Medical Error: Third Leading Cause of Death in the United States

Medical Error Third Leading Cause of Death in the United States

Medical Error Third Leading Cause of Death in the United States

Role of Evidence-Based Guidelines in Medical Malpractice

Medical errors rank behind heart disease and cancer as the third leading cause of death in the United States (see BMJ 2016; 353:i2139), with over 250,000 deaths a year.  700 a day.  And despite tort reform, medical malpractice litigation will never entirely disappear.  It remains important for physicians to understand the elements of a malpractice claim not only to protect themselves but more importantly to improve patient care.

The most confusing aspect of a medical malpractice claim is the standard of care element, and this is further complicated by the increasing use of evidence-based guidelines (EBG) or practice guidelines.  In some countries, EBG provide the legal standard of care, while most common law countries such as UK, Australia and New Zealand place great reliance on guidelines but allow courts discretion in accepting them on a case by case basis.

In the United States, most courts allow testimony using EBG both for and against physicians.  Whether a particular guideline applies to a specific case is simply another argument for the expert witnesses with the jury deciding who to believe.  In most cases, the actual written EBG may not be admissible as an exhibit.  It would fall into the same category as learned treatises and medical journals – the witness can talk about it and be cross-examined, but the document itself is not admissible.  Some courts have adopted a more liberal approach by admitting EBG as demonstrative aids.  Regardless of which approach, a physician on trial for malpractice must recognize that although EBG are not sacrosanct, any deviation from the guideline represents a very powerful argument to the judge or jury.

Neurologist and Attorney James C. Johnston, MD, JD and renowned medical malpractice attorney Thomas P. Sartwelle published the seminal article on expert witnesses discussing guidelines in the Journal of Child Neurology (http://journals.sagepub.com/doi/abs/10.1177/0883073813479669).

Dr. James C. Johnston is one of the very few neurologists in the world that is also qualified in law, and licensed to practice both professions.  He wrote the comprehensive chapter on advancing a neurology malpractice claim in Preparing and Winning Medical Negligence Cases, Third Edition (http://www.jurispub.com/Neurology-Chapter-11-Preparing-And-Winning-Medical-Negligence-Cases-Third-Edition.html).

He has published a number of journal articles and book chapters on how neurologists can improve patient care and protect themselves from malpractice claims.  These publications include book chapters in multiple editions of the American College of Legal Medicine textbook Legal Medicine and Medical Ethics, the Medical Malpractice Survival Handbook, and the landmark three volume treatise Legal and Forensic Medicine.  Dr. James Christopher Johnston has published peer-reviewed articles in Neurology Clinics, Journal of Child Neurology, Headache, Medical Law International, Journal of Legal Medicine, Medicine and Law, and a number of other journals.

In a recent Neurologic Clinics, Dr. James Christopher Johnston published a case studies article highlighting specific neurology claims related to malpractice (https://www.neurologic.theclinics.com/article/S0733-8619(16)30011-1/abstract).  This was co-authored with Thomas P. Sartwelle and leading neurosurgeon Professor Dr. Knut Wester, with the purpose of providing recommendations to improve patient care and safety.

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GLOBAL NEUROLOGY REPORT: PROTECTING HEALTH SECURITY

Dr. James Christopher Johnston

Disease outbreaks are no longer confined to small geographical areas, but have the potential to impact any region of the world due to an increasingly interconnected population combined with the dynamic nature of disease patterns.  This creates a global risk that must be managed through a coordinated approach in order to effectively control any type of epidemic.  The World Health Organization (WHO) promulgated International Health Regulations (IHR) to provide an overarching legal framework defining each nation’s duties in handling public health risks that are likely to cross borders.  The IHRs constitute a legal agreement among 194 nations.  These Regulations define when and how a country must report a disease outbreak to WHO, and highlight specific criteria for categorizing an outbreak as a “public health emergency of international concern,” which then triggers a very specific response.  Additionally, the Regulations contain provisions designed to protect the economy of a country that does declare an international emergency.  For example, these provisions preclude other nations from enacting travel or trade embargoes without a clear public health justification.  Neurologist and Attorney Dr. James C. Johnston is uniquely qualified to deal with the very specialized area of international medical law affecting health security.  He recently presented policy recommendations on these security matters to the United Nations High Level Political Forums on behalf of Global NeuroCare®, a non-government organization which holds Special Consultative Status with the United Nations ECOSOC.

GLOBAL NEUROLOGY REPORT: THE PERILS OF FETAL MONITORING IN AFRICA

Dr. James C Johnston

Maclean’s news recently interviewed neurologist and attorney Dr. James C. Johnston, his Ethiopian colleague and neurology Professor Dr. Mehila Zebenigus and Rwandan neurologist Dr. Jules Nshimiyimana for an editorial discussing the perils of using electronic fetal monitoring (EFM) in Africa.

Western medical advances exported to developing nations are supposed to improve healthcare and save lives.  However, “The West sometimes exports not just its medical advances, but its medical mistakes.”  This is unquestionably the case with EFM, a procedure that causes more harm than good.

EFM has been a birth myth for fifty years.  It is the standard of care in the West despite overwhelming evidence that it is ineffectual, rife with interpretive errors, has a 99% false positive rate, and has completely failed to reduce the incidence of cerebral palsy or any other neonatal neurological disorder.  EFM has, however, dramatically increased the caesarean section rate.  And C-sections create needless dangers to mothers and babies, increase risks in future pregnancies, and may account for an increased risk of future chronic diseases and neuropsychiatric disorders in children.

Why is this sham procedure being used against all scientific evidence?  To protect physicians and hospitals from lawsuits, as well as generate significant revenue.  And doing the procedure is not only medically harmful, but it completely neglects patient autonomy and informed consent.

Drs. Zebenigus and Johnston, along with renown medical ethicist Professor Berna Arda and leading medical malpractice attorney Thomas P. Sartwelle have discussed these concerns in the peer reviewed literature with publications in the Journal of Child Neurology, British Medical Journal, Journal of Maternal Fetal and Neonatal Medicine, Journal of Childhood and Developmental Disorders, Surgery Journal, Medical Law International, Neurologic Clinics and several other publications including the Legal Medicine and Medical Ethics textbook of the American College of Legal Medicine.  Many of these articles are freely available at ResearchGate.net:  https://www.researchgate.net/profile/James_Johnston6.

The more serious problem is that EFM is now being pushed in Africa, where the potential damage from a useless procedure is compounded by the utter waste of very limited resources.  The global fetal monitoring market is a multi-billion dollar business, and most of the growth in the next decade is projected to be in developing regions such as sub-Saharan Africa.  Drs. Zebenigus and Johnston have already seen the use of EFM machines increasing in Ethiopia, and Dr. Jules and other physicians report the same in Kenya, Rwanda, Tanzania, Uganda and other countries.

The cost of the EFM machines, training staff to read a useless test, and the resulting unnecessary C-sections all drain valuable resources that would be better used to care for children who have cerebral palsy.

“EFM has made birth less safe in the United States – and now, through a kind of medical imperialism, it is poised to potentially make birth less safe throughout the world.”

Read the Maclean’s news article at:

https://www.macleans.ca/society/health/the-use-of-electronic-fetal-monitoring-is-expanding-into-africa-and-thats-a-problem/

Global Neurology Report: WHO List of Essential Diagnostic Tests

On 15 May 2018, the World Health Organization (WHO) published the first Essential Diagnostics List, providing a catalogue of tests that are necessary to diagnose many common conditions as well as a number of global priority diseases.

This represents a crucial step to improving global healthcare since many people are unable to access diagnostic services, and others are incorrectly diagnosed due to poor quality or improper testing.  As a result, these people do not receive proper treatment and, in some cases, may actually be given the wrong treatment due to a misdiagnosis of their condition.

The list details 113 tests – 58 for common conditions such as diabetes, and the remaining 55 focus on priority diseases such as malaria, tuberculosis, HIV, hepatitis and syphilis.  Some of the tests are designed for primary health facilities in severely resource limited areas, and do not require electricity or trained laboratory technicians.  Other tests are more sophisticated and will necessarily be used in better equipped medical settings.

This Essential Diagnostics List will serve as a reference for countries to develop or update their own protocols within the context of local conditions, ensure appropriate supplies and equipment, and train personnel for the testing.

WHO intends to expand and update the list to incorporate additional non-communicable diseases, neglected tropical diseases, antimicrobial resistance and emerging conditions.

Drs. Mehila Zebenigus and James C. Johnston serve as Directors of Global NeuroCare®, an NGO accredited by WHO and in Special Consultative Status with the UN ECOSOC, and strongly support this initiative.

The full document may be accessed through the following link:

http://www.who.int/medical_devices/diagnostics/EDL_ExecutiveSummary_15may.pdf

American Academy of Neurology Meeting

Dr. James C Johnston

Dr. James C. Johnston recently attended the 70th American Academy of Neurology meeting in Los Angeles, California.

Over 13,000 neurologists and other medical professionals attended the annual meeting, coming from over 100 countries.  There were seven plenary sessions, 240 educational programs and over 3,000 scientific abstracts.

Dr. Johnston and one of his Ethiopian colleagues, neurologist Dr. Mehila Zebenigus, presented an abstract entitled The Spectrum of Neurological Disorders in Addis Ababa, Ethiopia.  (DOI:  10.13140/RG.2.2.15263.25769).

 This study was prompted by the fact that neurological disorders constitute a significant portion of the global burden of disease, and are rapidly increasing in sub-Saharan Africa, yet the paucity of data on neurological disease patterns in this region precludes effective allocation of the limited available resources.

The study incorporated all new patients referred to a neurology clinic in Addis Ababa, Ethiopia over a continuous twelve month period.  Board certified neurologists diagnosed and treated each patient after performing a history, examination and any necessary testing including laboratory, neurodiagnostic or neuroimaging studies.  A total of 4,195 patients were evaluated, with a mean age of 41.3 years and sex ratio of 106.9.

The most common conditions were musculoskeletal disorders (33.6%), predominantly degenerative spine disease (28.5%).  The most common neurological conditions were nerve, root and plexus disorders (15.4%), epilepsy (11.7%), headache (11.1%), cerebrovascular disease (8.4%), generalized neuropathies (6%), movement disorders (3.3%) and neurodegenerative diseases (2.7%).  Brain or spine tumors and psychiatric disorders were less common at 1.2 and 2.2% respectively.

This was the first report of disease patterns at a private outpatient neurology clinic in Ethiopia.  It demonstrated that degenerative spine disease with or without radiculopathy, entrapment neuropathies and episodic disorders (epilepsy, headache, cerebrovascular disease) comprise the vast majority of conditions.

More importantly, these common conditions are effectively treated within this resource limited setting, underscoring the importance of allocating resources to train more neurologists in developing nations.  Drs. Johnston and Zebenigus have emphasized this approach through the non-profit organization Global NeuroCare®.  (www.GlobalNeuroCare.org).