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The CMG Voice

Can Screening For Heart Disease Lead To Prevention And Treatment?

Posted Tuesday, March 28, 2017 by Gene Moen

For many years, people have been screened for possible diseases, such as breast cancer, colon cancer, and lung cancer. The screening is done even when no symptoms are present. However, there has been no consensus among cardiologists about whether cardiac disease screening should be done and how effective it is in determining risk of heart disease. This is true despite the fact cardiovascular disease is the number one cause of death among Americans.

A new computed tomography (CT) scan may change this, because it can show even a small buildup of coronary plaques which can restrict blood flow and cause a myocardial infarction. There is now increased interest among physicians in screening non-symptomatic patients. The simple CT imaging technique is called a coronary artery calcium (CAC) scan.

Traditionally, patients have been screened for possible heart disease by using a combination of historical and clinical data and a standard blood test to measure serum lipids and blood glucose levels. However, the risk scores from such screening have been of uncertain value. Increasing data indicates that a CAC scan would be much more accurate for this purpose. The importance of more accurate screening is that it can lead to life-style and dietary changes, as well as medications that can reduce the future risk of cardiovascular disease.

The lead author of the study that found the CAC improved prediction of cardiac risks was Alan Rozanski, MD, director of the cardiology fellowship training program at Mount Sinai Hospital in New York. He stated that “using current state-of-the-art scanners, CAC scans are associated with only very low radiation exposure, similar to that of a mammogram.” He went on to say that “there is increasing interest in determining whether the use of CAC scanning could lead to earlier and more effective treatment of heart disease.”

In summarizing the importance of CAC screening, Dr. Rozanski said that “the CAC score has become one of our most robust predictors of patient risk” and “even a CAC score of one or above is sufficient reason for patients to adopt more heart-healthy behaviors.”

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Does a surgeon have to tell you if she’s never performed this surgery before?

Posted Thursday, March 23, 2017 by Tyler Goldberg-Hoss

Not infrequently we get calls about surgeries gone wrong. Occasionally the caller is upset not just because of how the surgery went, but also about what information he or she knew prior to surgery. In particular, sometimes I hear a variation of “If I had known that this was the second time he’d ever done this surgery, I would never have agreed to it.”

When someone says something like this, they are essentially making a claim that they were not properly informed sufficient to give the surgeon consent to do the surgery. Every health care provider who is proposing a course of treatment has to tell the patient about all the “material facts” relating to the treatment, including risks and alternatives.

A “material fact” is one that a reasonably prudent patient in the same circumstance would attach significance to in deciding whether to go forward with the proposed treatment.

So the question is: is a surgeon’s lack of experience a “material fact”?

The answer, it may surprise you, is probably not.

One case in Washington involved a gallbladder removal. The surgeon had participated in a two-day class on how to do it, which included hands on participation in performing the procedure on three pigs. Soon after he met with a patient and determined she needed her gallbladder removed. He didn’t tell her he had never performed the procedure on a patient before.

The surgeon performed the procedure and injured the patient’s bile duct. She filed a lawsuit, and the jury determined that the surgeon’s experience was a material fact that needed to be shared. However, the Court granted the surgeon’s motion that, as a matter of law, the surgeon’s experience was not a material fact under the informed consent statute. The Court agreed.

The patient appealed, and the appellate court affirmed the trial court, saying “a surgeon’s lack of experience in performing a particular surgical procedure is not a material fact for purposes of finding liability predicated on failure to secure an informed consent.”Whiteside v. Lukson, 89 Wash. App. 109, 112, 947 P.2d 1263, 1265 (1997).

A similar case was decided in similar fashion in 2007. In that case, a patient sued her surgeon after complications from a laparoscopic hernia repair. The surgeon in that case had only performed one other such surgery.

The Court did not rule out that some set of facts would make a physician’s experience a “material fact”, just not this one:

“we are not categorically holding that a physician’s inexperience is never material to an informed consent claim. There may well be situations where evidence of a physician’s experience would be a significant factor in a patient’s decision to undertake a particular course of treatment. But such a situation is not present here.”

Housel v. James, 141 Wash. App. 748, 756, 172 P.3d 712, 716 (2007).

Although regular folks – including the jury in the Whiteside case – may think that a physician’s experience (or lack thereof) performing a procedure is something that should be disclosed, Washington Courts think otherwise. At least for now.

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More Thoughts On Electronic Medical Records

Posted Monday, March 20, 2017 by Gene Moen

There have been many recent articles about the challenges presented by electronic medical records (EMR) to both health care providers and their patients. Many of the criticisms have to do with the extra time needed to input information to the EMR system and the temptation to simply click buttons rather than providing detailed information. The major purpose of medical records is to provide information to future providers to assist them in diagnosing and treating medical problems.

The over-riding criticism of EMR, however, is the tendency to “cut and paste” information. This means that early errors in clinical information get repeated over and over again and can provide a false basis for medical decision-making. It also means that each time someone inputs information into the system, the same paragraphs are repeated. This means that finding any new information in the EMR can be a frustrating effort to ignore all of the duplicate information and try to tease out the pertinent information.

A good example was a recent review by me of emergency department records for a man who had symptoms of a heart attack. The initial paragraph about the reasons for his ER visit was repeated every time someone put in new information, such as lab results or other test results. In the 100+ pages of the printed EMR records, I counted at least 20 instances of the same paragraph being reprinted. Finding the important lab or test results in the midst of this set of records required great attention. So how is the busy physician or nurse going to find that information in the middle of a busy morning in the ER?

A physician writing about EMR made the following comment: “[i]n the past week I received a USB drive with 2402 pages from a hospital chart. It took me less than 30 minutes to scan more than 2300 of those pages and eliminate them as absolutely useless. Page after page of information was either downloaded automatically from a monitor or created for nothing more than to comply with regulations. Less than 5% of the chart contained potentially usable information (emphasis added).” Yet it’s that 5% which may mean the difference between good care and the death of a patient. Any system that makes it difficult to find the useful information in a medical chart is a system that needs to be changed.

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Recent Poll shows Nurses and Doctors rate highly in categories of honesty and ethical standards. Lawyers – not so much.

Posted Thursday, March 16, 2017 by Tyler Goldberg-Hoss

Gallup recently polled a number of Americans regarding how they perceived the honesty and ethical standards of various professions. The question was framed “Please tell me how you would rate the honesty and ethical standards of people in these different fields – very high, high, average, low or very low?”

Unsurprisingly, nurses were at the top again with 84% of those polled rating their honesty and ethical standards as “very high” or “High”. They have topped the list every year but one since this poll was introduced in 1999. Next on the list were pharmacists at 67% and medical doctors at 65%. Of note, chiropractors and psychiatrists checked in at 38%.

At the other end of the spectrum, 8% of those polled believed the honesty and ethical standards of members of Congress were Very High or High. That is worse than car salespeople (9%), insurance salespeople (9%), Business executives (17%) and, yes, lawyers (18%).

From the perspective of a medical malpractice attorney, this makes sense. Jurors tend to give the benefit of the doubt to the health care provider on trial for committing malpractice, and do the opposite to the plaintiff victim (and his or her attorney). But why is that?

One possible reason is motive. At the time that the alleged malpractice occurred, unless the doctor or nurse was drunk or on drugs, or otherwise should not be practicing medicine, he or she was trying to help the patient. It may be that in hindsight the treatment offered or diagnosis made was wrong, but those mistakes are “honest” because not only was there no malicious intent, one can infer there was benevolent intent.

Contrast that with the plaintiff, a person with his or her hand out asking for money from the doctor, sitting side by side with not only a lawyer, but a personal injury lawyer. The perception can easily be that their motives are not benevolent but fueled by anger, greed, or some combination of the two.

So much of a trial is a battle of which side is more credible. Reading polls such as this one from Gallup confirm my belief that these battles are tilted at the start.

You can read the full Gallup Poll here:

Americans Rate Healthcare Providers High on Honesty, Ethics

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Urgent Care Clinics – Attempting to Fill a Gap in Healthcare, But Can Patients Fall Through the Cracks?

Posted Monday, March 13, 2017 by Tyler Goldberg-Hoss

You may have noticed an Urgent Care Clinic near you these days. It may be called something a little different, like Immediate or Express Care, but the template is essentially the same. These clinics have sprung up to fill a perceived gap in healthcare, available for folks who have healthcare needs that don’t rise to the level (in both time and cost) of an emergency room visit, or when it is inconvenient (or impossible) to see their primary care doctor (if they have one).

While there are certainly benefits to such clinics, there are potential pitfalls for patients. You can read more about what Urgent Care Clinics are, who staffs them, who goes there for treatment, and what possible medical/legal issues there are arising from such treatment here:

Urgent Care Clinics – Attempting to Fill a Gap in Healthcare, But Can Patients Fall Through the Cracks?

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