Wednesday, May 31, 2006

Man bites dog:KY Surgeon prevails in malpractice verdict against attorney

In an environment where as much as forty percent of malpractice suites may be groundless, there are precious few tools for punishing plaintiff attorneys who attempt legal shakedowns. It is an expensive and frustrating process to counter-suit and most physicians don't have the time or resources to pursue it. However, when the right (or in this case wrong) doctor is sued who has both frustration with being sued and the resources to do something about it, sometimes the tables can be turned.

Twice in recent years in Louisville,KY (where I lived until recently) there have been stinging rebukes to attorneys who have pursued cases where they could find no medical experts to agree with their positions. Read here & here for these cases. Both cases involved several physicians whom I know and they represent some of the regional experts in their fields of Orthopedic Surgery & Neurosurgery.

An interesting proposal for addressing the broken system of medical malpractice has been proposed by the organization Common Good. They advocate the development of specialty "Health Courts" (similar to existing administrative tax or workmen's comp court proceedings)whose hallmark would be medically-trained, full-time judges making precedent-setting decisions about proper standards of care, would remedy the unreliability of our current system. Giving up jury trials and scheduling noneconomic damages such as pain and suffering would lead to more people being compensated, and to their receiving their money sooner.

Support for this alternative comes from sources ranging from The National Law Journal, USA Today, The Wall Street Journal, Forbes, the AMA, and the American College of Surgeons. Predictably, the ABA has opposed alternatives ththehe current swamp of medical torts, where almost 60% of all plaintif judgments are now consumed by attorney fees & court costs. The Harvard School of Public Health is working with Common Good in conducting research to answer unresolved health court policy questions. They are analyzing individual state constitutional impediments to health courts, doing projected cost analyses, developing a tiered schedule for noneconomic damages-which would have upper limits-and working out the standards for compensation.

Thursday, May 25, 2006

MRSA reference in USA-Today

Covering some of the issues I wrote aboout recently with Staph. infections, USA-Today looks @ how this is influencing Sports locker rooms and environments.

Click here to read.

Saturday, May 13, 2006

Important trend in breast cancer

There was a very important piece in the New York Times on adjuvant breast cancer treatment trends.

This is another post that's not really Plastic Surgery per se, but overlaps with our role with breast cancer reconstruction. Most women with invasive breast cancer are given chemotherapy, and in general if was a small tumor that had favorable characteristics and involved no (or few) axillary lymph nodes they traditionally received a two drug chemotherapy regimen (Adriamycin & Cytoxan). In contrast women with larger tumors, those with aggressive cellular characteristics, presentation in their 30's, and multiple (or palpable) axillary lymph node metastasis would get a third drug (usually Taxol) added which adds a lot of morbidity for the patient.

As with sentinel lymph node techniques which have decreased the number of women receiving axillary disections and the resultant 8-30% rates of lyphedema (arm swelling from disruption of lymphatic drainage), we're now parsing the data to figure out who can receive less or even no chemotherapy. The important subgroup that is being considered for this is those with estrogen (ER) or progesterone (PR) receptors present on the tumor.

The simple way to think about breast cancer (or any cancer) is that the more normal regulatory processes a cancer cell maintains, the more areas we have have to attack it with chemotherapy, immunotherpay, or hormone manipulation. An ER/PR+ tumor allows us to block the hormone binding sites and potentially induce programmed cell death (apoptosis) using drugs like .Tamoxifen or Arimidex. These kinds of drugs have few day to day side effects, but do appear to slightly increase other things like cervical cancer and incidence of blood clots. The relative risk of those side effects however, is largely outweighed by their reduction in breast cancer recurrence. Women with these ER or PR tumors seem to have similar or improved disease specific mortality irrespective of their chemotherapy when some epidemiologists retrospectively reviewed the data & is what's gotten us interested in this.

We're left with the interesting possibility of perhaps excluding chemotherapy for many women which would be a revolution in contemporary oncology and of tremendous benefit to our patients. Clinical trials of this strategy are being drawn up to give us data on this

Tuesday, May 02, 2006

Staph infections

I had a patient ask about her father who I was treating for a sternal wound infection after a coronary bypass operation. She asked what MRSA was as she'd been told her father was infected with it and she was concerned over stories she'd heard on TV.

MRSA is methicillin-resistant Staphylococcus (staph) aureus bacteria that's become an increasingly prevalent issues in society. Previously mostly confined to hospitals & nursing homes, we've now seen rapid changes in community infection patterns to where in some areas, drug-resistant staph infections are the rule rather then the exception. I'm usually surprised now when it's not a resistant infection that shows up in the ER or wards.

Some recent well-publicized infections from football fields and neonatal units have made headlines. Predictably, the lawyers are also now advertising this as a new tort for class action lawsuits.

What's driving this emergence of MRSA? A lot of things are being implicated.

- Inappropriate antibiotic use in the outpatient setting (think getting antibiotics from your internist or pediatrician for the common cold, a viral process not sensitive to antibiotics)

- Inappropriate antibiotic use in the inpatient setting (prolonged prophylactic antibiotic use for surgery, unnecessary broad spectrum coverage, failure to change prescribing patterns to hospital bacteria sensitivity profiles)

- The rise since the early 1980's of powerful new Penicillin-class (Unasyn,Zosyn,Fortaz) antibiotics followed by other new class of antibiotics like the Quinolones (Cipro,Levaquin,Tequin) which put tremendous tools in our hands for fighting infection, but also produced "social Darwinism" among bacterial strains that resulted in resistant species

- Massive use of antibiotics given to livestock, which result in larger feed animals

- Consumer products that now contain anti-biotic material (mouthwash, soaps)

- Breakdowns in universal precautions (gowns, hand-washing) to avoid patient to patient spread (which isn't really causing MRSA but facilitates it's transfer)

What's this got to do with Plastic Surgery? Well, many of us do in fact treat some of the worst soft tissue infections you'll see. In addition, antibiotics have historically been given indiscriminately after many elective cosmetic procedures. Despite a lot of evidence not supporting antibiotic use beyond the peri-operative period (or possibly at most 24 hours), you see a lot of people continue to give 5-7 days of oral cephalosporins (eg. Keflex).

What drives this? Defensive medicine & patient's expectations. Many people have rationalized that if a infection develops & they did not have someone on antibiotics that there will be both medical liability & upset patients. You may not be able to avoid the latter, but there is increasing data that we may in fact be causing more problems (on a system-wide perspective) then we are avoiding. Unrequired antibiotics will result in more cases of anti-biotic colitis & drug-resistant infections.