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The CMG Voice

Language Barriers in Medicine

Posted Monday, February 11, 2019 by Morgan Cartwright

The United States is becoming more and more diverse, with people immigrating here from every part of the globe. Currently, there are over 25 million people in the United States who have limited English proficiency.

Doctors who provide care to these people must recognize this and provide adequate language services to ensure a mutual understanding with the patient. Most of the time this requires the doctor obtaining a professional translator. This is most often a translator with expertise in translating in the medical field, rather than someone who just happens to speak the language of the patient. The difference can be enormous in the ability to communicate the medical terms necessary for the patient to understand care. Furthermore, when patients have questions, they must have an interpreter who is competent enough to get a complete answer.

Doctors who fail to recognize these language differences may risk performing procedures or making decisions about health care against the wishes of those with limited English proficiency.

This can open the physician up to liability. In a study of 35 malpractice cases involving translators, 32 had to do with a failure to use competent interpreters. Twelve involved failure to translate important documents, and twelve involved using family members to translate.

This population is particularly vulnerable because they may be less able to get help after they have been injured. They may not understand the legal system to take action or may have other fears of the legal system. We can only hope that as the diversity increases in this country, doctors will realize the importance of overcoming language barriers in Medicine with competent translators.

Your Legal Risks When Patients Don’t Speak English Well

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Artificial Intelligence continues making inroads into medicine by interpreting x-rays

Posted Monday, February 4, 2019 by Tyler Goldberg-Hoss

Followers of this blog may recall a recent post on how Artificial Intelligence (AI) was being used to screen patients for the eye disease diabetic retinopathy.

Mere months later, more data has come out about the algorithm “CheXNeXt”, created by researchers at Stanford. It was created to review chest x-rays for 14 different medical conditions.

Recently, it was “trained” with over 100,000 x-rays, after which it was tested against a panel of three trained (human) radiologists. CheXNeXt and each of the radiologists reviewed 420 x-rays one by one. The results were encouraging (for AI): for 11 of the 14 diseases, CheXNeXt was as good or better than the radiologists at catching the disease.

Not only is CheXNeXt’s accuracy similar to board certified radiologists, it comes with the added advantage of being very fast. While each of the radiologists reviewing the 420 images did so in about three hours, it took CheXNeXt 90 seconds.

This has some practice advantages. First, it may be used in underserved parts of the world where skill radiologists are lacking. Second, it can be used as a triage tool. For example, if a patient came in to the ER and his physical exam and lab results were consistent with pneumonia, the ER doc could use CheXNeXt to read the patient’s x-ray quicker than waiting for the radiologist to read it. In such a circumstance, the confidence in the diagnosis would be high, and antibiotics could be given the patient more quickly. However, if CheXNeXt came up with a different diagnosis, then a radiologist could review the images and consult with the ER doctor as needed.

Additionally, it might also serve as a quality control, scanning the images interpreted by radiologists during the day, and making sure that there were no “missed” diagnoses.

Forecasting the future, as much as this article makes efforts to not conclude the jobs of radiologists may be at stake, one cannot help but make that conclusion. From a medical negligence perspective, it will be interesting how claims involving radiology “misses” are dealt with in the setting of an algorithm essentially making the diagnosis. If there is no human health care provider, did anyone commit malpractice?

It may be that claims such as these in the future focus on either the manufacturer of the algorithm, or on how it is implemented. Either way, the future of medicine – and accountability for harms resulting from negligence care – looks to be changing. And quickly.

You can read more here:

Artificial intelligence rivals radiologists in screening X-rays for certain diseases

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The Physical Examination is Critical for Proper Care

Posted Monday, December 31, 2018 by Morgan Cartwright

It’s estimated that hospitalists and internal medicine interns spend less than 18% and 12%, respectively, of their time in direct patient care. Most of this is due to an increased reliance on diagnostic technology, lack of bedside teaching, and decreased interest in physical examination due to time limitations. As a result, patients’ care may be mismanaged, sometimes leading to significant risk of harm.

In one case study, the doctor describes a patient who goes to the emergency department for left-sided facial paralysis. The doctor ordered a CT that offered no diagnostic clues, and the patient was diagnosed with bells palsy. The next day, the patient returned with arm weakness. A thorough physical examination at that time discovered the patient’s forehead muscles were unaffected, making the diagnosis of bells palsy less likely.

Furthermore, the doctors were able to get at the issue by getting the patient to admit to daily heroin injections, despite having previously denied it. At this point specialists were able to evaluate him with an echocardiogram, which showed vegetation on his mitral valve. He then underwent emergent mitral valve replacement surgery to prevent recurrent embolic strokes.

This case illustrates that the initial examination on the first day should have been more thorough to prevent later complications.

While technology certainly has its place in the modern diagnosis of a patient, a thorough physical examination is also important. The advantages of being thorough include positive physician-patient relationship, improved patient safety, fewer diagnostic errors, and lower financial costs.

Importance Of Thorough Physical Examination: A Lost Art

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Industry Can Have Influence on Clinical Trials

Posted Thursday, December 20, 2018 by Morgan Cartwright

A recent study analyzed 200 industry-funded Phase III and Phase IV trials of vaccines, drugs, and devices during 2014-2017. It found that the academic authors were not solely responsible for more than 30% of the design, conduct, analysis, or reporting of those clinical trials. Instead, there was collaboration between industry personnel, academic investigators, and contract research organizations.

Following up on this study, a survey was sent to a number of authors of papers related to these clinical trials. The results showed that sometimes employees or contractors of the for-profit corporation funding the research do significant work without authorship. This includes undisclosed regulatory agency involvement in trial design, and undisclosed funder or contractor involvement in data analysis.

In total, only 4% of the trials were independent from industry involvement after being funded. This brings up an issue of clinical trials being reliable, truly independent, and in the patients’ best interests. Because the results of these clinical trials can impact millions of Americans, is it sensible for corporate interests to such have influence?

Read here to learn more:

Industry Involvement in Clinical Trials Huge, Often Downplayed

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Causes of Death on Death Certificates Often Incorrect

Posted Monday, December 17, 2018 by Morgan Cartwright

Studies from various states show that somewhere between 30-50% of death certificates list incorrect causes of death. The cause is a result of inadequate processes, training, and/or insufficient information. Unfortunately, many medical associations rely on death certificates for data on causes of death in areas to project and promote certain health guidelines. With such a large number of listed incorrect causes of death, there appears to be a significant possible problem with the underlying data.

The most common cause of death is heart disease, but this doesn’t always tell the whole picture. Many times, patients have underlying conditions that may not show up in the physical examination. Sometimes the patient passes away at a hospital that has no prior medical records to tell the hospital about the patient’s medical history.

In reality, determining causes of death is “part art, part science”, because it often requires a deeper understanding of everything that happened leading up to the death. With anything, you may gain a better understanding over time but many of those who write the death certificate are residents who are still learning the medical conditions.

Furthermore, the death certificates don’t always have the ability to enter the details of the death that are needed to describe the full situation, and instead require residents to conform to limited options. For all these reasons, the causes of death on death certificates should be viewed with this understanding.

A Whopping 1 in 3 Death Certificates list Wrong Cause of Death

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