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The CMG Voice

AMA Journal calls for change in how hospitals handle and disclose the practice of overlapping surgeries

Posted Monday, July 10, 2017 by Tyler Goldberg-Hoss

Recently I wrote a blog post about how Virginia Mason recently decided to disclose to their patients the practice of overlapping surgeries, including revising their informed consent process to make more clear that the practice occurred and how that might affect the patient.

One area of concern with the new Virginia Mason disclosure was that patients were being told that their surgeon would always been in the operating room for “critical portions” of the surgery, but that term was not defined.

Now the American Medical Association has published an article calling for reforms regarding this practice and disclosing it to surgical patients. It too finds fault in hospitals who allow their surgeons to decide which portions of the surgery were critical. Some surgeons believe that, in certain spine surgeries, there are no “crucial portions”, so the attending surgeon theoretically would never have to be in the OR.

Instead of this practice, the AMA article suggests that a committee within the hospital, and not just the particular surgeon, should define the “critical portion” of a given surgery. Additionally, the article suggests that there should be some method of tracking when a surgeon is physically in an OR.

The article points out that little is known on the subject of whether the common practice of overlapping surgeries actually impacts patient safety. Without that research, it’s impossible to say whether the above steps will have any effect on patient safety. However, at a minimum I hope that greater transparency about the practice will allay public fears.

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Artificial Intelligence is Coming to Healthcare

Posted Thursday, July 6, 2017 by Tyler Goldberg-Hoss

While perusing the Internet the other day I came upon an article at Fortune.com regarding the up and coming sectors of healthcare where Artificial Intelligence (AI) will make the most impact in the near future.

The article highlighted two areas: robot-assisted surgery and “Nursing Assistant Applications”.

Robotic surgeries are nothing new. The da Vinci Surgical System and others like it have been around for years and their use is growing: more and more hospitals are purchasing the $1.4 million dollar machines, and more and more surgeons are being trained in how to use them. These are not just general surgeons anymore, but cardiothoracic surgeons, colorectal surgeons, GI surgeons, gynecologic surgeons, neurosurgeons, orthopedic surgeons and others.

However, my impression of these systems was that they were essentially high prices, highly technical tools for the surgeon to use to do his or her job. A glamorous scalpel, essentially. This new article apparently is theorizing much more than that, including integrating information from pre-operative medical records and “machine learning” to improve surgical outcomes and reduce the length of a patient’s hospitalization.

As a medical negligence attorney focused on patient safety and accountability, I can imagine the complexity of a case involving an AI “robot”, a surgeon, and a surgical error. Who is in charge when the error occurred? Can the “robot” be in charge? Although my sense is that jurors will have an easier time finding fault with a faceless robot, these are complex questions that will need to be addressed to protect all of us from unnecessary medical errors.

The Nursing Assistant Applications appear to include a number of devices that will allow health care providers to monitor vital signs and patient symptoms remotely. These include a number of things already on the market, including apps for your Apple Watch that let a pregnant mother monitor heart rate and contractions and send that information to a health care provider (you can read a recent blog post about that here.

I expect this to continue, as large corporations providing health care will continue to attempt to improve efficiency by reducing the need for patients to actually see their doctor (or ARNP, or PA). After all, why see your doctor when you can hook yourself up at home and wirelessly send that information to him or her (or perhaps a robot with AI)?

The article goes on to list a few other possible areas where AI will be used in health care, including fraud detection and dosage error reduction.

I am certainly not a Luddite: I understand that improvements in technology have had and will continue to have a positive impact on the health of all of us. My worry lies in the unfortunate reality that our healthcare system is in many ways profit driven, and without proper checks and balances, profits will end up being more important than patients.

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Fireworks injuries expected to keep local ERs busy tomorrow

Posted Monday, July 3, 2017 by Tyler Goldberg-Hoss

The 4th of July is about as American as you can get. Along with it comes the tradition of fireworks. While some choose to watch large displays from a safe distance, others favor a more “hands on” approach.

Washington State, like most other states, allows the sale of some fireworks (Massachusetts and New Jersey ban sales entirely). And as you might expect, people can and do get hurt using and being near fireworks.

National data shows that children are much more likely than adults to get hurt – teenagers in particular. And no surprise, males are much more likely to be injured than females.

The most likely injuries sustained include thermal burns, contusions, lacerations, fractures, and foreign bodies. While injuries from fireworks occur at other times of year (particularly around New Year’s), the lion’s share of such mayhem occurs in early July.

For more information, this article includes some interactive graphs that illustrate the harms caused by fireworks.

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July 1 is almost here. Don’t get sick.

Posted Thursday, June 29, 2017 by Tyler Goldberg-Hoss

As June turns to July and summer begins in earnest, hundreds of medical school graduates around the country begin their residencies. These residents typically practice medicine under the direct or indirect supervision of an attending physician.

These residencies are part of graduate medical training and a necessary step in producing competent health care providers.

It also means that, across the board, the medical providers treating you in July are more likely to be less experienced than those who may have treated you in June. Associated with this is a perceived increased risk of medical errors: the so called “July effect”. While that may sound relatively benign, in the United Kingdom it is called the “killing season.”

Studies have been done investigating whether there is in fact a July effect – whether medical errors increase during this month. The studies have been equivocal – some found no difference in the rates of complications, particularly when the study focused on a particular disease process such as appendicitis or acute cardiovascular conditions.

Other studies, including a 2010 study from the Journal of General Internal Medicine, found that medication errors increased 10% in July in teaching hospitals from 1979 to 2006. Interestingly, the study did not find a similar error increase in nearby non-teaching hospitals. This suggests an increase due to medical students beginning their residencies, and in particular the new responsibility of prescribing drugs independently.

One criticism of the study suggested that the supervision of residents has improved over time, so that this 10% number is skewed by earlier data.

In a situation where a new resident commits an error and causes harm – even death – to her patient, it’s important to examine the entire situation when coming to any conclusions about fault and responsibility. When teaching hospitals have to balance the need to teach its residents with the safety of its patients, it may be more likely that ultimate responsibility is on the system itself for failing to properly do so.

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New study finds that we can boost cancer survival rates by letting patients more easily report side effects

Posted Monday, June 26, 2017 by Tyler Goldberg-Hoss

In the past, patients on chemotherapy and other cancer fighting treatments had to make an appointment to see their doctor to discuss complications and side effects from their treatment. This led to patients toughing it out through symptoms until their next appointment, and unfortunately leading a lower quality of life.

Given the results of a new study, it appears that these patients also sacrificed months of survival on average.

A new study gave cancer patients the opportunity to report side effects over the computer instead of waiting for an appointment. Nursing staff was often very responsive (80% of the time they responded immediately) with medications for the symptoms.

Those patients who participated in the study and took advantage of calling their providers for help with symptoms saw their quality of life improve. In addition, because patients were more comfortable they were able to stay on chemotherapy longer, and live longer.

You can read an article on this study here:

Quickly reporting cancer complications may boost survival

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