Archive for December, 2010

Body Image, Ideal Body Weight and Overall Health – A Message from the Nutcracker’s Ringer and Macaulay Fiasco.

Friday, December 31st, 2010

Jennifer Ringer

After the season of over-indulging, during which most Americans gain 5 to 15 pounds, there is usually the New Year’s resolution to lose 10 to 15 pounds (or more!).  Television commercials switch from luscious desserts to weight-loss products, the ab-roller and the amazing Bow-flex personal gym.  Department stores advertise every possible gym and exercise apparel as being “on sale” to cash in on the hype. It goes on and on; every year it’s the same.  For gym-goers, the gym is much more crowded than ever with increased wait-times for treadmills, elliptical trainers and exercise bikes.  One New York critic, however, wasted no time in telling a professional ballerina that she needed to cut back on her eating!

Alastair Macaulay, writer and critic,  attended and reviewed George Balanchine’s “The Nutcracker” at the New York Ballet.  His comments regarding Jenifer Ringer, the prima ballerina who portrayed the sugarplum fairy, stimulated much press, outrage and commentary.  Mr. Macaulay stated that Jenifer Ringer “…looked as if she ate one too many sugarplums.”  Miss Ringer appeared on the TODAY show on December 13th, and, if anyone saw the interview, she is far from being overweight! Just Google images for Jenifer Ringer, and one would be hard-pressed to criticize this beautiful young lady for being overweight.  It takes a lot of stamina, muscle strength and skill to perform in such a role as this ballerina, qualities that cannot be present when one is “starved”, anorexic or obese! Dr. Rebecca Puhl, clinical psychologist and Director of Research at the Rudd Center for Food Policy and Obesity at Yale University, wrote a blog for Medscape addressing this very issue.

So what is this stereotype? Did it actually start with Barbie dolls?

Some would say it did. The Barbie doll, marketed by Mattel, provides an image to very young girls of the “ideal” body type. Well, medical research has proven that not all body types are the same, and despite hours of exercise and regimented eating, some will never achieve the “Barbie-body.” One of the problems is that some young women actually die trying to achieve this ideal.  Anorexia and bulimia are both psychiatric conditions that have serious negative impacts on the body and its major organ systems.  Many models, and even ballerinas, struggle with body image as driven by the media and critics like Mr. Macaulay.  But so do many high school and college women!  The National Eating Disorders organization estimates that nearly 10 million women and 1 million men struggle with eating disorders in the US. For many of these individuals, it is a life-long battle with life and death!

WomensHealth.gov is a government source for women’s health topics, of which “body image” is a serious topic.  The site discusses issues such as cosmetic surgery, dieting, over-eating, and over-exercising.  The site also offers additional sources for being kind to your body and fact sheets related to the various eating disorders.

In the United States, there is currently an epidemic of obesity.  It is much publicized, and changes are being made both nationally through Congress and in local school systems where healthier options are provided for school childrens’ consumption.  Some school systems have even limited the number of birthday parties and treats allowed on a monthly basis.  This is NOT a bad thing!  When one considers the complications of morbid obesity alone, the burden on healthcare and the morbidity and mortality of the associated conditions is staggering!  Diabetes, congestive heart failure, respiratory failure and cirrhosis from fatty liver disease all come to mind. Then, apply some of the surgical procedures available today (namely gastric bypass) with the associated morbidity and mortality of these procedures, and the statistics related to surgical complications and even death rise even more rapidly.

So, what is the bottom line?

MODERATION!  EATING RIGHT!  EXERCISE!

Maintaining an ideal body weight is very important to overall health, but overall health cannot be achieved through diet alone. One must exercise routinely.  This is what should be taught in schools and in the home! Binge exercising in January as part of a New Year’s resolution, only to lose one’s way as the year progresses and life gets busier, is not much different than binge-eating or binge-dieting. We are talking about lifestyle changes that incorporate healthier food choices and routine exercise on a daily basis. Given that we are all creatures of habit, this is a change that is not an easy one!  It needs to start as early as possible and be maintained as long as possible.

We also need to stifle the comments of the Mr. Macaulay’s of this world; critique the performance, not the poundage of an ideal body weight ballerina who is in excellent physical condition!  We, as a society, cannot continue to promote thinness, per se.  Promote ideal body weight, physical conditioning (including flexibility) and healthy diets, and it must start at home!

What did you think of Mr. Macaulay’s comments? Do you know someone who suffered with this body image problem? How did they work their way out of this nightmarish existence?

Related Posts: Alistair Macaulay speaks out after the firestorm he created.

Neck & Back Pain: When is it something more serious?

Wednesday, December 22nd, 2010

Statistically, 4 out of every 5 adults under the age of 50 have experienced at least one episode of neck or back pain.  For most people, the symptoms resolve in a reasonable period of time with or without intervention.  For others, the symptoms become chronic, often leading to surgical procedures and even disability.  Sometimes, there is a specific identifiable incident that incited the pain while in other cases, no particular injury or overuse syndrome could be identified.  Neck and back pain are one of the most common complaints leading to medical evaluations in the emergency room, urgent care center or primary care physician’s office; they are also a significant cause of lost time from work, lost wages and productivity, and high expenditure from a healthcare perspective.

Neck and back pain are symptoms of an underlying problem.  The majority of the causes (~97%) are purely mechanical, that is related to the mechanics of movement of the neck or back, involving the bones, muscles, ligaments, discs and joint spaces.  They include such diagnoses as lumbar strain/sprain, degenerative disc disease, herniated discs, spinal stenosis, spondylolisthesis, osteoporotic compression fracture and traumatic fractures.  Some of these, obviously, are more serious with potential neurologic sequellae than others.  Any condition that results in compression of the spinal cord can cause permanent neurologic injury, including paralysis; these include fractures, stenosis and significant spondylolisthesis. Causes include acute traumatic injuries (car accidents, falls, direct blows), overuse syndromes, poor lifting techniques, poor posture, chronic degenerative arthritis leading to spinal stenosis and spondylolisthesis, and osteoporosis.

The remaining 3% of causes of neck and back pain are considered non-mechanical, but they can be further divided into non-mechanical spinal conditions (1%) and visceral (internal organ-related) conditions (2%).  Of the non-mechanical spinal conditions, neoplasias/malignancies comprise 0.7% while infections and inflammatory arthritides (inflammation of joints due to infectious, metabolic, or constitutional causes) comprise the remaining 0.3%.  Of the 2% visceral complications, etiologies are potentially due to vascular problems (aortic aneurysms, retroperitoneal hemorrhage, coronary syndromes, etc.), prostatitis, endometriosis, pelvic inflammatory disease, kidney stones/infections, pancreatitis, cholecystitis or ulcer perforation.  Thus, the sub-categories of non-mechanical neck and back pain have very small incidences in the global sense, but they are potentially more serious with more ominous consequences, including paralysis and death, making them diagnoses not to be missed or ignored.

So, how can one tell the difference between mechanical versus non-mechanical neck or back pain?

As a general rule, mechanical neck/back pain, since it is related to movement, is typically worse with movement or specific body positions and better with rest or lying supine without the burden of one’s weight causing an axial load on the vertebral column.  Non-mechanical neck/back pain is relatively constant and not related to body position or movement.  Pain in either case can be sharp or dull/aching, and each can have instances in which there is neurologic involvement causing pain to radiate along the nerves that exit the spinal column.  In the neck, nerve pain typically radiates to the arms causing pain, numbness and sometimes weakness.  In the upper to mid-back, nerve pain typically radiates to the anterior chest and abdomen.  In the lower back, nerve pain typically radiates into the pelvis, genital area, and especially the legs.  Radicular pain can be either one-sided or bilateral, the latter of which is more ominous and indicative of spinal cord compression as opposed to a single peripheral nerve root.

What are the “red flags” that raise concern for more serious problems?

There are specific risk factors that, when present, raise concerns for more systemic disease processes.  A history of cancer, for instance, increases the likelihood of the pain being related to a metastatic lesion or tumor.  Presence of a fever increases the likelihood of the pain being related to an infectious etiology.  Unexplained weight loss increases the likelihood of the pain being related to either a primary malignancy or metastatic cancer.  A history of intravenous drug use or even diabetes increases the risk for an acute or chronic infectious cause.  Blood in the urine can indicate a malignancy or other kidney-related problem.  Swollen glands can be indicative of a malignancy or infectious problem.  Anemia can be indicative of an underlying malignancy or vascular problem.  Rashes are often associated with rheumatologic or auto-immune problems that often involve the joints.  Chronic steroid use or other immunosuppression can increase the risk of infectious causes or osteoporosis with compression fracture.  Obviously, a history of trauma increases the risk of fracture, disc rupture/herniation and ligamentous injury leading to spinal instability, but it can also be a cause of intra-abdominal injuries or retroperitoneal injuries that present as back pain.  Any time there are neurologic deficits (numbness, tingling, weakness, muscle atrophy, etc.) beyond sciatica, the risk of nerve compression or spinal cord compression becomes higher.  Abdominal pain associated with back pain can be related to an intra-abdominal process (infection, abscess, aneurysm, ulcer perforation, etc.).  Neck pain that is associated with headache, fever and neck rigidity is often indicative of menigitis.

Overall, there are a plethora of potentially serious causes of neck and back pain.  One can see that the diagnosis of more serious conditions can be a little more complicated, especially since they are much rarer than the  common, everyday, garden-variety mechanical back pain without complications.  There are, however, a variety of clues that can lead one to an accurate and relatively rapid diagnosis.  The intention of this blog has been to introduce the topic and the dilemma faced by a provider when diagnosing these conditions.  Since the topic is broad and more complicated, a series of blogs dedicated to some of the more devastating etiologies of neck and back pain will follow.  The key to diagnosing any condition is an accurate and in-depth history and physical examination with keen attention to specific clues that are typically present.

Study reveals “staggering” statistics on Medicare patients who will die or be readmitted within one year of stroke

Wednesday, December 22nd, 2010

Today I came across an excellent post in theheart.org entitled “Death and readmission rates after stroke “staggering” for Medicare Patients.” As a general comment, if you are not familiar with this online journal, I would strongly recommend you register (it’s free). They post a number of excellent pieces on a consistent basis.

Dr. Gregg Fonarow and colleagues did a study examining the outcomes for 91,134 Medicare patients, who had suffered an ischemic stroke between April 1, 2003 and December 31, 2006. The researchers themselves described their findings as “staggering.” Here is the essential finding:

Almost two-thirds of Medicare beneficiaries discharged from the hospital after suffering an ischemic stroke die or are readmitted within a year.

Does the type of hospital make a difference?

While ostensibly not the major focus of the study, Dr. Fonarow’s research team did examine data to determine if the outcomes were significantly better if the patient was seen for the initial acute ischemic stroke at an academic center versus a non-academic (e.g. community hospital). The finding in this regard was not what I expected.

Rates were only slightly lower for academic hospitals than nonacademic centers. “That was surprising,” said Fonarow. “Whether a hospital was academic or bedside or, more important, a joint commission primary stroke center really did not make a large difference in outcomes.”

The impact on the healthcare system is obvious and alarming

I don’t claim to have any expertise in statistical analysis or application of such data to a system-wide root cause analysis. That being said, does it really take a statistician or mathematician to grasp the import of this “staggering” data? If you or someone you know is on Medicare and has suffered an acute ischemic stroke, there is a 2 out of 3 chance you (or the person you know) will be readmitted or die within one year of suffering that stroke!

The big questions: Why and What can be done?

Dr. Fonarow readily admits that the data he collected does not lend itself to the ultimate answers. What he does note, however, is that while further studies are clearly warranted, since more than one-half of the cases for readmission analyzed involved non-cardiovascular causes, “there’s room for better secondary-prevention efforts.”

“When you looked at causes of readmission, in many cases it was not a recurrent stroke or cardiovascular event but other comorbid conditions, such as pneumonia, falls, and GI bleeds,” he said. “It shows you that when caring for someone after a stroke, managing these comorbid conditions and related risks is going to be critical.”

He added that the period after discharge for an ischemic stroke offers a “window of opportunity” for interventions to reduce the burden of post-ischemic stroke morbidity and mortality.

The information shared by Dr. Fonarow is unequivocally “staggering.” One can only hope that further system-wide studies are performed soon to identify what improvements can and need be made in the delivery of health care to this population to reduce such loss of life and burden on the healthcare system secondary to readmissions.

What’s your reaction to Dr. Fonarow’s study? Are you aware of any data that is known for death and readmission rates in the non-Medicare population? If there is a significant difference in death and readmission rates between Medicare and non-Medicare patients, what is being done in the non-Medicare population that can be adopted for all patient populations?

Image from mountnittany


Confusion with Advanced Directives: Palliative Care, End-of-Life & Hospice Care

Tuesday, December 21st, 2010

In a previous blog, I raised the issue of “Advanced Directives” and how, according to a Medscape physician survey, physicians do not always honor these legal documents.  One of the “excuses” cited the definition of futility in treating a terminal medical condition, arguing for palliative care as opposed to withdrawal of care.  Obviously, confusion exists amongst these providers as to what constitutes comfort care versus unnecessary prolongation of life and/or exposure to unnecessary procedures in a patient with a terminal condition.

Palliative, End-of-Life and Hospice Care

Palliative care is essentially comfort care.  To “palliate” means to “ease” or “make less severe” – therefore, medical care that is designed to palliate symptoms of a particular disease is care designed to ease or lessen the severity of symptoms associated with that disease.  It can be in an acute condition, a chronic condition or even a terminal condition depending on the stage of the illness.  Some of the symptoms often palliated are nausea and vomiting (chemotherapy, cirrhosis), anorexia (cancers, AIDS), pain (rheumatoid arthritis, cancers), shortness of breath (COPD/emphysema, interstitial lung disease), dizziness (Meniere’s disease, multiple sclerosis), incontinence (spinal cord injuries, stroke), constipation (inflammatory bowel disease, chronic pain syndromes), and many others.  There are various treatments available for the treatment and/or management of these symptoms, but they are not necessarily curative of the underlying condition.  Some chronic conditions, like Rheumatoid Arthritis, are manageable but not necessarily curable, so the treatment rendered is to palliate/lessen the symptoms and hopefully put the auto-immune disorder into remission for a period of time.  Rheumatoid Arthritis, however, is NOT a terminal condition; patients usually die of complications or other co-morbidities.  Palliative care can also incorporate a variety of specialties with overall coordination of care that involves communication with the family, spirituality and emotional support.  Palliative care is a critical component of end-of-life and Hospice care.

End-of-Life care is a well-coordinated approach to end-of-life issues when a condition is deemed terminal, such as incurable metastatic cancer, end-stage multiple sclerosis or even liver cirrhosis when organ transplant is not an option.  Life expectancy can vary widely, with physician guestimates being greater than 6 months (as much as one year or more).  End-of-life care typically incorporates palliative care to ease the symptoms of the disease process as well as counseling services, emotional support and even spiritual support.

Hospice care is end-of-life care, incorporating palliative care, reserved for the last 6 months of life or less.  Care is shifted from curative therapies to pain management and ease of other symptoms of illness.  There are many Hospice programs that offer services in a variety of locations, all of which is dependent on the patient’s and the patients’ family’s wishes. They can be rendered at home, in a nursing home, in the hospital or in a dedicated Hospice facility.  Services provided by these organizations can even include basic housekeeping, personal hygiene care, grocery shopping, and even companionship in addition to the palliative medical therapies.

Where do advanced directives come into play?

Advanced directives can affect every one of these aspects of care.  They reflect the patient’s or the patient’s medical power of attorney’s wishes regarding palliative care modalities, end-of-life care and Hospice care.

About.com’s website on palliative care offers a great example of palliative care that transitions to end-of-life and at-home Hospice care for “Aunt Tilly”.

A patriarch of the family has essentially been healthy his entire life, shoveling  snow and cutting grass into his 85th year of life.  Things shift during the 86th year, and he develops congestive heart failure which has triggered multiple falls and syncopal episodes, presumably from hypoxemia.  There are several hospitalizations to evaluate his condition with institution of multiple medical therapies/drugs to stabilize his condition.  Unfortunately, his heart is weak, and ultimately his kidneys begin to fail.  No advanced directives had ever been discussed, as with many people of his generation; fortunately, he remained of sound mind.  At first, everything was a whirlwind……medication infusions to prevent irregular heart rhythms, blood transfusions to address his anemia since the kidneys were no longer working properly to stimulate the bone marrow to make more red blood cells, and finally, dialysis???  Well, if the kidneys are not working very well, not filtering the blood to produce urine and not stimulating the bone marrow to produce RBCs, we have to fix this, right?  What was not mentioned was that blood transfusions have to be given with intravenous fluids, which then worsen the fluid overload and congestive heart failure making it even more difficult for the poor man to breathe.  Higher and higher amounts of oxygen are needed to keep him comfortable, while his body is swelling up with fluids.  So, STOP THE MADNESS!  This family patriarch, after being informed of the complicated nature of his essentially end-stage condition, opted to forego hemodialysis; he did not want to be hooked-up to a machine for 3 hours a day, 3 days a week, just to filter his blood in an attempt to garner perhaps 6 more months of life; that kind of life had no quality to it in his mind.  In addition, since the blood transfusions would only worsen his breathing, he refused any more blood.  He wanted to be kept comfortable with pain medications and oxygen which was done in the hospital; he did not want to be shocked (defibrillated) or resuscitated in any way.  Comfort measures were provided in the hospital where he was given a large, private room, and he passed away peacefully within 3 days; there were no restrictions on family visitation, and he was surrounded by those dearest to him.  A chaplain was available within minutes of his death to comfort the family and offer prayer to ease everyone else’s suffering and loss; this patriarch was already at peace and without pain.

In this particular example, it was beneficial that my family member was of sound mind to make his own decisions at the end of life with regard to blood transfusions and hemodialysis.  It would have otherwise been very difficult for the family to come to some kind of consensus.  It was also better, in this case, that he remain in the hospital since his wife was still living and would have to return to their home alone following his death; having her live in the house in which her husband of 67 years had died would have been too much for her to bear.  This emphasizes the importance decision-making while one is of sound mind.  Cancers can spread to the brain; toxic metabolites that accumulate when vital organs fail can render a patient confused or even comatose; acute strokes can also affect one’s cognitive capabilities, not to mention other organ systems (breathing, toileting, swallowing, etc.).

Advanced directives can be as precise or as vague as one desires.  It seems to me that the more detailed the directive, the less chance one encounters of a physician or care provider ignoring the directive or “interpreting” the directive in a way that confuses loved ones, exposing the patient to unnecessary procedures and/or life-extending treatments.

Have you ever had to deal with any of these issues – advanced directives, palliative care, end-of-life care or hospice care? What has your experience been? Do you have any suggestions that might be helpful to others, who may be faced with similar issues?

More on this topic soon: What constitutes a terminal condition?

Related Posts:

Advanced Directives: The Right to Die With Dignity. Does the Medical Profession Honor Them?

Making Your Wishes Known at the End of Life (NY Times article by Dr. Pauline W. Chen )

Image from mylocalhealthguide.com


The Reality of Medical Malpractice Lawsuits: Demystifying and Dismantling the Medical Profession’s Arguments

Monday, December 20th, 2010

A couple of weeks ago, Dr. Kevin Pho published a blog in which he argued that medical malpractices lawyers do not help improve patient safety. My mentor and good friend, Brian Nash, (a medical malpractice lawyer) posted a counter-blog, disputing the validity of Dr. Pho’s conclusion. As a result of these two postings, the two author’s agreed to post Brian Nash’s piece on Dr. Pho’s website – KevinMD.com. This posting, Open dialogue on medical malpractice and patient safety led to an amazing, extensive, thought-provoking and still ongoing public discussion about the role of physicians, lawyers and patients in promoting patient safety. The last time I checked, this discussion generated just over 190 comments

Although many topics were addressed during this discussion, I could not help but notice an underlying sentiment of distrust with respect to lawyers in many of the comments posted in support of Dr. Pho’s blog.  Statements like “lawyers don’t care about the quality of their cases as long as they make money,” or “the medical malpractice system is failing because most cases are filed over bad outcomes and not medical negligence.” Such comments reflect an overall attitude that medical malpractice lawyers are the reason why there is an alleged nationwide medical malpractice crisis.

This argument is terribly misguided and, frankly, based on a number of false assumptions about the practice of law. In part, the misunderstanding stems from the fact that most critics are not lawyers and, thus, not familiar with a lawyer’s everyday incentives, interests, limitations, and obligations. Although a law review article would be more befitting this subject, the following discussion outlines a few considerations that should hopefully illuminate what drives a lawyer’s analysis with respect to the type of cases that should be pursued.

Ethics

Let me begin with the consideration that is most important to me. Lawyers, unlike most other service providers in the workforce, are bound by a code of ethics.  If they don’t follow it, they can be disciplined and even disbarred.  It is as simple as this: in each state, lawyers are subject to a plethora of proscriptive and prescriptive rules. For example, in Maryland, each lawyer must comply with the rules of professional conduct. These rules govern virtually every aspect of legal practice (i.e. conflicts of interest, acting in good faith, etc). In addition to these rules, Maryland lawyers must also abide by local rules of court, the rules of civil procedure and a plethora of cases dictating how lawyers should act.  In this matrix of Rules, many rules directly or indirectly prohibit a lawyer from making frivolous claims, pursuing claims without a good faith basis, and taking unsupported positions during the course of litigation, among other things.

In the District of Columbia, relatively recent legislation requires the giving of a substantive (i.e. not just – I’m going to sue you) notice to the potential defendant(s), which outlines the essential theories of the claim. Failure to give some notice in timely fashion can – and often does – result in the dismissal of a lawsuit in which this notice was not given. Once filed, a patient-plaintiff is, in essence, bound by the same requirements of proving his/her case as in Maryland, but more on that later.

A cynic may argue that the rules are no good if lawyers are not willing to live by them. The assumption that most lawyers don’t care about the rules of professional conduct is just that, an assumption – and a misguided one at that! Most of us care deeply about our clients. Most of us are very proud to be lawyers, and the vast majority of us diligently and religiously comply with our ethical obligations.   You don’t have to believe me; call your state’s bar association for studies directly on point.

As in any other profession, a few bad apples give us all a bad name from time to time.  When this happens, other lawyers are quick to initiate disciplinary actions. In medical malpractice cases, the persons with the greatest incentive to report unethical behavior are the defendant health care providers and their lawyers.  As you may suspect, reporting bad behavior in an adversarial system is a bit more incentivized when compared with reporting among physicians, who practice in a collaborative and non-adversarial environment (i.e. the same hospital, practice group or health care system).

The Financial Realities

In addition to various ethical constraints, I am convinced beyond all doubt that a lawyer would have to be completely out of his/her mind to pursue a meritless medical malpractice case. Don’t forget that a law practice is a business just like any other business. The vast majority of plaintiff medical negligence lawyers practice in small firms. Operational and the litigation costs are very high (if you know physicians who testify as experts in medical malpractice cases, for plaintiffs or defendants, ask them what their hourly charge is to review medical records, give depositions and testify in court. It would be enough in an of itself to make you reconsider your career choice). Generally speaking, most medical malpractice cases (conservatively estimated) require between $50k and $100k to bring to trial. Additionally, each lawyer can only pursue a small number of cases to insure diligence, and yes, compliance with the ethical rules of professional conduct. Keep in mind that the vast majority of medical malpractice cases are contingency fee cases, which means that the law firm (where permitted by law and ethics) advances all of the costs. None of these costs are recouped if the case is lost.

The obvious question – or at least what should be an obvious question is: why would a lawyer want to invest his/her money in a meritless or questionable case?  The simple economic reality of a medical malpractice firm is that it can never afford to pursue frivolous or meritless claims.  Pursing even questionable cases is a good way to go bankrupt. When a frivolous case is filed, guess who is waiting on the other side of the aisle ready to devour it and the lawyer who filed it? Unlike plaintiff lawyers, defense lawyers get paid by the hour. Their spending power on litigation is enormous since they have the financial backing of multi-million dollar insurance companies and/or self-insured institutions.  Because defense lawyers get paid by the hour, they have every incentive in the world to use every known legal tool and maneuver to increase the costs of litigation and defeat the claims against their clients.

Simply put, survival of the fittest (and the smartest) is the name of the game when it comes to choosing cases for litigation.  Every plaintiff’s lawyer asks this question more than any other before signing a case: just how strong is the evidence of negligence? The last thing a lawyer wants to  do is spend thousands of dollars on a case that is frivolous and destined to fail.  When handled by lawyers who are experienced in handling cases of medical negligence/malpractice, if case is in litigation, believe me, it is as far from being frivolous as it can get. This doesn’t mean the patient/plaintiff always wins. It simply a matter of common sense – experienced medical malpractice lawyers screen cases vigorously and don’t (and certainly can’t) make a living out of filing non-meritorious lawsuits.

Procedural Requirements

Assuming that a lawyer foolishly chooses to represent a client with a weak or meritless claim, there are still a number of procedural requirements that are purposely designed to prevent such claims.  In most states, a number of procedural/jurisdictional thresholds must be met before a case can even be filed in court. Such requirements are specifically designed to weed out non-meritorious cases.

For example, in Maryland, a lawyer must obtain a very specific certificate and report from a qualified physician, specifying that the defendant health care provider breached the standard of care (failed to act reasonably under the circumstances) and that this breach of acceptable medical standards of care caused the patient-plaintiff’s injuries.  The case must first be filed with a special arbitration commission and have certifying expert certificates and reports before it can be filed in court.  Throughout litigation, a plaintiff is required to obtain supportive, competent opinions from a number of medical experts. These experts cannot just generally or vaguely support the patient-plaintiff’s claim. They must specifically establish 1) what the defendant  health care provider should have done to comply with the standard of care, 2) that the  defendant health care provider breached the standard of care, 3) that the breach in the standard of care caused Plaintiff’s injuries, and 4) what patient’s injuries actually are – not just sheer speculative damages. Such testimony can not come from the lawyer, his/her client, or a lay person; it must come from other physicians. Medical malpractice litigation is not possible without the participation of health care providers, who are willing to testify as experts on behalf of the patient. As if this was not enough, an expert’s testimony cannot be based on a guess, speculation, or conjecture. Each expert opinion must be expressed to a reasonable degree of medical probability, and it must have a scientific basis. These procedural requirements are just the tip of a very large iceberg designed to prevent meritless cases.

Don’t Buy Into the Myths

The simple truth is that real (those who know what they are doing in this specialty area of law) medical malpractice lawyers have very little – if any – incentive to pursue frivolous, weak or questionable cases. Such cases are expensive, they must be supported by other physicians, and they must survive the rigor and scrutiny of litigation.

I often hear people say that most medical malpractice cases are filed because of bad outcomes and not because of real medical malpractice.  I am utterly convinced that such a statement could not be further from the truth. If it were true, most, if not all medical malpractice lawyers would be out of business. That’s the hard, cold reality. Don’t buy into the myths that are many times at the core of this s0-called medical malpractice crisis debate.

Have you been a party in a medical malpractice/negligence lawsuit? Have you been a juror in a medical negligence case? Even been a witness in these cases? What has been your experience? Share your story – let’s get to the real truth of issues that should be at the core of the “discussion” – “debate.”

Image from procrastinationgods.wordpress.com

Related Posts:

Every Bad Outcome Does Not a Malpractice Case Make! Some Practical Advice

Malpractice System Doesn’t Improve Patient Safety – Oh Really?

Tort Reform or Just Plain Medical Care Reform: the debate continues as thousands are injured annually in US

Many Doctors Don’t Blow Whistle on Colleagues



Join us on FacebookTwitter and LinkedIn



Electronic Medical Records – Why Would Insurance Companies Be Concerned About Informed Patients?

Thursday, December 9th, 2010

According to a study conducted by Conning Research and Consulting, an insurance industry research group, hospitals, physicians and other health care providers may end up paying more for medical malpractice if they use electronic medical records instead of the “old school” paper chart. Why, you ask? Get this, because patients will have access to medical records that will be legible to more than just the physicians who write them.  Seriously, this is one of the major reasons presented in the report.

The study warns that more patients will choose to sue doctors because electronic medical records are easier to access. They are, of course, easier to read. Additionally, because it is easier to compile, update, and organize information digitally, electronic records generally contain a lot more information than is customarily included in a paper chart.

The report also mentions that the cost of medical malpractice insurance may go up because of litigation associated with the implementation and maintenance of computer programs that are used to create electronic medical records. Yet another reason advanced is that medical malpractice lawyers will seek to obtain costly production of metadata associated with electronic medical records.

The latter two reasons seem to be a bit attenuated considering that most jurisdictions have specific definitions of medical negligence, which do not include torts arising from the actions of IT personnel. If anything, such torts would include claims of general negligence, negligent supervision and product liability. In these contexts, a health care provider’s medical malpractice insurance premiums should not be affected. With respect to requests for production of metadata, I am not sure the group really appreciates how easy it is to obtain metadata.  Matadata is nothing but code that can easily be derived from digitally stored information and copied on a CD at a very low cost.

How the Health Care Reform Bill Comes into Play

A more credible justification for an increase in the cost of medical malpractice insurance is the increase in transparency as more and more healthcare providers turn to electronic medical records.  There is no turning back.  Pursuant to President Obama’s recently enacted Health Care Reform Bill, health care providers must adopt electronic medical records by 2012 in order to qualify for federal funds.  Because the new law will enable an estimated 32 million people to become insured by 2014, the implementation of electronic medical records is seen as a necessary measure to make medical services more efficient.

The Maryland Experience

In Maryland alone, an estimated 200 health care providers have elected to participate in the State’s electronic medical record system.  It is estimated that another 1000 health care providers will turn to electronic medical records in light of the available 25 million dollar in federal assistance to help pay for the transition.

The Endgame

We have said it many times before in our blogs – information is power. If electronic medical records will make it harder for insurance companies to hide behind illegible, confusing, and incomplete medical records, this is great news for all patients. Hopefully, as electronic medical records become more prevalent, we can begin to deconstruct the notion that most medical malpractice cases are over bad results as opposed to genuine negligence by health care providers.

Has  your medical care has been impacted by inaccuracies or ambiguities in your medical record. Tell us  your story.I

Image from medicexchange.com

For more information about the prevalence of injuries as a result of medical errors, see  our previous posting, Medical Malpractice – Serious Medical Errors: Failure of the System or Just Plain Ignorance

Come Join Us! – We’d love to connect with you

Facebook Twitter LinkedIn

Therapeutic Switching: Who is Really Ordering Your Medications?

Wednesday, December 8th, 2010

The Simple Life

Once upon a time, in a little town called Mayberry, all things were good.  No one really became ill, but if he did, the local town doctor would prescribe a medicine that was promptly filled by the “Ma & Pa” Pharmacy.  The patient got better because of the doctor’s expertise and the prompt response of the pharmacy to deliver the prescribed medicine to the ailing individual.

If “Mayberry” ever really existed, it certainly does not today.  How many times have you been to the doctor for an ailment and the medicine prescribed by that trained and licensed practitioner was denied by your insurance company once you took that prescription to the pharmacy?  Two, three, maybe even 7 days later, after much haggling with the insurance company, you finally get your medication.  Or, when you pick up your prescription from the pharmacy, after doing a little shopping to occupy your time while the prescription is being filled, the pharmacy technician notifies you that your insurance company would not cover the prescribed medication, switching it instead for a cheaper version (not even generic version of the same drug)!  Believe it or not, sometimes the patient is not even notified of the switch!  And this is acceptable practice?!?

What Role Does Your Health Insurer Play?

In April of 2010, Maryland MedChi, the Maryland State Medical Society sponsored a survey for its members titled, “Impact of Patient Health Insurance Protocols on the Maryland Physician’s Ability to Provide Care.” This survey assessed the distribution of perceived problems across the state of Maryland and the impact of insurer protocols on patient care, physician practice management and physician professional satisfaction.  An essentially universal frustration amongst respondents (95%) was the negative impact of insurance carrier requirements on regarding what physicians can prescribe or order on behalf of their patients.  Depending on the insurer, there were pre-approval protocols, step-therapy protocols, therapeutic switching and others that significantly affected the physician’s ability to treat his or her patient.  The problems related to time spent “haggling” with the insurer, communicating with patients to explain the problems, researching potential interactions with other medications or patient conditions, determining other similar failed therapies in an attempt to justify the prescribed therapy, and others.  There are even instances when a patient presents to the hospital for admission to a Hospitalist, and the physician’s office sends the patient’s current medication list to corroborate current therapies only to find differences between the patient’s medication bottles and the current list due to therapeutic switching by the insurance company.  Another even more potentially problematic perception of the physician respondents (59.5%) involved arbitrary delays or outright denials of prescribed therapies by the insurers.

What’s the Motive?

So, you ask what the basis is for this and how do the insurers get away with such mandates?  It all boils down to money.   Typically businessmen run insurance companies, and these businessmen are making business decisions without any inkling of understanding of medicine or seeing an actual patient.  Medical News Today recently reported a survey performed by Global Healthy Living Foundation, a non-profit patient advocacy group, that corroborates the Maryland MedChi findings:  ”…up to 70 percent of prescription medications are changed by health insurers, denying patients the drugs their doctors prescribed” because the substituted drug is actually cheaper.  This survey has identified serious sequellae to this business practice such as adverse reactions, poor recovery rates and worsening of chronic conditions.

The trickle-down-effect of these business practices, in addition to the physical effects on the patient, involve basic economics.  Physician practices have to spend more time in communication with the insurer, the patient and the pharmacy trying to address the problem, taking time away from patient care with n0 compensation (up to 60 hours a week in some practices according to the Maryland MedChi survey).  Some busier practices have had to hire experienced medical professionals (up to $75,000/year salary) simply to intervene with the insurers for pre-approvals and authorizations.  Additionally, patient adverse outcomes and/or worsening of chronic conditions often lead to hospitalizations, time off work, and even job loss.  This seriously affects work production, family income, and in some cases, can lead to permanent disablility placing additional strain on the already over-burdened Medicare/Medicaid system.

How Did this Happen in the First Place?

My question is, how did businessmen get into the practice of prescribing medications?  After all, physicians have spent 4 years in undergraduate programs, 4 years in medical school, and 3+ years in residency and sometimes 1+ years in fellowships to learn medicine and pharmacologic interventions.  These businessmen have perhaps spent 4 years as business majors (not a lick of medicine) and maybe 2 years in a Masters of Business program (still no medicine) in order to dictate what medications an ill patient is taking?!  So, when did these businessmen get their degree to prescribe?  Essentially, that is what they are doing!  And for all of our kicking and screaming, it is still going on in 49 states and the District of Columbia.

The Louisiana “Purchase” Law

The state of Louisiana has led the way in fighting this trend; they passed legislation last year prohibiting the insurance companies from switching medications once they are prescribed.  Currently, New York, California and Missouri have legislation pending that would prohibit this practice, as well.  More states need to advocate for their citizens with regard to such practices; it would also help the physicians and other mid-level providers who prescribe medications provide effective patient care.  The anticipated physician shortage (124,000 less providers nationally by 2025) can only worsen as physicians threaten to retire early, sell their practice or move to other more physician-friendly states (not to mention the move to “boutique medical practices” that would bypass insurers completely) due to dissatisfaction with the profession.  The general public needs to be calling, emailing or writing letters to their legislators to advocate for these changes!  ”Mayberry” may never exist, but we can make the system better for everyone.

What’s your story?  Has this happened to you or someone you know? What can be done about this?

Image from maliasmiles.com

Join us on Facebook, Twitter and LinkedIn

KevinMD.com speaks out on medical malpractice and its lack of effect on patient safety

Tuesday, December 7th, 2010

Last week, Dr. Kevin Pho (KevinMD.com), posted a blog entitled The Malpractice System Doesn’t Improve Patient Safety. When I saw the posting that morning, I felt compelled to write a counter piece, which I did later that day.

I next wrote a comment on KevinMD.com’s page: “… I have posted a full reply via a blog that I invite you to read and comment on if and as you see fit:http://bit.ly/i5ophd. These are complex issues that do deserve an “open discussion.”

Later that day, Dr. Pho emailed me that he would take a look, which he did. What followed was a series of communications that led to our agreeing to cross-post these blogs so that our respective readers could view and comment on the role, if any, medical malpractice cases play in improving patient safety.

Dr. Pho (KevinMD) is an ardent believer in a no-fault system, rather than our current adversarial system. While I somewhat admire in principle the concept of such a no fault system, it has never taken root in this country on any large scale basis, yet medical malpractice goes on at an alarming rate every day.

Dr. Pho and I are cross-posting in an effort to have that “open discussion.” To that end, I present to you Dr. Kevin Pho’s original blog:

The Malpractice System Doesn’t Improve Patient Safety

RE-POST. To see this original blog post by Kevin Pho, please see http://www.kevinmd.com/blog/2010/11/malpractice-system-improve-patient-safety.html#more-49306


Dr. Kevin Pho

Dr. Kevin Pho

There has been significant media attention on a New England Journal of Medicine case report where a surgeon, Massachusetts General Hospital’s David Ring, described how he operated on the wrong hand of a patient.

Here’s a summary of the case:

Ring, along with colleagues at Massachusetts General and Harvard Medical School, detailed the series of missteps that led to the wrong operation in the patient whose ring finger on her left hand was stiff, painful and sometimes got stuck in a flexed position, a condition known as “trigger finger.”

The patient, a Caribbean native who spoke only Spanish, was the last operation on a day that included three major surgeries and three minor surgeries, Ring wrote. No interpreter was available, so Ring, who speaks Spanish, was asked to translate for her.

Stress was high because several other surgeons were behind schedule. As a result, the patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment.

Ring spoke to her in Spanish, which was mistakenly interpreted by a nurse in the room as a “time out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred. In addition, there was a change in nursing staff in the middle of the procedure and a bank of clinical computers that diverted nurses’ gazes away from the patient.

In the world of medical error, where the truth is often clouded in secrecy, taking the bold step of publicly describing your mistake is a brave one. Some would say it’s long overdue.

There have been studies that show an apology and admission of error lead to a lower rate of being sued. Beyond the malpractice implications, it’s simply the right thing to do. So, why isn’t it happening more often?

In 2006, then-Senators Hillary Clinton and Barack Obama penned a perspective piece in the NEJM, noting that many errors in medicine were not due to bad doctors intentionally trying to hurt patients, but on system-wide errors — similar to Dr. Ring’s case:

We all know the statistic from the landmark 1999 Institute of Medicine (IOM) report that as many as 98,000 deaths in the United States each year result from medical errors. But the IOM also found that more than 90 percent of these deaths are the result of failed systems and procedures, not the negligence of physicians. Given this finding, we need to shift our response from placing blame on individual providers or health care organizations to developing systems for improving the quality of our patient-safety practices.

The malpractice system does a lousy job to improve patient safety (along with poorly compensating injured patients). The mere fact that the media is making such a big deal about Dr. Ring’s story is a testament to that. It’s that rare.  Every error should be discussed in the open, used to improve the care of our patients, and reduce the risk of future mistakes.

The fact that that’s not happening can be chalked up to the adversarial nature of our flawed malpractice system, which encourages secrecy, suppresses apologies, and does little to improve patient safety.

Kevin Pho is founder and editor of KevinMD.com, also on Facebook, Twitter, and LinkedIn.

Click below to link to Dr. Kevin Pho’s blog:

Kevin Pho's Website

Kevin Pho's Website

Final Note:

I want to thank Dr. Kevin Pho for letting us post this article on our site and thereby opening the discussion to our readers on The Eye Opener. He has been totally gracious in his communications with me on this topic, and I look forward to reading his future posts as I have done so many times in the past. What he and I have agreed to do? Disagree but respectfully so.

Dr. Kevin Pho and I welcome your comments on this issue. Do malpractice cases encourage patient safety? Are they counter-productive to that goal?

Every bad outcome or injury does NOT a malpractice case make! Some practical advice.

Sunday, December 5th, 2010

I recently came across a posting on the internet, which reminded me of a number of the type of calls we receive from people throughout the year. I thought it might be useful to share this post and some comments for you to consider about “whether you have a lawsuit” worth pursuing.

The post read:

I recently had to undergo epidural injections at a local pain management clinic. I was told the stats about the procedure and what signs to look for regarding problems. I had lower lumber injections, and the doctor that did the procedure told me that he punctured the spinal cord, thus releasing fluid. My problem was that I was sent home, to drive myself, and had made repeated calls to them regarding a monstrous headache that made even getting out of bed difficult. After almost 14 days, I finally called the local ER and was given totally different advice from the on-call doctor. I then finally recieved the blood patch….is there any liability here?

The balance of the post consisted of a lawyer responding to the question and some back and forth between the two, which ended – properly so – with the lawyer learning that the potential client had fully recovered, had gone through two weeks of hell and had incurred medical expenses for follow-up care to the tune of $3,750. The lawyer then told the person –

would that $3750 have to be spent regardless of the delayed treatment?

If so, you really don’t have a claim for much of anything. Even if it wouldn’t, to have a valid claim, you would also have to prove their actions were substandard in regards to the established standards of care. Generally, for little or no damages, you are not going to get an attorney to take on a case that will easily cost 10′s of thousands of dollars.

A Basic Problem – Pure Economics

Putting aside the issues of whether the original care giver violated a standard of reasonable care and whether that care caused injury, the pure economics of this situation does not justify the bringing of a medical malpractice case – “little or no damages…[for] a case that will easily cost 10′s of thousands of dollars.”

This type of injury, while clearly serious to the patient, luckily was not permanent in nature. Ask yourself, if you were on a jury hearing this case (assuming you found in favor of the patient-plaintiff by deciding that the doctor’s care was substandard and caused injury) - what amount would you award someone for two weeks of pain and suffering and no permanent injury?

Next, take your answer and do the following math:

  • The “10′s of thousands of dollars” the lawyer mentioned are real numbers that would be spent in a case like this. Expert witness fees (which can be enormous), deposition costs, costs to obtain the records, filing fees, etc. would easily be in excess of $50,000 by the time this case was concluded. Trust me – this is a conservative figure!
  • Legal fees – as many of you are aware, these cases are often taken on a contingency fee basis. The lawyer will charge a percentage (varying from as low as one-third to perhaps a high of forty percent).

Unfortunately, the economics of the case are a practical reality that must be and are addressed with these type of potential case inquiries. That doesn’t mean is easy to explain this to someone who is very upset (many times rightfully so) with the care they received or the attitude of the care giver.

The Client’s Perspective

Clearly no one wants to hear that the injury, inconvenience, medical expenses or pain they endured simply isn’t worth the lawyer taking. Some will read this and no doubt scream out – “You see, it is all about the money after all!” Well, I guess in a way it is – in part. Put yourself back in the shoes of the patient-caller. Let’s say their case is similar to the example (above) case: bills of $3,750, pain for two weeks, no permanency, no future care costs. Whatever number you came up with as our “juror in the box” for a verdict, now go ahead and subtract one-third to forty percent for the fee and – let’s say – $30,000 of costs. Why do I know that the resulting number is a negative one?

Hate to say it – but that’s the cold, hard reality of these situations. Imagine the lawyer trying to explain how the lawyer made some money but the client netted absolutely nothing! Not a place I’ve been or ever want to be.

So What Can This Person Do?

Well there are choices.

  • Try the old-fashioned method – try to work it out with the doctor or health care provider
  • If that doesn’t work, in most jurisdictions, you can always file a small claims action by yourself. The rules of evidence are relaxed in most jurisdictions and the judges tend to be quite liberal in their interpretation of the applicable laws – letting you have your day in court.
  • File a grievance with the local licensing board – they really do care and will take virtually all complaints seriously – at least that has been my experience in Maryland and the District of Columbia.

I strongly urge that you try option #1 – just see if you can sit down and discuss it with the doctor. If you are asked to sign some waiver form or agreement, before you sign it, see if you can have a lawyer take a look at what you’re signing first. You don’t want to waive any rights you might otherwise have. All that being said – try to work it out. It sure is a lot less stress and way less time-consuming. It also may go a long way in making the system work. Many doctors and health care providers are willing to at least listen. Watch your tone; don’t accuse them of being incompetent, uncaring or the like – just have a meaningful discussion and see if you can’t just work it out. If it doesn’t work, and you still believe you have been wronged, there are always options #2 and #3.

The “Suggestion Box”

I’m sure our readers would appreciate any useful suggestions by those who have found themselves in this situation. What approach(es) did YOU take? Did they work? I for one am always interested in hearing our reader’s suggestions – especially in for a topic like this. If they make sense, I assure you we’ll share them in a another post on a related topic. Take a moment and give us your thoughts.

Love to have you join us on our social networks: FACEBOOK - TWITTER - LINKEDIN - we’re just a click away!

Image from web.mit.edu

Advanced Directives: The Right to Die with Dignity. Does the Medical Profession Honor Them?

Friday, December 3rd, 2010

Anyone who has presented to a hospital with some type of ailment in the last 10 years or so has been asked about advanced directives, a living will and/ or medical power of attorney. What are these things?  What do they do?  Better yet, you may ask: what are they intended to do?

Advanced directives are legal documents prepared while an individual is of sound mind that indicates his or her wishes with regard to medical decisions to be made in the event that the same individual becomes incoherent, comatose, or unable to make decisions for themselves.

These directives are intended to instruct the care-providers with regard to various medical interventions should their condition warrant intervention. These can be as “simple” as resuscitation orders (being “coded,” “shocked,” being intubated and/or placed on a mechanical ventilator), or they can be more complex such as gastric feeding tubes if one cannot eat by mouth, dialysis should one’s kidneys fail (even temporarily), intravenous fluids or intravenous nutrition, blood transfusions, surgical procedures if the condition is deemed terminal, pacemaker/defibrillator placement, and many other form of possible medical intervention.  A living will is a form of advanced directive that is less precise, but it is a legal document indicating a patient’s wishes with regard to end-of-life or terminal-condition medical care without assigning a medical power of attorney. A medical power of attorney legally identifies an individual, who is intimately trusted by the patient to make appropriate decisions with regard to medical care in accordance with the patient’s wishes should the patient become incapable of making those decisions. The American Academy of Family Physicians offers good information with regard to these topics.

How well does the medical community deal with these issues?

This is all well and good from the patient’s perspective, but where do the physicians and other medical care providers fall in line with such legal documents and end-of-life ethical decision-making?  According to an electronic survey of 10,000 physicians in 2009 by Medscape on medical ethics, a physician’s personal bias and personal beliefs played a role in their approach to end-of-life care. A second article from Medscape dealt specifically with end-of-life issues.

When queried as to physicians recommending or administering life-sustaining therapy, when one judged it as futile (otherwise terminal condition), 23.6% of the respondants (~5,300) said “yes”; 37% said “no”; 39.4% stated that their decision was situational. The second end-of-life ethical dilemma involved whether the physician would withdraw life-sustaining care in accordance with family wishes even if the physician thought it was premature; the results showed that 54.5% would NOT withdraw care while 16.3% would withdraw care, leaving 29.2% deciding upon the actual situation. Let’s not overlook that astounding number – only 16.3% said they would follow the patient/family’s wish to withdraw care!

Various rationales were cited as to why these physician-respondents held such opinions. Some questioned the motives of the patient’s family members, while others noted fear of litigation for providing medical interventions.  The very definition of “futile” took on both curative and palliative connotations. The legitimacy of advanced directives were also questioned since these can become viewed as stagnant, especially if created 5 or 10 years earlier while the patient was in a different mindset. Keep in mind, people do change their mind, as do their perspectives with age, experience and wisdom. Likewise, advanced directives need to be changed, modified or simply updated periodically to reflect such changes.

The Terri Schiavo lesson (if there was one)

The Terri Schiavo story brought the whole end-of-life ethical decision-making into the limelight in 2005. This very sad story was in the headlines every day as legal maneuvering played out on national television. People were divided on “who was right,” and they will always be divided. These decisions are personal. They are difficult to share and discuss with family members, let alone physicians, who are admitting patients for the first time. In Maryland, physician assistants have been required to acquire continuing education hours in end-of-life care on a yearly basis for the last 10 years! This is a critical step in understanding the terminal stages of disease as well as the psychologic impact it can have on patients and their families.  Being comfortable with the discussion of death and dying, and doing so with dignity, is a key component in the management of end-of-life decision-making.

A Personal Experience

On a personal note, as a practicing physician’s assistant, I have been involved in end-of-life decisions with several family members as well as patients presenting to the ER in my 13-year Emergency Medicine career. The family members I have encountered have run the gamut from cancer-related deaths to brain hemorrhages to congestive heart failure leading to kidney failure.

One memorable, personal, family incident that sticks involved a relative, who had been living with a stroke, chronic lymphocytic leukemia followed by the development of large cell lymphoma. The two different courses of chemotherapy for the lymphoma resulted in damage to his heart, causing episodes of ventricular tachycardia (a life-threatening heart rhythm); however, the lymphoma had returned, and he couldn’t eat due to illness.  His options with regard to the cancer were extremely limited with an extremely poor prognosis, but the cardiologist wanted to insert a defibrillator in case the ventricular tachycardia re-occurred; the defibrillator would deliver an internal shock to the heart to return it to a normal rhythm and prevent death. Well, what is worse in this case – dying from a painless, silent heart dysrhythmia or suffering from malnutrition and systemic pain from the cancer that was everywhere in his body?  This situation required forcing both the oncologist and cardiologist to meet with my relative and with the our family to discuss each option and the prognosis. My relative decided he wanted to go home as soon as possible without the defibrillator; he died within a few days, silently and by all observations – peacefully. That was his choice, and it was honored after convincing his caregivers to abide by his decision.

It’s not Marcus Welby who will be taking care of you

Our current medical system is so over-burdened with patients at every level of care that the days of the old-fashioned family doctor who still admits his or her own patients and “rounds” on them every day (in addition to fulfilling their office obligations) are long-gone. Some patients are admitted to “hospitalists” (whom they have never met before) while others get admitted to whomever might be on-call in any variety of specialties (whom they also have never met before). Specialty medicine is just that……they focus on their particular specialty (as in the case of my relative). So, having a heart-to-heart discussion with your trusted family physician regarding your beliefs about end-of-life issues many (if not most) times never translates to the acute medical condition that lands you in the hospital. Even nursing home patients with DNR (do not resuscitate) forms can be ignored if they are not properly completed or the patient is not wearing the matching bracelet!

It seems that not only do patients need to be educated about the benefits of an advanced directives, living will and power of attorney, but physicians also need to be educated regarding compassionate, end-of-life and terminal care involving the whole being, such that they can communicate with family members, accept advanced directives and offer solutions to the dilemmas often faced by confused and emotionally drained family members faced with such situations.

Just as there should be dignity with life, there should be dignity with death.  It is the responsibility of both patients and providers to ensure this aspect of the human condition at whatever stage of a patient’s illness.

Have YOU ever been faced with such a situation?

Have you ever been faced with a situation where you were asked to make care decisions without an advanced directive? Have you ever found yourself in a situation where there was an advanced directive but the physician would not abide by it? Do you believe that it is a patient’s right to determine how they want to die and what medical interventions should be withheld under certain circumstances? How did YOU deal with such a situation?

Photo from enrichmentjournal.ag.org