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: A CRITIQUE OF ELECTRONIC FETAL MONITORING

 

The Surgery Journal recently published a peer reviewed critique of electronic fetal monitoring (EFM) by neurologist James C. Johnston, MD, JD and leading healthcare attorney Thomas P. Sartwelle.

These authors, Thomas P. Sartwelle and Dr. James C. Johnston, along with pre-eminent medical ethicist Professor Dr. Berna Arda, have repeatedly advised that continuous EFM should not be performed in routine labour due to a 99.8% false positive rate, and the fact it does not predict or prevent cerebral palsy or any other neonatal neurological injury.

EFM does increase the caesarean section rate, with an increase in maternal and newborn deaths and birth complications as well as devastating long term complications. In fact, these very concerns have led Australia, New Zealand and the UK to advise returning to intermittent auscultation (IA) instead of EFM, and in 2017 the American College of Obstetrics and Gynecology finally provided a long overdue recommendation that women be given an informed choice between IA and EFM.

Unfortunately, there are EFM apologists continuing to defend the procedure, and journal editors suppressing scientific debate on the topic. This most recent Surgery Journal article exposes one example of these harmful practices, and should raise serious questions about those EFM proponents recommending a procedure that causes more harm than good to mothers and babies alike. But perhaps the more disturbing aspect is a medical journal editor determined to stifle scholarly debate.

This open access article is available through the following link:

https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0038-1632404

The authors have also published their concerns in the Journal of Child Neurology, Maternal Fetal and Neonatal Medicine, British Medical Journal, Neurologic Clinics, Journal of Pediatric Care, Maternal Health Neonatology and Perinatology, Medical Law International, Surgery Journal and several other journals and books. These articles are available at James C. Johnston’s ResearchGate.net site:

https://www.researchgate.net/profile/James_Johnston6/contributions

GLOBAL NEUROLOGY REPORT: NEUROIMAGING IN THE PATIENT WITH HEADACHE

The most common diagnostic error in neurology over the past three decades is the misdiagnosis of headache, often the failure to diagnose brain tumor or other intracranial structural disease.  This recurring error is partially attributable to the guidelines set forth by the American Academy of Neurology and six other professional societies under the United States Headache Consortium (USHC), which state that neuroimaging is not warranted in patients with migraine and a normal examination.

These guidelines were based on a meta-analysis of 11 small retrospective studies with serious flaws, all antedating 1985 and almost half using first generation CT scans.  This outdated data suggested a very low incidence of intracranial abnormalities in patients with headache (0.2%), and led to the improper conclusion that a normal examination excludes any brain tumor or other intracranial disease.  Both of these presumptions are flatly wrong.

Patient with headache and a normal examination

For example, proper imaging demonstrates intracranial abnormalities in 6-8% of people, far higher than the outdated figure of 0.2%.  Some of these abnormalities are incidental, but many warrant monitoring (aneurysm), further investigation (stroke) or treatment (arachnoid cyst).  Additionally, over 10% of patients with brain tumors present with isolated headache and a normal examination, so following the guidelines would deny imaging to 3-7% of patients with brain tumor.  Earlier imaging reduces the cost of headache care in patients that rank high on anxiety or depression scales.

Unfortunately, these outdated guidelines were parroted by the American Headache Society and the American College of Radiology which bluntly stated “Don’t do imaging for uncomplicated headache.”

This type of intransigent adherence to flawed, outdated guidelines falls below an acceptable standard of care.  Additionally, the failure to discuss the likelihood of finding an abnormality on imaging, and giving the patient an option of having an MRI, eviscerates any meaningful informed consent.

Dr. James C. Johnston discussed these concerns in several recent articles including Neurologic Clinics 2016; 34:747-773, and recommended deleting the guidelines until further research properly correlates intracranial abnormalities with individual patient data, headache patterns, underlying disease, imaging protocols, associated conditions and a host of other factors to provide rational evidence based guidelines. (https://www.researchgate.net/publication/305409777_Neurological_Fallacies_Leading_to_Malpractice_A_Case_Studies_Approach).

In the meantime, he advised it is prudent to consider imaging all patients presenting with a new headache, or a headache increasing in frequency or pattern, or with any other warning sign.

Dr. Johnston presented these findings at the 2017 World Association for Medical Law conference, and the concerns were discussed by Dr. Mehila Zebenigus of Addis Ababa, Ethiopia who noted that in her clinic most patients with headache are referred for a baseline imaging study.  Attendees from other countries echoed her recommendation.  And, yet, in the United States about 12% of patients with headache have an MRI, and some neurologists are calling for more restrictions, even stating that limiting MRI should be a “major national priority.”  It is past time for the USHC and Choosing Wisely societies to review the evidence and move forward.

GLOBAL NEUROLOGY REPORT: TRIANGULAR COOPERATION

Dr. James C Johnston

Triangular Cooperation | Dr. James C Johnston

Global NeuroCare is a non-profit organization dedicated to advancing neurological care in developing regions, especially sub-Saharan Africa and particularly Ethiopia.  It is one of the few non-government organizations to hold Special Consultative Status with the United Nations ECOSOC, which allows Director and Neurologist Dr. James C. Johnston to actively participate with the UN intergovernmental bodies, decision makers and related organizations.  Additionally, Global NeuroCare is accredited by the World Health Organization, and affiliated with the Office of the Special Adviser on Africa.

On behalf of Global NeuroCare, Dr. Johnston presented several statements over the past few years to the UN High Level Political Forum, the Commission for Social Development and the Integration Segment.  Four of these statements have been adopted and published, focusing on advancing collaborative partnerships between the North and South in an effort to improve healthcare in Africa.

Dr. Johnston emphasized the importance of ensuring that relationships between the North or developed countries and the South are based on sustainable, collaborative, ethically congruent partnerships that truly benefit the South, as opposed to the short term medical missions that are so harmful to developing regions.  Successful partnerships will allow sub-Saharan African nations to develop functional capacity building, thereby becoming self-sustainable, further advancing patient care, physician training and medical research.

These types of North-South partnerships can be even more effective by encouraging South-South and triangular cooperation.  South-South cooperation is the process whereby two or more developing countries pursue individual or shared objectives through exchanges of knowledge, skills and resources.  This is not a substitute for, but rather a complement to North-South partnerships.  In triangular cooperation, partnerships between two or more developing nations are supported by a developed country or even multinational organizations.

For example, Global NeuroCare focuses on advancing neurology in Ethiopia where Dr. Johnston serves as an Honorary Professor of Neurology in the Addis Ababa University Department of Neurology Residency Training Program.  This program has graduated 32 board certified neurologists over the past decade.  However, there are no local opportunities for advanced neurophysiology training, so Dr. Johnston arranges for the resident physicians to attend the University of Siena, Italy for 6 month fellowships.  This requires separate funding which has been provided through scholarships sponsored by a Canadian based neurophysiology society.  Thus Global NeuroCare coordinates Ethiopian training through Italy with financial support from Canada and, in turn, as an example of South-South cooperation, the Ethiopian physicians return to train their colleagues as well as physicians from other African nations.

Global NeuroCare plays a crucial role in coordinating this type of triangular coordination, which is the most effective means of ensuring sustainable capacity building leading to self-sufficiency that will truly advance healthcare in sub-Saharan Africa.

Global Neurology Report: Medical Training in Ethiopia

Addis Ababa University

Africa suffers one-quarter of the global burden of disease, yet has only 3% of the world’s healthcare workers. It consumes less than 1% of the world’s healthcare expenditure. And the continent’s population of one billion people is set to double in the next generation.

The situation is even more disconcerting in the least developed nations such as Ethiopia, which is perhaps the most medically underserved country in the world. A recent World Bank Study reported there were just over 2,000 doctors for the country of 100 million people. This is a dismal situation that warrants increased international support.

There is some recent improvement with an increasing number of medical schools – in 2006 there were four medical schools, and now there are over 30 training centers that will begin graduating 2,000 physicians annually. Additionally, Ethiopia trained 38,000 healthcare extension workers to provide basic health education and services in the rural areas where 85% of the population resides.

However, there remain very serious impediments to advancing healthcare in Ethiopia and the other least developed countries – poor infrastructure, inadequate transportation, lack of equipment and medications, limited geographical distribution of services, and a continuing dearth of specialists.

External support is critical to further advance healthcare and specialist services in these regions, but it must be the right type of help. Unfortunately, many United States academic medical centers have focused on self-serving short term medical missions which can and do cause harm to the very regions that so desperately need help. These types of missions are lucrative and beneficial to the sending institution, but do not provide any substantive benefit to the developing country.

Neurologist Dr. James C. Johnston discussed these concerns at the United Nations High Level Political Forums in 2016 and 2017, and at the World Association for Medical Law Congress Meetings in Los Angeles (2016) and Baku, Azerbaijan (2017). He recommended focusing on a sustainable, comprehensive, ethically congruent approach to partnerships with a focus on advancing patient care, physician training and medical research to benefit the South.

Global NeuroCare is a 501(c)(3) non-profit organization founded by Dr. Johnston to advance neurological services in developing nations, particularly Ethiopia, and strictly adheres to these principles of sustainable partnerships dedicated to capacity building. Dr. Johnston is an Honorary Professor of Neurology at Addis Ababa University in Ethiopia, where the Department of Neurology has graduated 32 board-certified neurologists over the past decade, with 21 more physicians in the expanding three year training program. These neurologists have improved the lives of countless thousands of Ethiopians, and are now training physicians from other African countries.

Continued support of neurological training is crucial, especially since the World Health Organization reported that neurological diseases are one of the greatest threats to global public health. Please go to www.GlobalNeuroCare.org to contribute your support which will have an immediate impact on the lives of many of the world’s most vulnerable people. This registered tax-exempt non-profit organization does not use any of the funds for administrative expenses or salaries – every penny goes to the people in need.