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The CMG Voice

Are Strokes In Younger People Increasing Or Are Classification Systems Changing?

Posted Tuesday, April 25, 2017 by Gene Moen

We usually think of strokes being associated with old age. But studies of stroke trends have indicated that there have been sharp increases among younger people. For example, there were 30,000 more hospitalizations for acute ischemic stroke in people under 65 in 2012 as compared to 2003. Among men ages 18-34, the rates have almost doubled. The increase in stroke prevalence in younger adults seems to mirror an increase in hypertension and hyperlipidemia in this population. Other factors that are related to strokes, such as diabetes and obesity, also increased in that group.

These increases have led stroke specialists to emphasize the importance of focusing on prevention in younger adults. But others question whether the increase is more a function of diagnostic classification systems and coding. Some observers think that similar diagnostic and coding factors may be involved in calculations of both stroke incidence and risk factor prevalence.

It has been noted that other factors that may account for the increases, including greater use of MRI imaging and changes in the definitions of TIA (temporary ischemic attack) and ischemic strokes. Some events diagnosed as TIA in 2003 would likely be diagnosed as ischemic stroke in 2012.

The difficulties in deciding whether there has been an actual increase, as opposed to changes in classification and coding factors, are frustrating for those who study stroke trends. According to James Burke, MD and Lesli Skolarus, MD, of the University of Michigan, “it is startling that in a country that spends almost 20% of [GDP] on healthcare, we cannot say with confidence whether the fifth leading cause of death in the United States is increasing or decreasing in the young.”

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New prostate cancer screening guidelines gain acceptance, if not clarity

Posted Friday, April 21, 2017 by Tyler Goldberg-Hoss

The US Preventive Services Task Force has recently updated its guidelines for screening men for prostate cancer using the prostate-specific antigen (PSA) lab test. Although the guidelines are a little muddier than they were the last time they were changed (in 2012), at least now there is consensus among other physician associations.

The current guidelines go like this: if you are a man older than 70 or younger than 55, the advice is don’t get screened. If you are 55-69 years old, talk with your doctor about the plusses and minuses of screening.

Luckily, both the American Cancer Society and the American Urological Association are mostly in agreement with these recommendations (there are slight differences in when men are recommended to talk with their doctor about PSA testing).

For men older than 70 and younger than 55, the Task Force has concluded that the risks outweigh the potential benefits. There are too many false positives, which lead to too many procedures that can cause real problems, including urinary incontinence and sexual dysfunction.

For those in the 55-69 age bracket, the Task Force felt the risks and benefits were such that it is worthwhile for each man to make the decision with his doctor.

There is a handy graphic here that shows this demographic, and in particular what happens when 1000 of these men are tested. 240 of those 1000 get a positive result, which leads to a biopsy. The biopsy confirms only 100 have cancer. Of those, 20%-50% of them have cancer that never grows, spreads or harms them.

Of those 100, 80 will choose surgery or radiation. These procedures come with serious possible complications discussed above.

Of those, only 3 will have avoided the cancer spreading, and 1 or 2 of those will have avoided a death from prostate cancer.

The rest either have cancer that never grows, spreads or harms them.

So men in this age bracket are doing some (hopefully) well-informed gambling. Do you want to be screened, knowing that it’s much more likely that it will result in urinary incontinence or sexual impotence (about 6%) instead of preventing death (.1%-.2%)?

For medical negligence attorneys, these new guidelines make it very difficult, absent extenuating circumstances, to argue that a client with metastatic prostate cancer should have been screened. The doctor can easily point to these recommendations as indications that it is not the standard of care to screen such patients.

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Physician Orders Under Electronic Records Systems

Posted Wednesday, April 19, 2017 by Gene Moen

In the old pre-computer days, physicians caring for patients in the hospital would order medications for their patients in a fairly simple way: just tell the nurse or write it into the order sheet. With the advent of entirely computerized record keeping, that simplicity is a thing of the past. Whether it improves patient care of safety, however, is not so clear.

At the present time, orders are made through a “Computerized Physician Order Entry” (CPOE). Physician orders, whether for medications, laboratory, radiology, or other purposes, now require the physician to go to the nearest computer, log in, and then use a password to get into the system. No more can the doctor tell the nurse or unit secretary, on the fly as he is passes by, “give the patient 600 mg of tylenol q 4 hours PRN.”

The doctor now has to enter this into the computer, thus interrupting what he or she was doing. It’s not a lot of time, but it adds up if this occurs dozens of times a day. And all of the time used in entering a computer order is time not spent with the patient. As one patient said about computers in the hospital: “I see the back of my doctor’s head more than I see his face.”

A recent article advocates development of an app that would allow voice commands to be placed via a smart phone. The nurse calls the physician asking for a medication order, and the physician dictates the patient’s name, which then pulls up the patient information on the phone. The physician would dictate the medication order and click “order.” In an age when almost anything can now be done via your smart phone, and the advent of voice recognition software, developing that app doesn’t seem like an insurmountable task. After all, anyone can now order their favorite pizza via their iPhone and dictating what they want before pushing a button or two. Computerized medicine is here to stay, and there should be a major effort to make it work faster and better and more safely.

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Jurors want a motive for why the doctor acted the way he did

Posted Wednesday, April 12, 2017 by Tyler Goldberg-Hoss

When one of my clients brings a case against a health care provider, it often feels like climbing up a mountain. A big reason is, unlike a claim involving a car crash, my client is pointing the finger directly at a health care provider, someone who has gone to a lot of school to learn how to help people, and was likely trying to help your client.

In my experience, doctors and nurses enjoy the benefit of the doubt in cases alleging bad care. Absent egregious wrongdoing, most folks are willing to give professionals in white coats a pass, even if the care is less than ideal.

One way to tip the balance and level the playing field is if you can show a bad motive on the part of the doctor or nurse for their actions. It is rare to find such things, as they are often not written down in a patient’s chart.

Still, once in a while you can gather enough evidence to show that, at least circumstantially, the defendant doctor, nurse or hospital was prioritizing other than the patient’s best interests.

A recent Seattle Times exposé shed light on a possible motive for poor medical care. The case of Dr. Johnny Delashaw, formerly of Swedish Hospital, highlights one possible motive: greed.

The series highlighted Swedish’s desire for increased revenue through this high-producing neurosurgeon, including an amazing $86 million in billed charges for the hospital in his first 16 months there. Allegations include unnecessary surgery, residents doing the bulk of surgeries while Dr. Delashaw was out of the OR, and a lack of resources to deal with post operative complications.

The ordeal at Swedish with Dr. Delashaw highlights my point: folks will forgive bad outcomes when doctors are trying to help; but when they find wrong motive, they are less forgiving.

You can read some of the fine journalism from the Seattle times here:

Quantity of Care – A special Investigation: High Volume, Big Dollars, Rising Tension

Top neurosurgeon Johnny Delashaw resigns from Swedish

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Need to go to the ER? How about Uber?

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

If you have ever needed an ambulance to take you to a hospital, you likely were in some distress. Assuming the distress was transitory and you recovered, you likely felt distress again when you received the bill from the ambulance.

Enter ride-sharing apps such as Uber and Lyft. Increasingly, those who need a ride to the emergency room are dialing up one of these services instead of calling 911.

Cost is certainly a motivating factor for some. Another is the patient can pick the hospital he or she wants to go to, unlike many ambulances who often have to take you to the nearest one.

Reliability is another, with many people, at least in urban locations, feeling like Uber and Lyft are more predictably around and available than ambulances.

Even some emergency medical providers like the idea, at least in “non-emergency, low-acuity” cases, where the person needs medical attention but it is not life threatening. Using a ride sharing app in such circumstances reduces the stress sometimes placed on ambulances, allowing them to focus their resources on the high acuity patients who really need them.

In fact, in Washington, D.C. they are studying whether its 911 operators should be routing calls to triage nurses, who could then determine whether the patient needs an ambulance, ride-sharing service, or something else.

Certainly, there are drawbacks. Drivers for these services cite the possible liability attached to giving a ride to a person in obvious need of medical attention. Ubers can’t speed like ambulances, and it can be difficult to judge what is an actual emergency versus not.

You can read more about this here:

For a trip to the ER, some are opting for Uber over an ambulance

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