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The CMG Voice

Staging skin cancer less exact than you might think

Posted Monday, July 17, 2017 by Tyler Goldberg-Hoss

Many of us have had suspicious lesions sampled and biopsied, looking for malignancies. Those biopsies are analyzed and interpreted by pathologists. If cancer is found, the pathologists often stage the cancer depending on the characteristics of it. Then those findings are sent back to the ordering provider to help direct patient care.

Recently, a study looked into how accurate the pathologists were at diagnosing the skin cancer. The study sent each pathologist a number of slides, then sent them the same slides 8 months later. The pathologists’ interpretations were condensed into five classes, and the results were then analyzed.

The study found that most pathologists issued the same diagnoses in both stages of the study on the extremes: most pathologists were consistent in calling cancers in the first and fifth classes of cancer. However, pathologists interpreting the middle classes of cancer were less accurate.

Researchers analyzing the results of the study estimated that nearly 1 in 5 suspected cases of skin cancer are diagnosed as more advanced than they really are, while a similar number are diagnosed as less advanced than they really are. While fortunately few of the biopsies are invasive cancer, this is disconcerting news to anyone dealing with results from such a test. Perhaps in certain situations, a second opinion may be warranted.

You can find the results of the study here:

Pathologists’ diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study

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Are Primary Care Decisions Based On Good Evidence?

Posted Thursday, July 13, 2017 by Gene Moen

There has been increasing reliance by physicians on “evidence-based medicine”, or EBM. EBM has been defined as the “conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients.” EBM integrates clinical experience and patient values with the best available research information. Often this information is presented in the form of ranking or grading of various approaches or diagnoses, based on how strongly the studies support those decisions.

A recent study by the University of Georgia’s College of Public Health analyzed 721 topics from an online medical reference for primary care doctors and found that only 18% of the clinical recommendations were based on high-quality EBM. In an online medical reference often used by physicians, areas of care that are supported by EBM are graded A, B, or C, depending on the strength and quality of the evidence supporting the issue.

Some areas of medicine, such as pregnancy, cardiovascular, and psychiatry, had higher levels of EBM reliance, while others, such as hematology and rheumatology, had the lowest. Many primary care doctors relied more on their acquired knowledge of the importance of laboratory markers or symptoms, rather than on studies that take into account such factors as morbidity, mortality, quality of life, or symptom reduction. Overall, only 51% of primary care recommendations to patients were based on well-established EBM.

In light of the ready availability of Internet information about EBM recommendations, it is unfortunate that so many primary care health recommendations do not utilize EBM. This is especially true for primary care visits, which account for 53.2% of all physician office visits.

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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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