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THE SEARCHLIGHT MESSENGER

Medical History

LEUKEMIA, THE PARADIGM MIRACLE

 
 
Another year has gone by, and in two short weeks, we celebrate National Cancer Survivor’s Day. When this day arrives, I am always taken back and remember those who never had a chance to celebrate this day.
 
Having practiced medicine for more than three decades, as a physician I was firmly involved with the care of little children. As a Family Doctor, Internist, and Hospitalist, I saw my fair share of childhood diseases. One could truly say, I was allowed to save many lives with help from others on the medical teams I was proud to work with, and of course the cutting edge technologies afforded those of us who are privileged to practice medicine in the United States.

It is interesting, the things in life which will push a man toward a life of education, and prepare him for the profession of medicine. One of those things was an event in my childhood in the early 1960s.
 
When I was a boy, I had many friends in school and outside of school alike. Growing up on a ranch in Nebraska, it was not unusual to have many friends who lived in small towns come to visit. One of my friends outside of school lived in a nearby town, but came over often. David and I were both eight years old. I remember fondly of playing “army” with David in the yard, and board-games indoors when he would come over. I liked him. He was friendly and got along with my sister and little brother too. We became fast friends, and I would always get excited when David came over or we went to his family's house. We were both Cub Scouts but in different troops. You would always hear about how much David loved Scouting.
 
Soon though, the visits became fewer and fewer. David seemed to look frail and discolored to me as time went by. The color thing really bothered me. I know this sounds awful, but in addition to his color, he had an odd smell around him that seemed to worsen every time I saw him. What's worse, is it seemed that I was the only person that thought he smelled funny.

I asked  Mom, “What’s wrong with David?” Mom said, “He’s sick, honey. He has cancer of the blood. It’s called leukemia”. As you can imagine, this was a little difficult for an eight year old to take in, but as time went by, I learned more and more.

David’s parents were good friends of my parents, so we saw each other as families often. After he became ill, we saw less and less of them. Very rarely did I get to see my friend. David had an ever advancing condition of weight loss, bruising, sore joints, infections, was easily brought to tears, and after a while, his hair even looked funny. How does an eight year old process this inevitable plunge? As children; David, his sister, my brother, my sister and I, we were not emotionally mature enough to process this whole thing.
 
At home we would get the occasional phone call that he was back in the hospital. My parents were great. When we would get these calls, Mom and Dad would sit with us and try their best to explain this thing called leukemia. Understand, this was 1961, and leukemia was known as an unrelenting killer of children. There were no cures. Not even a good treatment. The medical community was desperate for a foothold.
 
One night we received a phone call from David’s father. David had passed away at the young age of eight.  I remember, it was really the first time I heard those words, “passed away”. It was also the first funeral of someone that caused me to take pause, and realize we are mortal. I know, I was just a child. I had seen two grandfathers buried, but I was very quiet and overcome by this intense event. All of these grownups I knew as strong, would breakdown and start to cry. I never the less watched in a surreal world of sadness, my parents’ good friends bury my buddy, David…. And that image which is still so clear…. My friend, asleep in his Cub Scout uniform.
 
All the while I was there, I remember thinking David might come running out from behind that marble stone, but he never did.

Why had this happened? I seemed to feel a pull even then, “The Calling”, so many of us drawn to “Medicine” and trained as healers, will occasionally and quietly talk about.
 
Time went by, but I often thought of David and how unfair it had been for him and his family. The early 1960s saw almost all children die who had leukemia. The five year survival rates of children then, were only one in ten. All any family could do, was wait and watch while their babies died in agony. He never had a chance, I often reflected. A sweet kid, taken from his family at such a young age. He never got the chance to do anything after he became sick. Never got to be an Eagle Scout, play baseball, be cool at school, or fall in love. How scared he must have been. I come to tears just writing about this.
 
Time marched on and while in high school, I would hear of small advances in the fight against cancer and leukemia. Then, in the early 1970s, when I was in college studying chemistry, we began hearing about new therapies.

Although the drug, Methotrexate, had been used with some promise through the 1950s and 1960s, the survival rates continued to be low, and drug resistance was always a glaring problem. It killed leukemia cancer cells by attacking their ability to process folic acid for DNA synthesis.

But the 1970s and 1980s brought Bone Marrow Transplantation and Craniospinal Irradiation. Huge game changers which produced not just remission, but cures.
 
I had grown up with kids who had polio, but now, it was gone. Diphtheria was gone. Small pox was all but vanquished (completely eradicated by 1982). Psychiatric hospitals were giving way to more advanced neuroleptic drugs, allowing former patients to re-enter society and become productive citizens. They had just invented the CAT Scanner. They had started to use lasers in ophthalmology.  And, I thought, even William DeBakey is transplanting hearts with Denton Cooley down in Texas of all places! Things were really happening in Medicine, and I wanted to be on the inside not the outside.
I had an epiphany. Already a man of science, I realized then, that I was going to be a doctor.
 
As time went by, more of these anti-metabolite drugs became available and we started to see a real dent in childhood mortality from leukemia. Soon after, in the late 1970s, when I was a biochemist and starting my medical career, a drug from a flower called, “The Rosy Periwinkle”, which only grows in the rain-forests of Madagascar(go figure), gave us a new drug called Vincristine. A drug that could only be brewed in mother nature’s kitchen. We were now seeing high cure rates and remissions. Lives were now being saved in this war.
 
My friend David had what we call one of the “acute leukemias”. There are many types of leukemia, but there are two well known leukemias that prey on children. They are Acute Lymphoblastic Leukemia, ALL, the one David had, which generally seeks out kids two to ten years of age, and Acute Myelogenous Leukemia, AML, which generally hunts down our babies under one year of age.

The acute leukemias are proliferating bone marrow tumors of cancerous precursor white cells still in the immature blast cell phase. The cells do not work like healthy white cells to combat infection. They multiply wildly, creating havoc in the body, literally consuming the patient to death, a condition we call, "cachexia". Patients have intense bone pain, anemia, infections, swollen lymph nodes, enlarged spleens and livers, and, for some, meningitis, strokes, heart attacks, and kidney failure. Without treatment, they are dead in a few weeks to a few months.
 
We still do not have a full grasp on their cause. Most are caused by oncogenes, which are mutated cancer inducing genetic codes for programming carcinogenisis and disrupting programmed cell death we call “apoptosis”. What causes this, is the head scratcher. Many of us feel it is radiation exposure, or certain viruses. Perhaps environmental toxins, or even cosmic radioactive bursts. And of course, man-made toxins are obvious suspects.
 
By the early 1990s we were seeing cure rates in both ALL and AML of fifty percent and remission rates in the eighty percent range. What a leap. In just 3 decades we saw a paradigm shift in the treatment and outcomes of our children with leukemia, moreover, a shift in therapies which utilized a team approach to protect our children from the acute depression and other collateral illness which accompany these diseases. Newer drugs like Daunorubicin have accelerated this to even better outcomes. Although this drug is very effective, it is extremely cardiotoxic and not generally used in children. However, it should be noted that we are now seeing ninety five percent remission rates and sixty percent cure rates in our children with ALL, and AML, a true shift in mortality that could only be dreamed about just thirtyfive years ago.
 
Drugs like Methotrexate are still at the heart of leukemia therapy, and are used in combination with other drugs, along with bone marrow transplants and radiation treatments. Unfortunately, these drugs are very expensive, which creates an obvious ethical dilemma.
 
But now, what treatments are on the horizon for leukemia? There is a new drug. This drug arrived on the cancer chemotherapy shelves about fifteen years ago, but shows outstanding promise even outside of cancer therapy. Used mainly for Chronic Myelogenous Leukemia, CML, a leukemia seen mostly in older adults, it is highly effective. Rendering oncogenetic codes for cancer cell induction dead in their tracks. It is a target drug aimed at a specific chromosome translocation defect which exists in more than 90% of CML patients, called the Philadelphia Chromosome. The drug, Imatinib, was built from a rational drug design based on biochemical research already in place regarding the specific allele the Philadelphia Chromosome codes from, and shuts down the production of a protein called tyrosine kinase which induces cancerous breakdown of normally functioning white cells.
 
Imatinib has been used as therapy for other leukemias including refractory ALL and myeloproliferative disorders (bone marrow cancers) with outstanding success. But what is also very interesting is its experimental applications which are currently being investigated.
 
Imatinib has been touted as a treatment for pulmonary hypertension, a rapidly fatal form of high blood pressure in the lungs. It has been shown to reduce outcropping we call smooth muscle hypertrophy and hyperplasia of the pulmonary vascular tree. In systemic sclerosis, the drug has been tested for potential use in slowing down pulmonary fibrosis. In addition, current laboratory investigations show promise in stopping the progression of atherosclerotic vascular disease. Yes, a treatment for coronary artery disease.
 
At Emory University in Atlanta, there are promising studies suggesting that Imatinib could be used as an antiviral against smallpox. Why is this important? Although this disease has been wiped off the face of the earth with the remarkable efforts of the World Health Organization, and no case has been identified in over thirty-five years, We continue to believe a weaponized form of small pox launched from a rogue nation is possible.
 
Studies also suggest that a modified version of imatinib can bind to the protein which increases the production and accumulation of amyloid plaques in Alzheimer’s disease, rendering it inert. Yes, a treatment for Alzheimer’s Disease.
 
But with all of this in our doctor bags, there is still a dark and ominous specter. Although great strides have been made, and I was privileged to meet and take care of children with leukemia, and even watch them overcome the illness and move on with their lives, one patient stands out.
 
I was working the Emergency Department one night in 1995. It had been relatively quiet that evening, when at approximately two in the morning a man walked in carrying his teenage son. We acted quickly and helped him get his son to a gurney in an open bay.

The staff and I immediately recognized the man’s son as Eric, a well known high school football star. The father said he found his son crawling on the floor trying to get to the kitchen to get a drink of water. Eric looked awful. There was that damn color again. Eric was delirious with fever, weak, and poor to respond. We went to work on him immediately. His dad said that he was fine just a month ago, but had developed a sore throat at about that time, and was seeing one of our local doctors who just kept giving him antibiotics.

We managed to get young Eric stabilized. Just as we were settling him in and making his father comfortable, I received a call from the laboratory. The lab tech asked me to come down to the lab. I ran to the laboratory. When I got there the tech was shaking her head as if to say, “this is really bad”. I looked at the blood count machine’s screen. “my God”, I said to the tech. “His white count is seventy thousand”. I looked in the microscope. “Blast cells”. I knew right away we were looking at an acute type of leukemia, but couldn’t recognize it with just light microscopy. We needed more tests.
 
When I dashed back to the Emergency Department, Eric was coming around a little. I spoke with him and reassured him. But the look on my face when I turned to his dad? He knew I didn’t have good news. We talked at length, then, I called in Eric’s regular doctor.

They talked while the team and I continued to work on Eric. I called in the helicopter, spoke with the Hematology Fellows at the university, returned to Eric and his dad, made sure they knew what we were doing, and flew them both to University Hospital. All eyes turned to the Hematology Oncology Service with hope that they could help young Eric.
 
One week later, while seeing patients in my office, the Hematology service at the university telephoned me to say that Eric had “passed away”. You sit by yourself and reach for introspection when these things sting you as a healer. When we lose children, most of us as doctors weep in quiet seclusion and solitude (We all have PTSD).

I wondered. How does a robust young athlete get sick with leukemia, fail in health so quickly, and die in one month? As it turned out, Eric contracted a type of AML, called Promyelocytic Leukemia, one of the most deadly forms of AML, one which preys on teen-aged children, and takes them away from us with stealth and quickness.

So you see, our job is not done. I am reminded as to why we call it a “practice”.
Our knowledge of the genome, stem cell technology, oncogenetics, and nanotechnology races onward. Our ability for rational drug design is extraordinary, and the technical savvy to produce these great magic potions has been nothing short of miraculous.

In just over four decades, we have all but squashed the disease that took my friend, David. But as you can see with Eric, we are not finished. I still think of David fifty-five years later, and how his death stirred in a young boy, "The Calling". If I was educated only to save but one human being, it was all worth it.
 
We already have at our fingertips two technologies that must be placed into motion. Stem cell research has already given us the ability to crush this killer, and should never be interrupted. And, the science to manipulate the oncogenes so responsible for the fuel that drives these diseases.

My hope is that with our new technologies, in the near future, we will not need any drugs for leukemia. We will simply turn off the genetic machinery of bone marrow cancer, and not allow leukemia even to exist, and therefore, never threaten our children again.
 
Dr. Counce
 
 



"The Affordable Care Act" (and Its Impact)

In the United States, The Affordable Care Act (ACA) is a health care ordinance established by the federal government (it is commonly referred to as Obamacare). The Act was adopted as a law by US President Barrack Obama on March 23, 2010.

The goal of this law is to reform the United States health systems by providing and improving access to quality and affordable health care, health insurance, and providing American citizens with more rights and protections by reducing health care expenditure for both individuals and the government. The law also aims at expanding private and public insurance coverage, as well as, regulating the insurance industry. It is a fantastic thought, if it only worked as planned.

As we all know now, it is not completely as advertised. For those of us in the middle class we have realized all too well that it crushes us. It means more taxes. A staggering Five Hundred Billion Dollars in increased taxes and fees. This is passed down to us through higher pricing on medical expenses that we need.

You must purchase insurance, if you do not, your federal income taxes will be penalized. You will no longer get the return that so many count on every year. If you are covered with insurance through your employer, you should tread lightly. Thirty-five million people could lose existing coverage because the government has created incentives for employers to drop insurance benefits.

There are higher premiums and costs associated with the ACA. For a family of four earning ninety thousand dollars annually, take home income would be about sixty-nine thousand dollars after local, state, and federal taxes have been taken out. If these families lose their workplace coverage and move into the exchanges, they could find themselves paying as much as twenty-five percent of their take home pay on an average policy. That is a seventeen-thousand-dollar hit to their annual pay. That's the money they could have used to buy a car, save for college, or payoff their house.



Throughout my research I have interviewed Doctor Kem Hor, Doctor Charles Counce, and have read many articles both for and against ACA. I have also learned that the ACA really hurts Doctors. At the beginning of 2014 it has dumped an additional twenty million Americans into Medicaid. I personally had to start receiving Medicaid. What I have noticed, is that it is very hard to find a Doctor who accepts new Medicaid patients, let alone see them at all. For my family of five, that is very difficult. We have three younger children who need medical attention from time to time, and it can be extremely difficult to get them seen, sometimes taking up to a month to get an appointment.

Doctors feel overran by Medicaid patients. Some have stated that they don’t have enough time with their patients any longer. It feels to some patients that we are just a number. It shouldn’t be that way. Doctors are healers. Sometimes a little extra time with the patients can go a long way. Medicaid only pays Doctors approximately fifty-six percent of what private insurance pays. [Understand that insurance systems are also a discount contracted with doctors to lower their fees to see a group of patients. This means that Doctors lose as much as eighty percent of their fee everytime they see a Medicaid patient. They can't even pay the overhead associated with the patient's visit.]

Doctors are put in a tough spot, whether to accept Medicaid patients at a lesser rate or not accepting Medicaid patients at all. America is projected to face a shortage of nearly ninety-two thousand doctors by the year 2020. Just here in the greater Colorado Springs area there is a shortage of two hundred sixty doctors. Many surveys state that doctors have a negative view on the ACA and its impact on the medical field. One survey found that the ACA on top of all the other mandates like Tort Law costs, Skyrocketing Liability Insurance, this year's "ICD10", "CLIA", "OSHA", and "HIPAA" has become too much to bear, motivating forty-three percent of doctors to move up their retirement within the next five years.

My overall thoughts on this Affordable Care Act, is that it might be a good idea on paper, but after seeing it in action, it has caused many more headaches than not. It has forced many doctors out of the field to pursue other options. Doctors should not have to wait four to six months to get paid by Medicaid or Medicare. I understand that doctors need to get paid for services rendered in a timely fashion. They have bills as well as employees to pay, in addition to college and medical school tuition loan obligations and bread for their table. It should not take patients a month to see a healthcare provider either.

I have been waiting to see a specialist (a ninety minute drive north to Denver) for two and a half months now. The system is not working, and should never have been approved in its present form. Unfortunately, it is here to stay. So says the Supreme Court. We will all have to get used to it.

Obviously the Affordable Care Act does need a lot of improvements to actually do what it was meant to do, giving Americans better access to quality healthcare. [It has managed to do almost the opposite, by draining our pocketbooks, and scaring away the only people who can care for us.]












The Craziest Frivolous Malpractice Lawsuits


With their hands basically tied, what doctors didn't have in many states until recently, was the ability to counter sue to win back at least their legal fees after successfully defending a malpractice litigation.  It took decades to make changes to tort law, as most congressman lawmakers when not working in congress, are attorneys making money in "trial law". So they always slanted the law toward the consumer to guaranty their cash flow. Yeah, I know!

Remember that most lawsuits are pursued by most people because there is little or no financial risk to them. Almost all trial lawyers accept tort lawsuits on a contingency fee. Basically telling the so called plaintiff that they pay nothing until the lawsuit is won. These fees are usually in the range of 30% to 50% of the award. So when a person happens to win a large award, say 4 million dollars, the attorney just made 2 million.

But remember, even legitimate malpractice cases are usually not won by the plaintiff. Doctors win malpractice law suits brought against them, 80% of the time, but have to assume all risk, paying for attorney fees up front in the tens of thousands. Yes, they still end up losing large sums of money just defending themselves, let alone lost work hours, as well as stress to their practices, families, and reputations. 

The other fact you need to realize, is that we doctors have a red flag anyone can see. Yeah, it's called millions of dollars of malpractice insurance money that consumers and lawyers are drooling to get there hands on. They can see it, so they go after it.

Many people do not know that 25 years ago, to press their point that many malpractice cases were pursued in this regard, many doctors in "lawsuit crazy" Florida, went bare (no malpractice insurance). Many physicians and surgeons in high risk practices (Obstetrics and Neurosurgery) who averaged 4 to 5 malpractice suits a year, stated that after they went bare, they were no longer sued.

This move created a huge shift in attitudes in Florida, calling for tort reform immediately. Don't get me going about what goes on in Florida.

Today, if you sue a doctor and lose, you will face a counter suit. The result? Now the doctor owns your house, your car, your boat, and your first born. That's right! So if you go after a doctor to get in on "the medical lottery", you better know what you're doing, because the doctors have more money than you do, and will hire attorneys who will eat your lawyer for supper.

Frivolous lawsuits are a different animal all together, and tax both the legal community and the doctor community to absolutely unbelievable limits. Read on.


Physicians have long complained about frivolous malpractice lawsuits. The assault on their reputations and the emotional upheaval they face can be traumatic even when the lawsuit is obviously fraudulent.

The situation has improved to a degree, but baseless lawsuits still happen. As long as there is larceny in the human heart and an expert witness willing to advance ridiculous theories in court, they'll always exist.

Most states now require plaintiffs to submit an affidavit from an expert witness that a physician's treatment fell below the accepted standard of care before they can file suit. That has drastically cut down the number of frivolous cases, say defense attorneys and insurers.

Experienced plaintiffs' attorneys say that they must spend $50,000-$75,000 in expenses long before trial to secure and review medical records and expert testimony. "We can't afford to file frivolous cases," said Armand Leone, MD, a radiologist and attorney in Glen Rock, New Jersey. "We'd go out of business."

Although frivolous cases have declined significantly, they still exist, and some are truly outrageous. Some of the wildest examples are new, and some are decades old. We've compiled some notorious cases; some boggle the mind that they were ever even brought against a physician. See whether you agree.

The Patient Who Cut Off His Hand

One historical case that is surely the most bizarre that we found "was so idiotic that it defies belief," said veteran defense attorney John R. Fitzpatrick of Denver.

A construction worker with a long psychiatric history claimed that he saw a "666, the sign of the devil" on his right hand. To rid himself of this perceived demonic possession, he used a power saw to slice the hand off at the wrist. Horrified workers at the construction site packed the severed hand in ice, which was transported by helicopter along with the patient, Thomas Passmore, to Sentara Norfolk General Hospital in Virginia. The incident took place in 1997.

Hand surgeon Tad Grenga, MD, was called in to attempt to reattach the hand. Even though the patient seemed coherent when he gave consent for the operation, Dr. Grenga asked for a consult from a psychiatrist, who said the patient had the legal mental capacity to consent.

The patient was prepped for surgery and given sedatives. Just as he was being wheeled into the operating room, he changed his mind. "He said that if Dr. Grenga reattached his hand, he'd cut it off again," Fitzpatrick said.

Dr. Grenga again called for the psychiatrist, who found that the sedatives hadn't impaired the patient's capacity to give or withdraw consent. "The operation needed to be performed as soon as possible for any chance of success, and Dr. Grenga knew that self-mutilators have a high propensity to do it again," said the lawyer.

"The surgeon and a hospital risk manager asked a local judge for advice," said Fitzpatrick. "The judge said that as long as a psychiatrist certified that Passmore was competent, Dr. Grenga couldn't perform the operation against the man's will. If he did, he could be charged with criminal assault, and sued civilly as well."

Dr. Grenga told the patient that delaying the operation would mean the hand could never be reattached, but the patient again refused consent. The surgeon then closed up the wound.

The patient soon consulted an attorney and announced that he would sue the surgeon and hospital for $3 million. His legal theory: The doctor should have known that he was psychotic and therefore didn't have the capacity to give or withdraw consent. Dr. Grenga should have attempted to reattach the hand no matter what he said.

"You may wonder how a case this frivolous was allowed to proceed, but the plaintiff's attorney had expert witnesses lined up saying that the surgeon and hospital should have operated," said Fitzpatrick. "As long as an expert was willing to testify, the judge felt he had to let the case go on."

The Trial Was Surreal

The trial lasted nine days and was more than a bit surreal. When sworn in as a witness, plaintiff Thomas Passmore raised his right arm, a silver hook where his hand was formerly.

The jury took only 30 minutes to find in favor of Dr. Grenga. Several jurors congratulated him for being such a good doctor.

"Passmore also sued the psychiatry group at the hospital, which settled before trial for an amount believed to be in the mid- six figures," Fitzpatrick said. Defending Dr. Grenga cost his insurer more than $70,000.

"I disagree that frivolous suits are a thing of the past. It's easy to find an expert witness to advance bogus theories," he said. "Plaintiffs' attorneys know that most cases settle, and they figured Dr. Grenga would settle to avoid the nuisance and risk of the lawsuit."

Twitching Breasts?

Fitzpatrick had another outrageous case about 10 years ago. A 35-year-old woman believed she was at risk for breast cancer and had a surgeon perform a double mastectomy. The reconstruction didn't use a traditional breast implant, but instead used the patient's abdominal tissue.

"The patient developed a romantic interest in the surgeon and wrote him several suggestive love letters. When he rejected her advances, the patient filed a lawsuit claiming that her breasts now 'twitch' when she has sexual activity," said Fitzpatrick. "Her lawyer found an expert who said this must be the surgeon's fault."

"The case went to trial. Her lawyer wanted to put on a demonstration to show how the breasts twitch, but the judge wouldn't allow it. The trial lasted five days before the judge finally threw it out."

Psychic Can No Longer Practice Her Special Powers

A historical malpractice case that achieved international notoriety and was cited during political campaigns as the "poster child" for tort reform concerned a psychic who claimed she suffered severe headaches that rendered her unable to practice her profession as a psychic or to read auras after having a dye injected into her as a prelude to having CT.

Psychic Judith Haimes had assisted several law enforcement agencies in the Northeast in finding bodies and solving crimes. She sued Temple University Hospital in Philadelphia, saying that her severe reaction to the dye used in CT scans led to chronic and disabling headaches, which prevented her from going into the state of deep concentration necessary to read auras.

A jury took just 45 minutes to deliberate and awarded her $600,000 plus $386,000 in interest.

Common Pleas Court Judge Leon Katz said the verdict was "so grossly excessive as to shock the court's sense of justice." He said it was likely that the jurors had disregarded his instructions that they could consider only whether Haimes should receive damages for the pain and mental anguish she suffered from the immediate allergic reaction. He'd ruled that her attorney had failed to provide any evidence linking the CT scan and her continuing headaches that impaired her psychic abilities. He ordered a new trial. The parties ultimately reached an undisclosed settlement.

Nerve Block on the Wrong Knee

In 2012, an anesthesiologist administered a nerve block to a patient who was prepped for minor knee arthroscopy; however, he administered it to the wrong knee. The orthopedist realized the mistake right away and never started the operation, said John Hart, a malpractice defense attorney in Portland, Oregon, who represented the anesthesiology group.

"The surgeon and anesthesiologist immediately told the patient of the mistake and apologized. They offered the patient the opportunity to still do the surgery on the correct knee, and the patient agreed," he said. "The patient was grateful for their candor, and the operation was successful.

"They told the patient the effects of the nerve block would wear off within 48 hours," he said. "The patient was fine with that, and neither doctor heard anything for almost two years. However, in 2014, one week before the statute of limitations was to expire, the patient sued both doctors." The amount he asked for? $825,000.

He charged them with negligence for causing pain and disability by anesthetizing the wrong knee. "The attitude of judges is that as long as there's a question of fact, let the jury take care of it," Hart said. "Some judges are fearful of being reversed by an appeals court. Judges could do more to encourage settlement, but they often don't." The case is still pending.

When Patients Represent Themselves

Hart adds that pro se cases (ones in which a plaintiff brings suit and represents him- or herself, without an attorney) are notorious for frivolous claims. "Sometimes the plaintiff fails to comply with deadlines, or they don't even show up for hearings," he said. "But judges will bend over backward to give the plaintiff a chance. If I were a judge, I might do the same. People should have access to the courts, even when there's not an ice cube's chance in hell of winning."

Stephanie Sheps, director of claims at Coverys, a professional liability barrier based in Boston, agrees with Hart. "I've seen judges go the extra mile to make sure a pro se plaintiff is treated fairly. In one case involving a neurologically impaired infant, the damages were severe, but there really was no liability by the doctor.

"The plaintiff had trouble finding an expert witness," she said. "The judge took it upon himself to hire an expert that the state paid for. The court hired one of the top ob/gyns from a Massachusetts teaching hospital. He found that there was no malpractice, but the judge wanted the plaintiff to have every chance she could. Judges are very hesitant to take away someone's day in court."

Vasectomy and Circumcision 'Mishaps'

Dr. Jeffrey Segal, MD, JD, is a neurosurgeon who started Medical Justice, an organization that provides physicians with legal resources to fight frivolous suits and brings complaints before bar associations, state licensing boards, and professional medical societies. He tracks outrageous cases.

A couple of examples are illustrative. About 10 years ago, a patient had a vasectomy. His postoperative sperm count was zero, as expected. One year later, the patient's wife became pregnant. The man sued his urologist. However, a paternity test quickly explained what happened, Dr. Segal said: The wife had had an extramarital affair, which resulted in a pregnancy. The lawsuit was dropped.

In another case, a urologist was sued for not removing enough foreskin during a circumcision on an infant. That led to a revision a year later. The doctor was sued in 2000, and the case was finally settled 12 years later. "One can always remove additional foreskin later," said Dr. Segal. "On the other hand, if a urologist is too aggressive… Well, enough said."

Doctor Never Met the Patient

Ob/gyn Ward P. Vaughan, MD, was sued over an obstetric procedure performed at a Virginia hospital where he never had privileges. He also never even met the patient.

Plaintiff's attorney Michael P. Weatherbee had reviewed an operative report that noted the lead surgeon was assisted by "Bob Vaughan," according to court records. Several Vaughans were listed on the Virginia Board of Medicine's Website. Weatherbee wrongly assumed he'd picked the correct one.

Dr. Vaughan was ultimately dismissed from the case and then filed a complaint with the Virginia State Bar Association, which determined that the lawyer had committed professional misconduct, including filing a frivolous lawsuit and failing to act with competence and diligence.

Cleveland, Ohio, orthopedic surgeon Michael A. Banks, MD, won $4500 in attorney's fees for defending a lawsuit filed against him, even though the patient told her attorney that he was not the doctor who had mistreated her. The Ohio Supreme Court upheld the award.

When Doctors Fight Back

Attorneys don't always carefully investigate a claim before filing suit. Sometimes, they hope the doctor will settle rather than face a trial. Gastroenterologist Zev Randy Maycon, MD, was the on-call physician at Mercy Medical Center in Canton, Ohio. He ordered care for a patient whose gallbladder and colon were perforated during a liver biopsy performed by another doctor.

Dr. Maycon was one of several doctors sued by the patient in 2002. The plaintiff's expert witness never criticized him in his report. Still, plaintiff's attorney Catherine C. Little refused to dismiss him from the case. She suggested to his attorney that he could be released if he made a settlement offer.

Dr. Maycon was ultimately cleared in the malpractice suit, and then sued attorney Little. A judge ordered the lawyer to pay the physician $6000. An appeals court upheld the ruling, calling the malpractice case "clearly frivolous."

West Virginia thoracic surgeon Saad Mossallati, MD, was sued in a wrongful death case involving a patient he'd never seen. His name was briefly mentioned in the chart when a nurse suggested contacting him. It took four years before plaintiff's attorney William E. Parsons II would dismiss him from the case. Dr. Mossallati countersued the attorney and won an undisclosed settlement.

"Doctors should hold the legal profession accountable when attorneys overstep," he said. "Give them a taste of their own medicine, and ask for damages."

The number of frivolous cases has declined significantly since various tort reform measures have been enacted. If physicians are lucky, outrageous cases will be dismissed before too much expense is incurred. And fighting back could be a useful tactic for physicians. 











The Milgram Experiment, an Ethics Milestone


The Milgram experiment is one of the most famous studies of obedience in psychology to date. Begun in 1961, the experiment was done in order to better comprehend the acts of genocide committed by the Nazi’s in World War Two. Stanley Milgram, a psychologist at Yale University, was the mastermind behind the study. The focus of the experiment was “conflict between obedience to authority and personal conscience”. Milgram wanted to explore the justifications of genocide based on the testimonies given by the accused during the Nuremberg War Criminal Trials. The accused claimed that they were just “following orders given by their superiors”; this defense shaped the concept of the Milgram experiment.

Milgram began the experiment with a public announcement stating; “Persons needed for a study of memory, we will pay you $4.00 for one hour of your time.” This baited hook brought in over 600 people for Milgram to test and study. Once people accepted the announcement they pulled straws to fill three roles; the teacher, learner and the observer. Once the roles were distributed the experiment could begin. Milgram started by having the teacher assist the observer in connecting shock inducing electrodes to the learner. The teacher then read off a list of words that the learner would have to memorize and repeat back. If the learner gave any wrong answers, the teacher was instructed to shock the learner. With every wrong answer given, the voltage of shock increased; starting at 15 volts, and increasing by 15 volts until the voltage reached 450. The shock machine in front of the teacher was set up like a switchboard. The machine consisted of 30 switches with the voltage and description of shock placed next to the switch. The 10 level or 150 volts was “strong shock”; the 17 level or 255 volts was “intense shock”; the 25 level or 375 volts was “danger severe shock”; while the last two switches 435 volts and 450 volts were simply marked XXX standing for “ultimate pain”.

However, while the teacher thought they were helping test the learner, the observer was really testing the teacher. The learner and the observer were both part of Milgram’s staff and were trained to act the part they played in order to get more realistic results. The learner was not being shocked at all, but was cued to scream in pain when the switches were flipped. If the teacher ever refused to flip the switch, the observer was given four sayings to try and motivate the teacher to continue. The first “motivator” was simple yet polite, “please continue”, after that, they continued to get increasingly demanding; “the experiment requires you to continue.”, “it is absolutely essential that you continue”, and lastly “you have no other choice but to continue”. If the teacher refused to continue after all four “motivators”, the experiment ended. If the teacher continued, the experiment ended when 450 volts was reached. After the experiment concluded, Milgram debriefed the participants and scheduled a follow-up meeting with them. During the debriefing the true nature of the experiment was revealed.

Milgram’s results shocked him and the rest of the psychologists in his community. 65% of the teachers completed the experiment by reaching 450 volts. All of the volunteers continued the experiment to 300 volts. Milgram repeated the experiment 18 times changing multiple variables in order to confirm the idea that it was human nature to follow orders. With a change of location, obedience dropped to 47.5%. When there was less personal responsibility, obedience increased to 92.5%. When the teacher got physical with the learner, obedience dropped to 30%. When the authority figure was giving orders from a distance, obedience fell to 20.5%.

Milgram was determined in researching how far people will go when listening and acting upon instructions given to harm another human being in all different scenarios. Milgram came to the conclusion that “Ordinary people are likely to follow orders given by an authority figure, even to the extent of killing an innocent human being. Obedience to authority is ingrained in us all from the way we are brought up. People tend to obey orders from other people if they recognize their authority as morally right and/ or legally right based. This response to legitimate authority is learned in a variety of situations, for example in family, school or work place.” 

Milgram’s experiment received, and continues to receive a great deal of criticism. In 1968, Orne and Holland made the statement that Milgram’s experiment lacked “experimental realism”. Experimental realism is the extent to which situations created in social psychology experiments are real and impactful to participants. The concept of experimental realism was developed in response to criticism; in that most social psychology experiments take place in artificial laboratory settings, [and thus], are invalid for examining how people truly think and act. Another complaint, was that Milgram’s study was all Males, and the question still remains would the results stay the same if females were tested. The final complaint was that Milgram’s experiment cannot be seen as representative of the American population as his sample was “self selected”. Meaning that the teachers of the experiment were all responding to an advertisement found in the paper and are assumed to have a volunteer personality which not everyone has.

Although the complaints about the experiment are valid, it becomes very easy for others to point out the faults or mistakes in another’s study. Experimental realism, although very useful, is hard to accomplish in any study, in any field. The main problem comes down to weather the person being studied is truly being honest during the study in which they are taking part. This simply boils down to human error, because we can never truly know what another person is feeling or thinking. While the second complaint seems applicable, Milgram was doing the study based on the testimonies given by the Nazi soldiers who were 90% Male. The new argument could be that Milgram should have performed the study with 10% of the volunteers being women. However, during World War II, it was said that Nazi women were not in the position to harm, or given orders to harm anyone. If Milgram included women in the study, the results would be worthless in inquiring whether the accused had a valid defense. As for the volunteers, every experiment needs volunteers. No one can make anyone do an experiment against their will. So, even with the volunteer personality they will find the closest most realistic results that anyone would be able to obtain in the given circumstance.

While people will always have criticism, more people have problems with the ethical issues behind Milgram’s study. Deception; the teacher’s were unaware that they were not actually shocking the learner. Protection of the participants; the teachers were exposed to tremendously stressful scenarios that could have lead to psychological problems. The signs of tension showed in the teachers; trembling, sweating, stuttering, laughing nervously, and biting lips, while three teachers had uncontrollable seizures. Right to Withdrawal; British Psychology Society states that, “the researchers should make it plain to participants that they are free to withdraw from the experiment.” With Milgram's four motivators, the psychology society feels that the teachers were given no chance to withdraw from the experiment.  


With every criticism that came Milgram's way, he had a retort. As far as deception went, Milgram explained, “Illusion is used when necessary in order to set the stage for the revelation of certain difficult-to-get-at-truths”. When it came to the psychological well being of his volunteers, Milgram debriefed them right after the experiment and set up an interview with them after one year had past. After that year, over 80% of the volunteers had been “glad to be a part of the experiment” while less than 2% wish they had never taken part. The psychological well being of the volunteers is a big part of the experiment. While no one wanted the volunteers to walk away with psychological problems, it would have been a huge insight into the mind of a human who could do harm to another human simply by “following orders”. After Milgram had debriefed the participants at the end of the experiment, the stress levels and signs of tension decreased dramatically. During the follow-up meeting a year later Milgram noticed no long lasting psychological problems, so even with the risk of psychological harm, it was necessary to the experiment.

The British Psychological Society says that everyone should have the right to withdraw from an experiment. With the way Milgram's “motivators” were phrased, the psychology community believes that they made it nearly impossible for them to withdraw from the experiment. However, Milgram pointed out that while the “motivators” might have made it difficult to withdraw from the experiment, withdrawal was still possible, because 35% of the volunteers withdrew from the study.

Ultimately, I find what Milgram did, to be very noble and risky; he had conceived an idea for an experiment and executed it. For people, it is easier to find flaws and mistakes in another’s work, instead of admiring the process and guts it took to complete something new. I understand where the psychological community is coming from and their concerns with all of the ethical issues. In an ideal world the perfect execution of an experiment wouldn’t have any ethical issues linked to it. However, we do not live in an ideal world and sometimes to get to the dirty truth we have to play a little bit dirty. I think for Milgram, this experiment was a huge success for everything he believed in as a psychologist, and completely reflects his beliefs in his career.     

“Only in action can you fully realize the forces operative in social behavior. That is why I am an experimentalist. For me and my beliefs, I think that history repeats itself, and for us to be better prepared for the future, we have to understand the past, making this study appropriate. With technology and science where they are today, I see no better way to execute this study. Maybe as imperfect beings we cannot create a perfect study, but to stop trying because of obstacles makes us failures before we even have the chance to succeed.” Milgram saw success through his obstacles and succeed in accomplishing one of the most well-known social psychology studies of the twentieth century.


WHY ARE WE SO AFRAID OF THE FLU?


New York Emergency Department Just this last January, The New York Times reported that this year’s influenza outbreak had crossed into the epidemic domain, having hospitalized record numbers and killing thousands of Americans, despite an ongoing and very active vaccination program.

This flu is a Type A flu, for which we prepare vaccines designed on apparent new strains each year. This winter, the H3N2 variant, appears to be the real culprit wafting the flames of death from pneumonia this now well documented killer brings. It appears that the epidemic reached its zenith in January, but the influenza outbreak remains, and its effects a real concern for future outbreak patterns, attacking and killing most of us over 65 with concomitant disease or poor immune response and even some who have been vaccinated, with stealth and speed.

Having had this flu in January, I can count myself as one of its survivors, fighting back with antiviral medication, anti-inflammatory drugs, and other “magic potions” for palliation of my very icky symptoms. The illness I experienced lasted about 10 days, with the first 4 seeing me miss work due to extreme difficulty in breathing through my nose and throat, making it impossible to eat, all the while coughing my head off, reeling from throbbing headaches, muscle pain, and running a fever. But at no time did I feel my health was in danger, as my symptoms were initially very intense but tapered quickly and only involved catarrhal effects. And unlike many of my friends and colleagues who suffered the flu this winter, I felt fully recovered after 2 weeks. But I also attribute this to a vegetarian diet, my bicycle, and a personal fitness trainer who never lets up, even when I’m ill. A subject which will be discussed in future posts.

This whole experience prompted me to discuss why we worry about the flu so much, vaccinate against it annually, and have government agencies watch each new strain so carefully. In addition to being a physician and professor of medical science, I am also an American History professor. So for me, the answer is quite obvious when we peer back 95 years. An epidemic of influenza occurred then that literally brought the world to its knees, and keep in mind that the First World War was in full swing. But the epidemic killed more than this horrible war could ever consume. This plague killed so many that the death toll from the war paled when compared to this assault on Mankind.

New York Police, 1918
A true pandemic, The 1918 Flu, also known as the Spanish Flu, Infected 500 million humans worldwide, and estimated to have killed 50 million. In eleven short months between January and November of 1918 it killed 700 thousand humans inside the borders of the United States alone, shutting down whole cities and local governments. Some states went as far as to shut down their legislative sessions to thwart exposure to our leadership. To this day, it is considered the worst human natural disaster in history. And many have almost forgotten this epic and even “Biblical” event.

Because of the ominous size of the war and its inevitable line changing outcome, to maintain morale, Department of War censors minimized early reports of illness and mortality in Germany, Britain, France, and the United States, but the press was free to report the epidemic's effects in neutral Spain, where the grave illness and subsequent recovery of the King of Spain, Alfonso the XIII, created a false impression of Spain as especially hard hit, thus the pandemic's nickname, the “Spanish Flu.”

It is not truly known from where it was spawned, perhaps the battlefields in France, and Belgium, where most of the western front was fought. A trench war where axes of advance moved so slowly they never really budged until the war’s final weeks.  A trench war that lasted 4 years. A trench war of deep mud, sewage, and blood, that stretched for hundreds of miles on each side, dug ten feet deep to protect whole columns of men, and shored up with dead bodies and body parts of humans, and horses. Body parts that soldiers utilized so often, they became inert to the macabre vision of this war torn Martian Landscape. If you can only imagine protruding arms, hands, legs, and other body parts as utility hangers and weapon racks. Or a dead man’s face staring at you while you set your cup of coffee on the side of his cheek to lean it against the blood streaked mud, while bullets fly over the trench’s roof of ashen and putrid sky. “The war to end all wars”, it was called.

British and American Trench InfantryThe war to end all wars...What we do know for sure? Modern transportation systems made it easier for soldiers, sailors, and civilian travelers to spread the disease, and spread it throughout the planet very quickly.

But here’s the deal. Back here in the United States, there were 2 niduses of outbreak that are now well accepted. In January of 1918 there was an outbreak at Fort Riley in Kansas followed by an outbreak of an apparently more virulent strain in Boston 6 months later. By November, 700 thousand Americans lay dead. Not overseas fighting a war, but at home, minding their own business. What is really scary is that this viral attack on humanity was especially evil. Most influenza outbreaks disproportionately kill little children, elderly, or already weakened patients. But in contrast, the 1918 pandemic killed predominantly robust healthy young adults. Yeah, the strength and future of our post war nation, succumbing to a hemorrhagic pneumonia sometimes within 24 hours of initial infection.

Walter Reed Hospital, 1918 Needless to say, America was horrified and almost morally undone by this specter of death and an ongoing war in Europe. Understand, we didn’t know it was a virus back then, and even though the nineteenth century had heralded in the great science of microbiology and the knowledge of bacterial infectious disease, little was known about viruses, and many considered virology a fringe science.

Let’s put this in perspective. If there was an influenza outbreak now that started in January and killed almost a million Americans by November, we would be a nation in full panic, buying hand sanitizers; antiviral medication; folk medicine and herbs of all kinds; gloves, masks, and respirators; never going out; staying away from any public event; not allowing people into our homes; and certainly not travel from city to city. Police and fire fighters would be slow to respond to anything. We would be absolutely terrified and paralyzed.

But the real truth is this. If you translate those numbers from 1918 to the equal and proportionate numbers in 2013, the frightening and ominous specter speaks for itself. And this is why we as physicians and scientists pay very close attention to “The Flu”. If the same pandemic of 1918 occurred now, 10 million Americans would be killed in less than 10 months, 500 million would be dead worldwide, that’s half a billion! Seven percent of the world’s population snuffed out in less than a year. So maybe now, you understand just how big the 1918 Flu really was.

Electron Micrograph of The H5N1 varientA plague so big, only the infamous “Black Plague” of medieval Europe which killed nearly 200 million in five years can even come close. But the Black Plague was a bacterial infection from Yersinia pestis, spread by rodents and flees, hanging around for years, possibly burning out after a decade, it still pops up annually all over the world and is treated with antibiotics. The Spanish Flu on the other hand, vanished almost as quickly as it attacked. It apparently hit us so hard that it’s host sources died fast, leaving only exposed survivors who were now immune to this virus, leaving no one to infect. “A self cleaning oven”.

So what do we know about this truly brutal and powerful threat that brought us to our knees almost a century ago? In 2005 the genetic sequencing of this virus was reproduced, revealing it to be an H5N1 variant type virus. Yeah, an Avian Strain. A "Bird Flu" which had mutated into a human killer. And now you know why we have a government employee stationed at every airport in the United States whose sole purpose is to monitor all individuals who travel to our country from countries where bird flu deaths have been reported. We will never, and I mean never let this happen to us again.

Hemorrhagic PneumoniaSo why did this virus cause such death and destruction on a scale unseen before? No one answer is reachable, and many of us in the medical profession continue to scratch our heads. One thing is evident though. In the late twentieth century, victims of the 1918 Flu were exhumed and studied for pathogenic profiling. What we found, especially in our young adults who died so quickly, was evidence of a Cytokine Storm. Cytokines are part of an immunomodulating cascade of proteins that can flood our vascular system when prompted by a strong pathogen. Especially in robust battle hardened immune systems, this can go awry, releasing immunologic agents in a vicious feedback loop of inflammatory response and phagocytosis that destroys alveoli and capillary vascular beds rapidly, leaving the victim with hemorrhaging and infected lung tissue and imminently quick death, thus, killing humans with strong immune systems. You guessed it, killing our healthy 20 to 30 year olds.

On the battlefields of Europe in 1918, there were no field radios. There were no telephones or telegraphs to communicate from the front to the rear command centers. In the “No Man’s Land" of Trench Warfare there were no telephone poles to run wire. There weren’t even any trees on the scorched surface of Europe.

Isn’t it interesting that during World War I, both sides used Carrier Pigeons to send messages back and forth from fighting on the fronts to their rear guards and commanding brass. One can only suspect what gave birth to the most vicious killer of humans in history.

So yeah, we pay very close attention to Influenza, particularly the A strains and their ever changing variant intruders.

In my next article we will discuss how vaccination changed humankind forever. I will leave you with this. One hundred years ago any American’s definition of “good health” would have been “the absence of disease”. Keep in mind that the top killers in 1913 were Tuberculosis, Small Pox, Diphtheria, and Influenza. What would you say is your definition of good health now, especially those of you who are into “personal fitness”?  

Dr. Counce