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.
American Headache Society
A consultant neurologist for Legal Medicine Consultants, Dr. James C. Johnston earned his doctor of medicine from The University of Texas Health Science Center in San Antonio, and complete residency at the Texas Medical Center in Houston. Dr. James C. Johnston has written numerous scientific articles, including co-authoring a text entitled Migraine and Medical Malpractice for the American Headache Society.
In Migraine and Medical Malpractice, the authors discuss the role of neuroimaging in a patient with migraine headaches and a normal examination. The article specifically addresses the situation of a woman with a long history of migraines that progressively worsened despite an initial improvement on triptan medication.
In considering the woman’s condition, the authors pose the question of whether the evaluation should incorporate an MRI of the brain even though her neurological examination was normal. They concluded that she should have an MRI. Dr. Johnston recommended that physicians perform a complete history and physical examination on every patient with headache to determine the possibility of a serious underlying etiology such as brain tumor, aneurysm or other structural disease. The presence of warning signs – such as the increasing frequency of headaches in this patient – mandates further evaluation including neuroimaging.
The article goes on to answer questions such as how to respond if the MRI request receives denial in precertification, how to properly discuss medication side effects and other relevant points.
Crimean Congo Haemorrhagic Fever
A graduate of the University of Texas Health Science Center in San Antonio, TX, and the founding director of Global NeuroCare, Dr. James C. Johnston strives to increase the effectiveness and accessibility of neurology care worldwide. Focused particularly on the needs of sub-Saharan Africa, Dr. James C. Johnston co-authored a paper on the use of ribavirin as a treatment for Crimean Congo haemorrhagic fever.
Crimean Congo haemorrhagic fever is a viral infection with a fatality rate of 30 to 40 percent. It occurs most commonly in Africa, as well as in those areas of the Middle East, Asia, and the Balkans that lie south of 50 degrees above the equator. First discovered in the Ukraine in 1944, it made itself known in the Con go in the late 1960s and thus acquired its current name. It spreads as a tick-borne illness and is prone to amplification in the bodies of host animals, whose blood can then pass the disease on to humans. Similarly, humans may spread the disease among their own populations through contact with infectious bodily fluids.
Crimean Congo haemorrhagic fever has a typical incubation period of 1 to 13 days, depending on the source of infection. Once symptomatic, it presents with the sudden appearance of fever, dizziness, neck and back pain, and headache. Patients are also likely to experience muscle aches, photosensitivity, and eye pain, as well as early digestive distress and subsequent emotional agitation. As the disease progresses, a patient may become lethargic and develop haemorrhagic rashes, liver enlargement, and swollen lymph nodes. Patients who recover may begin to see improvement 9 to 10 days after symptom onset.
A private practice neurologist and lawyer, Dr. James C. Johnston currently serves as director of Legal Medicine Consultants, and as a partner in Global Neurology Consultants. Dr. James C. Johnston is also committed to advancing the legal and medical fields through scholarship, including through a recent peer-reviewed article he coauthored, published in the Journal of Child Neurology: ‘Cerebral Palsy Litigation: Change Course or Abandon Ship.’
In the article the authors assert that the majority of cerebral palsy litigation is driven by electronic fetal monitoring, a 40-year practice that lacks scientific support, yields a false positive rate higher than 99 percent, and increases the cesarian section rate with all of the attendant morbidity and mortality from that procedure. Despite its inability to predict cerebral palsy, electronic fetal monitoring continues to be endorsed as an effective practice by professional birth-related organizations around the world.
The authors further explain that electronic fetal monitoring is propagated by trial lawyers who have a monetary interest in using the results of the monitoring to their benefit. According to the article, electronic fetal monitoring reinterpretation in the courtroom has remained widespread, unreliable, and significantly biased.
The article goes on to explore how various legal tactics have failed to reduce cerebral palsy litigation. In conclusion, the authors propose using the Daubert doctrine to eliminate unsound science in the courtroom and thereby reduce the use of electronic fetal monitoring and, with it, the occurrence of cerebral palsy litigation.
The authors Thomas Sartwelle and Dr. James C. Johnston discuss cerebral palsy litigation further in a chapter they contributed to the 9th edition of the American College of Legal Medicine textbook: ‘Legal Medicine and Medical Ethics.’
An accomplished neurologist and attorney, Dr. James C. Johnston has published extensively on medical malpractice litigation. Dr. James C. Johnston co-authored a paper discussing cerebral palsy litigation and electronic fetal monitoring. It was published in the 2014 Journal of Child Neurology.
Electronic fetal monitoring, used for over four decades after its introduction without any clinical trials, has repeatedly proven clinically ineffectual, with a 99% false positive prediction of fetal distress, thereby increasing C-section rates with resultant harm to mothers and newborns alike. It has not affected the incidence of cerebral palsy, perhaps unsurprising when one considers the vast majority of cases develop before labor.
Nevertheless, electronic fetal monitoring today remains the most common obstretrical procedure, even as evidence against its efficacy countinues to mount. It is the foundation for the continuing cerebral palsy birth injury litigation crisis, increasing malpractice costs and even driving skilled physicians away from the delivery room. Fetal monitoring also compels obstetricians to commit daily ethical breaches, ignoring the principles of informed consent and non-maleficence or ‘do no harm.’
Thomas P. Sartwelle and Dr. James C. Johnston propose a straightforward solution that would change the standard of care, link electronic fetal monitoring to the exclusionary doctrine recognized by all the world’s courts – Daubert – and end cerebral palsy litigation.