August 27, 2010 | 5:01 pm

Admitting Our Mistakes

Posted by Albert Fuchs, M.D.

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I’ve written before about how the error rate in the practice of medicine is far greater than that in other industries.  I’m not talking about when doctors make a difficult decision that in retrospect was wrong; I’m talking about just plain mistakes, such as when one medication is ordered but another is dispensed or when the dose dispensed is 10 times greater than what was what was intended because of an extra zero was written in the order.  We are finally looking to fields such as aviation to learn how to adopt safe practices in every part of patient care.

And though our error rate is too high, even with best practices it will never be zero.  Even in aviation some planes go through the regular maintenance, go through the take-off checklist, and still crash.  In a diner, an error might lead to a ruined meal.  In healthcare, and error can lead to a catastrophic injury.  So what should doctors do after an error has already happened?

The standard paradigm for handling medical error management has been the legal defense.  Doctors were advised not to communicate with the patient or the family for fear that they would disclose something that would increase their legal liability.  Patients and family members felt cut off from information just when they felt most injured and vulnerable.  Doctors felt unable to continue caring for the patient and to express remorse for what happened.  Rather than concentrate on helping the family and the patient recover from the mistake, the focus was on preparing for the anticipated lawsuit.

Fortunately, the paradigm is shifting.  More and more institutions are moving to a policy of complete and prompt error disclosure.  Physicians are trained to sit with patients and families immediately after adverse events, explain what happened, tell them what is known so far, and explain that the institution will promptly investigate the details of the case to see if errors occurred.  Importantly, physicians can express remorse.  If errors are discovered by the internal investigation, the patient or family are informed of the error and offered compensation.

This open approach has met with some resistance due to the fear that it would lead to more frequent malpractice suits and awards.  A study in the current issue of Annals of Internal Medicine suggests that the opposite may be the case.  The study reviews malpractice claims against the University of Michigan Health System (UMHS) from 1995 to 2007.  In 2001 UMHS implemented a program of full disclosure of medical errors with offers of compensation.  The study shows that the rate of lawsuits, patient compensation and legal costs all declined after the change.

So transparency and honesty after errors is not just the most ethical policy.  It’s the better business policy too.  The hardest time to be honest is after something goes horribly wrong, but that’s when patients most count on our honesty.  Many patients and families are ready to forgive if they see that we are doing everything possible to assure the error doesn’t happen again.  We now no longer have a legal excuse for not knowing how to say we’re sorry.

Learn more:

New York Times article:  When Doctors Admit Their Mistakes

Annals of Internal Medicine article:  Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program

My post in 2007 about teaching physicians to disclose errors:  Learning to Say “I’m Sorry”

My post in 2009 about adopting a culture of safety in healthcare:  Got Safety?

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

August 20, 2010 | 2:56 pm

Time for Flu Shots

Posted by Albert Fuchs, M.D.

Summertime, and the livin’ is uneasy Stocks are slumpin’ Unemployment is high

(with apologies to George Gershwin)

Reminders of the end of summer are upon us.  Kids are returning to school.  Rain covers are thrown over backyard grills.  Flu vaccines are arriving in doctor offices.

This season’s influenza vaccine is here.  It contains the flu strains most likely to reach North America this fall including H1N1, the flu strain formerly known as swine flu which caused so much hoopla last year.

The Centers of Disease Control this year decided that that the flu shot should be recommended for everyone over 6 months of age so as to limit the spread of flu and protect more people.  The vaccine is particularly important for the following groups:

• Pregnant women
• Children younger than 5, but especially children younger than 2 years old
• People 50 years of age and older
• People of any age with certain chronic medical conditions
• People who live in nursing homes and other long-term care facilities
• People who live with or care for those at high risk for complications from flu, including:
  • Health care workers
  • Household contacts of persons at high risk for complications from the flu
  • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated)

The following people should not be vaccinated:

• People who have a severe allergy to chicken eggs.
• People who have had a severe reaction to an influenza vaccination.
• People who developed Guillain-Barré syndrome (GBS) within 6 weeks of getting an influenza vaccine.
• Children less than 6 months of age (influenza vaccine is not approved for this age group), and
• People who have a moderate-to-severe illness with a fever (they should wait until they recover to get vaccinated.)

So get your flu shot now, and start dreaming of an influenza-free winter.

Learn more:

The Centers for Disease Control and Prevention:  Key Facts About Seasonal Flu Vaccine

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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August 13, 2010 | 2:10 pm

Startling Scientific Finding:  Dieting Leads to Weight Loss

Posted by Albert Fuchs, M.D.

What sort of diet helps people lose more weight?  Do overweight people lose more weight on a low-carbohydrate diet (like Atkins) or on a low-fat diet (like Weight Watchers and others)?

A carefully designed study published in the current issue of the Annals of Internal Medicine answers that question.  The study enrolled over 300 obese adults and randomized them to a low-carbohydrate diet or a low-fat diet.  Importantly, patients with diabetes, high cholesterol and high blood pressure were excluded.  The low-carbohydrate diet group was instructed to restrict carbohydrates and to have as much fats and proteins as needed to feel satisfied.  (This is essentially the Atkins diet.)  The group randomized to a low-fat diet was instructed to limit total calories to between 1200 and 1800 kcal per day, with less than 30% of total calories from fat.

Both groups attended periodic behavioral group sessions to discuss their progress and learn skills for persevering with the diet.  Both groups were also instructed to pursue an exercise program consisting largely of walking.  The groups were followed for two years.

The authors’ were trying to show that a low-carbohydrate diet would lead to greater weight loss, but actually the weight loss was the same in both groups.  Each group lost an average of 24 lb after one year and 15 lb (or an average of 7% of their body weight) after two years.  About a third of the participants in each group had dropped out by two years.

One lesson from this study is that perseverance in any diet program will yield meaningful weight loss.  It doesn’t matter which diet.  The second lesson, highlighted by the large numbers of drop-outs, is that this is hard to do.  So get started, and don’t quit.

Learn more:

Annals of Internal Medicine article:  Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate Versus Low-Fat Diet

My post in 2009 comparing different diets:  Scientifically Proven Weight Loss Method: Eat Less

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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August 6, 2010 | 4:22 pm

Rethinking Calcium Supplements

Posted by Albert Fuchs, M.D.

This week I discovered how painful it can be to change a habit.  Not because it means admitting I was doing the wrong thing, but because it means analyzing how feeble my reasons were for the habit in the first place.

Ever since I started practice I’ve been recommending calcium supplements to post-menopausal women.  Why?  Mostly out of habit.  There’s not a shred of evidence that calcium supplements prevent fractures, but some suggestion that they may help bone density.  But what’s the harm?  Calcium supplements are safe and wholesome and natural, right?

Last week the journal BMJ published a meta-analysis of randomized trials which compared calcium supplement against placebo.  (Expand your geeky medical literature vocabulary!  A meta-analysis is a study that systematically reviews already published studies on a particular topic and statistically pools together the results of all these studies.  The goal of a meta-analysis is to reach a more definitive conclusion than the individual studies did.)  It’s important to note that these trials were not studying the effects of calcium supplement on heart attacks.  They were each looking at the effect of calcium on different outcomes – bone density, fractures, colon cancer, whatever.  The investigators looked through the original study data and (where the data was available) counted the numbers of heart attacks in patients taking calcium supplements and in those taking placebo.

For the studies in which data was available on individual patients, about 3.5% had heart attacks on calcium while about 2.7% had a heart attack on placebo over an average follow up of 3.6 years.  That may not seem like a big difference but it means that for every 69 patients on calcium rather than placebo for 5 years there was one extra heart attack.  Some media reports characterized this as a small increased risk of heart attacks, but it’s not.  It’s in the same numerical ballpark as the decrease in heart attacks from treating high blood pressure.

Even if this harm was numerically small, remember, we have to weigh it against a completely unproven benefit.  Doctors have been recommending calcium supplements on the assumption that they prevent fractures, an assumption that has not been demonstrated in trials.  The study calculates that, even taking optimistic estimates for fracture reduction from calcium supplements, treating 1,000 people with calcium supplements for five years would cause an additional 14 heart attacks and prevent 26 fractures.  That’s a terrible tradeoff.

So calcium supplements seem to be a bad idea.  But there are some important additional points.  First, the authors were careful to state that dietary calcium (calcium in your food, not in supplements) has never been implicated in heart attack risk and is presumably safe.  So we should be getting our calcium in our diets, not in supplements.  Second, this study did not address vitamin D, which has many proven benefits that calcium does not.  So keep taking your vitamin D supplements.  Finally, patients with osteoporosis who are taking medications that rebuild bone need excellent calcium intake for the medication to be effective.  In these patients, who are at high risk for fracture, the benefit of calcium supplements may be greater than the risk.

An editorial in the same issue of BMJ concluded that “given the uncertain benefits of calcium supplements, any level of risk is unwarranted,” and that calcium supplements “should not be given without concomitant treatment for osteoporosis.”

So as painful as it is to change my mind about something I thought was completely benign two weeks ago, for my patients who do not have osteoporosis, I recommend stopping calcium supplements.  Obviously, if you have questions about your unique situation, ask your doctor.

Maybe next week I’ll find out that smelling roses causes seizures.

Learn more:

BMJ article:  Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis

BMJ editorial:  Calcium supplements in people with osteoporosis

LA Times Booster Shots:  Calcium supplements increase the risk of heart disease in the elderly, study says

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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