’ll dream it.

Monday, September 26th 2011

Optic Nerve

It’s fair to say that vision is the most important sensation, the one from which we draw the most information.

The first order neurons of the visual pathway are the rods and cones lying deep in the retina.

On the diagram light would enter from the left, pass through the cornea, lens, vitreus humor and multiple layers of the retina to reach the first order neurons in the pathway. Rod cells are peripherally located cells with a low activation threshold, some responding to single photons. They are primarily associated with “night vision” and peripheral vision. Many rod cells may converse on a single second order neuron. This convergance of data means that the acuity of rod cells is not nearly as great as the more centrally located cone cells which converge nearly one to one on second order bipolar and amacrine cells.

The physiology of the activation of rod and cone cells is complex but here is a good very basic summary.

The short bipolar and amacrine cells in the retina relay the signal to the third order ganglion cells. The long axons of the ganglion cells converge to form the actual optic nerve.

The axons converge at the disc and form the optic nerve which exits posteriorly where it becomes myelinated and takes up the dural covering of the brain. The nerve exits the orbit at the optic canal. The tracts within the optic nerve are grossly somatically organized.

Generally the temporal fields of both retina travel laterally in the nerve and the nasal fields from both retina travel medially. Even this gross simplification takes some thinking about. Essentially objects of focus in the right visual field project onto the nasal fields of the right eye and the temporal fields of the left eye.

This is something to think about as the optic nerves come to the optic chiasm. At the chiasm approximately half of the ganglion cell axons will decussate. Primarily the axons carrying information from the nasal fields decussate. Functionally what you end up with is information from the right visual fields(temporal fields of the left eye and nasal fields of the left eye) in the left optic tract and information from vision to the right (temporal fields of the right eye and nasal fields of the left eye) in the optic tract on the right.

However, because the lens inverts the image prior to it reaching the retina, things you see to your left actually end up as information traveling through the left optic tract and vice/versa.

The first branches from the optic tracts travel to the superior colliculi and the pretectal area. These represent the afferent limb of the pupillary light reflex. They will synapse on the pretectal nuclei which will send axons to the accessory nucleus of the third nerve, then on to the cillary ganglion, then on to the sphinter pupillae muscle causing narrowing of the pupil.

The majority of the axons in the optic tracts however continue on the lateral geniculate bodies in the thalami.

The above image sourced here.

The neurons in the lateral geniculate body send axons which make up the optic radiations which run posteriorly around the temporal and occipital horns of the lateral ventricles to the occipital lobe, particularly the medial surface, Brodmann Area 17.

The primary clinical considerations are understanding how lesions along the pathway might manifest in terms of visual field deficits.

Friday, September 23rd 2011

Seeing What You See

God bless functional MRI as it proceeds to do everything from predict our future behavior to tell us whether we’re lying or not.

Now making the rounds in the international media are reports of a study published this week in Current Biology by a group out of the University of California.

While volunteers watched movie clips, a scanner watched their brains. And from their brain activity, a computer made rough reconstructions of what they viewed.

[...]

For now, the reconstructed movie clips are only crude representations, loosely mimicking shapes and movement, but not nearly detailed enough to show that a blurry human-like figure represents the actor Steve Martin, for example.

As the video at the top of the post shows very cool. However the work is hardly arising de novo. It builds off of work out of Japan that could accurately reconstruct still images patient’s stared at based off of fMRI data. Here’s one of their major papers out of Nature.


Japanese Mind Reading Technology by NTDWorldNews

I’m not sure of the incredible limits of what we’re going to be able to do with functional MRI by the time my career as a physician is over.

Thursday, September 22nd 2011

Predicting Outcome After Traumatic Brain Injury

Background
The Corticosteroid Randomization After Significant Head injury (CRASH) trail was a huge international double blinded randomized trial which collected a huge cohort of patients suffering traumatic brain injuries with GCS less than 14 on presentation and presenting within 8 hours of injury and randomizing them to receiving a 48 hour course of methylprednisolone versus a placebo. The final results were published in The Lancet in 2005.

As if that was not enough the database collected for the study was the largest, most complete database of patients following head injury in the world. It included more than 10,000 patients from across the world and had a very high rate of follow up through 6 months. This database was used to create a prognostic model for outcome following head injury. Published in the British Medical Journal in 2008 the CRASH model has become one of more widely cited outcome prediction models in clinical practice when dealing with patients with head injury.

MRC CRASH Trial Contributors. “Predicting Outcome after Traumatic Brain Injury: Practical Prognostic Models Based on Large Cohort of International Patients.” Bmj 336.7641 (2008): 425-29

The original paper is available for free as full text on the BMJ website.

Design
This was a retrospective review of outcome of a large cohort of patients.

The database included 10,008 patients originally collected for the CRASH Trial. The database contained information on a large number of variables but the prognostic model focused on 9 initial variables: age, sex, etiology of the trauma, time on presentation, GCS on presentation, pupil reactivity on presentation, results of CT scan, whether the patient had a major extracranial injury, level of per capita income in the country where the injury occured.

They prognosed to two outcomes death within 14 days of injury or outcome at 6 months as measured by the Glasgow Outcome Score which they dicotomized into favorable outcomes (moderate disability or good recovery) and unfavorable outcomes (dead, vegetative state or severe disability).

They developed two models with the above variables: a basic model which excluded the findings on CT imaging and a CT model which included them.

Internally they validated the two models using bootstrap resampling. And then they externally validated the model using the 8000+ patients suffering head injury included in the independent International Mission for Prognosis And Clinical Trial (IMPACT) database. The original description of the IMPACT Trial is here on PubMed.

Results
All nine of the variables included in the final two models independently had strong associations with both outcomes (death at 14 days and poor outcome at 6 months). The table showing the odds ratios for each variable can be found here.


Regression of outcome of model including CT scan findings

After this internal validation they compared their model to outcomes observed in the IMPACT Trial blinded.


CRASH model predictions of outcomes for patients enrolled in IMPACT versus variable outcome

It showed good discrimination in the external validation with a C-score of 0.77 (essentially the area under the reciever operator curve). And for the basic model and the CT model in high income countries there was very good calibration by the Hosmer-Lemeshow test.

The authors have published a calculator with predictive outcomes based on the regression. The calculator gives odds for death at 14 days and poor outcomes at 6 months based on both models.

Critique
The sample size of this study is legitimate and one of the stronger points of it. The database appears well maintained and exceptionaly complete considering the number of patients and the challenges of coordinating data collection across continents. Looking at the demographics it appears relatively representative. As well the follow up to 6 months is a legitimate end point for the goals of the study and the sample included a great number of patients to that end point.

The outcomes measured to seem clinically relevant and were set prior to the models being designed. The variables included in the regressions as well have previously been validated at predicting outcomes in other smaller studies and are clinically readily available.

The study found no difference in outcomes based on treatment, including the randomization to steroids or placebo in the trial itself, which is an important consideration.

It is true the CT model in particular showed comparatively poor calibration for patients injured in lower income countries. Even there however the Hosmer-Lemeshow measure isn’t particularly off. The smaller sample size of patients with readily available CT imaging findings may in part explain such.

The major critiques otherwise of the study seem to be those available to be leveled at all published prognostic models. Generalization is a difficult thing especially to individual anecdotal scenarios. However for a study with in vivo data from patients seemingly encountered early following representative head injury and undergoing real world salvage attempts the model shows remarkable, if not perfect, calibration and discrimination.

Conclusion
The models developed from the CRASH trial are very likely the “best” available prognostic models for predicting outcome early after traumatic head injury. The calculator published by the authors appears a valid and useful tool for any health care provider encountering significant neurotrauma. A “better” prognostic model for the prediction of outcome early after head injury seems unlikely.

Wednesday, September 21st 2011

Establishing Immediate Trust

I’ve written before about a sense of urgency sometimes lacking amongst patients and family and friends when asking permission for surgery. The majority of the time that appears to come from being overwhelmed, rarely it comes from a lack of trust.

I was thinking about situations in which physicians need to establish trust in very short order. I suppose that’s always the case in the patient-physician relationship. But there’s something to be said for the acuity of a hospital visit and what things like resident work hours, increased physician hand offs, co-management of patients between different physicians have done for the inpatient-physician relationship and what it means for establishing trust during a scary period for most people – when they’re in the hospital.

Last night, for example, I was cross covering at the county hospital. Basically I’m on rotation at another hospital, but because the county hospital, with its high level of neurotrauma, is the only participating facility in my residency that we take in house call at they need residents at the other facilities to come take call there some nights.

Not quite inevitably but often there are inpatients at the county hospital who are going to the operating room the next day and who have not been consented for surgery. And so that responsibility falls to me overnight.

This is a situation where I’ve never met this patient before, haven’t participated to this point in his care and in our first encounter I’m going to go over, amongst other things, what potentially horrific sounding things could happen to him during brain surgery.

It’s not easy presenting it with some confidence, humility, frankness to someone you’ve just met and leaving the situation with them feeling confident in the major step they’re taking tomorrow. I’ve certainly bungled it, and seen many another physician bungle it, even when they have a good pre-existing relationship with the patient.

I think the key is being confident, friendly but professional and dedicating some time to explaining the situation.

That may seem obvious, but sometimes the response on a busy cross cover night is to rush the situation. The patient usually knows they’re going to surgery tomorrow and has a general idea why and what for. Sometimes amidst the ICU and the consults the idea is to do the consent as quickly as possible and move on.

Being frank about who you are, your role in the introduction, describing the surgery and then being frank and honest but apologetic and realistic in the risks are good strategies for making patients as comfortable as possible as they contemplate surgery the next day. Doing it earlier, rather than later in the evening is also a good move.

And then poof, after such an important life discussion you’re gone. As for that patient I consented last night there is a good chance I may never see him again. That probably says something about physician coverage, work hours and the like but I’m not sure what in full.

Tuesday, September 20th 2011

Depression and Back Surgery

There are strong psychosocial components to pain syndromes. That isn’t a disparaging statement or a claim that pain is anything but real and each individual patient’s unique experience. But I feel that sometimes recognizing that major psychological component of pain and putting it into the decision algorithm for or against surgery is taboo.

The fact is you probably shouldn’t perform a back fusion surgery on a smoker for pain with instability. And its becoming clear that maybe you shouldn’t perform decompressive surgeries for pain on patients with poorly treated depression.

Strong independent associations were seen between depression burden (the sum of preoperative, 3-month and 6-month BDI scores) and 2-year disability, symptom severity, and poor walking capacity.

[...]

Depressive symptoms interfere strongly with the ability of patients to obtain an optimal surgery outcome. Treatment models including the assessment and treatment of depression are encouraged.

This is a tough decision, you’re playing with the chicken and the egg here seeing as it is often a difficult assessment how much a patient’s pain syndrome is contributing to their mental health issues. But the fact is back surgery is major surgery with many, many serious risks and you should want the risk/benefit from the surgery to strongly favor the latter.

Monday, September 19th 2011

No Drugs For You

Major pharmaceutical manufacturers are stopping delivery of unpaid for drugs to funding starved public healthcare systems in struggling Eurozone countries like Greece.

Greek hospitals have large debts to many drug companies, according to the Hellenic Association of Pharmaceutical Companies, or SFEE. As of June 30 this year, Greek’s state-financed hospitals had paid for just 37% of the €1.9 billion ($2.62 billion) worth of drugs delivered by SFEE member companies in the 18 months to June, 2011, the organization said in a recent report.

[...]

Early this year, Greece tried to clear some of its pharmaceutical debts by giving companies government bonds. “We didn’t have a choice. Everybody got government bonds. The question was, you got nothing or you got government bonds,” Mr. Schwan said, adding that Roche sold the bonds immediately.

[...]

Patients at some hospitals now must take their prescriptions to a local pharmacy, and, in the case of intravenous or injected cancer drugs, bring them back to the hospital to be administered, he said.

Mr. Schwan said patients haven’t been deprived of their medication as a result of the new measures, which he said Roche may need to adopt in Spain, as well. Some state-funded hospitals in Portugal and Italy have also fallen far behind on payments, he said.

There are hospitals “who haven’t paid their bills in three or four years,” Mr. Schwan said. “There comes a point where the business is not sustainable anymore.”

I can’t say, the little I know, I blame the big pharmacutrical companies. I know their margins worldwide, but why, as a for profit enterprise, would you continue these hand outs? For instance Novo Nordisk recieved significant criticism last year when it pulled the FlexPen from the Greek market over a unilateral move by the Greek government to start paying less for medicines. As the Eurozone crisis widens however I’m not sure how far we should expect healthcare corporate compassion and loss to extend.