Posts Tagged ‘standard of care’

So just what is ‘Defensive Medicine’? The other side of the ‘story’ being told.

Wednesday, July 14th, 2010

There is a recurring theme being pushed on the public that trial lawyers are driving up the cost of healthcare by making doctors so afraid of lawsuits that they are practicing “defensive medicine” in order to protect themselves.  A recent survey reported in the Wall Street Journal indicates that approximately 90% of doctors surveyed believe that doctors order more tests than needed in order to protect themselves from lawsuits, with an estimated $60 billion being spent each year on such unnecessary treatment.  This report must be taken with a grain of salt at best.

First off, what exactly is defensive medicine?  Is it performing medical procedures that are unnecessary? Is it tests to check for diseases that are statistically unlikely?  Is it tests whose results turn out to be negative (and, therefore, deemed not needed in the first place)?  There is no clear-cut definition of what constitutes defensive medicine.  A quick review of the term on Google shows a number of definitions that all boil down to some variation of the following – ordering tests or procedures out of concern to reduce exposure to malpractice suits rather than out of concern for quality patient care, or refusing to treat high-risk patients or undertake high-risk procedures with the same goal in mind.  In other words, it is the doctor’s motivation in ordering a test – and not the appropriateness of the test itself – that apparently defines defensive medicine for the purposes of these studies.

Even if you can define defensive medicine, how is it measured?  By asking subjective questions of the doctors themselves as to how often they believe they practice defensive medicine.  Are doctors keeping track of each order they write over the course of a year?  Are they keeping track of each test or procedure they perform with a notation of the specific motivation that drove them to get each test?  Of course not! This survey does nothing more than capture a doctor’s subjective (and clearly undocumented) “feeling” as to how often defensive medicine is practiced.  And then a dollar figure is thrown in at the end of the study that is supposed to represent the cost of defensive medicine.  However, without a clear definition, and without a clear test for measuring what tests and procedures are being performed unnecessarily, it is impossible to assess a monetary value for defensive medicine or test the validity of the “estimated $60,000,000,000. (Also, given that doctors are the subject of lawsuits, might one reasonably assume that the doctors have a bias in answering these questions?).

Inherent in this theory of the high costs of defensive medicine is that trial lawyers are constantly bringing frivolous lawsuits that are resulting in million dollar settlements or jury verdicts.  This is simply not the case.  I don’t know any reputable malpractice lawyer who sets out to file frivolous lawsuits.  Those who do should be sanctioned.  At our law firm, we decline the vast majority of inquiries we get from injured patients, which is in line with the experience of other law firms that specialize in medical negligence.  Many of these cases are rejected only after careful review by expert physicians in the field, who tell us that they believe the care was appropriate.  Furthermore, the law in Maryland requires that before a lawsuit can even be filed against a doctor or hospital, the plaintiff must obtain a certificate under oath from an expert in the same field of medicine who, after reviewing the records, has determined that the defendant doctor violated the standard of care and caused injury to the patient.  Frivolous lawsuits cannot even make it past the system’s initial screening stage.

This theory of defensive medicine also leads us to a more fundamental question – what level of care does the law expect of doctors? It is a common misperception that plaintiff’s lawyers expect doctors to perform every available test on every patient, no matter what, or else they’re going to get sued.  Some doctors go to great lengths to perpetuate this myth.  For example, in a recent article on the topic of greedy trial lawyers, a doctor was quoted as saying (and I’m paraphrasing) that if someone comes into an Emergency Department nowadays with a headache, that person is going to get an MRI, a CT scan, you name it.  With all due respect to this doctor, he is wildly exaggerating to make a point.

To answer the question of what is expected for doctors, the law has developed a standard to which health care providers must comply, and that standard is “reasonableness.”  A doctor breaches the standard of care when he or she fails to do what a reasonable physician would have done in the same or similar circumstances.  No more and no less.  The law does not demand perfect care or extraordinary care, and the law does not punish doctors simply because there has been a bad outcome. (There is actually a jury instruction in the District of Columbia called the “Bad Result” instruction that tells jurors they cannot find the doctor liable just because there simply was a bad outcome).  The law only requires that a doctor act reasonably in the circumstances.

As a simple example, let’s say that a patient (a 50-year-old man) sees his primary care physician because he developed low back pain after a weekend spent lugging around bags of mulch in his back yard.  His back is painful and stiff. In that context, what level of care do we expect of the doctor?  If we are to believe the theory of defensive medicine, this primary care doctor would immediately refer the patient to get an MRI, a CT scan, and a consultation with a neurosurgeon just to be sure that he doesn’t get sued.  For anyone who’s ever had back pain and gone to the doctor, he or she can realize how silly this scenario is.

Let’s take another example.  A 38-year-old man comes into the Emergency Department with chest pain.  Questioning by the doctor reveals that he has no history of heart problems or other serious illness.  It is also learned that he just wolfed down a large pizza and a few beers after his company softball game.  The doctor thinks it’s probably just a case of indigestion or heartburn, but to be safe he orders an electrocardiogram to check for heart problems.  This test comes back normal.  Is this defensive medicine?  Does this ER doctor consider it defensive medicine for the purposes of answering survey questions?  Should the EKG not have been done because the odds of a heart attack were minimal?  In this situation, one can easily make the argument that the EKG was reasonable.  Even though the risk of a heart attack was small, the severity of harm to the patient if the diagnosis is missed is great.  Shouldn’t we encourage reasonable testing that catches life-threatening illness?

There is obviously a balance between over-reacting and under-reacting, which is where the concept of reasonableness comes into play.  We applaud doctors exercising medical judgment as they were trained to do, and we expect them to act reasonably.  However, when doctors fail to act reasonably and injure a patient, the law provides a mechanism by which the patient can recover. At the end of the day, it isn’t trial lawyers who determine what is reasonable or unreasonable treatment.  It is juries that decide, after listening to both sides of the story.

The Unexpected Killers: Hospital-Acquired Infections

Wednesday, February 24th, 2010

According to an article published by NPR, a recent study found that as many as 48,000 people die each year in the U.S. from hospital-acquired infections. Researchers say that this is the first truly national study of its kind, involving 69 million cases of hospital-acquired infections in 40 states.

This study, unlike its predecessors, specifically isolated cases of hospital-acquired infections from cases involving patients  with possible existing infections at the time of admission. In part, this was accomplished by focusing on patients admitted to undergo elective surgery.

The researchers found the death toll from avoidable pneumonia and sepsis is bigger than from traffic fatalities. It’s more than three times higher than that for AIDS, and roughly twice as much as annual deaths from firearms.

Examples of hospital-acquired infections include: pneumonia, sepsis (infection of the blood), urinary tract infections, gastroenteritis, clostridium difficile (c-diff), tuberculosis, and staphylococcus-related infections.

Most hospital-acquired infections can be effectively treated with the proper choice of antibiotics.  There is simply no justification for such an incredibly high mortality rate  to be associated with a series of preventable and treatable medical conditions. For this reason, the results of the study are truly disturbing.

Contributing author: Jon Stefanuca

Tort Reform – Tennessee Style: ER doctors back bill 'redefining' malpractice – NO KIDDING!

Sunday, February 21st, 2010

As I was going through the listings and hashtags on my TweetDeck yesterday, I came across this tweet from a report in a Tennessee online publication - Emergency doctors back bill redefining malpractice | | The Tennessean. While I don’t practice in Tennessee, any trend in legislative changes affecting a patient’s right of access to the legal system is on my watch list.  

Here’s the essence of the proposed legislation according to this article:

Under the bill filed last month, the definition of medical malpractice would be changed from “negligence” to “gross negligence,” which would raise the bar for mistakes that could trigger a lawsuit.

To put this in context, Maryland and the District of Columbia, where I am licensed to practice, have many times defined “gross negligence.”  Those definitions are precisely what caused a chill to run up and down my spine when I saw the proposed change to Tennessee’s malpractice law.

In Maryland there is legislation called the Good Samaritan Act and the Fire and Rescue Company Act, which essentially provides in relevant part that in an emergency setting, only extraordinary or outrageous conduct by a person giving assistance or medical care in an emergency, or by a member of a fire company or rescue company, can be termed “gross negligence.”  For the lawyers among you, see, e.g. McCoy v Hatmaker, 763 A2d 1233 (2000).

In the District of Columbia, one case that gives multiple but somewhat common definitions for  ’gross negligence is D.C. v Walker, 689 A2d 40 (D.C. 1997):

[Gross negligence is] [t]he failure to exercise even slight care,” and “such negligence as would shock fair-minded men.”Shea v. Fridley, 123 A.2d 358, 363 (D.C.1956).  Similarly, the United States Court of Appeals for this circuit has stated that “gross negligence implies an ‘extreme departure from the ordinary standard of care.’ ” Wager v. Pro, 195 U.S.App. D.C. 423, 428, 603 F.2d 1005, 1010 (1979).  We have applied Maryland law to define gross negligence in the driving context as “a wanton or reckless disregard for human life or for the rights of others,” and “indifference to the consequences … [which] implies malice and evil intention.” Hall v. Hague, 257 A.2d 221, 223 (D.C.1969).  * * * And our federal court of appeals, applying what it apparently perceived to be District law, has said that, “[t]o constitute willful or wanton negligence, the police actions must involve ‘such reckless disregard of security and right as to imply bad faith.’ ”      

And just what is the alleged justification for this ‘gross negligence’ in ER’s standard being proposed?  Well here you go:

“In my personal practice, if I knew that I couldn’t be sued except for things that I truly believe I should get sued over, I could eliminate half of my lab tests, two-thirds of my X-rays and 90 percent of my CT scans because all of those tests are done for my protection, not the patient’s,” said Dr. Andy Walker, a local emergency physician and vice president of the Tennessee chapter of the American Academy of Emergency Medicine. “For TennCare patients, of course, the Tennessee taxpayer is paying for that.”

Yeah – that’s my emphasis added to the above quote.  Is this doctor kidding?  He does twice the number of labs, three times the number of x-rays and ninety percent of the CT scans he orders – to protect himself, not the patient?  And his litmus test for getting sued is what?  - “… things that I truly believe I should get sued over.”  Maybe when the Senate Committee is done investigating the ‘stents controversy’ at St. Joseph Medical Center in Maryland, they can take a look at what’s going on in Tennessee!

Using this wonderful test – “I should only get sued for what I believe is malpractice” – I am pretty confident that  there won’t be much medical malpractice litigation concerning ER care in the state of Tennessee should this wonderful piece of legislation go through.

Perhaps I should also make you aware that there is also pending in the legislature of this state a cap on non-economic damages.   If you are wondering at what amount they want such damages capped – it’s $1,000,000.  Apparently, however, the lobbyists for the medical profession really would like to see such damages capped at $300,000 since they believe such a low figure would “take away the profit motive of trial lawyers.”

I wonder if this double-pronged legislative initiative isn’t a variant on the old shell game.  Throw enough legislation out there and negotiate to get at least one of them passed.

Tell you what – I won’t be moving our firm to Tennessee any time soon.

FDA and International Serious Adverse Events Consortium Complete Third Data Release

Saturday, February 20th, 2010

Do you know what ‘adverse event reporting’ is all about?  Well, in case you don’t, here it is – as defined by the Food and Drug Administration (FDA):

The Adverse Event Reporting System (AERS) is a computerized information database designed to support the FDA’s post-marketing safety surveillance program for all approved drug and therapeutic biologic products. The FDA uses AERS to monitor for new adverse events and medication errors that might occur with these marketed products.

Yesterday, February 19, 2010, the FDA issued a news release -Regulatory Science Update: FDA and International Serious Adverse Events Consortium Complete Third Data Release – concerning data on the genetic basis of drug-induced liver injury (DILI) and serious skin reactions (SSRs).  This consortium report was the product of the combined efforts of the U.S. Food and Drug Administration and the International Serious Adverse Event Consortium (SAEC).

The concept behind their efforts is the identification of genetic factors  in a subset of patients and thereby assist researchers to better predict an individual’s risk of developing these serious complications.

Drug-induced liver injury occurs in a small subset of patients and is often associated with a drug that is an unpredictable liver toxin, and may be the cause of acute liver failure in some patients. Although the exact mechanism behind drug-induced liver injury is unknown, research suggests that a person’s genes contribute to their likelihood of developing this injury.                                                                                    

Drug-induced SSRs, such as Stevens-Johnson, present as allergic-like skin reactions (blistering and peeling of the skin) and are considered serious enough to discontinue treatment with the medication. These reactions can be fatal if the signs and symptoms are not quickly recognized.

“FDA is pleased with the Consortium’s progress,” said ShaAvhree Buckman, M.D., Ph.D., director of the Office of Translational Sciences in the FDA’s Center for Drug Evaluation and Research. “The continued accumulation of scientific information on the genetic basis of adverse drug events provides researchers with invaluable tools for understanding why some people respond to medicines differently than others.”

If you have ever seen or read about a person suffering from a condition such as Stevens-Johnson Syndrome (SJS), you can well appreciate the significance of this research project.

Debating the Unknowns in Obesity Surgery for Children –

Tuesday, February 16th, 2010

Bariatric surgery – commonly referred to as weight-loss surgery, is apparently on the rise in the pediatric population.  A New York Times article - Debating the Unknowns in Obesity Surgery for Children – – reports that these surgeries are on the rise in the United States.      

“I honestly believe that in 5 to 10 years you’ll see as many children getting weight-loss procedures as adults,” said Dr. Evan Nadler, co-director of the Obesity Institute at Children’s National Medical Center in Washington.

For those who may not be familiar with exactly what a surgeon does to the intestinal tract, there are numerous videos available on the internet that provide a good overview of this surgery – for example, here is an example showing one form of such surgery known as a by-pass.   There are a number of types of bariatric surgery, including two of the most common – Roux-en-Y gastric bypass and gastric banding procedures.

While such surgeries of often medically necessary and truly constitute a life-saving measure for some, they are not just an alternative to diet and exercise – that is, they are not without substantial risks no matter what form of bariatric surgery is being considered.

Here’s a list of just some of the potential complications -depending on the type of surgery – that are recognized risks of this surgery:

  • Bleeding
  • Complications due to anesthesia and medications
  • Deep vein thrombosis
  • Dehiscence (wound breakdown)
  • Infections
  • Leaks from staple line breakdown
  • Marginal ulcers
  • Pulmonary (lung) problems
  • Spleen injury
  • malabsorption
  • nutritional complications
  • death (reported as less than one percent)

On the other side of the equation, there is no doubt that when indicated, this surgery can certainly provide much needed restoration of health and longevity to these juvenile patients:

Obese children can suffer from a long list of problems better known in adults: insulin resistance, high blood pressure, fatty liver, a thickening of the left side of the heart, and even depression.

So far, the studies have found that the body starts to repair itself as the weight falls. For example, two years after gastric bypass, the left side of the heart has started to return to normal in most adolescents, according to cardiologists at Cincinnati Children’s. Research also suggested that for at least as long as the children have been followed, the procedure appeared safe, and about 85 to 90 percent of adolescents maintained their initial weight loss, Dr.  (Thomas H.)Inge [director of the surgical weight loss program at Cincinnati Children’s] said.

Those on the other side of this significant debate are not so confident in the long-term effects/benefits of having children undergo weight-loss surgery:

Some physicians, including Dr. Edward Livingston, chairman of gastrointestinal and endocrine surgery at the University of Texas Southwestern Medical Center at Dallas, say advocates could be drawing conclusions too early. No one can say whether the changes will translate into a health advantage later on. Dr. Livingston noted that a third of the children in the Australian gastric-banding study had to go back to the operating room over concerns about the device — and that even the children in the group that did not have surgery showed respectable improvements in blood pressure, insulin resistance and other measures. With or without surgery, he said, “both groups got better.”

The NY Times article reports: “No one knows exactly how many adolescents are turning to surgery to get thinner. One of the few studies, published in 2007, reported that bariatric surgery in teenagers was relatively rare but rising fast: from 2000 to 2003 (the last year examined), the number of operations tripled, to about 800.”

In one article, it is estimated that 220,000 bariatric procedures were performed in 2008 with an estimated increase of approximately 20,000 in 2009.

There is also an ongoing debate as to which form of weight-loss surgery is indicated for adolescents – bypass or banding.

Nor do surgeons agree on which of the two procedures used most — banding or bypass — is more appropriate for youths. Dr. Nadler, of Children’s National Medical Center, prefers banding, saying it is less radical and can be more easily undone if need be. In November, in The Journal of the American College of Surgeons, he described a study finding that among 41 teenagers followed for two years after gastric banding, their excess body weight had dropped by about half, on average, and other measures of their health had improved.

There is no doubt the debates will rage on for years to come.  What is evident, however, to those of us who have litigated many cases involving bariatric surgery performed on adults, is that this is not to be considered a ‘quick fix’ for being overweight.  It is not a form of cosmetic surgery.  This is serious stuff and reasoned considerations must be made: (1) is it medically indicated?; (2) what are the alternatives?; (3) who are the surgeons skilled in these procedures?; (4) is the adolescent properly being screened and counseled before undergoing surgery?; (5) what post-operative follow-up is needed?; (6) is the facility where the procedure is to be performed truly recognized as being capable of dealing with such patients and potential post-operative complications?; and (7) does the child and his/her parent(s) truly understand the risks associated with such procedures? – just to name a few of the many issues that must be addressed.

Patient dies in hospital after 'do not resuscitate' form is mistakenly put in his files | Mail Online

Wednesday, February 10th, 2010

Well apparently we don’t have a corner on the market for committing malpractice.  This deadly incident -reported on February 7, 2010 – occurred in Derbyshire, which is in the north midlands of England.

What occurred?  I truly can’t recount this any better than the reporter, who wrote the article:

A patient who suffered a heart attack on a hospital ward died because clerical staff had mistakenly inserted a ‘Do Not Attempt Resuscitation’ form into his medical notes.

Peter Clarke was not treated by doctors after going into cardiac arrest as a nurse had spotted the form in his files and, even though it was blank and had not been filled in, told other ward staff he should not be revived.

The blunder emerged at an inquest into the incident at Derby Hospitals NHS Trust, where bosses revealed staff had been ‘routinely’ placing the forms alongside medical records before they had been correctly signed and witnessed by senior doctors.

Before you wind-up having ‘no say’ in whether you get to live or die should catastrophic injury strike, you should consider (a) having a living will/advance directive and (b) at least discussing with your loved ones what you want done by way of medical intervention, if anything, should you wind-up in a state such a coma or a persistent vegetative state – to name just a few. – truly opt for the former but don’t be afraid to engage in the latter.

An order for DNR (do not resuscitate)is an extraordinary measure.   Think clearly and long about your decision, but once made, let it be known.

Last bit of advice:  check what’s on the nursing station desk next to your medical record before you get in bed.

Bariatric Surgery Can Be Safer Than Living With Obesity

Sunday, January 31st, 2010

For those of us in the law, who have litigated dozens of bariatric surgery cases, the following article from Medical News Today (Bariatric Surgery Can Be Safer Than Living With Obesity) must be read with the following paragraph from the article kept in the forefront when patients are decided WHERE to go to have this surgery performed:

To help alleviate a patient’s fears before surgery, the bariatric team ensures that patients and their families are thoroughly informed and comfortable with the procedure. Prior to surgery, patients undergo medical, psychological and nutritional evaluations, plus they attend two patient support groups and three educational classes.

Wondering what this surgery is all about?  It’s the medical term for what may commonly be called ‘weight loss’ surgery.  To get a basic understanding of the procedure as well as the ‘before and after’ care issues that are key to a successful procedure, here’s a video from YouTube.

Keep in mind that there are a lot of surgeons doing bariatric surgery; however, in most instances, the way you avoid a visit to your lawyer’s office is to chose the right surgeon and facility.

The American Society for Metabolic and Bariatric Surgery has a useful website on which there’s a patient primer about this procedure.  You can learn about the Centers for Excellence Program of the Society and get a listing of the members of the organization, who perform this surgery in your area.  It’s definitely worth checking out before you sign-up with a surgeon to have this potentially life-saving but nonetheless risky procedure performed.

Patients – Know Thy Physician!

Medical News: Sorting Out the Mammography Mess – in Hematology/Oncology, Breast Cancer from MedPage Today

Saturday, January 30th, 2010

Confused about when you should start undergoing screening mammography?  A recent article in medpage today -Medical News: Sorting Out the Mammography Mess – in Hematology/Oncology, Breast Cancer from MedPage Today – attempts to educate women about this seemingly ever-changing set of guidelines.

The article contains an audio interview with Dr. Len Lichtenfeld, Deputy Chief Medical Officer of the American Cancer Society, which is worth a ‘listen.’

This whole new discussion as to when women should get screening mammograms arose when the US Preventive Services Task Force issues its recent recommendations.

Perhaps the best advice – Women be knowledgeable about the recommendations and discuss them and their application to you and your risk factors for breast cancer with your gynecologist.  If you are a young woman or are unfamiliar with what a mammogram is all about, you may want to consider watching a video of what this test is all about and how it is performed.

RISKY BUSINESS: NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor

Saturday, January 30th, 2010

In December 2003, ACOG, the American College of Obstetricians  and Gynecologists, issued a Practice Bulletin (#49) for its members, in which it recommended the use of intrauterine monitoring of contractions during augmentation or induction of labor in select patients, such as those suffering from obesity.  There were some obstetrical organizations who were recommending the routine use of internal contraction monitoring to assess contractions more accurately.

Of course, the intent behind such recommendations was ostensibly to provide the attending obstetrician with better/more accurate information with which to make clinical decisions regarding the need for an operative birth (i.e. C-section or instrument assisted birth), dosing effectively with oxytocin nad avoidance of complications in such labor situations – the common end-result being to improve fetal and maternal outcomes in such deliveries.

On the other side of the risk/benefit equation, it is only common sense that the use of an internal monitor would increase certain risks – the medical literature speaks of the most common of these as being placental and/or fetal vessel damage, infection and anaphylactic reaction.

A new study by the Academic Medical Center in Amsterdam, led by Jannet J. H. Bakker, MSc, and reported by The New England Journal of Medicine on January 28, 2010 - NEJM — Outcomes after Internal versus External Tocodynamometry for Monitoring Labor raises serious questions about the use of such monitoring when one applies a science-based risk/benefit analysis.

The study reports in pertinent part:

In summary, the results of our trial do not support the routine use of internal tocodynamometry for monitoring contractions in women with induced or augmented labor.

In this multicenter, randomized trial we found no significant difference in rates of operative delivery with internal tocodynamometry as compared with external monitoring of uterine contractions among women in whom oxytocin was used for induction or augmentation of labor. On the basis of the lower boundary of the confidence interval around the observed relative risk of the primary outcome, our data are plausibly consistent with no more than a 9% reduction and up to a 20% increase in the risk of operative delivery associated with internal tocodynamometry. For cesarean section alone, plausible results range from a 17% reduction in risk to a 30% increase in risk with internal tocodynamometry. These results are in concordance with those of three previous small trials that compared internal and external uterine monitoring (each including between 127 and 250 patients), all of which showed a nonsignificant increase in the frequency of cesarean sections in the internal-tocodynamometry group.

Our trial also showed no significant difference between the two types of monitoring in the rates of adverse neonatal outcomes, rates of use of analgesia or antibiotics, or time to delivery. Similarly, none of the earlier studies showed significant benefits in terms of other maternal or neonatal outcomes with the use of an intrauterine pressure catheter.

For a full review of the patient population, the limitations of the study, please refer to the NEJM article.

Physician Warning – Opioids – 'Know Thy Patient' – Reuters Health – News Page

Tuesday, January 19th, 2010

For those lawyers, such as those in our firm, it is well known that there is a true risk to a patient/client on prescribed pain killers/opioids that such people may well become addicted and ‘at risk’ for greater harm – namely a lifetime of addiction or even worse – death.

There is an important posting in today’s Reuters Health – News Page,which speaks to this issue quite well.

A well-placed quote from a physician with the Centers for Disease Control summarizes the problem:

As a society, we have underestimated the possible risks from the dramatic increase in use of opioids,” said Dr. Leonard Paulozzi of the U.S. Centers for Disease Control and Prevention, who was not involved in the new study.

The study, conducted by a team headed by Michael Von Korff, ScD, a  senior investigator at Group Health Research Institute, was  published in the Annals of Internal Medicine and is summarized well in a posting found at

From our standpoint as lawyers, in terms of good medical practice and standards of quality care, the key elements of interest were outlined by the author:

The team said that this research and the data reviewed cannot determine whether higher doses are a cause of overdose, but he noted that physicians should carefully evaluate and closely monitor patients using opioids long-term. (emphasis added)

Previous research had not tracked nonfatal overdoses. “Fatal overdose may be only the tip of the iceberg,” said Dr. Von Korff. “For every fatal overdose in our study, 7 nonfatal overdoses occurred, and most of the nonfatal overdoses were medically serious.”

The keys – ‘evaluate’ and ‘monitor.’  How many times over my 35 year career have I heard stories of patients ‘doctor shopping’ and dealing with the receptionist or office nurse in the seemingly never-ending quest to just get more drugs.  Their motives are rarely for financial gain – they are simply out of control and in need of good, quality of care oversight and monitoring.