Medical mistakes have been receiving a lot of attention in the last few years.  The number of patients injured due to medical mistakes, especially in hospitals, has caused pressure at every level of health care to reexamine how patients can be protected.  Many of these error prevention measures are technical – computerized drug interaction checking, pharmacy algorithms to prevent dispensing medications to which the patient is allergic, redundant verification of critical pieces of information like the side of a surgery or the blood type.  These technical procedures go a long way to prevent catastrophes, and more of them are being adopted all the time.

But what about after an error has already occurred?  What about after a patient has already been harmed, not by her disease, but by a mistake?  This week’s New England Journal of Medicine has an important perspective article on the toll of medical mistakes on patients and families.  The article was also covered in this story in today’s New York Times.  The authors interviewed patients, family members and physicians that were involved in medical mistakes.  They found three unifying themes to many of the interviews:  family members feel guilty for not protecting their loved one from the medical error, family members and patients fear retribution from health care workers if they express themselves about the error, and physicians frequently isolate and cut off communications with the patient and the family after an error occurs, when the family feels most vulnerable.

Many institutions are learning from these lessons.  Cedars-Sinai has been quite aggressive in assuring prompt and full communication with patients and with families after errors occur.  As part of their Leadership Development Program, I’ve worked closely with their risk management department and have heard their commitment to prompt and full disclosure of errors.  Cedars-Sinai recently has also adopted the practice of not charging for any care that is needed to recover from a medical error.  So if a hospitalization is prolonged or an extra surgery is needed to repair harm done by an error, Cedars will not bill for the additional care.  They are also working on a curriculum which will be available to all the residents and medical staff about “having a difficult conversation” which will train doctors to compassionately have the discussions we all dread:  to break the news about a terrible diagnosis, to convey an unexpected outcome, to admit a mistake.

A business coach once taught me the motto “Systematize the predictable.  Humanize the exceptional.”  This applies particularly well in medicine.  To prevent errors we have to use technology to systematize the thousands of daily routines that keep hospitals running safely.  But once the error has happened technology is useless, and we must be guided by the goal of restoring trust, respect and compassion between human beings.

Tangential Miscellany:

Two weeks ago a lot of you emailed me about the outrageous ways that doctors or their offices have annoyed, inconvenienced and disregarded you.  I’m trying to collect lots of these anecdotes, and your stories may actually prevent similar things from happening to future patients, so please keep the emails coming.  (I’ll let you in on what this is all about as the project ripens.)

Bell’s palsy is a fairly common condition that causes the sudden paralysis of half of the face.  Effected people can’t fully close the effected eye and have an asymmetric smile, since only one side of the mouth moves well.  The cause is unknown and has always assumed to be viral.  The symptoms slowly resolve over a few months.

The accepted treatment has always been steroids and acyclovir (an anti-viral medication), each for about 10 days.  A study in this week’s New England Journal of Medicine finally put the accepted practice to the test.

About 500 patients who presented for care within 72 hours of developing Bell’s palsy were randomized to receive either steroids, or acyclovir, or both medications, or placebo.  The results: steroids clearly helped, acyclovir didn’t.

Tangential Miscellany:

Women frequently accuse men of not listening to them and only being interested in sex.  For these men, yesterday’s FDA warning that medications for erectile dysfunction may cause sudden hearing loss is not necessarily bad news.

The West of Scotland Study was a landmark in preventive medicine.  It was published in the early 1990s and was the first study to definitively show that statins (a family of cholesterol-lowering medicines) could prevent a first heart attack in people with high cholesterol.  It randomized over 6,000 middle-aged men with high cholesterol who had never had a heart attack to either pravastatin (Pravachol) or placebo.  In about 5 years of follow up, pravastatin clearly prevented heart attacks and saved lives.  This launched multiple follow up studies, the development of many new statins, and the revision of national cholesterol standards to ever lower goals.  Statins have become one of the most prescribed families of medications.  You probably know someone on a statin.  Tell them they partially owe their good health to the West of Scotland Study.

This week’s New England Journal of Medicine has a study that lets us visit with the same patients a decade later.  The study followed the West of Scotland patients for another decade.  During that time, they were just under their individual doctors’ care, and were not receiving any study medicine.  In fact, about a third of the patients who were initially in the placebo group and about a third in the statin group were being prescribed statins by their doctors a decade later.  The question this study asked was: would 5 years of statin therapy continue to have benefits that persisted after the original study ended?

The surprising answer was “yes”.  Even a decade later, the group that was initially on pravastatin had a significantly lower rate of death from cardiovascular causes than the group that was initially on placebo.  So five years of statin therapy prevents heart attacks and saves lives many years later, even after the medication is discontinued.  That’s good stuff!

Tangential Miscellany:

I’m trying to collect as many different examples of ways that doctors’ offices frustrate, inconvenience, or annoy patients.  If you have an example (even if it was my office) of terrible customer service from a doctor’s office, please email it to me.

At any given time thousands of people feel unwell and are dissatisfied with the diagnoses offered them by their doctors.  They struggle to understand their illness and frequently form patient groups for mutual support.  Every few years a new diagnosis captures their attention and becomes the latest vogue illness, usually without any scientific evidence.  Even worse, unscrupulous doctors latch on to these fad diagnoses to promise cures to patients who are desperate for relief.  A few years ago the fringe diagnosis du jour was chronic Epstein-Barr virus infection.  Then it was systemic Candida infection.  Now it’s chronic Lyme disease.

This week’s New England Journal of Medicine has a very helpful review article on the phenomenon of chronic Lyme disease.  The important point is that while Lyme disease is a well described and understood entity, chronic Lyme disease is a diagnosis that has never been substantiated despite careful attempts to study it.  It is an entity that is either self-diagnosed by patients or offered by physicians whose practice is, um, let’s say not evidence-based.  The patients are offered long term antibiotics for their symptoms, despite the multiple trials showing that this treatment is no more effective than placebo, and has all the potentially serious side effects of antibiotic therapy.

The entire article is available free even if you don’t subscribe.  If you know someone who is being treated with long term antibiotics for chronic Lyme disease you owe it to them to send them a link to the article.

Tangential Miscellany:

Fall is here.  Get your flu shots.