Clinicians Must Watch for Drug Abuse in Drugs That Should Not Have Abuse Potential

Medical professionals use immense care to prevent drug abuse, particularly when prescribing narcotics, such as opiods. These controlled substances are stringently regulated because of their exploitation potential. Often, nevertheless, those precautions are overlooked regarding medications that may be just as easily addictive and are more readily accessible. Doctors must be cognizant of the potential for exploitation of medicines which could not be as well known for their exploitation potential.

A muscle relaxant also known as Soma, carisoprodol, is one instance of a non-controlled drug that has a long history of abuse. Some states classify carisoprodal (accessible since 1959) as a controlled substance, yet, at the federal level, the drug avoided that classification until 2012. Precise figures on the degree of abuse of non-regulated medications aren't precise due to constraints in the way that data is reported and collected.

Other drugs that hold potential for abuse include antipsychotics, antidepressants, and some anticonvulsants. By combining these materials with other drugs, the abuse potential may be increased.

Over-the-counter medicines which have active pharmaceutical ingredients can also be abused. These medications, often cold medicines or cough syrups, are particularly susceptible to abuse since they are affordable and easy to obtain with no prescription. The National Institute on Drug Abuse notes that cold medicines introduce a high risk of exploitation because of ingredients that can create hallucinations or euphoria when taken in high quantities. Some abusers take the medications directly, but others take them in combination with other drugs or blend the substances with soda for flavor.

Doctors must know about the misuse and dependence potential of controlled substances. Nevertheless, an entire assessment of a patient's welfare must also include knowledge of the risks presented by non-controlled substances.

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Two Crazy Cases Against Doctors

As a physician today, there's constantly worry about a potential medical malpractice litigation. Occasionally these medical malpractice suits are not warranted and some are just plain crazy because the harm came from the actions of the patient.

Medscape lately summarized a case against a cardiologist who lost a medical malpractice lawsuit because the family said he did not advise the patient not to take part in tasks that were stressful. The patient went to the cardiologist complaining of pain radiating into his arm. The cardiologists, noting the high risk of cardiovascular disease, ordered a nuclear stress test. Before the evaluation was done, the patient died of a coronary while engaging in a threesome with another man and a woman. Because there was no documentation that the man was warned by the cardiologist against stressful tasks, the jury found the doctor was 60% responsible for his death and that the patient was 40% responsible. The family was awarded $3 million, which was $2 million over the cardiologist's malpractice insurance.

An even more unusual case saw a man who was admitted to the ER complaining the effects of having inserted a bottle up his rectum. The attending physician gave the patient two alternatives: to have the bottle either manually or surgically removed. The patient decided to have the bottle manually removed. Sadly the removal did not go well and testing revealed signs of a colonic perforation. The bottle was then removed surgically.  The review board of California then severely sanctioned the ER doctor for gross negligence.

Certainly the cardiologist in the first case could have documented his advice and had the patient sign to make sure he understood. The ER doctor could have run the tests first before trying to pull the bottle sparing the patient a good deal of pain and herself a lot of professional damage. Both cases were a consequence of patients behaving poorly, the court and the review board found the doctors in question liable.

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Medical Education System needs an Overhaul

The current medical education system based on rote memorization is not preparing physicians for how medicine is currently practiced.  Today, with the ability to look up any detail instantly, memorizing biochemical pathways or other such trivia isn't an excellent use of anyone's time. Critics assert that students must be taught the best way to find info and how to utilize it rather than simply memorizing facts. This argument is supported by the fact the body of medical knowledge doubles every couple of years.

Today's medicine is often practiced in a team environment working together for the most effective possible outcomes. The "hero physician" model of training has a tendency to produce physicians that are unable to work well in a team and therefore are unprepared to practice in today's collaborative setting.

Residency-training plans may need to be updated too. Currently, these programs encourage recent graduates to go into specialization training as opposed to primary care. The amount of specialized training positions has gone up almost 60% versus just an 8% increase in primary training positions, despite the considerably greater need for primary care physicians. Programs that support and prepare doctors to work in underserved or rural areas are also lacking.

The American Medical Association (AMA) is starting to recognize the demand for change and are working on plans to change the medical education system. One new program focuses on preparing doctors to work in the current practice setting. Most of the changes center on the changes found in the "digital age". Electronic health records, global online collaborations, personalized medicine, the ability to quickly locate and use information on any topic, and continuously evolving technologies are some of the areas the new program intends to focus on.

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Pain Medication Addiction – Could it be Malpractice?

Could it be medical malpractice if a patient becomes addicted to narcotic painkillers that were prescribed to battle chronic back pain?  It all depends on the circumstances and requires the advice of a medical expert in the same field as the doctor being sued weighing in on the ‘standard of care’.

An example from an article in NOLO described a doctor who prescribed pain medication to a patient who had a heroin addiction.  Is it malpractice if the patient did not disclose this past addiction? Another example involves a physician who prescribed pain meds to a patient for post-operative back pain.  After five years, the severe back pain was still present and the patient was now addicted to the pain medication.  A case could be made that the doctor was negligent for not referring the patient to a pain management specialist for treatment with non-narcotic drugs.

Especially with the addition of meaningful use, physicians have very little time with patients and often have to prescribe pain medications without being able to ask every possible question about their history. 

Guidelines are in place that strictly require doctors to warn patients about the risks of addiction.  The question in a lawsuit would be whether the patient heeded the warnings and followed instructions, or was the physician negligent in giving proper warnings.

A medical malpractice lawsuit about pain medication involves proving negligence on the part of the doctor.  However, could lawsuits like these do more harm than good since doctors might be more reluctant to provide pain medications for fear of lawsuits even if those medications are necessary? 

What is your opinion?

Did They Deserve to Get Sued? How Malpractice Suits Change Doctors

Patients can, and should, make use of the capability to bring a lawsuit against a physician when the situation requires it. What's astonishing is how frequently these lawsuits are a complete surprise to the doctor.

Medscape’s recent Internal Medicine Malpractice Report noted 74% of physicians who are named in a medical malpractice lawsuit say they were blind-sided by the notification.  Only 24% thought a suit might be coming and only 1% said they were certain a patient would sue.

The surprise may come because specialized physicians may only see the patient for a short period of time and have very little interaction with them aside from a single evaluation before the patient returns to a primary care physician. Thus, they might have no idea how the patient is doing. Some patients go directly to a suit without communicating with the doctor first. In other instances, the doctor may just miss the signals of an impending lawsuit.  In other cases, the patient may simply go directly to a lawsuit without communicating with the physician at all.

Does a malpractice lawsuit change a doctor? Even if the suit is dismissed, the process can be quite stressful and can take years to be resolved. Most physicians continue to see patients during the process. According to the Medscape study, about 30% of doctors said after a suit was filed against them, they stopped trusting their patients. It's understandable that a natural response to getting sued is practicing more defensive medicine.

Legal action must remain an option, however it ought to be the final recourse when nothing else has brought a remedy that is reasonable. Physicians need to trust their patients just as patients need to trust their doctors.

To learn more about medical malpractice lawsuits simply contact us today!

The Complex Physician Credentialing Process

Physician credentialing is the procedure for evaluating practice history and the qualifications of a doctor prior to acceptance of hospital privileges, employment, insurance plan approval, or licensure. There are few agencies that keep credentialing documents, thus, the process is burdensome and time consuming with few shortcuts for doctors who are submitting qualifications to multiple agencies.

Credentialing calls for a formal application by a doctor that is then verified against information from the American Board of Medical Specialties or The National Practitioner Data Bank. Any state where the doctor has an active license is contacted to identify any practice problems. Training and education are checked through direct contact with hospital programs and schools, and registration with the Drug Enforcement Agency and Medicare/Medicaid is usually confirmed. Board certification is also verified. Other essential information includes personal information like credit history or bankruptcy which could reveal a malpractice claim settled out of pocket and unreported to the data bank. Lapses in employment must be explained and are also thoroughly investigated.

Credentialing usually takes about 90 days, however it's best to allow at least 150 days to complete the procedure. Any disparities including missing, outdated, or incomplete information can delay the process. The most common areas that cause delay are verification of current work status, work history, malpractice coverage, hospital privileges, and attestations.

In 1906, the American Medical Association established Physician Masterfile to keep membership information including education, certifications, and training. This information is available to agencies and organizations that verify physician credentials. Background information can be certified by the Federation of State Medical Boards for a fee, paid by the physician.

Many agencies accomplish the credentialing procedure on a physician's behalf for a fee, and these agencies are in high demand because of the need created by the cumbersome credentialing procedure.

Healthcare facilities could be held liable in malpractice suits if they allow incompetent physicians on staff, hence before determining who to hire, as much information as possible is verified.

Have you ever experienced a rise in the credentialing requirements?  Do you have any solutions to this cumbersomeprocess?

Overdiagnosis and Overtreatment Can Lead to Treatment Worse Than the Disease

It may be hard to understand, but in cancer cases, the treatment can sometimes be worse than the disease itself. The possible outcomes should be considered in cases where diagnosis leads to unnecessary treatment.

Many cancer treatments come with serious side effects to patients because treatments, such as chemotherapy, which are toxic to cancer cells, also can affect normal cells which leads to side effects and sickness.  Some damage from chemotherapy might be permanent, thus, doctors must be sure diagnosis decisions avert treatment that the patient may not need in the first place.

Overdiagnosis mainly occurs as a result of screening tests done by a doctor to be able to detect diseases early. Early detection is a great thing as it enables early intervention and treatment which could lead to cancer remedy. Unfortunately, cancer screenings regularly find tumors that are clinically of no consequence. If that discovery leads to unneeded treatments, it is not difficult to understand how the treatment can be worse than living with the ailment.

One common example of overdiagnosis resulting in treatment is prostate cancer. The prostate-specific antigen test is frequently elevated in older men. Those results can lead to over radiation therapy or aggressive surgery, which expose the individual to possible unwanted side effects like incontinence and impotency. Autopsies of males who died from conditions besides cancer have found that prostate cancer is extremely common particularly as men age. However, developing the cancer in the form that's deadly is rare.

Hypertension is just another common malady which could result in overtreatment. A recent study in The BMJ noted that about 40% of adults worldwide have hypertension with more than half of those having a mild form of the disease that is low risk and has not progressed to cardiovascular disease. The study also found that more than half of the patients with mild hypertension are treated with medications despite the lack of medical evidence that this treatment actually reduces the risk of cardiovascular disease. 

Screening evaluations are essential to educating medical diagnosis, however, there are limits to testing. Doctors must ensure that treatments are specific to each patient and disease as much as possible. Contact us to share a story about overdiagnosis or overtreatment.

Standard of Care is no Protection Against Malpractice Lawsuits

The medical standard of care is broadly accepted as determined by printed, evidence-based and expert-opinion established clinical practice guidelines. The issue is there are thousands of published guidelines, some narrowly defined for specific diseases, while others are much more extensive in range. Examples include the "Choosing Wisely" initiative made to reduce unnecessary tests and worthless treatments; others including quality indicators issued by the CMS, are meant to guide practices to better outcomes by regulating insurance payments.

The definition of medical malpractice is "professional negligence by act or omission by a doctor in which the treatment provided drops below the recognized standard of practice..". Many doctors believe that if their treatment options are supported by this "standard of care", that they're protected against malpractice lawsuits. After all, if a doctor is following the latest clinical practice guidelines, how can he/she fall below the standard of practice?

Guidelines in many cases are written for text-book examples, so, without completely assessing a patient, if this guideline is followed by a doctor, they may be guilty of negligence. A guideline normally can't be admitted as evidence in a malpractice lawsuit unless expert witnesses agree that it applies to a specific case.

Before offering guidelines as evidence in a litigation, intent and correctness of individual guidelines have to be considered. Some guidelines are meant to guide insurance payments, not patient care - like the CMS's "never events". Others are based on opinion or consensus instead of real clinical evidence. Some are obsolete before they are even printed because of rapid progress in the medical field. Still others might be tainted by manufacturing company or pharmaceutical interests.

The wisest course of action seems to be for doctors to treat guidelines as general outlines of care likely to change rather than fail safe statements of the standard of care.

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Characteristics of a Good Doctor

A recent e-mail caught my attention with all the heading "Characteristics of a Great Doctor". It's interesting to take some time and consider what features are important to health care? Patients frequently tout that they want a doctor who listens, who is kind, helpful, and caring. Frequently doctors fail to convey caring or kindness to patients even though that would seem obvious.

Patient perception is another element to be considered. We all see interactions predicated on our previous encounters, so it is vital to keep in mind that the patient might be bringing preconceptions from past experiences which can put the doctor at a real disadvantage. The best I can do to carry out my mandate to be a "good physician" is to really BE helpful, kind and caring, even if this message gets lost in translation.

Professionalism is another important attribute that is certainly usually noted in surveys about "What is a Good Doctor". Professionalism must be learned, practiced, and chosen consciously in scenarios where emotions could otherwise win out. This is difficult, but the occupation has an importance greater than personalities or biases. We, as healthcare providers, have been allowed a great privilege and with that comes the responsibility to subordinate our prejudices and our quirks.

Knowledge is another major requirement of being an excellent physician. Board certification reassures patients of expertise and it is important for me to keep my knowledge base current to be able to be, in my understanding, a "good doctor". Other aspects include empathy, the ability to listen actively, flexibility, and self assurance. 

The ability to collaborate, to admit our limitations, and also a willingness to seek help are three top qualities of a good physician, in my book. There are many more attributes that could be listed. A "good doctor" doesn't have to be superhuman, but should attempt to be the best he or she can be.

What qualities do you think are important in a doctor? What qualities have you respected in co-workers or mentors? Do you struggle with any one of these places? I'd love to hear from you!