Advancing Neurology in Africa

A neurologist and attorney, James C. Johnston, MD, JD, is the founder of Global NeuroCare, a nongovernment organization (NGO). Global NeuroCare was established by Dr. James C. Johnston to improve neurological services in developing regions. Dr. Johnston and one of his Ethiopian colleagues Dr. Mehila Zebenigus, serve as Directors of this organization.

Holding Special Consultative Status with the United Nations ECOSOC, the highest status granted to an NGO by the UN, Global NeuroCare has engaged in a long-term collaborative partnership with Addis Abada University Department of Neurology to advance the training of physicians in Ethiopia. The Neurology Residency Training Program has been an outstanding success, substantially increasing the number of practicing neurologists in the country, leading to the treatment of more patients. These neurologists are also teaching a new generation of doctors to manage common neurological problems which represents the most effective was to improve healthcare in regions with a severe shortage of doctors and other healthcare providers.

On behalf of Global NeuroCare, Dr. Johnston and one of his Ethiopian colleagues Dr. Mehila Zebenigus have discussed the medical, ethical and legal aspects of advancing healthcare in developing regions at several meetings over the recent years including the United Nations High Level Political Forums, World Congresses for Medical Law and American Academy of Neurology conferences. They have highlighted the serious concerns of short term medical missions which fail to provide any substantive benefit to the host nation, and may cause significant harm to the local population. An additional concern is that developing nations have inherently vulnerable populations that may be intentionally or unintentionally exploited by these types of brief self-serving medical missions.

Drs. Zebenigus and Johnston presented the Ethiopian model to demonstrate that effective capacity development requires increasing the recruitment, training and retention of medical staff, which mandates stable long-term collaborative North-South partnerships focused on establishing local training programs, staffed by local physicians, to address the particular local community needs. They recently published a white paper for the UN on this topic, and will be present those recommendations at the 26th Congress Meeting of the World Association for Medical Law.

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. 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. 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.

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.