Choose the Right Horse

Choose the Right Horse

“For a good horse to put in a good performance, a good jockey is essential. But a good jockey can’t do much for a poor horse.”

Charles H. Wheeler

Twenty-one percent of care delivered in the healthcare system today is unnecessary. Two million patients obtain infections in the hospital setting- infections that they didn’t have before they were admitted. Forty percent of cardiac patients receive inadequate or inappropriate care. These are all gaps in care that contribute to the 3rd leading cause of death in the United States today, which is medical error.

We need to do our best to identify these gaps in care, and essentially, we can do that during your initial case review. When the patient or the family presents to you, the attorney, you are evaluating the potential value or merit of the case. This is really where the physician needs to step into that room as well, via video conference, to identify the medical processes and policies that may have been breached, and assist in taking the case and moving forward in the legal process, if the case is strong enough.

Essentially, what we as physicians could do is help you select the right case and “weed out” the cases in which you do not wish to proceed. This way you would never have to represent in a case that you felt was too weak to begin with, or probably had no chance of winning. If we put all our energy into the beginning of the case, when it is presented, it will save a lot of time in the end.

You want to be able to focus on identifying and selecting the right cases to represent. Choosing the right case is the most critical part of the entire process. If you have the wrong case, the pieces fall apart, and the energy goes into something that’s not worth chasing.

This is no different than wanting to identify the right horse in a race. You must have the right horse and the right jockey to get to the finish line first.

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Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP
KayurVPatel@ExpertWitness.MD

Right Care

The best reward that I could get as a physician is if my patient was on 6 medications, and after six months I was able to bring them down to 5, 4, or maybe even 3 medications instead. That would be a reward for me and is what should be our target of focus as clinicians.

Over the years, I think we have forgotten about the true definition of health. We need to look back to the World Health Organization in the mid-40s that defined health as “not merely the absence of disease”, meaning a patient can look physically healthy; weight is perfect, BMI (Body Mass Index) is great, muscle-to-fat ratio is great. But maybe there is something brewing.

Maybe the patient’s labs are creeping up and we need to take a look inside. We may see that there is a disease that could erupt over the coming weeks, months, or even years. We could stop this trend in healthcare, but the only way to do that is by collecting quarterly labs.

A 25-year-old comes into the clinician’s office to establish a relationship. As a routine, we would get baseline labs, which would likely include HbA1C. This is the Standard of Care and is used as a marker for pre-Diabetic screening. However, it is an absolute myth that A1C is a predictor of Diabetes. It is actually designed to evaluate the compliance of medications and diet once the patient has already been diagnosed. This is not to make a pre-Diabetic diagnosis.

A1C is a measurement of the RBC (Red Blood Cell) function and the amount of glucose that is on the RBCs. The RBCs in our blood only live for about 90-120 days. It’s a fallacy and a false satisfaction to the patient to think they aren’t at risk if their A1C is okay, because it’s only a 90-day indicator.

What we should be measuring instead, for optimal diabetic care, is the insulin level. Why? We want to go to the factory where the insulin is produced- the pancreas. If we can see the function of the factory, we can ask ourselves, “is the factory getting tired?” If the pancreas produces an abundance of insulin, which is what stabilizes the blood sugar, for weeks, months, or years, eventually it becomes fatigued. That’s what we want to be able to see. The fasting insulin level can be drawn on a quarterly basis to see if there is an increase in insulin, and from there we can determine if a patient is at risk for Diabetes. A patient should be getting annual labs at the bare minimum, but ideally, they should get these labs quarterly, so the clinician can look for signs of early disease. It is optimal care for the patient to see if there is any reason to believe that they may be at risk.

No disease creeps up overnight. You weren’t healthy yesterday and got Diabetes or cancer today. It was a gradual process over time that could have been discovered if you were getting routine labs on a quarterly basis.

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Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP
KayurVPatel@ExpertWitness.MD

Zero Tolerance For Medical Errors

Zero Tolerance For Medical Errors

Imagine a fully-occupied Boeing 747 Jumbo Jet crashing every night and killing all passengers on board.

As horrifying as this sounds, that number is equivalent to the number of deaths caused each day by medical error. What’s even more disappointing about these statistics is that the healthcare industry doesn’t acknowledge that they even exist. The public doesn’t recognize this because we depend on the media to get our information. It would be a headline news story on CNN if an aircraft skidded off the runway, even if there were no casualties, because this is news.

The Federal Aviation Administration requires a root cause analysis to be completed on every adverse event, with a review of policies, procedures and guidelines, as well as modifications to prevent these errors from reoccurring.

Now imagine if the healthcare industry did the same. How many errors could we prevent?

IOM released a report in 1999 that identified medical errors as the third leading cause of death in the United States. This is not a new statistic. The numbers have not changed in 20 years, despite many efforts to improve them.

When a root cause analysis is completed on a medical error, the results are that 80% of these errors occur at the critical decision-making point in the diagnosis. This is a crucial point in the process, as the choice is made to provide the right medication, the right dose, and the right tests to correct the illness. How can we ensure that the right care is provided each time?

We must focus on our current guidelines, procedures, and policies, and modify them in such a way that we can prevent these errors from occurring in the first place. Technology is evolving every day, and electronic medical records should be capable of alerting medical staff when something doesn’t appear accurate. We need to look at the methodology of dispensing medications, as well as minimize human error as much as possible by consistent trainings on new guidelines and procedures as they change. Most of all, we must conform to a culture of zero tolerance. Bottom line is, in healthcare, 99% isn’t good enough.

The aviation industry has this system figured out. The healthcare industry needs to do the same, so that we are not repeating these errors 10 years from now.

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Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP
KayurVPatel@ExpertWitness.MD

Autopsy of An Autospsy Report

Autopsy of An Autospsy Report

We have all reviewed death certificates and autopsy reports. We often look at these reports and see the cause of death, and we think the answer is clear.

This is a common misconception

For example, the reports typically state the cause of death was heart failure, cardiac arrest, aneurysm. But how many times have we seen on the certificate or report where it states the cause was due to medical error? Never. That’s because the cause of death on a death certificate or autopsy report is directly linked with the ICD code for the diagnosis. The CDC relies on these codes to calculate statistics for deaths nationwide. ICD billing codes are what clinicians use for medical records and insurance reimbursement claims. These billing codes are not meant for national health statistics. Furthermore, there is no code for medical error.

A recent U.S. patient-care study by Johns Hopkins University estimated that more than 250,000 hospital patient deaths per year stemmed from medical error, making it the third leading cause of death in the United States today. This calculation doesn’t include the number of Americans who die at home as a result of these errors. The authors of the study concluded that the current method in reporting cause of death has a serious limitation, and they have recently appealed to the CDC requesting a change in the current method of listing cause of death on reports. To date, no changes have been made.

Illness or injury are not the only reasons people die. They also die from preventable causes, such as unintended acts or diagnostic errors. If someone trips and accidentally disconnects a ventilator power cord and the patient on the ventilator dies, the cause of death listed on the death certificate is likely to be respiratory failure, though the actual cause was human error. Without that documentation, however, it’s as though the problem of medical errors doesn’t exist.

How Can We Make An Impact?

We need to take a closer look. We need to review medical records, not just look to the death certificate or autopsy report for answers. We must distinguish between cause of death and manner of death. We need to investigate the disease process, and the cause of death itself, to determine where things went wrong. We need to evaluate the events preceding the patient’s death, to help prevent these medical errors in the future.

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Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP
KayurVPatel@ExpertWitness.MD