THE SEARCHLIGHT MESSENGER
Many of you have read my article on
My Headache a Migraine
. Recently I have been approached with questions
from my college campus students regarding their children and the brittle
headaches their kids endure. Two students in particular stated that their child’s
doctor had diagnosed them as having migraines, prescribed the medicine, periactin as needed, but did not explain to them what
migraines in children are really all about.
This is a little disturbing to me, as I feel the more educated my patients are, the better they are able to manage their headaches and lead normal healthy lives. This falls on the treating doctor, and unfortunately, it seems this new era of doctors is in such a hurry, it has forgotten how to teach. Osler would role in his grave!
This part of treatment is obviously more important than the "periactin". And both should be part of an overall plan. "Written down and easy to follow", by both the parents and the little one.
So, I thought this would be a good
time to again discuss this very debilitating disorder. No one ever wants to see a child suffer through these. I recommend reviewing the
above article in addition to this one.
When you think about someone having
a headache, you probably think of an adult. But many kids have headaches too,
and for many of the very same reasons that adults have them.
Children and teens can experience
muscle tension or migraine headaches. Among school age children ages 5 to 17 in the
United States, 20% are prone to headaches. Approximately 15% of these kids
experience muscle tension headaches and 5% are dealing with migraines.
Chronic or frequent headaches can be
tough to handle, and are even harder to understand when you are young, especially
if you do not know anyone else who has them.
By the time they reach high school,
most young people have experienced some type of headache. Fortunately, less
than 5% of headaches are the result of serious disease, such as a tumor,
abscess, infectious disease, or head trauma.
Most headaches are muscle tension type, the
result of good and bad stress, sleep issues, or in a few instances,
environmental or food triggers. About 5% of recurrent headaches will be diagnosed
Episodic headaches are those that
occur a few times a month at most. Chronic headaches occur with much more
frequency, even several times in a week. If a child who has only had an
occasional headache (once or twice a month) starts experiencing them more
frequently (two, or three times a week), then these should be considered
chronic and medical attention should be sought as soon as possible.
One of the most frustrating aspects
of chronic headaches is the stress factor. Avoiding a known trigger is usually
easier than avoiding stress. Young people want to do well on tests and in
school, and they want to attend important events, but anticipating a math quiz
or musical recital, or eagerly looking forward to a party or being in the
school play, can result in anxiety or excitement. And, for some kids, this
leads to a headache.
Up to 4% of children have their
first headache before they reach elementary school, and they may not yet know
how to describe the pain. If a young child has been crying or not eating, or
has been restless or irritable, consult with your doctor about finding the
source of discomfort or pain. Remember, the child has no idea what is happening and this can be very frightening.
The more knowledge (and easy to understand guide lines) school health officials, as well as parents have about children and chronic migraines, such as common
triggers, symptoms, prevention, and treatments, the easier it will be to
identify the child who is suffering through these headaches.
The best evidence based approach to treatment, interestingly, is the more holistic approach to little patients. It entails two things: 'chronic therapy', which addresses decreasing the frequency and intensity of the headaches, and 'acute therapy', which gives the patient and parents weapons to stave off an evolving attack.
As I have discussed in other
articles, in adults, a migraine's throbbing head pain usually occurs on one side
of the head, but in children it can affect both sides. The migraine is often
accompanied by nausea, vomiting, dizziness, blurred vision, sensitivity to
light and sound, and changes in temperament and personality. A headache's duration
varies from individual to individual. But, generally, unlike adult migraine,
which can continue up to four days, a child's migraine might be as short as one
hour or may last for a day or so. Children also improve more rapidly to sleep.
So, the best treatment for children is a nap in a quiet, and dark room.
About 15% of kids experience a migraine
headache with an Aura. A typical aura is seeing colored or flashing lights,
blind spots, or wavy lines or feeling a tingling in the face or an arm or leg.
An aura alerts a migraine sufferer to the onset of a headache, warning the
child several minutes before the pain starts. A small percentage of migraine
sufferers also encounter temporary motor weakness, as they may lose their sense
of coordination, stumble, or have trouble expressing themselves.
Young children with migraine may not
have head pain at all but rather experience recurrent stomach problems or
dizziness. These types of migraine are called migraine variants (Migraine
Variants will be addressed in a future article). Children who have migraine
also are more prone to motion sickness.
For most kids, migraine is inherited from a parent. Migraine
occurs because of alterations in a person’s genetic makeup. An
individual migraine attack is often triggered by a particular environmental or
emotional event. In some cases, triggers can be identified. Among the most
commonly recognized ones are stress (good or bad), a change in routine, a change in sleep
pattern, bright lights or loud noises, or certain foods and beverages. Let’s
look at these for moment.
One of the things I first have
patients, especially children do regarding brittle migraines, is keep a diary
of foods, sleep patterns, and other possible triggers. The best way to do this
is to get the whole
family involved, and
use a big wall calender with plenty of space for everyone to write down what
they observe, as one person may notice something another didn't.
There are many triggers in childhood
migraines that should be weeded out. Foods are huge, but other things as
mentioned above, like stress level, even positive stressors like more money,
new teacher, family gatherings, etc. can be big. Sleep can be a major player. I can't stress enough, the value of regular sleep
patterns and at least 9 hours of sleep every day for kids.
Food is probably the biggest player, so you have to read labels closely. Here
are the biggest triggers I've seen in practice:
(1), Caffeine in any form, even in medicines. Keep in mind that caffeine is
also used to treat headaches, but can be a two edged sword, and, induce “rebound
phenomena”. (2), Mint, it's in everything, start tossing it out. (3), Red food
dyes. (4), Yellow food dyes. (5), Hard aged cheeses, like Parmesan, and
cheddars, remember also, that cheeses are not naturally yellow ( they have
yellow dye in them). (6), Pizza. (7), Lunch meats. (8), Hot dogs and sausages. (9),
Bacon, use "fresh-side", or "sugar cured".
The above meats have nitrates in them which
(10), chocolate in any form. (11), yogurt. (12), Chinese food (oriental).
(13), The additive, Mono-Sodium Glutamate (MSG) is a monster and must be avoided, it is in
everything from snack foods, frozen foods, bullion, and ramen, to canned soups. (14), All citrus products. And watch out for sugar binges. Remember to write down every little detail that appears significant on that calendar,
and let your doctor know how it's going.
After a formal diagnosis, a doctor's
goal is to help reduce or eliminate the symptoms of a migraine and prevent
to treatment, sometimes children, especially young
children, do not need any medication to treat a headache. Often there are
non-medicinal treatments that can provide primary, or added benefit.
During a migraine attack, a child
should be allowed to rest, and even sleep, in a quiet, dark and cool room.
Raising the child’s head up on a pillow and providing a cool compress for the
eyes or forehead can help them feel more comfortable. When at school, a child should
be allowed to go to the nurse’s office and rest. Sometimes a quick nap is all
it takes and they can return to the rest of the school day.
Trigger avoidance and a regular
schedule are huge preventive measures that can be taken to avoid the frequency of
attacks. Relaxation and stress management
techniques can be helpful during an attack and to help alleviate stress before
it becomes a full blown an attack. Daily physical activity is also very
important in headache management and stress reduction. Two methods that have
been well documented to help children with migraine include meditation and
biofeedback. There is also much research that suggests hyper-hydration with plain water may
prevent frequency in migraine attack.
Once a migraine has begun, several
types of medication can alleviate the symptoms. Analgesics, such as acetaminophen or
ibuprofen, are first-line pain relievers for treatment of headaches in children
and adolescents. The Triptans can be helpful in those children who don’t find
simple analgesics helpful. There are several different triptans available and
two (almotriptan [Axert®] and rizatriptan [Maxalt®]) are FDA-approved for
children. In addition, your doctor may also prescribe anti-emetics to stop the
nausea and vomiting or a sedative to help a child rest.
Aspirin is not generally recommended
for kids, as there is now, well documented evidence linking aspirin to the development of
Reye's Syndrome, a rare disorder that children and teenagers can get while they
are recovering from childhood infections, such as chicken pox, flu, and other
viral infections. Reye's symptoms include nausea, severe vomiting, fever,
lethargy, stupor, restlessness, and even delirium.
Children and adolescents who
experience migraine attacks more than twice a week and which interfere with
school or social activities, may be prescribed a daily medicine to try to
prevent headaches. There are no medications that have been specifically
designed for migraine so they all come from other categories including
anti-seizure, blood pressure and anti-depressant drug classes. Common
preventive medicines include beta blockers, tricyclic antidepressants,
topiramate, and valproate. Please note: none of these medications are approved
for migraine treatment in children. However, research in this area continues
with excellent progress and doctors will utilize these medications as "off label" prescriptions.
Frequent headaches, especially those
that occur more than once a week, deserve treatment, with both medication and
non-medicinal options. Headaches are not good for the brain and
headaches often lead to more headaches. With the right treatment regimen your
child can get his or her headaches under control and prevent further
Further questions can be directed
below, and look for continued articles on headaches in future posts on The Searchlight Messenger.
Doctors Strike Back
much of the controversy surrounding Maintenance of Certification (MOC), is the question of how much, or even
whether, the process as currently structured actually improves physician
performance and/or patient outcomes.
On February 3, 2015, many physicians
received a surprising email from Richard Baron, MD, MACP, president and chief
executive officer of the American Board of Internal Medicine
(ABIM). Referring to the board’s controversial maintenance
of certification (MOC) program, Baron wrote, “ABIM clearly got it wrong. We
launched programs that weren’t ready and we didn’t deliver a MOC program that
physicians found meaningful…We got it wrong and sincerely apologize. We are
Baron’s email— which went to the
approximately 200,000 internists and practitioners of 20 sub-specialties who
have obtained their board certifications from the ABIM—followed by a few weeks
(and many believe was at least partially in response to) the announcement a new
organization, the National Board of Physicians and Surgeons
(NBPAS), with the announced goal of giving doctors “an
alternative route for continued board certification.” It is led by Paul
Teirstein, MD, chief of cardiology at the Scripps Clinic in La Jolla, California
, and an outspoken MOC critic.
While the controversy surrounding MOC
remains far from settled, it seems clear that critics of the process and of
ABIM have scored some significant gains, by forcing ABIM to review or scrap
some elements of MOC, and by possibly opening new paths to maintaining
Evolution of MOC requirements
The creation of NBPAS and the ABIM’s
apology are but the latest developments in a long-simmering dispute over how
doctors should best keep their skills and knowledge up-to-date—and prove that
they are doing so. The controversy dates to the 1990s, when the ABIM instituted
a policy whereby, beginning in 2000, physicians who certified after 1990 would
have to recertify every 10 years. (Until then certification had been
life-long.) The change was subsequently adopted by the other 24 boards
comprising the American Board of Medical Specialties
The 10-year maintenance requirement
produced some grumbling among doctors, but no organized resistance. That
changed at the start of 2014 when ABIM announced that doctors would need to
earn accreditation points on a continual basis over the 10 years between taking
the recertifying examination. Moreover, doctors who had board certified before
1990 would be listed as “certified, not meeting MOC requirements” on the ABIM’s
For Teirstein and many of the
physicians boarded by the ABIM, these latest changes were the final straw. They
were further incensed by what they regarded as the excessive growth of the
nonprofit ABIM—whose budget exceeded $59 million—and the nearly $29 million
spent on salaries, benefits and “other expenses” during the ABIM’s 2014 fiscal
year. A few months later Teirstein launched an online petition opposing the MOC
requirements that to-date has garnered more than 23,000 signatures, he says.
In addition, he says, “I began getting
comments like, ‘it’s great we have all these signatures, but what do we have to
show for it? Have they [the ABIM] actually changed anything?’ And they had
The NBPAS alternative
Teirstein’s response was to found the NBPAS, a nonprofit organization
with what he describes as “a much less expensive, much simpler approach to
life-long learning.” In the news release announcing its formation, the
organization says it is “committed to providing certification that ensures
physician compliance with national standards and promotes lifelong learning.”
Among the requirements for continued certification are that a candidate be
previously certified by an ABMS-member board and have completed 50 hours of CME
in the past two years.
Teirstein describes NBPAS as a “grass- roots organization,” one
that is funded entirely by its members. Membership fees are $85 per year or
$169 for two years, and cover all specialties and sub-specialties covered by
the ABMS. “Right now we’ve got about a thousand members and we’re making ends
meet doing that,” he says. Teirstein is taking no salary.
As of mid-April none of the nation’s hospitals were accepting
NBPAS certification as a basis for admitting privileges, but Teirstein notes
that the process usually involves approval from numerous boards and committees
and thus will take some time. “I’m of the firm belief that the as long as the
medical community is willing to stand up and say this is what they want we’ll
figure out a way to make it happen, but it won’t be overnight,” he says.
Teirstein and other NBPAS board members say they support the
notion of physicians keeping their knowledge and skills up to date, but think
CME offers the best method for accomplishing that. Teirstein notes that CME
courses must be accredited by the American Council for Continuing Medical
Education (ACCME) to count towards license renewal. “We’ve decided the best
compromise is where you can have lifelong learning which doctors don’t consider
onerous,” he says. “The doctors can choose which offerings to attend. They’re
not going to pay and take time to go to something that’s not relevant.”
‘It’s not good learning’
Harry Sarles, MD, FACG, an NBPAS board member and past president
of the American College of
objects to what he calls the “esoterica” on the
certification examinations. “It’s not good learning. It’s learning for the
test,” he says.
“ABIM should not be allowed to set the bar, make the rules, and
then provide all the CME that can only be accepted to meet their rules,” he
adds. “I’m answering to my hospital, my state, my patients, the health plans,
in terms of my quality being measured and monitored. And now ABIM steps in and
says you should be doing something for us too. I felt like I was in the middle
of a shakedown.”
“When I took my certification I felt proud and driven to
continuously improve myself,,” he says. “But everything ABIM has instituted
since then, to my way of thinking, has really been about themselves and not
what’s best for physicians.”
Sarles endorses the idea of physicians demonstrating quality and
a commitment to ongoing education, but wants to see “multiple pathways” for
doing so. “I’m all for competition, because it will make us all better,” he
says. “If we only had one kind of car to buy it would probably be a crappy car.
Whatever your criteria are, competition is very healthy and I believe in it.”
The ABIM response
ABIM’s February 3 statement, while not
directly acknowledging NBPAS, did appear to address some of its complaints and
those of others who have been critical of the MOC process. It said that the
- Suspend the practice assessment,
patient voice and patient safety requirements of the MOC program for at
least two years,
- By August, 2015 change the
language used to report a diplomate’s MOC status on the ABIM’s website
from “meeting MOC requirements” to “participating in “MOC,”
- Update the internal medicine exam
so that it better reflects what practicing physicians are doing,
- Keep MOC enrollment fees at or
below 2014 levels through at least 2017, and
- Allow internists to use most forms
of ACCME-approved CME to demonstrate self-assessment of medical knowledge
by the end of 2015.
In addition, according to the
statement, “ABIM will work with medical societies and directly with diplomates
to seek input regarding the MOC program” via meetings, webinars, forums, and
other venues. “We are embarked on a whole new way of doing business and much
more engagement with our community,” Baron said in a phone interview with Medical
As evidence, he cites implementation of
“a sub-specialty board structure that involves depth in each of the disciplines
in internal medicine,” and that includes physicians in community practice as
well as patients and other public stakeholders.
“Those groups have been reaching out to
colleagues and members of their societies,” Baron says. “And what we’re hearing
is that lots of the activities we had either as board products or expectations
maybe are being done by other people in the [healthcare] delivery system better
than we’re doing them. And in that case we want to learn more about those and
figure out how to give people credit for the work that they’re doing during
their day jobs and avoid redundancy and wasting members’ time.”
Responding to the complaint that MOC
tests doctors on knowledge and skills they don’t encounter in their practice,
Baron says he took the exam a year ago and acknowledges that it included topics
he’d not seen in his general internist/geriatrics practice. On the other hand,
he says, “I think all of us in practice confront that there’s a difference
between what we use every day and what we might need to use some time.”
Baron recalls joining the ABIM’s
test-writing committee in the summer of 2001 and being surprised to find the
test included a question on anthrax. But several months later it was a
board-certified internist in Miami, Florida (Larry Bush, MD) who first
identified anthrax as the mysterious substance being sent through the mail that
was sickening—and in the case of Bush’s patient, killing—recipients was anthrax.
”That’s a doctor who had a piece of
knowledge that he didn’t use every day, but fact that he had it made a huge
difference for a patient,” Baron says. (Bush subsequently coauthored an article
about the incident in The New England Journal of Medicine
Regarding the fees associated with MOC,
Baron says, “Nobody likes to write checks, and when I was in practice there
were a lot of things I wished I didn’t have to pay for. But I want to
acknowledge that it’s really hard for doctors in practice now and every check
is a painful check. We are looking at ways to reduce the cost.”
As evidence, he points to the February
3 announcement regarding enrollment fees. “We are taking time to listening to
physician feedback about all aspects of our program before announcing any
additional changes,” he says.
“We know that doctors need to
experience more value in the program, and the areas we pulled back on were
those that doctors were in effect saying, ‘I’m not getting much out of this,’”
What do the data show?
Underlying much of the controversy surrounding MOC is the
question of how much—or even whether—the process as currently structured
actually improves physician performance and/or patient outcomes. A great many
internists clearly believe it does not, according to a study published in the
January 2015 issue of JAMA Internal Medicine
The authors assembled a focus group consisting of 50
board-certified primary care and subspecialist internal medicine and family
medicine physicians in an academic medical center and community sites. They
found that “at present, MOC is perceived by physicians as an inefficient and
logistically difficult activity for learning or assessment, often irrelevant to
practice, and of little benefit to physicians, patients, or society.”
Data on the effectiveness of certification since the institution
of time limitations is sparse, consisting largely of a handful of studies
published over the past 15 years in Academic Medicine
, the Journal of the American
College of Cardiology
, among others. And while MOC
supporters say the studies support MOC’s effectiveness, in a debate earlier
this year with Baron and Lois M. Nora, president and chief executive officer of
the ABMS, Teirstein maintained that the studies’ results are, at best,
He cited, for example, the results of a 2014 investigation
published in JAMA comparing clinical outcomes among patients at four
Veterans Administration hospitals treated by internists with time-limited and
time-unlimited certifications (i.e. those who were grandfathered out of the
ABIM’s 10-year certification requirements and those who were not.) The authors
found “no significant differences” between the two groups on 10 primary care
“If you say we have data that supports our MOC process, you’d
better have the data,” Teirstein said in his interview with Medical
Economics. “And if you look at the papers they cite, they’re very
Baron acknowledges that the evidence in support of MOC “could be
stronger,” but also notes “at least one of the studies he (Teirstein)
criticized met rigorous methodological standards.”
“I don’t think it’s unusual to have good faith people arguing
about whether the evidence shows ‘x’ or ‘y,” Baron says. “Every clinician
operates all the time in an environment where the patient didn’t walk out of an
article in a journal. You have to navigate between what you know you know and
how close the patient before you gets to that.”
Teirstein says NBPAS has no plans to try and link ongoing
education and training to quality and patient outcomes. “I just don’t think you
can measure this adequately,” he says. “Would randomizing really work? A doctor
might be more inspired to do a good job because he wants to prove you don’t
have to do this [maintain certification.] It’s just not the kind of thing that
lends itself to scientific study.”
Looking ahead, Teirstein envisions the NBPAS playing a watchdog
role for the ABMS and its member boards, in addition to providing
certification. “We’ll be keeping an eye on things and making sure everyone
knows physicians are not just going to take whatever they’re given. We’re going
to react and try to make our voices heard.”
- Possess a valid and unrestricted
license to practice medicine and enroll in maintenance of certification
- Earn MOC points by completing some
MOC activity every two years and earn 100 points every five years (at
least 20 points in medical knowledge). Points earned every two years will
also count toward your five-year requirement, and also count toward the
milestones for the certifications you are maintaining. Points earned count
toward all certifications being maintained.
- If you are dual-boarded by one or
more of the other American Board of Medical Specialties (ABMS) member
Boards, your self-evaluation requirements will be waived.
- Pass the MOC exam in your
specialty(ies) every 10 years (first exam attempt in each certification
area you maintain earns 20 MOC points).
- Other requirements may apply
depending on your specialty and situation. For complete requirements,
Board of Internal Medicine
- Candidates must have been
previously certified by an American Board of Medical Specialties (ABMS)
- Candidates must have a valid,
unrestricted license to practice medicine in at least one US state.
Candidates who only hold a license outside of the U.S. must provide
evidence of an unrestricted license from a valid non-U.S. licensing body.
- Candidates must have completed a
minimum of 50 hours of continuing medical education (CME) within the past
24 months, provided by a recognized provider of the Accreditation Council
for Continuing Medical Education (ACCME). CME must be related to one or
more of the specialties in which the candidate is applying. Re-entry for
physicians with lapsed certification requires 100 hours of CME with the
past 24 months. Physicians in or within two years of training are exempt.
- Other requirements may apply
depending on your specialty and situation. For complete requirements,
Board of Physicians and Surgeons
Two recent studies in the Journal of the American Medical Association
are sparking fresh controversy over the effectiveness of, and need for, the maintenance of certification
(MOC) requirements mandated by the American Board of Internal Medcine (ABIM.)
The studies in JAMA’
s December 10 issue both look at MOC’s impact on the costs and quality of patient care, although in different ways. The first study
led by ABIM’s Bradley Gray, Ph.D., compared costs and outcomes for two
groups of Medicare beneficiaries during the years 1999-2005: one group
treated by internists who received board certification in 1991, and were
thus required to recertify in 2001, and a second group treated by
internists who certified in 1989, and were thus grandfathered out of
ABIM’s recertification requirements.
The study used a quality measure the annual incidence of ambulatory
care-sensitive hospitalizations (ACSH) per 1000 beneficiaries. (The
authors define ACSH as “hospitalizations triggered by conditions thought
to be potentially preventable through better access to and quality of
The study found no statistically significant association in ACSH growth
between the MOC-required and MOC-grandfathered physicians, but did find
a 2% slower growth in the cost of care provided by the physicians who
had to recertify compared with the grandfathered cohort.
The second study
led by John Hayes, MD, of the Zablocki VA Medical Center in Milwaukee,
Wisconsin, compared performance data of 71 MOC-required and 34
MOC-grandfathered physicians at four VA medical centers, including
Zablocki, for 12 months starting in October, 2012. The ten performance
measurements ranged from colorectal screening to blood pressure control
to post-myocardial infarction use of aspirin. It found “there were no
significant differences between those with time-limited ABIM
certification and those with time-unlimited ABIM certification om 10
primary care performance measures.”
While the study results might appear to provide ammunition to MOC opponents, an accompanying editorial
by Thomas Lee, MD, MSc, chief medical officer for Press Ganey and a
practicing internist, notes that “another assessment might be that the
effect of MOC is unknown at best and that changes to its structure must
be undertaken with caution and sensitivity to their effect on
physicians’ professional lives.”
Lee points out that ACSH, the outcome measure used in the Gray-led
study, “was designed to assess access to primary care in populations,
not the quality of care delivered by individual physicians” and applied
only to about 80 patients in each participating physician’s panel.
Moreover, “the 2% reduction in spending is as large or larger than the
savings recorded by Medicare accountable care organizations in their
first two years, so further study to determine if this finding is real
and reproducible is critical.”
(Gray and his co-authors note in their study that even small
per-patient savings, when extrapolated over Medicare’s nearly 50 million
beneficiaries, would far exceed the costs of administering the MOC
The most significant finding of the Hayes study, Lee says, is that all
the performance measurements were significantly better than those of the
general population, regardless of whether the patient received care
from a MOC-required or MOC-grandfathered physicians, and thus “provide a
reminder that healthcare today has become team-based.”
In mid-December JAMA convened a webcast to discuss the studies’ findings and answer questions. Judging by
tweets accompanying the events, MOC’s critics remain unconvinced of the
value of ongoing recertification.
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
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
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.
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
"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."
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
"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."
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
"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."
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
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.
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."
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
Well, enough said."
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.
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.
We’ve been seeing a lot of NFL players wearing pink this month. Every October, we celebrate our strides against breast cancer and push to make people aware of the disease and help hunt for a cure. Certainly, when efforts such as these have come before, we have been stalwart, and winners against cancer. All one has to do is look back on the 1960’s and see the horrible disease that childhood leukemia was, and now, 95% survival rates and 60% remission rates are the rule. Or how about cervical and uterine cancer, and our success against this one time leading cause of cancer death in women, now controlled.
National Breast Cancer Awareness Month is so important. Over the years it has helped to raise awareness of the severity of the disease in medical and economic impact. Ultimately, we look for ways to save human lives. Much has changed over the years. One has to remember that just not long ago, we “Baby Boomers” watched as our mothers succumbed to the most common death inducing cancer in women, uterine cancer. That’s right. Up until the early 1970’s, this was the cancer most common in killing women. The fight with breast cancer has been ongoing, with diagnostic screening meeting new challenges around every turn.
In 1959, the introduction of a standard screen called The Papanicolaou (Pap) smear changed everything, and a national campaign to get women into the doctor for Pap screenings created a paradigm shift in the routine care of women when visiting their doctor. With this tool, we eventually discovered that there was a culprit now known as, “The Papillomavirus”; we were able to develop a vaccine against. With this victory, however, Breast cancer became the real malignant villain in taking down women. It has become rampant, involving all kinds of theories as to cause, including everything from medicines, hormones, and lifestyle practices to oncogenetics and environmental exposure.
Controversial guidelines in physical screenings and imaging continue to change. Economically, it seems sometimes that insurance companies drive our screening studies. Basing guidelines on thready actuarial information, they change mammography guidelines constantly, jumping on any information that suggests spending less on screening. Now, a recent study suggests that mammography may not be as important as previously thought in reducing a woman's risk of dying from breast cancer. Coming on the heels of guideline changes from the U.S. Preventive Services Task Force in 2009, indicating women do not need mammograms in their 40s, this latest research, published in the New England Journal of Medicine, adds another “scratch your head” position to the idea that mammograms make a substantial impact in saving lives.
The study, conducted in Norway, showed that women who receive breast cancer screenings have a 10 percent lower risk of dying from cancer, but researchers could trace only a third of this so-called reduced risk to mammograms themselves. Screenings reduced death from breast cancer by only 2.4 per 100,000 women. The Norwegian study followed more than 40,000 women with breast cancer.
American women shouldn't be too quick to back away from recommended biannual screenings for breast cancer for those over age 50, however. Dr. Otis Brawley, chief medical officer of the American Cancer Society, feels the Norwegian study was too short in duration. According to Dr. Brawley, "The report's estimate of the relative value of mammography is lower than in a number of previous screening studies". This may be due to the relatively short two year follow-up of the population. Brawley points out, that most randomized trials have at least 10 years of follow-up after the last round of screenings, and many have covered periods of 20 to 40 years.
Dr. Daniel B. Kopans, professor of radiology at Harvard Medical School, agrees and feels the study was incomplete and not long enough in duration. "This study contradicts other studies from the Netherlands and Sweden which show just the opposite, namely that screening accounts for over 60% of the decrease in deaths seen over the past 50 years," he says. "I suspect that most everyone who cares for women with breast cancer would acknowledge that therapy only saves lives when breast cancers are found and treated early."
As a physician, I must add that the ability of doctors to perform a thorough palpatory exam is crucial. Many doctors just have their patient lie down on the exam table and circumferentially feel both breasts and consider them examined. The real physician will ask pertinent questions while examining the “patient”, not just their breasts. In addition, the exam should start with a visual exam of the patient and her breasts, looking carefully for skin and nipple changes, and then utilizing maneuvers that force breast tissue to respond to different angles of muscular contraction along the chest wall. This captures lesions deep along the ligamentous attachments of the breasts. This should then be followed with a very thorough palpatory exam of both breasts and the axillae.
I should also comment that regular breast cancer screenings heighten women's awareness of the disease. This leads to early detection and a better prognosis. While the American Cancer Society no longer recommends monthly breast self-examination, I feel current guidelines regarding mammography should not be changed. The total body of science supports the fact that regular mammography is an important part of a woman's preventative health care.
Wear some pink this month,