Dr. James C. Johnston is the founding partner of Global Neurology and Director of the non-profit organization Global NeuroCare. As a board-certified neurologist with thirty years of experience, Dr. James C. Johnston has authored over one hundred peer reviewed journal articles, papers and book chapters on various topics related to neurology and global health including cerebral palsy (CP).
The high rate of CP in developing nations has led many of these regions to seek electronic fetal monitoring (EFM) as a means of reducing perinatal mortality and morbidity. However, EFM is an ineffective modality with a 99% false positive rate, and does not predict cerebral palsy, acidemia, neonatal neurological injury, stillbirths or neonatal encephalopathy. It does increase the C-section rate and is a significant source of harm to mothers and babies.
Despite 50 years of continuous use of EFM, the cerebral palsy rate and rate of other neurological birth related maladies remains unchanged. Continuous EFM should not be used in normal pregnancies, especially in developing regions where it will waste money that is so desperately needed for prenatal and post-partum care for mothers and babies, and add another layer of undesirable morbidity and mortality to an already critical situation.
Dr. James C. Johnston and his colleagues have published a number of peer reviewed articles concerning EFM and CP. They have discussed CP litigation in the Journal of Child Neurology; ethical concerns related to EFM in Maternal Health, Neonatology and Perinatology; review of the Task Force failure to address this problem in J Maternal Fetal and Neonatal Medicine; the history of EFM and medical training for EFM in separate articles in the Surgery Journal; and some of the legal and ethical concerns in Medical Law International.
J of Child Neurology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4431995/
Maternal Health, Neonatology and Perinatology: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697350/
J Maternal, Fetal and Neonatal Medicine: https://www.ncbi.nlm.nih.gov/pubmed/26067269
Surgery Journal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530627/
Surgery Journal: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5553489/
Medical Law International: http://journals.sagepub.com/doi/abs/10.1177/0968533217704883
These and related articles are also available through Researchgate.net at https://www.researchgate.net/profile/James_Johnston6.
A Neurologist, Partner with Global Neurology Consultants, and Founding Director of the nonprofit organization Global NeuroCare, Dr. James C. Johnston is a Diplomate of the American Board of Psychiatry and Neurology, and a Fellow of both the American College of Legal Medicine and the Australasian College of Legal Medicine. Dr. James C. Johnston is a widely published author with recent articles appearing in the Neurologic Clinics; Medical Law International; Neurology; Surgery Journal; and several other peer-reviewed medical journals.
The Surgery Journal published two articles from Dr. Johnston and his colleagues, the most recent entitled “The Ethics of Teaching Physicians Electronic Fetal Monitoring – And Now for the Rest of the Story.” Dr. Johnston and his colleagues Professor Berna Arda and Thomas P. Sartwelle, composed an articulate critique of electronic fetal monitoring (EFM) as a method of predicting and preventing cerebral palsy (CP). The article draws upon Mr. Sartwelle’s decades of experience as a top medical malpractice defense attorney, Dr. Johnston’s considerable medical and legal expertise, and Professor Arda’s unique views of medical ethics gained by her years of teaching at Ankara University where she holds the Chair of Medical Ethics.
“The Ethics of Teaching Physicians Electronic Fetal Monitoring” reviews the history of EFM with a specific focus on CP. Citing the available literature, the article concluded that, not only has EFM proven ineffectual in the diagnosis and prevention of CP, it increases the rate of cesarean sections with concomitant harms to mothers and babies alike. Further, Dr. Johnston and his colleagues stated that EFM, as it is used in defensive medical practice, is a violation of patient autonomy and raises serious ethical concerns. The article may be accessed through the link below:
A neurologist in private practice, Dr. James C. Johnston is also a partner with Global Neurology Consultants. In addition, Dr. James C. Johnston is the founder and director of Global NeuroCare, an international nonprofit organization dedicated to improving neurological services worldwide. Global NeuroCare focuses on sub-Saharan Africa.
As a region, sub-Saharan Africa faces a number of obstacles preventing treatment of neurological disorders such as epilepsy. Cultural beliefs play a major role in epilepsy treatment, with family members often hiding the condition, believing that seizures are caused by supernatural forces. People with epilepsy are generally shunned by society, and children may be prohibited from attending school. This phenomenon is not unique to the developing world, as people with epilepsy in developed nations may face various forms of discrimination.
Access to specialist neurology care also presents a major challenge in sub-Saharan Africa. According to a 2009 study published in the journal Seizure, the average round-trip transit time to rural epilepsy clinics in Ethiopia was more than 10 hours, and these are clinics without neurologists, imaging facilities or EEG equipment.
Because most antiepileptic medications are prohibitively expensive or simply unavailable, physicians typically only have access to the anti-epileptic drug phenobarbital. Not only does phenobarbital have numerous adverse side effects, it also limits neurologists in terms of treatment options. As such, it is not surprising that the International League Against Epilepsy cited consistent access to medication as the most important obstacle to bridging the treatment gap in sub-Saharan Africa.
Under the direction of Dr. James C. Johnston, Global NeuroCare works closely with the Addis Ababa University Department of Neurology in an effort to increase the number of locally trained neurologists, advance patient care and overcome some of the obstacles impeding neurological services.
American Academy of Neurology
Having received his medical degree from the University of Texas Health Science Center in San Antonio, TX, Dr. James C. Johnston is board-certified by the American Board of Psychiatry and Neurology. He holds additional certification in rehabilitation medicine. Practicing medicine for over 25 years, Dr. James C. Johnston specializes in neurology and is a member of the American Academy of Neurology (AAN), World Association for Medical Law (WAML), and Fellow of both the American and Australasian Colleges of Legal Medicine.
Dr. James C. Johnston attended the AAN Annual Meeting in Vancouver, British Columbia in April of this year. The World Association for Medical Law recently held the annual Congress of Medical Law in Los Angeles during August 7-11 where Dr. James C. Johnston presented a lecture on The Ethical and Legal Challenges of Global Health Development. Dr. Johnston based this presentation on his work through Global NeuroCare, a 501(c)(3) nonprofit organization that is in Special Consultative Status with the United Nations.
Shortly before the WAML meeting Dr. James C. Johnston presented a written statement to the United Nations ECOSOC High Level Political Forum providing recommendations to improve global health partnerships.
Along with co-authors Thomas Sartwelle and Professor Berna Arda, Dr. Johnston also presented on Electronic Fetal Monitoring and Cerebral Palsy at the WAML meeting, following several recent publications on this topic with the same co-authors.
electronic fetal monitoring (EFM)
A board-certified neurologist and an attorney, Dr. James C. Johnston serves as medical director of Legal Medicine Consultants in San Antonio, Texas. Dr. James C. Johnston has written numerous articles on topics intersecting medicine and law, including a recent peer-reviewed article, coauthored with Thomas P. Sartwelle, entitled Neonatal Encephalopathy 2015: Opportunity Lost and Words Unspoken, which was published in the Journal of Maternal-Fetal & Neonatal Medicine.
The article addresses the Task Force Study on Neonatal Encephalopathy Second Edition 2014, which recommended the use of electronic fetal monitoring (EFM). In the 19th century, it was believed that cerebral palsy and other conditions such as encephalopathy were caused by asphyxia during birth. EFM machines are intended to monitor the infant’s heartbeat during labor and indicate whether a physician should perform a caesarian section to prevent health issues associated with birth asphyxia.
EFM has never been subjected to a clinical trial, however, and has been shown to have a 99 percent false positive rate. Further, studies have proven that cerebral palsy is not caused by birth asphyxia. The use of EFM greatly increases the rate of caesarian sections, exposing both mother and baby to all of the potential risks and complications of that often unnecessary procedure. More importantly, it does not prevent or reduce the rate of cerebral palsy.
Thus, recommending the use of a test that has been shown to be at best imprecise and at worst harmful by exposing more women to cesarean sections is ethically dubious and goes against the fundamental medical tenet of “first do no harm.” While EFM may be useful in some contexts, it causes more harm than good and, the article concludes, should certainly not be used as legal evidence against physicians.