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The CMG Voice

Doctors Have A "Gut" Feeling About The New Frontier In Medicine

Posted Friday, March 30, 2018 by Gene Moen

A recent article spelled out new interest in the “gut microbome” as an opportunity to control illnesses as diverse as obesity, diabetes, inflammatory bowel disease, and even atherosclerotic disease. Gut microbiome (formerly known as gut flora) is the name given today to the microbe population living in our intestines.

Our gut microbiota contains tens of trillions of microorganisms, including at least 1000 different species of known bacteria with more than 3 million genes (150 times more than human genes). It’s a jungle in there, and new finds are occurring on a frequent basis by those willing to explore.

Experts think that the microbiome affects many aspects of our bodies, including a powerful influence on digestion, the immune system, and the central nervous system. So a new goal of many medical researchers is to find the underlying cause of many diseases and treat them at the source within the gut.

At a recent meeting of the North American Microbiome Congress in February, there was an emphasis on the connection between the gut and overall health. One product of this emphasis is the development of microbiome therapies in clinical trials. Pharmaceutical companies are seeing new possibilities for patenting these therapies in a developing market.

While much of the research is focused on obvious health problems like obesity, diabetes, and inflammatory bowel disease, the new research frontiers will be in areas where there is no current treatment for a disease. But even apart from those possibilities, simply dealing with obesity through this research could save billions of health care dollars.

The bottom line is that there is a huge amount of promise within the gut microbiome, with research in this area just starting to gain attention and momentum within the scientific and medical communities.

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Labor, drug and administrative costs the main reasons why the US spends so much on health care.

Posted Monday, March 26, 2018 by Tyler Goldberg-Hoss

A recent study published in the Journal of the American Medical Association (JAMA) looked at health care spending in the United States and how it compares with other “high-income” countries such as Germany, Canada, Australia, and France.

The study found a number of interest things:

In attempting to answer why we spend so much to get comparable (or worse) health care, the report focused on three things.

First, we pay our health care providers more. For example, we pay general physicians $218,173/year, while in the other countries the range was $86,607-$154,126.

Second, we pay substantially more per person for the costs of goods, particularly drugs. In the US per capita spending is $1443, versus $466-$939 in other countries.

Finally, administrative costs accounted for 8% of all health care spending in the US, versus a range of 1%-3% in the other countries.

In my line of work, malpractice litigation, some focus group participants and jurors have a tendency to believe that malpractice itself – in the form of rising professional insurance or defensive medicine – is a large reason why our health care costs are so high.

The report addressed this indirectly, stating:

“The data also suggest that some of the more common explanations about higher health care spending in the United States, such as underinvestment in social programs, the low primary care/specialist mix, the fee-for-service system encouraging high volumes of care, or defensive medicine leading to overutilization, did not appear to be major drivers of the substantially higher US health care spending compared with other high-income countries.” (emphasis added)

It is clear, not only from this report but also from our collective understanding, that health care is an ongoing issue in our country. On the bright side, this report gives us clues as to how we might fix it.

You can read the full report here:

Health Care Spending in the United States and Other High-Income Countries

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Remote Monitoring In The ICU

Posted Thursday, March 22, 2018 by Gene Moen

A recent article describes new methods of using remote monitoring in intensive care units (ICUs). In most ICUs, the rooms are arranged so that one or more central nurses’ units allow direct sight into the patients’ rooms. There are also monitors at one or more of the nurses’ units so bells or alarms can sound if vital signs change for the worse. A problem with that arrangement is that, when things are busy, nurses may be in another patient’s room and not realize that a patient is having difficulties.

The newer designs for ICU’s incorporate a central monitoring unit where paramedics can monitor cardio-respiratory changes and can utilize cameras and audio systems to “see and hear” the patient. The paramedics thus have real-time visualization of the patient, can review vital signs, and communicate quickly with the care team if adverse events occur. The paramedics view patient’s vital signs on computer screens and video screens in a central location.

For example, if a patient’s oxygen saturation drops below 90, indicating risk of respiratory distress, the paramedic can see if a nurse if with the patient. If not, the monitoring paramedic can contact the patient’s assigned nurse. If faster action is required, the paramedic can activate a “rapid response team.”

The monitoring units have computer software that delivers text alerts of the patient’s alarms to the nurse’s cell-phone, and the paramedics can confirm the alarm signal quality is working and can visualize the patient’s clinical appearance.

Sophisticated software also allows more than alarms. For example, the electronic health record can be customized to tell the paramedic if a patient with a central line or port develops a fever of an elevated white blood cell count, and thus can trigger a review of the patient’s antibiotic status. If needed, the paramedic sends a text to the treating doctor to notify him/her of the risk factors that are present so that appropriate medications can be ordered before the patient’s condition deteriorates.

In the future, it is possible that this system can be used for real-time tracking of patients with chronic conditions, in their homes or community hospitals. The future of remote electronic monitoring is only limited by the imagination and innovation changes that hospitals, doctors, and computer specialists can apply to the task.

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How Are Focus Groups Used In Medical Malpractice Cases?

Posted Monday, March 19, 2018 by Gene Moen

Most firms that represent injured patients in medical malpractice cases will use focus groups in preparing for trial. A focus group is simply a group of people, who theoretically match what a jury would look like in the case. The focus group participants are selected in various ways, from posting notices in places like the YMCA to putting ads on Craigslist. Most attorneys try to end up with a balanced group in terms of political leanings, age, and gender.

They are then invited to a focus group session that might last from three to five hours, and paid a fee ranging form $75 to $125. Many focus group sessions take place in the evening or on a Saturday, so those who are work during the day are not excluded. Usually, the firm tries to avoid having the participants know which side the firm represents. The group’s size will usually range from six to twelve members.

What is the purpose of a focus group? Someone once said that “lawyers are from Mars and jurors are from Venus.” Lawyers are trained to think a certain way and to assess the facts of their case in a logical fashion. As any trial attorney will tell you, however, jurors do not think like lawyers and are influenced in their decision-making by factors a lawyer might not even know exists in the case. The focus group is a chance for the lawyer to present selected facts about the case and find out how “ordinary” people react. Some lawyers treat it like a “mock jury,” having different people present the case from both the plaintiffs’ and defendant’s perspective, and finding out how the jurors rule on the issues.

More commonly, selected facts about the case are presented to the focus group, and then comments are asked for. Reactions might be put down on paper, and then the facts are discussed and the participants can then change their initial conclusions based on that discussion. In some focus groups, there may be only one or two key issues on which the lawyers want to get input. For example, in a medical negligence case in which there is finger-pointing between a doctor and another medical provider, the lawyers may want to see how this issue is perceived under different scenarios. The discussion by the participants is more important than their “decisions,” because the lawyers are looking for ways to improve their presentation to obtain maximum impact.

There are jury consultants who make their living by flying around the county arranging focus groups in large cases. The costs can be quite high. Others may offer a special focus group facility and assist the lawyer in setting up the session and finding participants. There are many articles about focus groups and how they should be run. Many lawyers, like those in our firm, use a building conference room away from their office so it isn’t clear who is putting on the session, and then use a dedicated cell-phone to talk to, and choose, the participants.

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Getting a second opinion

Posted Thursday, March 15, 2018 by Tyler Goldberg-Hoss

We tend to run focus groups on our cases, inviting folks who approximate possible jurors in a given venue to listen to facts of a real case and give their thoughts and opinions. Of course, I run groups on actual cases, and as such a bad outcome has occurred.

Commonly, some jurors are critical of the choices made by the patient in a given circumstance. For example, one case may involve a patient going to her doctor, and the doctor misdiagnosing her, causing harm. In those situations, I routinely hear things like “I would have gone straight to the ER and demanded a (insert test here that would have picked up the problem)” or “I would have gotten a second opinion”.

This latter sentiment – that I would have gotten a second opinion – is a particularly common sentiment for folks who are faced with a story involving a doctor allegedly making a mistake and causing great harm. It can be easier for folks to think of themselves as fundamentally different from the patient who suffered the harm. This has a name: “attribution bias” or “negative attribution bias”. It is the juror’s own unconscious defense mechanism to feel safer about the world.

Still, I have always been curious as to how often people do ask for and get second opinions. From a 2011 Harvard Publication, about 70% of Americans don’t get a second opinion or do additional research. A 2005 Gallup poll found that about half never seek a second opinion. Whatever the actual number, it appears that more than half of all of us never seek a second opinion.

I count myself among that group, having never asked a doctor for a referral to another doctor to check the first doctor’s work. My guess is the reasons so few of us ask for second opinions are similar: the time involved in getting one, the fear of insulting the first doctor, the worry of getting two different opinions and ending up more confused than before.

Unfortunately, though, second opinions are often helpful in diagnosis and treatment. A recent Mayo Clinic study found that, of those patients who sought a second opinion for a complex condition, nearly 88% went home with either a new or refined diagnosis – changing their care plan and possibly saving their lives.

Certainly, my clients who have suffered tremendous harm due to a medical error would love to go back in time and get that second opinion. For complex issues, perhaps moving forward we would all be better served if we got them.

You can read more about the Mayo study here:

The value of second opinions demonstrated in study

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