Follow-up on whose fault is it if a patient doesn't follow up

My post entitled "Who is at fault if a patient doesn't follow up?" from 7/19/13 has had over 1000 page views. There were several comments on Twitter.

In three parts, here is some follow-up on following up.

1. A surgeon saw a new patient with flank pain. He had undergone an appendectomy a few years before by another surgeon at a different hospital. He said that the surgeon told him the pathology report was "fine."

Physical examination was not enlightening.

A CT scan showed a possible ureteral stone. A urologist was consulted, saw the patient and said there was no stone.

The patient called the surgeon who told the patient to come back to her office to discuss further work-up. He did not keep the appointment. The surgeon made two more phone calls urging the patient to return and documented them in her office records. He was also called by the urologist, a consultant gastroenterologist and his family doctor. He never followed up with any physician.

Two years later he presented to the ED with a small bowel obstruction. At surgery, carcinomatosis from his ruptured mucinous carcinoma of the appendix was found.

The CT scan showing the possible stone was re-reviewed and still showed no evidence of a tumor.

The original pathology report said "mucinous tumor [not cancer] of the appendix."

Everyone except the surgeon who had done the appendectomy and the pathologist was sued. They escaped because of the statute of limitations.

The insurance companies advised all of the doctors to settle, which they did.

So much for documenting your attempts to have the patient seen.

2. Two of my Twitter followers from Australia sent me a link to a case that illustrates that patients in that country are somewhat responsible for their fate.

Briefly, it concerned a man who needed a Q fever vaccination for work. A skin test for Q fever was negative, but serology was weakly positive. An infectious disease specialist recommended that vaccination not be done. He was told to return in a month for a repeat serology. He failed to do so and contracted Q fever about 4 years later.

He sued. A judge ruled in favor of the physician saying the patient "understood the advice he was given by [the doctor] that he was low positive, that he needed further testing and that he could not be immunized. There was nothing in [the patient's] presentation in court or within his evidence that suggested he did not comprehend what was said to him by [the doctor]. He denied being told to return by [the doctor]. I reject his account for the reasons already mentioned."

3. This last one is hard to believe.

A brief "Viewpoint" article in JAMA from May of 2013 tells of the discovery of a new disease. It is called "Medication Nonadherence" and it has six different phenotypes.

They are as follows: "(1) the patient does not understand the relevance of medication adherence to continued health and wellbeing; (2) the patient has concluded the benefits of taking medications do not outweigh the costs; (3) the complexity of medication management exceeds the information processing capacity of the patient; (4) the patient is not sufficiently vigilant; (5) the patient holds inaccurate, irrational, or conflicting normative beliefs about medications; and (6) the patient does not perceive medication to have therapeutic efficacy."

I had trouble getting past the above portion of the paper.

However, the authors advocate screening all patients for this malady and treating it when found. They say, "Each medication nonadherence phenotype requires different diagnostic tools and treatments in the same way that subtypes of a medical condition, such as heart failure (diastolic vs systolic), require them."

I thank God I am no longer in practice.

Is a woman's purse really more contaminated than a toilet seat?

I've been wondering ever since this revelation splashed across the Internet.

Like most of these groundbreaking discoveries, this one got plenty of media attention. Despite the numerous articles mentioning the purse-toilet seat connection study and its sponsor, the Initial Washroom Hygiene Solutions company, I wasn't able to locate the full text or even an abstract of the investigation itself.

What I have pieced together from several different reports and the company's press release is that 25 handbags were examined and 100 objects were swabbed.

It seems that only one in five of the purses had excessive contamination.

And here's more interesting stuff from the press release: "Initial Washroom Hygiene, one of the UK’s leading hygiene and washroom services companies, today unveiled research showing that the handles of women’s handbags are home to more bacteria than the average toilet flush." [emphasis added]

So the contamination was with the handles of the bag and the comparison was to a toilet flush, not the toilet seat, which was the focus of many headlines. For example, this is what New York's CBS News outlet said, "Study: Handbags May Have More Bacteria Than A Toilet Seat." 

Or here's video from Slate which compares handbag contamination to both a toilet seat and a toilet (exact area of comparison not stated).

Let's talk about some problems.

The study was small. It was sponsored by a maker of hygiene products. How does one measure the amount of bacteria in a toilet flush? Wouldn't that depend on what was in the toilet bowl at the time? How many flushes were analyzed? The reporting was somewhat crappy since a flush was somehow conflated with a seat.

Finally, the press release was dated August 5, 2012. Why did this suddenly become news almost a year later?

It is possible that a woman's purse is more contaminated than a toilet flush, a toilet seat or even a toilet, but this "study" doesn't prove anything. It simply serves to confuse lay people.

It is one of a new genre of studies that apparent consider the toilet seat as the "gold standard" for contamination.

Here are some items that have been allegedly found to contain more bacteria that a toilet seat: cell phones, barbecues, desktops, kitchen sponges, light switches, computer keyboards, money, motel bedspreads, ATM keypads, office telephones, restaurant menus, grocery carts, steering wheels, gym equipment, and kitchen faucet handles.

As far as I know, disease transmission has not been linked to the handles or any other part of a woman's purse or any of the other objects said to be more contaminated than a toilet seat.

Come to think of it, what about disease transmission from a toilet seat?  Although a recent study linked over 9000 penile crush injuries over an 8-year period to falling toilet seats, there is no evidence that you can catch any infectious disease from a toilet seat.

Here's a quote from a WebMD article on the subject: "To my knowledge, no one has ever acquired an STD on the toilet seat—unless they were having sex on the toilet seat!" said Abigail Salyers, PhD, president of the American Society for Microbiology.

So can we please stop comparing things to toilet seats?

What we should be comparing things to is shower heads. See "Did Your Morning Shower Spray You With Bacteria?"

Who is at fault if a patient doesn't follow up?

In keeping with the mind-set of most Americans today, the answer to the question posed in the title of this post is, "the doctor."

American Medical News reports that "Medical liability experts say missed appointments and failures to follow up pose some of the greatest legal risks for physicians." And these problems are increasing with more hand-offs and more people being involved with the "team" taking care of the patient.

The article began with an anecdote about a patient who needed at cardiac catheterization but wanted to think about it. He went home and died. The family sued and said the doctor did not tell "them how critical it was for him to have the procedure.”

The doctor did not document the conversation about the need for the procedure in the chart and lost the case.

Failure to make sure that appropriate follow-up was done and failure to contact patients about missed appointments are among the most frequent deficiencies cited as big legal risks for physicians.

Get this. "A common claim in lawsuits that involve missed appointments is lack of informed refusal. The allegation arises when patients admit they declined or ignored treatment recommendations, but allege they were not adequately educated about the medical risks of their decision."

Lack of informed refusal. That's a new one on me.

The article says that adequate documentation by the doctor will support his version of events.

What is to prevent any patient, who is explained any plan or procedure and declines, from simply saying, "I didn't realize how serious this was"?

And where does this end? Should a doctor call all her patients every day to ask if they took their medications?

"Hello, Mrs. Balotelli. Did you take your Placebolol today?"
"No, I didn't think it was important."

"Mrs. Balotelli, I wouldn't have prescribed it for you if I didn't think you needed it. I told you that you have to take it to prevent you from having a stroke."
"Well, doctor, I didn't understand that a stroke might be a bad thing. And I don't think my blood pressure is that high today anyway."

Whatever happened to personal responsibility?

I guess it's always someone else's fault when anything goes wrong.

The article ends with a list of 16 things that a doctor and her staff should do for every patient to try to counter this disturbing trend.

Here are a few of them:

    Maintain a current list with dates of problem identification, reviews and resolutions.
    Use the patient's own words when documenting.
    Indicate in writing or electronically that all results of tests, consultants and referrals were reviewed.
    Document all after-hours patient calls.
    Document all advice in the patient's record.
    Detail the patient's level of understanding during the informed consent process.

I'm sure these tasks won't take much time or effort.

And some lawyer will probably say that what the doctor wrote on the chart is not what the patient remembers him saying.

See  this follow-up post on following up.

Live chat Wednesday July 17 at noon EDT

I hope to chat with you on Wednesday, July 17 at noon EDT (-4GMT).

Any topic you want is fine.

Reminder: We still can't support chats from mobile users. We are working on it. The live chat app, called NowTalk, is in the right lower par of the blog. It's anchored on the edge so no need to scroll.

What's up with intern "Boot Camps"?

A concept that has been percolating in the medical literature boiled over into the mainstream as the New York Times published this story, "Chicago's Intern 'Boot Camp' is a rehearsal for life or death medical issues."

The article describes a new internal medicine intern having to deal with a simulated patient who is critically ill and has alarms going off.

Another intern had to tell a "patient" played by an actor that he had terminal cancer.

The performances of both of the young doctors were evaluated by instructors. The 81 interns in the program must "pass graded tests in procedures and communication skills before being allowed to move ahead."

The boot camp described in the Times piece was the subject of a paper published in Academic Medicine earlier this year. It concluded that "Boot-camp-trained interns all eventually met or exceeded the MPS [minimum passing standard] and performed significantly better than historical control interns on all skills (P < .01), even after controlling for age, gender, and USMLE Step 1 and 2 scores (P < .001)."

Here is how the Mayo Clinic describes its boot camp for fourth year med students, "An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns."

They compared survey results from students who had done the boot camp to those who had not and found the boot camp prepared students for internship better than conventional sub-internships did.

Similar "boot camps" are being held in many surgical residencies.

At the University of Connecticut, surgical interns undergo "a 2-month (July and August 2011) boot camp curriculum consisting of two 2½-hour knowledge-based and procedural skills (SimMan) didactic sessions per week and completion of 25 core intensive introductory American College of Surgeons Fundamentals of Surgery web-based self-study modules, followed by a standardized patient clinical skills assessment."

At Baystate Medical Center in Massachusetts new trainees are taught essential skills in patient care and procedures. Over the four year period during which interns experienced the boot camp, "Individual simulation-based Boot Camp performance scores for cognitive and procedural skills assessments in PGY-1 residents [interns] correlate with subjective and objective clinical performance evaluations."

The Department of Surgery at the University ofPennsylvania holds a boot camp for senior students interested in surgical career. The introduction to the abstract describing the program says, "Medical school does not specifically prepare students for surgical internship."

It appears that boot camps are both necessary and effective.

I have one question. Why can't "boot camp" skills be taught in all medical schools?

"System errors" plague the NTSB and a San Francisco TV station

By now you have probably heard about the San Francisco TV station that broadcast what it thought were the names of the four pilots of Asiana Flight 214 that crashed landed last week.

The names were not those of the pilots and were typical racist stereotypes.

If you haven't seen it, here's a 30 second clip that shows all you need to know.

The station, of course, apologized and said that it had confirmed the names with the National Transportation Safety Board, which promptly blamed a "summer intern" for the debacle. This is according to an NBC News/Reuters story, one of the very few that didn't repeat the names.

That story also points out that the real names of the two pilots at the controls had been released earlier in the week.

Is another case of system errors and not human errors? Let's see.

The NTSB said, "Appropriate actions will be taken to ensure that such a serious error is not repeated." The intern was supposed to have referred such questions to official NTSB media people.

The station's vice president and general manager said, "Nothing is more important to us than having the highest level of accuracy and integrity, and we are reviewing our procedures to ensure this type of error does not happen again."

The apparently clueless anchorwoman who read the names has said, "A serious mistake was made."

Here is what spokespeople for the Asian American Journalists Association had to offer, "We are embarrassed for the anchor, who was as much a victim as KTVU's viewers and KTVU's hard-working staff."

Wait a sec. The anchor and KTVU's hard-working staff were victims?

"We never read the names out loud, phonetically sounding them out," said a different KTVU anchor.

Another AAJA member wrote, "Common sense indicates that simply sounding out the names would have raised red flags,"

Sound out the names? They were so obviously fake that a high school kid would have noticed simply by silently reading them.

How could everyone at the TV station, the producers, editors, writers and the anchor who read the story on the air with a straight face, not have noticed that the names were not only not very plausible, but also exceedingly offensive?

Also unclear is how the station acquired the supposed names in the first place.

System errors? I don't think so.

Additional source: Los Angeles Times

Search "System Errors" on my blog to see 12 other posts on this topic.

Transgastric appendectomy. Would you have one?

A study in the British Journal of Surgery says that removing an inflamed appendix via the stomach is feasible and "promising." This is what is known as NOTES or natural orifice transluminal endoscopic surgery.

The paper (full text plus videos under "Supporting Information" tab) describes the first 15 cases done at the University of Heidelberg in Germany.

There is so much wrong with this paper and the concept in general that it is hard to know where to start.

During the year from April 2010 to April 2011, 111 patients were offered the chance to have this procedure done and only 15 agreed to do so. It appears that patients have a lot more common sense than some physicians think. The patients were carefully selected. Those with BMIs > 30 and with perforated appendicitis were excluded

The procedure was done by inserting an endoscope through the mouth and then through the stomach wall,  but if you read only the abstract, you would miss the fact that a separate trocar was inserted via the umbilicus to facilitate the operation. Therefore, it is not a pure NOTES procedure. The NOTES crowd would call this a "hybrid" procedure.

Several complications occurred. The first case had to be converted to an open appendectomy because of "severe inflammation." This was not explained in the paper but was revealed in the typically uncritical MedPage Today article about it.

Two patients developed postoperative pelvic abscesses requiring what they called "laparoscopic revision" which is their euphemism for second operations. A second operation is very uncommon in patients without perforated appendicitis.

In one patient, a technical problem necessitated ligation of the stump of the appendix through the umbilical port. Another patient had bleeding which had to be controlled by clips. For an obese patient (curious, as only patients with BMIs < 30 were said to have been included), the appendix had to be cut into two pieces because it would not fit through the opening in the gastric wall.

The median duration of the NOTES cases was 105 minutes with a range of 59 to 150 minutes. The average time for a standard three-port laparoscopic appendectomy is about 25 to 35 minutes which means that the NOTES takes three times as long.

The median hospital stay was 3 days with a range on 1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy in the United States is < 24 hours.

The heavily edited videos are worth a look, especially the fourth one, which shows that it takes at least 10 snips of the tiny endoscopic scissors before the appendix is completely divided.

Because of the two patients in the series who developed abscesses, the authors advise caution for those with purulent appendicitis and suggest doing a standard laparoscopic appendectomy instead. The problem is that the surgeon would not know that a patient has purulent appendicitis until she has looked and made what would then have been an unnecessary hole in the stomach.

Most standard laparoscopic appendectomy scars are invisible anyway. If just one patient suffered a leak of the stomach wall closure which would cause sepsis and other major complications, that would strongly negate the minimal cosmetic gain from the trans-gastric operation.

The study ended two years ago but was just published. I always wonder about that. What took so long? Was it rejected by other journals? You would think the authors would want this sort of breakthrough brought to light as soon as possible. Have they done more cases since then? What were the outcomes?

After reading the paper and seeing the videos, is there a surgeon in the world who would want a trans-gastric appendectomy performed on herself or a loved one? An unscientific Twitter poll indicated they would decline. One surgeon said, "Not sure if I'd answer 'No' or 'Hell No,' and I do NOTES research."

Here's the bottom line. Unless you have promised your patient trouble, only the most ardent proponent of NOTES could call these results "promising".