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Doc says sobbing attorney and crying medical expert led to unfair million-dollar verdict
Jurors found obstetrician-gynecologist Charles H. Marks, DO, negligent for failing to follow up on a patient’s complex cyst and hyperechoic nodule, which resulted in a delayed ovarian cancer diagnosis. But during the doctor’s 4-day trial, several parties had emotional outbursts in front of the jury, including the plaintiff’s’ attorney, a physician expert witness, the patient, and a family member.
According to trial transcripts, a gynecologic oncologist expert began crying on the stand after providing a clinical description of the symptoms that plaintiff, Chasidy Plunkard, would probably experience leading up to her death. When asked how long the patient had to live, the oncologist said “months” and later added, “I think she is living for this trial.”
After these comments, Ms. Plunkard’s attorney, Kila Baldwin, also began crying and requested a break to regain her composure, according to district court documents. During the 3 minutes the attorney was gone, the courtroom was silent other than the sound of Ms. Plunkard and her cousin sobbing.
The following day, U.S. District Judge Jennifer P. Wilson warned Ms. Baldwin that she would consider declaring a mistrial if the outburst happened again, according to trial transcripts.
“I expect counsel to maintain a professional demeanor even when eliciting emotionally laden testimony,” Judge Wilson said. “…I will not allow another recess. Further, if we have another incident like we had yesterday, I would have to entertain, if a motion for mistrial is made, I would have to seriously consider that, because I am concerned that this jury already has had a demonstration of a level of emotion that may make it difficult for them to set that aside and render a verdict that’s based only on a dispassionate consideration of what I perceive to be a legitimate dispute regarding liability.”
Judge Wilson later instructed jurors to disregard certain testimony at the request of Dr. Marks’ attorneys and reminded them not to be influenced by sympathy. After jurors rendered their $1.3 million verdict against Dr. Marks, he requested a new trial, claiming the witness’s testimony and the emotional displays of the witness and the attorney unfairly influenced the jury.
The expert witness “and plaintiff’s counsel undoubtedly affected the jury’s ability to decide this case in a dispassionate and impartial way and denied Dr. Marks his right to a fair trial,” attorney Matthew Rappleye wrote in Dr. Marks’ motion for a retrial. “Just as the court feared, as a result of these events, the jury was ‘tainted’ and could no longer decide this case divorced of sympathy for Ms. Plunkard.”
In response, an attorney for Ms. Plunkard emphasized that Dr. Marks did not request a retrial during the trial and that he was granted objections to the relevant testimony that he sought.
“In any event, the jury had the benefit of substantial evidence concerning Dr. Marks’ negligence, and the jury was entitled to construe that evidence in Plaintiff’s favor” attorney Charles Becker wrote. “…Indeed, the jury’s economic damages award of $585,000 not only fell well below the projection of plaintiff’s expert, but also ran at the low-end of the projection provided by Defendant’s economist. As to the non-economic damages, the jury’s award of $750,000 could have been far higher…. Nothing about either verdict or the damages award suggests a jury that was influenced by impermissible displays of emotion by the trial participants.”
In a December 13, 2021, decision, the U.S. District Court for the Middle District Court of Pennsylvania denied Dr. Marks’ request for a retrial. In her decision, Judge Wilson wrote that nothing in the jury’s verdict appeared to indicate that jurors were swayed by sympathy and that the verdict appeared to be conservative in light of the testimony presented.
Attorneys for Dr. Marks did not respond to a request for comment. In a statement, Ms. Baldwin said that the judge’s decision was correct.
“The district court got it exactly right, and we look forward to Ms. Plunkard receiving the compensation awarded by the jury in this tragic case,” she said.
Why did the patient sue?
Ms. Plunkard’s lawsuit against Dr. Marks stemmed from a January 2016 visit for complaints of bloating, pelvic pain, irregular periods, and an abnormal pelvic ultrasound. The ultrasound, ordered by her primary care physician, showed a thickened endometrial lining; a normal left ovary; and an enlarged, abnormal right ovary containing a complicated cyst, according to Ms. Plunkard’s complaint. Dr. Marks performed an endometrial biopsy and advised Ms. Plunkard that she would not need to take further measures if the result was benign, according to her lawsuit.
The result was benign, so Ms. Plunkard said she sought no further treatment for the cyst and none of her treating physicians followed up on the cyst. In February 2017, Ms. Plunkard presented to an emergency department with severe right upper quadrant abdominal pain and an ultrasound showed possible gallstones and pleural effusion, according to court documents.
After laparoscopic cholecystectomy, it was discovered that Ms. Plunkard had an inflamed pelvis and an omental lymph node was removed and biopsied. Surgeons reported that the lymph node showed metastatic cancer of probable gynecologic origin.
The patient underwent exploratory laparotomy, resulting in a radical abdominal hysterectomy, appendectomy, resection of the rectosigmoid with end-to-end anastomosis, and removal of cancerous implants. She was ultimately diagnosed with stage IVB low-grade metastatic ovarian cancer and went through six chemotherapy courses.
The patent’s cancer briefly went into remission but returned. In her complaint, Ms. Plunkard said Dr. Marks’ negligence allowed the cancer to spread from stage I to stage IVB, increasing her risk for harm and untimely death.
Dr. Marks argued that a follow-up ultrasound was not required, that the cyst on the patient’s right ovary was benign and resolved itself, that Ms. Plunkard’s cancer originated on the left, and that a follow-up ultrasound would not have detected primary cancer on the left ovary, according to legal documents.
On January 7, 2022, Dr. Marks appealed the jury’s verdict and the order denying his request for a retrial to the U.S. Court of Appeals for the Third Circuit.
A version of this article first appeared on Medscape.com.
Jurors found obstetrician-gynecologist Charles H. Marks, DO, negligent for failing to follow up on a patient’s complex cyst and hyperechoic nodule, which resulted in a delayed ovarian cancer diagnosis. But during the doctor’s 4-day trial, several parties had emotional outbursts in front of the jury, including the plaintiff’s’ attorney, a physician expert witness, the patient, and a family member.
According to trial transcripts, a gynecologic oncologist expert began crying on the stand after providing a clinical description of the symptoms that plaintiff, Chasidy Plunkard, would probably experience leading up to her death. When asked how long the patient had to live, the oncologist said “months” and later added, “I think she is living for this trial.”
After these comments, Ms. Plunkard’s attorney, Kila Baldwin, also began crying and requested a break to regain her composure, according to district court documents. During the 3 minutes the attorney was gone, the courtroom was silent other than the sound of Ms. Plunkard and her cousin sobbing.
The following day, U.S. District Judge Jennifer P. Wilson warned Ms. Baldwin that she would consider declaring a mistrial if the outburst happened again, according to trial transcripts.
“I expect counsel to maintain a professional demeanor even when eliciting emotionally laden testimony,” Judge Wilson said. “…I will not allow another recess. Further, if we have another incident like we had yesterday, I would have to entertain, if a motion for mistrial is made, I would have to seriously consider that, because I am concerned that this jury already has had a demonstration of a level of emotion that may make it difficult for them to set that aside and render a verdict that’s based only on a dispassionate consideration of what I perceive to be a legitimate dispute regarding liability.”
Judge Wilson later instructed jurors to disregard certain testimony at the request of Dr. Marks’ attorneys and reminded them not to be influenced by sympathy. After jurors rendered their $1.3 million verdict against Dr. Marks, he requested a new trial, claiming the witness’s testimony and the emotional displays of the witness and the attorney unfairly influenced the jury.
The expert witness “and plaintiff’s counsel undoubtedly affected the jury’s ability to decide this case in a dispassionate and impartial way and denied Dr. Marks his right to a fair trial,” attorney Matthew Rappleye wrote in Dr. Marks’ motion for a retrial. “Just as the court feared, as a result of these events, the jury was ‘tainted’ and could no longer decide this case divorced of sympathy for Ms. Plunkard.”
In response, an attorney for Ms. Plunkard emphasized that Dr. Marks did not request a retrial during the trial and that he was granted objections to the relevant testimony that he sought.
“In any event, the jury had the benefit of substantial evidence concerning Dr. Marks’ negligence, and the jury was entitled to construe that evidence in Plaintiff’s favor” attorney Charles Becker wrote. “…Indeed, the jury’s economic damages award of $585,000 not only fell well below the projection of plaintiff’s expert, but also ran at the low-end of the projection provided by Defendant’s economist. As to the non-economic damages, the jury’s award of $750,000 could have been far higher…. Nothing about either verdict or the damages award suggests a jury that was influenced by impermissible displays of emotion by the trial participants.”
In a December 13, 2021, decision, the U.S. District Court for the Middle District Court of Pennsylvania denied Dr. Marks’ request for a retrial. In her decision, Judge Wilson wrote that nothing in the jury’s verdict appeared to indicate that jurors were swayed by sympathy and that the verdict appeared to be conservative in light of the testimony presented.
Attorneys for Dr. Marks did not respond to a request for comment. In a statement, Ms. Baldwin said that the judge’s decision was correct.
“The district court got it exactly right, and we look forward to Ms. Plunkard receiving the compensation awarded by the jury in this tragic case,” she said.
Why did the patient sue?
Ms. Plunkard’s lawsuit against Dr. Marks stemmed from a January 2016 visit for complaints of bloating, pelvic pain, irregular periods, and an abnormal pelvic ultrasound. The ultrasound, ordered by her primary care physician, showed a thickened endometrial lining; a normal left ovary; and an enlarged, abnormal right ovary containing a complicated cyst, according to Ms. Plunkard’s complaint. Dr. Marks performed an endometrial biopsy and advised Ms. Plunkard that she would not need to take further measures if the result was benign, according to her lawsuit.
The result was benign, so Ms. Plunkard said she sought no further treatment for the cyst and none of her treating physicians followed up on the cyst. In February 2017, Ms. Plunkard presented to an emergency department with severe right upper quadrant abdominal pain and an ultrasound showed possible gallstones and pleural effusion, according to court documents.
After laparoscopic cholecystectomy, it was discovered that Ms. Plunkard had an inflamed pelvis and an omental lymph node was removed and biopsied. Surgeons reported that the lymph node showed metastatic cancer of probable gynecologic origin.
The patient underwent exploratory laparotomy, resulting in a radical abdominal hysterectomy, appendectomy, resection of the rectosigmoid with end-to-end anastomosis, and removal of cancerous implants. She was ultimately diagnosed with stage IVB low-grade metastatic ovarian cancer and went through six chemotherapy courses.
The patent’s cancer briefly went into remission but returned. In her complaint, Ms. Plunkard said Dr. Marks’ negligence allowed the cancer to spread from stage I to stage IVB, increasing her risk for harm and untimely death.
Dr. Marks argued that a follow-up ultrasound was not required, that the cyst on the patient’s right ovary was benign and resolved itself, that Ms. Plunkard’s cancer originated on the left, and that a follow-up ultrasound would not have detected primary cancer on the left ovary, according to legal documents.
On January 7, 2022, Dr. Marks appealed the jury’s verdict and the order denying his request for a retrial to the U.S. Court of Appeals for the Third Circuit.
A version of this article first appeared on Medscape.com.
Jurors found obstetrician-gynecologist Charles H. Marks, DO, negligent for failing to follow up on a patient’s complex cyst and hyperechoic nodule, which resulted in a delayed ovarian cancer diagnosis. But during the doctor’s 4-day trial, several parties had emotional outbursts in front of the jury, including the plaintiff’s’ attorney, a physician expert witness, the patient, and a family member.
According to trial transcripts, a gynecologic oncologist expert began crying on the stand after providing a clinical description of the symptoms that plaintiff, Chasidy Plunkard, would probably experience leading up to her death. When asked how long the patient had to live, the oncologist said “months” and later added, “I think she is living for this trial.”
After these comments, Ms. Plunkard’s attorney, Kila Baldwin, also began crying and requested a break to regain her composure, according to district court documents. During the 3 minutes the attorney was gone, the courtroom was silent other than the sound of Ms. Plunkard and her cousin sobbing.
The following day, U.S. District Judge Jennifer P. Wilson warned Ms. Baldwin that she would consider declaring a mistrial if the outburst happened again, according to trial transcripts.
“I expect counsel to maintain a professional demeanor even when eliciting emotionally laden testimony,” Judge Wilson said. “…I will not allow another recess. Further, if we have another incident like we had yesterday, I would have to entertain, if a motion for mistrial is made, I would have to seriously consider that, because I am concerned that this jury already has had a demonstration of a level of emotion that may make it difficult for them to set that aside and render a verdict that’s based only on a dispassionate consideration of what I perceive to be a legitimate dispute regarding liability.”
Judge Wilson later instructed jurors to disregard certain testimony at the request of Dr. Marks’ attorneys and reminded them not to be influenced by sympathy. After jurors rendered their $1.3 million verdict against Dr. Marks, he requested a new trial, claiming the witness’s testimony and the emotional displays of the witness and the attorney unfairly influenced the jury.
The expert witness “and plaintiff’s counsel undoubtedly affected the jury’s ability to decide this case in a dispassionate and impartial way and denied Dr. Marks his right to a fair trial,” attorney Matthew Rappleye wrote in Dr. Marks’ motion for a retrial. “Just as the court feared, as a result of these events, the jury was ‘tainted’ and could no longer decide this case divorced of sympathy for Ms. Plunkard.”
In response, an attorney for Ms. Plunkard emphasized that Dr. Marks did not request a retrial during the trial and that he was granted objections to the relevant testimony that he sought.
“In any event, the jury had the benefit of substantial evidence concerning Dr. Marks’ negligence, and the jury was entitled to construe that evidence in Plaintiff’s favor” attorney Charles Becker wrote. “…Indeed, the jury’s economic damages award of $585,000 not only fell well below the projection of plaintiff’s expert, but also ran at the low-end of the projection provided by Defendant’s economist. As to the non-economic damages, the jury’s award of $750,000 could have been far higher…. Nothing about either verdict or the damages award suggests a jury that was influenced by impermissible displays of emotion by the trial participants.”
In a December 13, 2021, decision, the U.S. District Court for the Middle District Court of Pennsylvania denied Dr. Marks’ request for a retrial. In her decision, Judge Wilson wrote that nothing in the jury’s verdict appeared to indicate that jurors were swayed by sympathy and that the verdict appeared to be conservative in light of the testimony presented.
Attorneys for Dr. Marks did not respond to a request for comment. In a statement, Ms. Baldwin said that the judge’s decision was correct.
“The district court got it exactly right, and we look forward to Ms. Plunkard receiving the compensation awarded by the jury in this tragic case,” she said.
Why did the patient sue?
Ms. Plunkard’s lawsuit against Dr. Marks stemmed from a January 2016 visit for complaints of bloating, pelvic pain, irregular periods, and an abnormal pelvic ultrasound. The ultrasound, ordered by her primary care physician, showed a thickened endometrial lining; a normal left ovary; and an enlarged, abnormal right ovary containing a complicated cyst, according to Ms. Plunkard’s complaint. Dr. Marks performed an endometrial biopsy and advised Ms. Plunkard that she would not need to take further measures if the result was benign, according to her lawsuit.
The result was benign, so Ms. Plunkard said she sought no further treatment for the cyst and none of her treating physicians followed up on the cyst. In February 2017, Ms. Plunkard presented to an emergency department with severe right upper quadrant abdominal pain and an ultrasound showed possible gallstones and pleural effusion, according to court documents.
After laparoscopic cholecystectomy, it was discovered that Ms. Plunkard had an inflamed pelvis and an omental lymph node was removed and biopsied. Surgeons reported that the lymph node showed metastatic cancer of probable gynecologic origin.
The patient underwent exploratory laparotomy, resulting in a radical abdominal hysterectomy, appendectomy, resection of the rectosigmoid with end-to-end anastomosis, and removal of cancerous implants. She was ultimately diagnosed with stage IVB low-grade metastatic ovarian cancer and went through six chemotherapy courses.
The patent’s cancer briefly went into remission but returned. In her complaint, Ms. Plunkard said Dr. Marks’ negligence allowed the cancer to spread from stage I to stage IVB, increasing her risk for harm and untimely death.
Dr. Marks argued that a follow-up ultrasound was not required, that the cyst on the patient’s right ovary was benign and resolved itself, that Ms. Plunkard’s cancer originated on the left, and that a follow-up ultrasound would not have detected primary cancer on the left ovary, according to legal documents.
On January 7, 2022, Dr. Marks appealed the jury’s verdict and the order denying his request for a retrial to the U.S. Court of Appeals for the Third Circuit.
A version of this article first appeared on Medscape.com.
Jeopardy! champion’s parents sue doctors, hospital when patient dies after colectomy
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
Mr. Smith, who suffered from ulcerative colitis, underwent a colectomy on Jan. 15, 2021, at St. Rose Dominican Hospital–San Martin Campus in Las Vegas. At the time, the 24-year-old man was malnourished, extremely weak, and was having more than 10 bloody bowel movements a day, according to a Jan. 11, 2022, lawsuit filed by Smith’s parents.
The allegations state that, after the procedure, hospital staff did not provide Mr. Smith with anticoagulants and did not administer or suggest that Mr. Smith take anticoagulants upon his discharge on Jan. 19. On Jan. 29, 2021, Mr. Smith collapsed at home and his family called an ambulance. He was taken back to St. Rose where he died from bilateral pulmonary emboli.
Mr. Smith’s legal complaint claims that treatment by Smith’s surgeon, hospitalist, and nursing staff fell below the standard of care because they failed to administer anticoagulants following the surgery. After the surgery, Mr. Smith’s surgeon referenced “DVT/VTE prophylaxis/anticoagulation” in the record and another note read “already ordered,” according to Keith Beiermeister, MD, a colon and rectal surgeon retained by the Smiths’ attorney, Robert E. Murdock. However, the order section of the notes included no specific order for heparin or Lovenox (enoxaparin). A hospitalist who cared for Mr. Smith after the surgery also mentioned “DVT prophylaxis” in the progress notes, but the hospitalist did not order it nor ensure that anticoagulants were given, the lawsuit claims.
“In a surgery such as this, the standard of care requires both mechanical and chemical anticoagulation,” Dr. Beiermeister wrote in the complaint. “This is especially true after colectomy and with Brayden’s history. Anticoagulants and mechanical anticoagulation are needed to prevent emboli. The medical literature is clear that patients undergoing colorectal surgery as compared to general surgery have a significant increase in the risk of emboli. This is especially true with preexisting inflammation as is present in inflammatory bowel disease.”
A spokesman for St. Rose said the hospital does not comment on pending litigation.
Mr. Smith was a five-time Jeopardy! winner and gained national fame during his championship run. In a statement, Jeopardy! officials said the Jeopardy! family was “heartbroken by the tragic loss of Brayden Smith” and that he “will be missed.”
Surgeon must face second trial in stroke suit
A cardiovascular surgeon must face a second trial over claims that he performed an unnecessary surgery that caused a patient’s stroke, the Iowa Supreme Court has ruled.
William McGrew visited a Waterloo, Iowa, cardiovascular surgeon in 2014 after experiencing transient foggy vision in one eye. An ophthalmologist initially diagnosed Mr. McGrew with cataract, but he was referred to the surgeon to rule out other possibilities.
Because of Mr. McGrew’s age (69) and history of hypertension, the cardiovascular surgeon suspected carotid disease and recommended a CT angiogram to further investigate, according to a summary in the Iowa Supreme Court’s opinion.
The CT angiogram was performed at a local imaging center and read by a radiologist who interpreted it as showing 65% stenosis, or narrowing, of the right carotid artery. The surgeon did his own review and interpreted the results as showing 70% stenosis, according to court documents. The surgeon believed that McGrew was at significant risk for stroke and he recommended surgery, specifically a right carotid endarterectomy to remove the plaque from the right carotid artery. He advised McGrew of the surgery’s possible risks, the most common being a stroke.
The endarterectomy initially appeared successful, but the next morning, Mr. McGrew experienced facial droop and weakness on his left side. An MRI and CT scan showed that Mr. McGrew experienced a stroke on the right side of his brain. A CT angiogram showed that his right carotid artery was blocked. The surgeon performed another surgery to remove the carotid artery blockage, but the second surgery did not alleviate Mr. McGrew’s symptoms, according to court documents. Mr. McGrew remains wheelchair-bound, unable to move his left side, and requires nursing home care.
Mr. McGrew and his family later went to a neurologist who analyzed Mr. McGrew’s prior CT angiogram. He interpreted the angiogram as showing only 40% stenosis. The neurologist also asked a neuroradiologist to analyze the CT angiogram, and he assessed the stenosis at 32%. In his opinion, 40% stenosis was not significant to justify an endarterectomy, the neurologist told Mr. McGrew.
Mr. McGrew sued the surgeon and the radiologist in 2016, and later settled with the radiologist. The McGrews claimed that the surgeon negligently misinterpreted the CT angiogram and performed an ill-advised surgery that resulted in a stroke. The McGrews sought damages for pain and suffering, permanent loss of function, loss of income, past and future medical expenses, and loss of consortium.
At trial, attorneys for the surgeon asked the court to limit his and the radiologist’s testimonies, arguing that their opinions were not properly disclosed in expert reports. The trial court granted the motion, and jurors heard only a limited version of the testimony. In addition, some medical records were redacted. A jury found in the surgeon’s favor, deeming him not negligent.
The McGrews appealed. In a Jan. 21, 2022, opinion, the Iowa Supreme Court ruled that the trial court abused its discretion by not allowing the earlier testimonies. Justices said both the neurologist and the neuroradiologist should have been allowed to testify on the applicable standard of care. The district court also abused its discretion in preventing Mr. McGrew from introducing complete versions of the contemporaneous medical records, the court ruled.
Justices reversed the district court’s decision and remanded the case for a new trial.
Court: Patient must pay doc’s legal expenses
A patient must pay a physician about $20,000 in legal expenses after the patient’s malpractice suit was thrown out, an Arizona appeals court has ruled.
Scottsdale plastic surgeon Corwin Martin, MD, performed dental implant surgery on Penny Preszler in February 2012. Following the surgery, Ms. Preszler claimed numbness in her face and mouth, according to the appellate decision. She sued Dr. Martin and his practice for malpractice in 2015.
As the case continued, Ms. Preszler withdrew her first expert and disclosed a new expert. When Ms. Preszler’s second standard of care expert withdrew, she was given 30 days to disclose a new expert. When she failed to do so, Dr. Martin asked the court to dismiss the suit based on Ms. Preszler’s failure to disclose a proper standard of care expert.
She eventually presented a third expert, but Martin’s attorneys argued that the doctor was not a qualified expert under state law because he was board certified in periodontia, while Dr. Martin is board certified in oral and maxillofacial surgery. By this time, the case had gone on for 4 years.
When Ms. Preszler couldn’t come up with a fourth expert who was qualified, the court dismissed the case. The judge also awarded Dr. Martin $19,279.05 for expenses incurred in discovery related to Ms. Preszler’s first expert, attorneys’ fees, and expenses.
Ms. Preszler appealed, arguing that the periodontist was qualified to testify against Martin because he performed dental implant surgeries in the past without the board certification Dr. Martin obtained. In its Jan. 20, 2022, decision, a panel of the Arizona Court of Appeals upheld the decision, ruling that the expert was not qualified to opine. The patient must also pay the physician’s legal expenses as ordered by the lower court.
“[Ms.] Preszler has not shown the superior court abused its discretion in the award issued,” appellate judges wrote. “Three years after [Ms.] Preszler disclosed her first expert witness, that expert withdrew. [Dr.] Martin claimed substantial expenses relating to discovery addressing [Ms.] Preszler’s first expert, which were no longer beneficial given his withdrawal. ... [Ms.] Preszler has not shown that the expenses awarded to [Dr.] Martin were unreasonable or disproportionate to the time and costs expended regarding the withdrawn expert.”
A version of this article first appeared on Medscape.com.
Were these true medical miracles? Doctors disagree
It was a freezing December day, and two young brothers were playing outside near a swimming pool when the younger boy, a 3-year-old toddler, fell into the water.
The 7-year-old immediately jumped into the pool to save his brother and was able to pull the toddler to the pool steps where the boy’s head was above water. But the icy temperatures overcame the older brother and he drifted underwater.
“Despite being at the forefront of medicine, what we don’t understand often exceeds what we do understand,” said Harley Rotbart, MD, author of “Miracles We Have Seen” (Health Communications: Deerfield Beach, Fla., 2016).
Paramedics arrived to find both boys unconscious and rushed them to the Children’s Hospital of Philadelphia. The younger boy regained consciousness in the ICU and recovered. The 7-year-old, however, was unresponsive and remained in a coma, said Dr. Rotbart a pediatrician and author based in Denver.
Family members stayed at the boy’s bedside and prayed. But after several weeks, the child’s condition remained unchanged. His parents began to discuss ending life support and organ donation. Then late one night, as Dr. Rotbart sat reading to the unconscious patient, the little boy squeezed his hand. In disbelief, Dr. Rotbart told all of his colleagues about the squeeze the next morning. Everyone attributed the movement to an involuntary muscle spasm, he said. After all, every test and scan showed the boy had no brain function.
But later that day, the child grasped another staff member’s hand. Shortly after that, he squeezed in response to a command. Dr. Rotbart and his staff were stunned, but cautious about feeling too much hope.
Days later, the child opened his eyes. Then, he smiled. His parents were overjoyed.
“When he walked out of the hospital more than 2 months after the near-drowning and his heroic rescue of his little brother, we all cheered and cried,” Dr. Rotbart wrote in his book. “We cried many times in the weeks preceding, and I still cry whenever I recall this story.”
The experience, which happened years ago when Dr. Rotbart was a trainee, has stayed with the pediatrician his entire career.
“His awakening was seemingly impossible – and then it happened,” Dr. Rotbart said. “Despite being at the forefront of medicine and science, what we don’t understand often exceeds what we do understand. And even when we think we understand, we are frequently proven wrong.”
For many, Dr. Rotbart’s experience raises questions about the existence of medical miracles.
Do physicians believe in medical miracles? The answers are diverse.
“I have no doubt that extraordinary outcomes happen where patients who are overwhelmingly expected not to survive, do,” says Eric Beam, MD, a hospitalist based in San Diego. “That’s one of the reasons we choose our words very carefully in our conversations with patients and their families and remember that nothing is 0%, and nothing is 100%. But doctors tend to treat situations that are 99.9% as absolute. I don’t think you can practice medicine with the hope or expectation that every case you see has the potential to beat the odds – or be a medical miracle.”
Disappearing cancer hailed as ‘miracle’
In 2003, physicians projected that Joseph Rick, 40, had just a few months to live. His mucosal melanoma had spread throughout his body, progressing even after several surgeries, radiation therapy, and a combination of chemotherapy agents, recalled Antoni Ribas, MD, PhD, an oncologist and director of the tumor immunology program at Jonsson Comprehensive Cancer Center in Los Angeles.
Mr. Rick’s melanoma had spread to his intestines with traces on his stomach and bladder. Tumors were present on his liver, lungs, and pancreas. Rick bought a grave and prepared for the worst, he recounted in a Cancer Research Institute video. But his fate took a turn when he enrolled in an experimental drug trial in December 2003. The phase 1 trial was for a new immune modulating antibody, called an anti–CTLA-4 antibody, said Dr. Ribas, who conducted the trial.
Over the next few weeks and months, all areas of Rick’s melanoma metastases disappeared. By 2009, he was in remission. He has lived the rest of his life with no evidence of melanoma, according to Dr. Ribas.
Mr. Rick’s case has been referenced throughout literature and news stories as a “medical miracle” and a “cancer miracle.”
Does Dr. Ribas think the case was a medical miracle?
“The response in Joseph Rick was what happened in 10%-15% of patients who received anti-CTLA-4 therapy,” Dr. Ribas said. “These were not miracles. These patients responded because their immune system trying to attack the cancer had been stuck at the CTLA-4 checkpoint. Blocking this checkpoint allowed their immune system to proceed to attack and kill cancer cells anywhere in the body.”
The scientific basis of this therapy was work by University of Texas MD Anderson Cancer Center immunologist James Allison, PhD, that had been done 5 years earlier in mouse models, where giving an anti–CTLA-4 antibody to mice allowed them to reject several implanted cancers, Dr. Ribas explained. Dr. Allison received the 2018 Nobel Prize in Physiology or Medicine for this work, subsequently opening the door for what we now call “immune checkpoint blockade therapy for cancer.” Dr. Ribas added.
“We tend to call miracles good things that we do not understand how they happened,” Dr. Ribas said. “From the human observation perspective, there have been plenty of medical miracles. However, each one has a specific biological mechanism that led to improvement in a patient. In cancer treatment, early studies using the immune system resulted in occasional patients having tumor responses and long-term benefits.
“With the increased understanding of how the immune system interacts with cancers, which is based on remarkable progress in understanding how the immune system works generated over the past several decades, these ‘miracles’ become specific mechanisms leading to response to cancer, which can then be replicated in other patients.”
Patient defies odds after 45 minutes without heartbeat
Florida ob.gyn. Michael Fleischer, MD, had just performed a routine repeat cesarean birth, delivering a healthy baby girl. His patient, Ruby, had a history of high blood pressure but medication taken during the pregnancy had kept her levels stabilized.
In the waiting room, Dr. Fleischer informed Ruby’s large family of the good news. He was planning to head home early that day when he heard his name being called over the hospital’s loudspeaker. Ruby had stopped breathing.
“The anesthesiologist was with her and had immediately intubated her,” Dr. Fleischer said. “We checked to make sure there was no problems or bleeding from the C-section, but everything was completely fine. However, we couldn’t keep her blood pressure stable.”
Dr. Fleischer suspected the respiratory arrest was caused by either an amniotic fluid embolism or a pulmonary embolism. Intubation continued and physicians gave Ruby medication to stabilize her blood pressure. Then suddenly, Ruby’s heart stopped.
Dr. Fleischer and other doctors began compressions, which they continued for 30 minutes. They shocked Ruby with defibrillator paddles multiple times, but there was no change.
“I was already thinking, this is hopeless, there’s nothing we can do,” he said. “The writing is on the wall. She’s going to die.”
Dr. Fleischer spoke to Ruby’s family and explained the tragic turn of events. Relatives were distraught and tearfully visited Ruby to say their goodbyes. They prayed and cried. Eventually, physicians ceased compressions. Ruby had gone 45 minutes without a pulse. The EKG was still showing some irregularity, FDr. leischer said, but no rhythm. Physicians kept Ruby intubated as they waited for the background electrical activity to fade. As they watched the screen in anguish, there was suddenly a blip on the heart rate monitor. Then another and another. Within seconds, Ruby’s heart went back into sinus rhythm.
“We were in disbelief,” Dr. Fleischer said. “We did some tests and put her in the ICU, and she was fine. Usually, after doing compressions on anyone, you’d have bruising or broken ribs. She had nothing. She just woke up and said: ‘What am I doing here? Let me go see my baby.’ ”
Ruby fully recovered, and 3 days later, she went home with her newborn.
While the recovery was unbelievable, Dr. Fleischer stopped short of calling it a medical miracle. There were scientific contributors to her survival: she was immediately intubated when she stopped breathing and compressions were started as soon as her heart stopped.
However, Dr. Fleischer said the fact that lifesaving measures had ended, and Ruby revived on her own was indeed, miraculous.
“It wasn’t like we were doing compressions and brought her back,” he said. “I can scientifically explain things in my mind, except for that. That when we finally stopped and took our hands off her, that’s when something changed. That’s when she came back.”
How do ‘medical miracles’ impact physicians?
When Dr. Rotbart was writing his book, which includes physician essays from across the world, he was struck by how many of the events happened decades earlier.
“This is another testament to the powerful impact these experiences have on those witnessing them,” he said. “In many cases, physicians describing events occurring years ago noted that those early memories served to give them hope as they encountered new, seemingly hopeless cases in subsequent years. Some contributors wrote that the ‘miracle experience’ actually directed them in their choice of specialty and has influenced much of their professional decision-making throughout their careers. Others draw on those miraculous moments at times when they themselves feel hopeless in the face of adversity and tragedy.”
Dr. Fleischer said that, although Ruby’s story has stayed with him, his mindset or practice style didn’t necessarily change after the experience.
“I’m not sure if it’s affected me because I haven’t been in that situation again,” he said. “I’m in the middle. I would never rule out anything, but I’m not going to base how I practice on the hope for a medical miracle.”
In a recent opinion piece for the New York Times, pulmonary and critical care physician, Daniela Lamas, MD, wrote about the sometimes negative effects of miracle cases on physicians. Such experiences for instance, can lead to a greater drive to beat the odds in future cases, which can sometimes lead to false hope, protracted critical care admissions, and futile procedures.
“After all, in most cases in the ICU, our initial prognoses are correct,” she wrote. “So there’s a risk to standing at the bedside, thinking about that one patient who made it home despite our predictions. We can give that experience too much weight in influencing our decisions and recommendations.”
Dr. Beam said unexpected outcomes – particularly in the age of COVID-19 – can certainly make physicians think differently about life-sustaining measures and when to discuss end-of-life care with family members. In his own practice, Dr. Beam has encountered unexpected COVID recoveries. Now, he generally gives extremely ill COVID patients a little more time to see if their bodies recover.
“It remains true that people who are really sick with COVID, who are on ventilated or who are requiring a lot of up respiratory support, they don’t do well on average,” he said. “But it is [also] true that there are a handful of people who get to that point and do come back to 80% or 90% of where they were. It makes you think twice.”
What to do when parents hope for a miracle
In his palliative care practice, Nashville, Tenn., surgeon Myrick Shinall Jr., MD, PhD, regularly encounters families and patients who wish for a medical miracle.
“It happens pretty often from a palliative care perspective,” he said. “What I have experienced the most is a patient with a severe brain injury who we don’t believe is recoverable. The medical team is discussing with the family that it is probably time to discontinue the ventilator. In those situations, families will often talk about wanting us to continue on [our life-sustaining efforts] in the hopes that a miracle will happen.”
Dr. Shinall and Trevor Bibler, PhD, recently authored two articles about best practices for responding to patients who hope for a miracle. The first one, published in the American Journal of Bioethics, is directed toward bioethicists; the second article, in the Journal of Pain and Symptom Management, targets clinicians.
A primary takeaway from the papers is that health professionals should recognize that hope for a miracle may mean different things to different people, said Dr. Bibler, an ethicist and assistant professor at Baylor College of Medicine, Houston. Some patients may have an innocuous hope for a miracle without a religious connotation, whereas others may have a firm conviction in their idea of God, their spirituality, and a concrete vision of the miracle.
“To hear that a family or patient is hoping for a miracle, one shouldn’t assume they already know what the patient or the family might mean by that,” Dr. Bibler said. “If a patient were to say, ‘I hope for a miracle,’ you might ask: ‘What do you mean by a miracle?’ Health professionals should feel empowered to ask that question.”
Health care professionals should explore a patient’s hope for a miracle, be nonjudgmental, ask clarifying questions, restate what the patient has said, and delve into the patient’s world view on death and dying, according to Dr. Bibler’s analyses. In some cases, it may be helpful to include a chaplain or the presence of a theology outsider in discussions.
When his patients and their families raise the subject of miracles, Dr. Shinall said he inquires what a miracle would look like in their opinion and tries to gauge how much of the assertion is a general hope compared with a firm belief.
“I try to work with them to make sure they understand doctors’ decisions and recommendations are based on what we know and can predict from our medical experience,” he said. “And that there’s nothing we’re going to do to prevent a miracle from happening, but that that can’t be our medical plan – to wait for a miracle.”
Despite the many patients and families Dr. Shinall has encountered who hope for a miracle, he has never experienced a case that he would describe as a medical miracle, he said.
Dr. Rotbart believes all physicians struggle with finding balance in how far to push in hope of a miracle and when to let go.
“Miracles, whether they happen to us, or we hear of them from colleagues or we read about them, should humble us as physicians,” he said. “I have come to believe that what we don’t know or don’t understand about medicine, medical miracles, or life in general, isn‘t necessarily cause for fear, and can even be reason for hope.
“Medicine has come a long way since Hippocrates’ theory of The Four Humors and The Four Temperaments, yet we still have much to learn about the workings of the human body. As physicians, we should take comfort in how much we don’t know because that allows us to share hope with our patients and, occasionally, makes medical miracles possible.”
A version of this article first appeared on Medscape.com.
It was a freezing December day, and two young brothers were playing outside near a swimming pool when the younger boy, a 3-year-old toddler, fell into the water.
The 7-year-old immediately jumped into the pool to save his brother and was able to pull the toddler to the pool steps where the boy’s head was above water. But the icy temperatures overcame the older brother and he drifted underwater.
“Despite being at the forefront of medicine, what we don’t understand often exceeds what we do understand,” said Harley Rotbart, MD, author of “Miracles We Have Seen” (Health Communications: Deerfield Beach, Fla., 2016).
Paramedics arrived to find both boys unconscious and rushed them to the Children’s Hospital of Philadelphia. The younger boy regained consciousness in the ICU and recovered. The 7-year-old, however, was unresponsive and remained in a coma, said Dr. Rotbart a pediatrician and author based in Denver.
Family members stayed at the boy’s bedside and prayed. But after several weeks, the child’s condition remained unchanged. His parents began to discuss ending life support and organ donation. Then late one night, as Dr. Rotbart sat reading to the unconscious patient, the little boy squeezed his hand. In disbelief, Dr. Rotbart told all of his colleagues about the squeeze the next morning. Everyone attributed the movement to an involuntary muscle spasm, he said. After all, every test and scan showed the boy had no brain function.
But later that day, the child grasped another staff member’s hand. Shortly after that, he squeezed in response to a command. Dr. Rotbart and his staff were stunned, but cautious about feeling too much hope.
Days later, the child opened his eyes. Then, he smiled. His parents were overjoyed.
“When he walked out of the hospital more than 2 months after the near-drowning and his heroic rescue of his little brother, we all cheered and cried,” Dr. Rotbart wrote in his book. “We cried many times in the weeks preceding, and I still cry whenever I recall this story.”
The experience, which happened years ago when Dr. Rotbart was a trainee, has stayed with the pediatrician his entire career.
“His awakening was seemingly impossible – and then it happened,” Dr. Rotbart said. “Despite being at the forefront of medicine and science, what we don’t understand often exceeds what we do understand. And even when we think we understand, we are frequently proven wrong.”
For many, Dr. Rotbart’s experience raises questions about the existence of medical miracles.
Do physicians believe in medical miracles? The answers are diverse.
“I have no doubt that extraordinary outcomes happen where patients who are overwhelmingly expected not to survive, do,” says Eric Beam, MD, a hospitalist based in San Diego. “That’s one of the reasons we choose our words very carefully in our conversations with patients and their families and remember that nothing is 0%, and nothing is 100%. But doctors tend to treat situations that are 99.9% as absolute. I don’t think you can practice medicine with the hope or expectation that every case you see has the potential to beat the odds – or be a medical miracle.”
Disappearing cancer hailed as ‘miracle’
In 2003, physicians projected that Joseph Rick, 40, had just a few months to live. His mucosal melanoma had spread throughout his body, progressing even after several surgeries, radiation therapy, and a combination of chemotherapy agents, recalled Antoni Ribas, MD, PhD, an oncologist and director of the tumor immunology program at Jonsson Comprehensive Cancer Center in Los Angeles.
Mr. Rick’s melanoma had spread to his intestines with traces on his stomach and bladder. Tumors were present on his liver, lungs, and pancreas. Rick bought a grave and prepared for the worst, he recounted in a Cancer Research Institute video. But his fate took a turn when he enrolled in an experimental drug trial in December 2003. The phase 1 trial was for a new immune modulating antibody, called an anti–CTLA-4 antibody, said Dr. Ribas, who conducted the trial.
Over the next few weeks and months, all areas of Rick’s melanoma metastases disappeared. By 2009, he was in remission. He has lived the rest of his life with no evidence of melanoma, according to Dr. Ribas.
Mr. Rick’s case has been referenced throughout literature and news stories as a “medical miracle” and a “cancer miracle.”
Does Dr. Ribas think the case was a medical miracle?
“The response in Joseph Rick was what happened in 10%-15% of patients who received anti-CTLA-4 therapy,” Dr. Ribas said. “These were not miracles. These patients responded because their immune system trying to attack the cancer had been stuck at the CTLA-4 checkpoint. Blocking this checkpoint allowed their immune system to proceed to attack and kill cancer cells anywhere in the body.”
The scientific basis of this therapy was work by University of Texas MD Anderson Cancer Center immunologist James Allison, PhD, that had been done 5 years earlier in mouse models, where giving an anti–CTLA-4 antibody to mice allowed them to reject several implanted cancers, Dr. Ribas explained. Dr. Allison received the 2018 Nobel Prize in Physiology or Medicine for this work, subsequently opening the door for what we now call “immune checkpoint blockade therapy for cancer.” Dr. Ribas added.
“We tend to call miracles good things that we do not understand how they happened,” Dr. Ribas said. “From the human observation perspective, there have been plenty of medical miracles. However, each one has a specific biological mechanism that led to improvement in a patient. In cancer treatment, early studies using the immune system resulted in occasional patients having tumor responses and long-term benefits.
“With the increased understanding of how the immune system interacts with cancers, which is based on remarkable progress in understanding how the immune system works generated over the past several decades, these ‘miracles’ become specific mechanisms leading to response to cancer, which can then be replicated in other patients.”
Patient defies odds after 45 minutes without heartbeat
Florida ob.gyn. Michael Fleischer, MD, had just performed a routine repeat cesarean birth, delivering a healthy baby girl. His patient, Ruby, had a history of high blood pressure but medication taken during the pregnancy had kept her levels stabilized.
In the waiting room, Dr. Fleischer informed Ruby’s large family of the good news. He was planning to head home early that day when he heard his name being called over the hospital’s loudspeaker. Ruby had stopped breathing.
“The anesthesiologist was with her and had immediately intubated her,” Dr. Fleischer said. “We checked to make sure there was no problems or bleeding from the C-section, but everything was completely fine. However, we couldn’t keep her blood pressure stable.”
Dr. Fleischer suspected the respiratory arrest was caused by either an amniotic fluid embolism or a pulmonary embolism. Intubation continued and physicians gave Ruby medication to stabilize her blood pressure. Then suddenly, Ruby’s heart stopped.
Dr. Fleischer and other doctors began compressions, which they continued for 30 minutes. They shocked Ruby with defibrillator paddles multiple times, but there was no change.
“I was already thinking, this is hopeless, there’s nothing we can do,” he said. “The writing is on the wall. She’s going to die.”
Dr. Fleischer spoke to Ruby’s family and explained the tragic turn of events. Relatives were distraught and tearfully visited Ruby to say their goodbyes. They prayed and cried. Eventually, physicians ceased compressions. Ruby had gone 45 minutes without a pulse. The EKG was still showing some irregularity, FDr. leischer said, but no rhythm. Physicians kept Ruby intubated as they waited for the background electrical activity to fade. As they watched the screen in anguish, there was suddenly a blip on the heart rate monitor. Then another and another. Within seconds, Ruby’s heart went back into sinus rhythm.
“We were in disbelief,” Dr. Fleischer said. “We did some tests and put her in the ICU, and she was fine. Usually, after doing compressions on anyone, you’d have bruising or broken ribs. She had nothing. She just woke up and said: ‘What am I doing here? Let me go see my baby.’ ”
Ruby fully recovered, and 3 days later, she went home with her newborn.
While the recovery was unbelievable, Dr. Fleischer stopped short of calling it a medical miracle. There were scientific contributors to her survival: she was immediately intubated when she stopped breathing and compressions were started as soon as her heart stopped.
However, Dr. Fleischer said the fact that lifesaving measures had ended, and Ruby revived on her own was indeed, miraculous.
“It wasn’t like we were doing compressions and brought her back,” he said. “I can scientifically explain things in my mind, except for that. That when we finally stopped and took our hands off her, that’s when something changed. That’s when she came back.”
How do ‘medical miracles’ impact physicians?
When Dr. Rotbart was writing his book, which includes physician essays from across the world, he was struck by how many of the events happened decades earlier.
“This is another testament to the powerful impact these experiences have on those witnessing them,” he said. “In many cases, physicians describing events occurring years ago noted that those early memories served to give them hope as they encountered new, seemingly hopeless cases in subsequent years. Some contributors wrote that the ‘miracle experience’ actually directed them in their choice of specialty and has influenced much of their professional decision-making throughout their careers. Others draw on those miraculous moments at times when they themselves feel hopeless in the face of adversity and tragedy.”
Dr. Fleischer said that, although Ruby’s story has stayed with him, his mindset or practice style didn’t necessarily change after the experience.
“I’m not sure if it’s affected me because I haven’t been in that situation again,” he said. “I’m in the middle. I would never rule out anything, but I’m not going to base how I practice on the hope for a medical miracle.”
In a recent opinion piece for the New York Times, pulmonary and critical care physician, Daniela Lamas, MD, wrote about the sometimes negative effects of miracle cases on physicians. Such experiences for instance, can lead to a greater drive to beat the odds in future cases, which can sometimes lead to false hope, protracted critical care admissions, and futile procedures.
“After all, in most cases in the ICU, our initial prognoses are correct,” she wrote. “So there’s a risk to standing at the bedside, thinking about that one patient who made it home despite our predictions. We can give that experience too much weight in influencing our decisions and recommendations.”
Dr. Beam said unexpected outcomes – particularly in the age of COVID-19 – can certainly make physicians think differently about life-sustaining measures and when to discuss end-of-life care with family members. In his own practice, Dr. Beam has encountered unexpected COVID recoveries. Now, he generally gives extremely ill COVID patients a little more time to see if their bodies recover.
“It remains true that people who are really sick with COVID, who are on ventilated or who are requiring a lot of up respiratory support, they don’t do well on average,” he said. “But it is [also] true that there are a handful of people who get to that point and do come back to 80% or 90% of where they were. It makes you think twice.”
What to do when parents hope for a miracle
In his palliative care practice, Nashville, Tenn., surgeon Myrick Shinall Jr., MD, PhD, regularly encounters families and patients who wish for a medical miracle.
“It happens pretty often from a palliative care perspective,” he said. “What I have experienced the most is a patient with a severe brain injury who we don’t believe is recoverable. The medical team is discussing with the family that it is probably time to discontinue the ventilator. In those situations, families will often talk about wanting us to continue on [our life-sustaining efforts] in the hopes that a miracle will happen.”
Dr. Shinall and Trevor Bibler, PhD, recently authored two articles about best practices for responding to patients who hope for a miracle. The first one, published in the American Journal of Bioethics, is directed toward bioethicists; the second article, in the Journal of Pain and Symptom Management, targets clinicians.
A primary takeaway from the papers is that health professionals should recognize that hope for a miracle may mean different things to different people, said Dr. Bibler, an ethicist and assistant professor at Baylor College of Medicine, Houston. Some patients may have an innocuous hope for a miracle without a religious connotation, whereas others may have a firm conviction in their idea of God, their spirituality, and a concrete vision of the miracle.
“To hear that a family or patient is hoping for a miracle, one shouldn’t assume they already know what the patient or the family might mean by that,” Dr. Bibler said. “If a patient were to say, ‘I hope for a miracle,’ you might ask: ‘What do you mean by a miracle?’ Health professionals should feel empowered to ask that question.”
Health care professionals should explore a patient’s hope for a miracle, be nonjudgmental, ask clarifying questions, restate what the patient has said, and delve into the patient’s world view on death and dying, according to Dr. Bibler’s analyses. In some cases, it may be helpful to include a chaplain or the presence of a theology outsider in discussions.
When his patients and their families raise the subject of miracles, Dr. Shinall said he inquires what a miracle would look like in their opinion and tries to gauge how much of the assertion is a general hope compared with a firm belief.
“I try to work with them to make sure they understand doctors’ decisions and recommendations are based on what we know and can predict from our medical experience,” he said. “And that there’s nothing we’re going to do to prevent a miracle from happening, but that that can’t be our medical plan – to wait for a miracle.”
Despite the many patients and families Dr. Shinall has encountered who hope for a miracle, he has never experienced a case that he would describe as a medical miracle, he said.
Dr. Rotbart believes all physicians struggle with finding balance in how far to push in hope of a miracle and when to let go.
“Miracles, whether they happen to us, or we hear of them from colleagues or we read about them, should humble us as physicians,” he said. “I have come to believe that what we don’t know or don’t understand about medicine, medical miracles, or life in general, isn‘t necessarily cause for fear, and can even be reason for hope.
“Medicine has come a long way since Hippocrates’ theory of The Four Humors and The Four Temperaments, yet we still have much to learn about the workings of the human body. As physicians, we should take comfort in how much we don’t know because that allows us to share hope with our patients and, occasionally, makes medical miracles possible.”
A version of this article first appeared on Medscape.com.
It was a freezing December day, and two young brothers were playing outside near a swimming pool when the younger boy, a 3-year-old toddler, fell into the water.
The 7-year-old immediately jumped into the pool to save his brother and was able to pull the toddler to the pool steps where the boy’s head was above water. But the icy temperatures overcame the older brother and he drifted underwater.
“Despite being at the forefront of medicine, what we don’t understand often exceeds what we do understand,” said Harley Rotbart, MD, author of “Miracles We Have Seen” (Health Communications: Deerfield Beach, Fla., 2016).
Paramedics arrived to find both boys unconscious and rushed them to the Children’s Hospital of Philadelphia. The younger boy regained consciousness in the ICU and recovered. The 7-year-old, however, was unresponsive and remained in a coma, said Dr. Rotbart a pediatrician and author based in Denver.
Family members stayed at the boy’s bedside and prayed. But after several weeks, the child’s condition remained unchanged. His parents began to discuss ending life support and organ donation. Then late one night, as Dr. Rotbart sat reading to the unconscious patient, the little boy squeezed his hand. In disbelief, Dr. Rotbart told all of his colleagues about the squeeze the next morning. Everyone attributed the movement to an involuntary muscle spasm, he said. After all, every test and scan showed the boy had no brain function.
But later that day, the child grasped another staff member’s hand. Shortly after that, he squeezed in response to a command. Dr. Rotbart and his staff were stunned, but cautious about feeling too much hope.
Days later, the child opened his eyes. Then, he smiled. His parents were overjoyed.
“When he walked out of the hospital more than 2 months after the near-drowning and his heroic rescue of his little brother, we all cheered and cried,” Dr. Rotbart wrote in his book. “We cried many times in the weeks preceding, and I still cry whenever I recall this story.”
The experience, which happened years ago when Dr. Rotbart was a trainee, has stayed with the pediatrician his entire career.
“His awakening was seemingly impossible – and then it happened,” Dr. Rotbart said. “Despite being at the forefront of medicine and science, what we don’t understand often exceeds what we do understand. And even when we think we understand, we are frequently proven wrong.”
For many, Dr. Rotbart’s experience raises questions about the existence of medical miracles.
Do physicians believe in medical miracles? The answers are diverse.
“I have no doubt that extraordinary outcomes happen where patients who are overwhelmingly expected not to survive, do,” says Eric Beam, MD, a hospitalist based in San Diego. “That’s one of the reasons we choose our words very carefully in our conversations with patients and their families and remember that nothing is 0%, and nothing is 100%. But doctors tend to treat situations that are 99.9% as absolute. I don’t think you can practice medicine with the hope or expectation that every case you see has the potential to beat the odds – or be a medical miracle.”
Disappearing cancer hailed as ‘miracle’
In 2003, physicians projected that Joseph Rick, 40, had just a few months to live. His mucosal melanoma had spread throughout his body, progressing even after several surgeries, radiation therapy, and a combination of chemotherapy agents, recalled Antoni Ribas, MD, PhD, an oncologist and director of the tumor immunology program at Jonsson Comprehensive Cancer Center in Los Angeles.
Mr. Rick’s melanoma had spread to his intestines with traces on his stomach and bladder. Tumors were present on his liver, lungs, and pancreas. Rick bought a grave and prepared for the worst, he recounted in a Cancer Research Institute video. But his fate took a turn when he enrolled in an experimental drug trial in December 2003. The phase 1 trial was for a new immune modulating antibody, called an anti–CTLA-4 antibody, said Dr. Ribas, who conducted the trial.
Over the next few weeks and months, all areas of Rick’s melanoma metastases disappeared. By 2009, he was in remission. He has lived the rest of his life with no evidence of melanoma, according to Dr. Ribas.
Mr. Rick’s case has been referenced throughout literature and news stories as a “medical miracle” and a “cancer miracle.”
Does Dr. Ribas think the case was a medical miracle?
“The response in Joseph Rick was what happened in 10%-15% of patients who received anti-CTLA-4 therapy,” Dr. Ribas said. “These were not miracles. These patients responded because their immune system trying to attack the cancer had been stuck at the CTLA-4 checkpoint. Blocking this checkpoint allowed their immune system to proceed to attack and kill cancer cells anywhere in the body.”
The scientific basis of this therapy was work by University of Texas MD Anderson Cancer Center immunologist James Allison, PhD, that had been done 5 years earlier in mouse models, where giving an anti–CTLA-4 antibody to mice allowed them to reject several implanted cancers, Dr. Ribas explained. Dr. Allison received the 2018 Nobel Prize in Physiology or Medicine for this work, subsequently opening the door for what we now call “immune checkpoint blockade therapy for cancer.” Dr. Ribas added.
“We tend to call miracles good things that we do not understand how they happened,” Dr. Ribas said. “From the human observation perspective, there have been plenty of medical miracles. However, each one has a specific biological mechanism that led to improvement in a patient. In cancer treatment, early studies using the immune system resulted in occasional patients having tumor responses and long-term benefits.
“With the increased understanding of how the immune system interacts with cancers, which is based on remarkable progress in understanding how the immune system works generated over the past several decades, these ‘miracles’ become specific mechanisms leading to response to cancer, which can then be replicated in other patients.”
Patient defies odds after 45 minutes without heartbeat
Florida ob.gyn. Michael Fleischer, MD, had just performed a routine repeat cesarean birth, delivering a healthy baby girl. His patient, Ruby, had a history of high blood pressure but medication taken during the pregnancy had kept her levels stabilized.
In the waiting room, Dr. Fleischer informed Ruby’s large family of the good news. He was planning to head home early that day when he heard his name being called over the hospital’s loudspeaker. Ruby had stopped breathing.
“The anesthesiologist was with her and had immediately intubated her,” Dr. Fleischer said. “We checked to make sure there was no problems or bleeding from the C-section, but everything was completely fine. However, we couldn’t keep her blood pressure stable.”
Dr. Fleischer suspected the respiratory arrest was caused by either an amniotic fluid embolism or a pulmonary embolism. Intubation continued and physicians gave Ruby medication to stabilize her blood pressure. Then suddenly, Ruby’s heart stopped.
Dr. Fleischer and other doctors began compressions, which they continued for 30 minutes. They shocked Ruby with defibrillator paddles multiple times, but there was no change.
“I was already thinking, this is hopeless, there’s nothing we can do,” he said. “The writing is on the wall. She’s going to die.”
Dr. Fleischer spoke to Ruby’s family and explained the tragic turn of events. Relatives were distraught and tearfully visited Ruby to say their goodbyes. They prayed and cried. Eventually, physicians ceased compressions. Ruby had gone 45 minutes without a pulse. The EKG was still showing some irregularity, FDr. leischer said, but no rhythm. Physicians kept Ruby intubated as they waited for the background electrical activity to fade. As they watched the screen in anguish, there was suddenly a blip on the heart rate monitor. Then another and another. Within seconds, Ruby’s heart went back into sinus rhythm.
“We were in disbelief,” Dr. Fleischer said. “We did some tests and put her in the ICU, and she was fine. Usually, after doing compressions on anyone, you’d have bruising or broken ribs. She had nothing. She just woke up and said: ‘What am I doing here? Let me go see my baby.’ ”
Ruby fully recovered, and 3 days later, she went home with her newborn.
While the recovery was unbelievable, Dr. Fleischer stopped short of calling it a medical miracle. There were scientific contributors to her survival: she was immediately intubated when she stopped breathing and compressions were started as soon as her heart stopped.
However, Dr. Fleischer said the fact that lifesaving measures had ended, and Ruby revived on her own was indeed, miraculous.
“It wasn’t like we were doing compressions and brought her back,” he said. “I can scientifically explain things in my mind, except for that. That when we finally stopped and took our hands off her, that’s when something changed. That’s when she came back.”
How do ‘medical miracles’ impact physicians?
When Dr. Rotbart was writing his book, which includes physician essays from across the world, he was struck by how many of the events happened decades earlier.
“This is another testament to the powerful impact these experiences have on those witnessing them,” he said. “In many cases, physicians describing events occurring years ago noted that those early memories served to give them hope as they encountered new, seemingly hopeless cases in subsequent years. Some contributors wrote that the ‘miracle experience’ actually directed them in their choice of specialty and has influenced much of their professional decision-making throughout their careers. Others draw on those miraculous moments at times when they themselves feel hopeless in the face of adversity and tragedy.”
Dr. Fleischer said that, although Ruby’s story has stayed with him, his mindset or practice style didn’t necessarily change after the experience.
“I’m not sure if it’s affected me because I haven’t been in that situation again,” he said. “I’m in the middle. I would never rule out anything, but I’m not going to base how I practice on the hope for a medical miracle.”
In a recent opinion piece for the New York Times, pulmonary and critical care physician, Daniela Lamas, MD, wrote about the sometimes negative effects of miracle cases on physicians. Such experiences for instance, can lead to a greater drive to beat the odds in future cases, which can sometimes lead to false hope, protracted critical care admissions, and futile procedures.
“After all, in most cases in the ICU, our initial prognoses are correct,” she wrote. “So there’s a risk to standing at the bedside, thinking about that one patient who made it home despite our predictions. We can give that experience too much weight in influencing our decisions and recommendations.”
Dr. Beam said unexpected outcomes – particularly in the age of COVID-19 – can certainly make physicians think differently about life-sustaining measures and when to discuss end-of-life care with family members. In his own practice, Dr. Beam has encountered unexpected COVID recoveries. Now, he generally gives extremely ill COVID patients a little more time to see if their bodies recover.
“It remains true that people who are really sick with COVID, who are on ventilated or who are requiring a lot of up respiratory support, they don’t do well on average,” he said. “But it is [also] true that there are a handful of people who get to that point and do come back to 80% or 90% of where they were. It makes you think twice.”
What to do when parents hope for a miracle
In his palliative care practice, Nashville, Tenn., surgeon Myrick Shinall Jr., MD, PhD, regularly encounters families and patients who wish for a medical miracle.
“It happens pretty often from a palliative care perspective,” he said. “What I have experienced the most is a patient with a severe brain injury who we don’t believe is recoverable. The medical team is discussing with the family that it is probably time to discontinue the ventilator. In those situations, families will often talk about wanting us to continue on [our life-sustaining efforts] in the hopes that a miracle will happen.”
Dr. Shinall and Trevor Bibler, PhD, recently authored two articles about best practices for responding to patients who hope for a miracle. The first one, published in the American Journal of Bioethics, is directed toward bioethicists; the second article, in the Journal of Pain and Symptom Management, targets clinicians.
A primary takeaway from the papers is that health professionals should recognize that hope for a miracle may mean different things to different people, said Dr. Bibler, an ethicist and assistant professor at Baylor College of Medicine, Houston. Some patients may have an innocuous hope for a miracle without a religious connotation, whereas others may have a firm conviction in their idea of God, their spirituality, and a concrete vision of the miracle.
“To hear that a family or patient is hoping for a miracle, one shouldn’t assume they already know what the patient or the family might mean by that,” Dr. Bibler said. “If a patient were to say, ‘I hope for a miracle,’ you might ask: ‘What do you mean by a miracle?’ Health professionals should feel empowered to ask that question.”
Health care professionals should explore a patient’s hope for a miracle, be nonjudgmental, ask clarifying questions, restate what the patient has said, and delve into the patient’s world view on death and dying, according to Dr. Bibler’s analyses. In some cases, it may be helpful to include a chaplain or the presence of a theology outsider in discussions.
When his patients and their families raise the subject of miracles, Dr. Shinall said he inquires what a miracle would look like in their opinion and tries to gauge how much of the assertion is a general hope compared with a firm belief.
“I try to work with them to make sure they understand doctors’ decisions and recommendations are based on what we know and can predict from our medical experience,” he said. “And that there’s nothing we’re going to do to prevent a miracle from happening, but that that can’t be our medical plan – to wait for a miracle.”
Despite the many patients and families Dr. Shinall has encountered who hope for a miracle, he has never experienced a case that he would describe as a medical miracle, he said.
Dr. Rotbart believes all physicians struggle with finding balance in how far to push in hope of a miracle and when to let go.
“Miracles, whether they happen to us, or we hear of them from colleagues or we read about them, should humble us as physicians,” he said. “I have come to believe that what we don’t know or don’t understand about medicine, medical miracles, or life in general, isn‘t necessarily cause for fear, and can even be reason for hope.
“Medicine has come a long way since Hippocrates’ theory of The Four Humors and The Four Temperaments, yet we still have much to learn about the workings of the human body. As physicians, we should take comfort in how much we don’t know because that allows us to share hope with our patients and, occasionally, makes medical miracles possible.”
A version of this article first appeared on Medscape.com.
Electrocuted by 11,000 volts, now a triple amputee ... and an MD
Bruce “BJ” Miller Jr., a 19-year-old Princeton (N.J.) University sophomore, was horsing around with friends near a train track in 1990 when they spotted a parked commuter train. They decided to climb over the train, and Mr. Miller was first up the ladder.
An explosion ripped through the air, and Mr. Miller was thrown on top of the train, his body smoking. His petrified friends called for an ambulance.
Clinging to life, Mr. Miller was airlifted to the burn unit at Saint Barnabas Medical Center in Livingston, N.J..
Physicians saved Mr. Miller’s life, but they had to amputate both of his legs below the knees and his left arm below the elbow.
“With electricity, you burn from the inside out,” said Mr. Miller, now 50. “The voltage enters your body – in my case, the wrist – and runs around internally until it finds a way out. That is often the lower extremities as the ground tends to ground the current, but not always. In my case, the current tried to come through my chest – which is also burned and required skin grafting – but not enough to spare my legs. I think I had a half-dozen or so surgeries over the first month or 2 at the hospital.”
Waking up to a new body
Mr. Miller doesn’t remember much about the accident, but he recalls waking up a few days later in the ICU and feeling the need to use the bathroom. Disoriented, Mr. Miller pulled off his ventilator, climbed out of bed, and tried to walk forward, unaware of his injuries. His feet and legs had not yet been amputated. When the catheter line ran out of slack, he collapsed.
“Eventually, a nurse came rushing in, responding to the ventilator alarm bells going off,” Mr. Miller said. “My dad wasn’t far behind. It became clear to me then that this was not a dream and [I realized] what had happened and why I was in the hospital.”
For months, Mr. Miller lived in the burn unit, undergoing countless skin grafts and surgeries. Because viable and nonviable tissue take time to be revealed after burns, surgeons take the minimum amount of tissue during each operation to give damaged tissue a chance to heal, he explained. In Mr. Miller’s case, his feet were amputated first, and later, his legs.
“In those early days from the hospital bed, my mind turned to issues related to identity,” he said. “What do I do with myself?
Mr. Miller eventually moved to the Rehabilitation Institute of Chicago (now called The Shirley Ryan AbilityLab), where he started the grueling process of rebuilding his strength and learning to walk on prosthetic legs.
“Any one day was filled with a mix of optimism and good fight and 5 minutes later, exasperation, frustration, tons of pain, and insecurity about my body,” he said. “My family and friends held the gate for me in a way, but a lot of the work was up to me. I had to believe that I deserved this love, that I wanted to be alive, and that there was still something here for me.”
Mr. Miller didn’t have to look far for inspiration. His mom had lived with polio for most of her life and acquired post-polio syndrome as she grew older, he said. When he was a child, his mom walked with crutches, and she became wheelchair-dependent by the time he was a teenager.
After the first surgery to amputate his feet, Mr. Miller and his mom shared a deep discussion about his joining the ranks of “the disabled,” and how their connection was now even stronger.
“In this way, the injuries unlocked even more experiences to share between us, and more love to feel, and therefore some early sense of gain to complement all the losses happening,” he said. “She had taught me so much about living with disability and had given me all the tools I needed to refashion my sense of self.”
From burn patient to medical student
After returning to Princeton University and finishing his undergraduate degree, Mr. Miller decided to go into medicine. He wanted to use his experience to help patients and find ways to improve weaknesses in the health care system, he said. But he made a deal with himself that he wouldn’t become a doctor for the sake of becoming one; he would enter the vocation only if he could do the work and enjoy the job.
“I wasn’t sure if I could do it,” he said. “There weren’t a lot of triple amputees to point to, to say whether this was even mechanically possible, to get through the training. The medical institutions I spoke with knew they had some obligation by law to protect me, but there’s also an obligation that I need to be able to fulfill the competencies. This was uncharted water.”
Because his greatest physical challenge was standing for long periods, instructors at the University of California, San Francisco, made accommodations to alleviate the strain. His clinical rotations for example, were organized near his home to limit the need for travel. On surgical rotations, he was allowed to sit on a stool.
Medical training progressed smoothly until Mr. Miller completed a rotation in his chosen specialty, rehabilitation medicine. He didn’t enjoy it. The passion and meaning he hoped to find was missing. Disillusioned, and with his final year in medical school coming to an end, Mr. Miller dropped out of the Match program. Around the same time, his sister, Lisa, died by suicide.
“My whole family life was in shambles,” he said. “I felt like, ‘I can’t even help my sister, how am I going to help other people?’ ”
Mr. Miller earned his MD and moved to his parents’ home in Milwaukee after his sister’s death. He was close to giving up on medicine, but his deans convinced him to do a post-doc internship. It was as an intern at the Medical College of Wisconsin, Milwaukee, that he completed an elective in palliative care.
“I fell immediately in love with it the first day,” he said. “This was a field devoted to working with things you can’t change and dealing with a lack of control, what it’s like to live with these diagnoses. This was a place where I could dig into my experience and share that with patients and families. This was a place where my life story had something to offer.”
Creating a new form of palliative care
Dr. Miller went on to complete a fellowship at Harvard Medical School, Boston, in hospice and palliative medicine. He became a palliative care physician at UCSF Health, and later directed the Zen Hospice Project, a nonprofit dedicated to teaching mindfulness-based caregiving for professionals, family members, and caregivers.
Gayle Kojimoto, a program manager who worked with Dr. Miller at UCSF’s outpatient palliative care clinic for cancer patients, said Miller was a favorite among patients because of his authenticity and his ability to make them feel understood.
“Patients love him because he is 100% present with them,” said Ms. Kojimoto. “They feel like he can understand their suffering better than other docs. He’s open to hearing about their suffering, when others may not be, and he doesn’t judge them. Many patients have said that seeing him is better than seeing a therapist.”
In 2020, Dr. Miller cofounded Mettle Health, a first-of-its-kind company that aims to reframe the way people think about their well-being as it relates to chronic and serious illness. Mettle Health’s care team provides consultations on a range of topics, including practical, emotional, and existential issues. No physician referrals are needed.
When the pandemic started, Dr. Miller said he and his colleagues felt the moment was ripe for bringing palliative care online to increase access, while decreasing caregiver and clinician burnout.
“We set up Mettle Health as an online palliative care counseling and coaching business and we pulled it out of the healthcare system so that whether you’re a patient or a caregiver you don’t need to satisfy some insurance need to get this kind of care,” he said. “We also realized there are enough people writing prescriptions. The medical piece is relatively well tended to; it’s the psychosocial and spiritual issues, and the existential issues, that are so underdeveloped. We are a social service, not a medical service, and this allows us to complement existing structures of care rather than compete with them.”
Having Dr. Miller as a leader for Mettle Health is a huge driver for why people seek out the company, said Sonya Dolan, director of operations and cofounder of Mettle Health.
“His approach to working with patients, caregivers, and clinicians is something I think sets us apart and makes us special,” she said. “His way of thinking about serious illness and death and dying is incredibly unique and he has a way of talking about and humanizing something that’s scary for a lot of us.”
‘Surprised by how much I can still do’
Since the accident, Dr. Miller has come a long way in navigating his physical limitations. In the early years, Dr. Miller said he was determined to do as many activities as he still could. He skied, biked, and pushed himself to stand for long periods on his prosthetic legs.
“For years, I would force myself to do these things just to prove I could, but not really enjoy them,” he said. “I’d get out on the dance floor or put myself out in vulnerable social situations where I might fall. It was kind of brutal and difficult. But at about year 5 or so, I became much more at ease with myself and more at peace with myself.”
Today, Dr. Miller’s prosthetics make nearly all ambulatory activities possible, but he concentrates on the activities that bring him joy.
“Probably the thing I can still do that surprises people most, including myself, is riding a motorcycle,” he said. “As for my upper body, I’m thoroughly used to living with only one hand and I continue to be surprised at how much I can still do. With enough time and experimentation, I can usually find a way to do what I need/want to do. It took me awhile to figure out how to clap! Now I just pound my chest for the same effect!”
Dr. Miller is an animal-lover and said his pets and nature are a large part of his self-care. His dog Maysie travels nearly everywhere with him and his cats, the Muffin Man and Darkness, enjoy making guest appearances on his Zoom calls. The physician frequently visits the desert in southern Utah and said he loves the arts, architecture, and design.
Dr. Miller’s advice for others who are disabled and want to go into medicine? Live out loud with your truths and be open about your disabilities. Too often, disabled individuals hide their disabilities, lie about them, or shield the world from their story, he said.
“These are rich, ripe experiences that are incredibly valuable to someone who wants to go out and be of service in the world,” he said. “We should be proud of our experiences as disabled people. The creativity we’ve had to exercise, the workarounds we’ve had to employ, these should not be points of embarrassment, but points of pride. Anyone who wants to pursue clinical training of any kind should use these experiences explicitly. These are sources of strength, not something to be forgiven or tolerated or accommodated.”
The same goes for physicians who do not have disabilities but who have lived through hardship, pain, struggle, or adversity, he emphasized.
“Find a way to learn from them, find a way to own them,” he said. “Use them as a source of strength and the rest of the world will respond to you differently.”
A version of this article first appeared on Medscape.com.
Bruce “BJ” Miller Jr., a 19-year-old Princeton (N.J.) University sophomore, was horsing around with friends near a train track in 1990 when they spotted a parked commuter train. They decided to climb over the train, and Mr. Miller was first up the ladder.
An explosion ripped through the air, and Mr. Miller was thrown on top of the train, his body smoking. His petrified friends called for an ambulance.
Clinging to life, Mr. Miller was airlifted to the burn unit at Saint Barnabas Medical Center in Livingston, N.J..
Physicians saved Mr. Miller’s life, but they had to amputate both of his legs below the knees and his left arm below the elbow.
“With electricity, you burn from the inside out,” said Mr. Miller, now 50. “The voltage enters your body – in my case, the wrist – and runs around internally until it finds a way out. That is often the lower extremities as the ground tends to ground the current, but not always. In my case, the current tried to come through my chest – which is also burned and required skin grafting – but not enough to spare my legs. I think I had a half-dozen or so surgeries over the first month or 2 at the hospital.”
Waking up to a new body
Mr. Miller doesn’t remember much about the accident, but he recalls waking up a few days later in the ICU and feeling the need to use the bathroom. Disoriented, Mr. Miller pulled off his ventilator, climbed out of bed, and tried to walk forward, unaware of his injuries. His feet and legs had not yet been amputated. When the catheter line ran out of slack, he collapsed.
“Eventually, a nurse came rushing in, responding to the ventilator alarm bells going off,” Mr. Miller said. “My dad wasn’t far behind. It became clear to me then that this was not a dream and [I realized] what had happened and why I was in the hospital.”
For months, Mr. Miller lived in the burn unit, undergoing countless skin grafts and surgeries. Because viable and nonviable tissue take time to be revealed after burns, surgeons take the minimum amount of tissue during each operation to give damaged tissue a chance to heal, he explained. In Mr. Miller’s case, his feet were amputated first, and later, his legs.
“In those early days from the hospital bed, my mind turned to issues related to identity,” he said. “What do I do with myself?
Mr. Miller eventually moved to the Rehabilitation Institute of Chicago (now called The Shirley Ryan AbilityLab), where he started the grueling process of rebuilding his strength and learning to walk on prosthetic legs.
“Any one day was filled with a mix of optimism and good fight and 5 minutes later, exasperation, frustration, tons of pain, and insecurity about my body,” he said. “My family and friends held the gate for me in a way, but a lot of the work was up to me. I had to believe that I deserved this love, that I wanted to be alive, and that there was still something here for me.”
Mr. Miller didn’t have to look far for inspiration. His mom had lived with polio for most of her life and acquired post-polio syndrome as she grew older, he said. When he was a child, his mom walked with crutches, and she became wheelchair-dependent by the time he was a teenager.
After the first surgery to amputate his feet, Mr. Miller and his mom shared a deep discussion about his joining the ranks of “the disabled,” and how their connection was now even stronger.
“In this way, the injuries unlocked even more experiences to share between us, and more love to feel, and therefore some early sense of gain to complement all the losses happening,” he said. “She had taught me so much about living with disability and had given me all the tools I needed to refashion my sense of self.”
From burn patient to medical student
After returning to Princeton University and finishing his undergraduate degree, Mr. Miller decided to go into medicine. He wanted to use his experience to help patients and find ways to improve weaknesses in the health care system, he said. But he made a deal with himself that he wouldn’t become a doctor for the sake of becoming one; he would enter the vocation only if he could do the work and enjoy the job.
“I wasn’t sure if I could do it,” he said. “There weren’t a lot of triple amputees to point to, to say whether this was even mechanically possible, to get through the training. The medical institutions I spoke with knew they had some obligation by law to protect me, but there’s also an obligation that I need to be able to fulfill the competencies. This was uncharted water.”
Because his greatest physical challenge was standing for long periods, instructors at the University of California, San Francisco, made accommodations to alleviate the strain. His clinical rotations for example, were organized near his home to limit the need for travel. On surgical rotations, he was allowed to sit on a stool.
Medical training progressed smoothly until Mr. Miller completed a rotation in his chosen specialty, rehabilitation medicine. He didn’t enjoy it. The passion and meaning he hoped to find was missing. Disillusioned, and with his final year in medical school coming to an end, Mr. Miller dropped out of the Match program. Around the same time, his sister, Lisa, died by suicide.
“My whole family life was in shambles,” he said. “I felt like, ‘I can’t even help my sister, how am I going to help other people?’ ”
Mr. Miller earned his MD and moved to his parents’ home in Milwaukee after his sister’s death. He was close to giving up on medicine, but his deans convinced him to do a post-doc internship. It was as an intern at the Medical College of Wisconsin, Milwaukee, that he completed an elective in palliative care.
“I fell immediately in love with it the first day,” he said. “This was a field devoted to working with things you can’t change and dealing with a lack of control, what it’s like to live with these diagnoses. This was a place where I could dig into my experience and share that with patients and families. This was a place where my life story had something to offer.”
Creating a new form of palliative care
Dr. Miller went on to complete a fellowship at Harvard Medical School, Boston, in hospice and palliative medicine. He became a palliative care physician at UCSF Health, and later directed the Zen Hospice Project, a nonprofit dedicated to teaching mindfulness-based caregiving for professionals, family members, and caregivers.
Gayle Kojimoto, a program manager who worked with Dr. Miller at UCSF’s outpatient palliative care clinic for cancer patients, said Miller was a favorite among patients because of his authenticity and his ability to make them feel understood.
“Patients love him because he is 100% present with them,” said Ms. Kojimoto. “They feel like he can understand their suffering better than other docs. He’s open to hearing about their suffering, when others may not be, and he doesn’t judge them. Many patients have said that seeing him is better than seeing a therapist.”
In 2020, Dr. Miller cofounded Mettle Health, a first-of-its-kind company that aims to reframe the way people think about their well-being as it relates to chronic and serious illness. Mettle Health’s care team provides consultations on a range of topics, including practical, emotional, and existential issues. No physician referrals are needed.
When the pandemic started, Dr. Miller said he and his colleagues felt the moment was ripe for bringing palliative care online to increase access, while decreasing caregiver and clinician burnout.
“We set up Mettle Health as an online palliative care counseling and coaching business and we pulled it out of the healthcare system so that whether you’re a patient or a caregiver you don’t need to satisfy some insurance need to get this kind of care,” he said. “We also realized there are enough people writing prescriptions. The medical piece is relatively well tended to; it’s the psychosocial and spiritual issues, and the existential issues, that are so underdeveloped. We are a social service, not a medical service, and this allows us to complement existing structures of care rather than compete with them.”
Having Dr. Miller as a leader for Mettle Health is a huge driver for why people seek out the company, said Sonya Dolan, director of operations and cofounder of Mettle Health.
“His approach to working with patients, caregivers, and clinicians is something I think sets us apart and makes us special,” she said. “His way of thinking about serious illness and death and dying is incredibly unique and he has a way of talking about and humanizing something that’s scary for a lot of us.”
‘Surprised by how much I can still do’
Since the accident, Dr. Miller has come a long way in navigating his physical limitations. In the early years, Dr. Miller said he was determined to do as many activities as he still could. He skied, biked, and pushed himself to stand for long periods on his prosthetic legs.
“For years, I would force myself to do these things just to prove I could, but not really enjoy them,” he said. “I’d get out on the dance floor or put myself out in vulnerable social situations where I might fall. It was kind of brutal and difficult. But at about year 5 or so, I became much more at ease with myself and more at peace with myself.”
Today, Dr. Miller’s prosthetics make nearly all ambulatory activities possible, but he concentrates on the activities that bring him joy.
“Probably the thing I can still do that surprises people most, including myself, is riding a motorcycle,” he said. “As for my upper body, I’m thoroughly used to living with only one hand and I continue to be surprised at how much I can still do. With enough time and experimentation, I can usually find a way to do what I need/want to do. It took me awhile to figure out how to clap! Now I just pound my chest for the same effect!”
Dr. Miller is an animal-lover and said his pets and nature are a large part of his self-care. His dog Maysie travels nearly everywhere with him and his cats, the Muffin Man and Darkness, enjoy making guest appearances on his Zoom calls. The physician frequently visits the desert in southern Utah and said he loves the arts, architecture, and design.
Dr. Miller’s advice for others who are disabled and want to go into medicine? Live out loud with your truths and be open about your disabilities. Too often, disabled individuals hide their disabilities, lie about them, or shield the world from their story, he said.
“These are rich, ripe experiences that are incredibly valuable to someone who wants to go out and be of service in the world,” he said. “We should be proud of our experiences as disabled people. The creativity we’ve had to exercise, the workarounds we’ve had to employ, these should not be points of embarrassment, but points of pride. Anyone who wants to pursue clinical training of any kind should use these experiences explicitly. These are sources of strength, not something to be forgiven or tolerated or accommodated.”
The same goes for physicians who do not have disabilities but who have lived through hardship, pain, struggle, or adversity, he emphasized.
“Find a way to learn from them, find a way to own them,” he said. “Use them as a source of strength and the rest of the world will respond to you differently.”
A version of this article first appeared on Medscape.com.
Bruce “BJ” Miller Jr., a 19-year-old Princeton (N.J.) University sophomore, was horsing around with friends near a train track in 1990 when they spotted a parked commuter train. They decided to climb over the train, and Mr. Miller was first up the ladder.
An explosion ripped through the air, and Mr. Miller was thrown on top of the train, his body smoking. His petrified friends called for an ambulance.
Clinging to life, Mr. Miller was airlifted to the burn unit at Saint Barnabas Medical Center in Livingston, N.J..
Physicians saved Mr. Miller’s life, but they had to amputate both of his legs below the knees and his left arm below the elbow.
“With electricity, you burn from the inside out,” said Mr. Miller, now 50. “The voltage enters your body – in my case, the wrist – and runs around internally until it finds a way out. That is often the lower extremities as the ground tends to ground the current, but not always. In my case, the current tried to come through my chest – which is also burned and required skin grafting – but not enough to spare my legs. I think I had a half-dozen or so surgeries over the first month or 2 at the hospital.”
Waking up to a new body
Mr. Miller doesn’t remember much about the accident, but he recalls waking up a few days later in the ICU and feeling the need to use the bathroom. Disoriented, Mr. Miller pulled off his ventilator, climbed out of bed, and tried to walk forward, unaware of his injuries. His feet and legs had not yet been amputated. When the catheter line ran out of slack, he collapsed.
“Eventually, a nurse came rushing in, responding to the ventilator alarm bells going off,” Mr. Miller said. “My dad wasn’t far behind. It became clear to me then that this was not a dream and [I realized] what had happened and why I was in the hospital.”
For months, Mr. Miller lived in the burn unit, undergoing countless skin grafts and surgeries. Because viable and nonviable tissue take time to be revealed after burns, surgeons take the minimum amount of tissue during each operation to give damaged tissue a chance to heal, he explained. In Mr. Miller’s case, his feet were amputated first, and later, his legs.
“In those early days from the hospital bed, my mind turned to issues related to identity,” he said. “What do I do with myself?
Mr. Miller eventually moved to the Rehabilitation Institute of Chicago (now called The Shirley Ryan AbilityLab), where he started the grueling process of rebuilding his strength and learning to walk on prosthetic legs.
“Any one day was filled with a mix of optimism and good fight and 5 minutes later, exasperation, frustration, tons of pain, and insecurity about my body,” he said. “My family and friends held the gate for me in a way, but a lot of the work was up to me. I had to believe that I deserved this love, that I wanted to be alive, and that there was still something here for me.”
Mr. Miller didn’t have to look far for inspiration. His mom had lived with polio for most of her life and acquired post-polio syndrome as she grew older, he said. When he was a child, his mom walked with crutches, and she became wheelchair-dependent by the time he was a teenager.
After the first surgery to amputate his feet, Mr. Miller and his mom shared a deep discussion about his joining the ranks of “the disabled,” and how their connection was now even stronger.
“In this way, the injuries unlocked even more experiences to share between us, and more love to feel, and therefore some early sense of gain to complement all the losses happening,” he said. “She had taught me so much about living with disability and had given me all the tools I needed to refashion my sense of self.”
From burn patient to medical student
After returning to Princeton University and finishing his undergraduate degree, Mr. Miller decided to go into medicine. He wanted to use his experience to help patients and find ways to improve weaknesses in the health care system, he said. But he made a deal with himself that he wouldn’t become a doctor for the sake of becoming one; he would enter the vocation only if he could do the work and enjoy the job.
“I wasn’t sure if I could do it,” he said. “There weren’t a lot of triple amputees to point to, to say whether this was even mechanically possible, to get through the training. The medical institutions I spoke with knew they had some obligation by law to protect me, but there’s also an obligation that I need to be able to fulfill the competencies. This was uncharted water.”
Because his greatest physical challenge was standing for long periods, instructors at the University of California, San Francisco, made accommodations to alleviate the strain. His clinical rotations for example, were organized near his home to limit the need for travel. On surgical rotations, he was allowed to sit on a stool.
Medical training progressed smoothly until Mr. Miller completed a rotation in his chosen specialty, rehabilitation medicine. He didn’t enjoy it. The passion and meaning he hoped to find was missing. Disillusioned, and with his final year in medical school coming to an end, Mr. Miller dropped out of the Match program. Around the same time, his sister, Lisa, died by suicide.
“My whole family life was in shambles,” he said. “I felt like, ‘I can’t even help my sister, how am I going to help other people?’ ”
Mr. Miller earned his MD and moved to his parents’ home in Milwaukee after his sister’s death. He was close to giving up on medicine, but his deans convinced him to do a post-doc internship. It was as an intern at the Medical College of Wisconsin, Milwaukee, that he completed an elective in palliative care.
“I fell immediately in love with it the first day,” he said. “This was a field devoted to working with things you can’t change and dealing with a lack of control, what it’s like to live with these diagnoses. This was a place where I could dig into my experience and share that with patients and families. This was a place where my life story had something to offer.”
Creating a new form of palliative care
Dr. Miller went on to complete a fellowship at Harvard Medical School, Boston, in hospice and palliative medicine. He became a palliative care physician at UCSF Health, and later directed the Zen Hospice Project, a nonprofit dedicated to teaching mindfulness-based caregiving for professionals, family members, and caregivers.
Gayle Kojimoto, a program manager who worked with Dr. Miller at UCSF’s outpatient palliative care clinic for cancer patients, said Miller was a favorite among patients because of his authenticity and his ability to make them feel understood.
“Patients love him because he is 100% present with them,” said Ms. Kojimoto. “They feel like he can understand their suffering better than other docs. He’s open to hearing about their suffering, when others may not be, and he doesn’t judge them. Many patients have said that seeing him is better than seeing a therapist.”
In 2020, Dr. Miller cofounded Mettle Health, a first-of-its-kind company that aims to reframe the way people think about their well-being as it relates to chronic and serious illness. Mettle Health’s care team provides consultations on a range of topics, including practical, emotional, and existential issues. No physician referrals are needed.
When the pandemic started, Dr. Miller said he and his colleagues felt the moment was ripe for bringing palliative care online to increase access, while decreasing caregiver and clinician burnout.
“We set up Mettle Health as an online palliative care counseling and coaching business and we pulled it out of the healthcare system so that whether you’re a patient or a caregiver you don’t need to satisfy some insurance need to get this kind of care,” he said. “We also realized there are enough people writing prescriptions. The medical piece is relatively well tended to; it’s the psychosocial and spiritual issues, and the existential issues, that are so underdeveloped. We are a social service, not a medical service, and this allows us to complement existing structures of care rather than compete with them.”
Having Dr. Miller as a leader for Mettle Health is a huge driver for why people seek out the company, said Sonya Dolan, director of operations and cofounder of Mettle Health.
“His approach to working with patients, caregivers, and clinicians is something I think sets us apart and makes us special,” she said. “His way of thinking about serious illness and death and dying is incredibly unique and he has a way of talking about and humanizing something that’s scary for a lot of us.”
‘Surprised by how much I can still do’
Since the accident, Dr. Miller has come a long way in navigating his physical limitations. In the early years, Dr. Miller said he was determined to do as many activities as he still could. He skied, biked, and pushed himself to stand for long periods on his prosthetic legs.
“For years, I would force myself to do these things just to prove I could, but not really enjoy them,” he said. “I’d get out on the dance floor or put myself out in vulnerable social situations where I might fall. It was kind of brutal and difficult. But at about year 5 or so, I became much more at ease with myself and more at peace with myself.”
Today, Dr. Miller’s prosthetics make nearly all ambulatory activities possible, but he concentrates on the activities that bring him joy.
“Probably the thing I can still do that surprises people most, including myself, is riding a motorcycle,” he said. “As for my upper body, I’m thoroughly used to living with only one hand and I continue to be surprised at how much I can still do. With enough time and experimentation, I can usually find a way to do what I need/want to do. It took me awhile to figure out how to clap! Now I just pound my chest for the same effect!”
Dr. Miller is an animal-lover and said his pets and nature are a large part of his self-care. His dog Maysie travels nearly everywhere with him and his cats, the Muffin Man and Darkness, enjoy making guest appearances on his Zoom calls. The physician frequently visits the desert in southern Utah and said he loves the arts, architecture, and design.
Dr. Miller’s advice for others who are disabled and want to go into medicine? Live out loud with your truths and be open about your disabilities. Too often, disabled individuals hide their disabilities, lie about them, or shield the world from their story, he said.
“These are rich, ripe experiences that are incredibly valuable to someone who wants to go out and be of service in the world,” he said. “We should be proud of our experiences as disabled people. The creativity we’ve had to exercise, the workarounds we’ve had to employ, these should not be points of embarrassment, but points of pride. Anyone who wants to pursue clinical training of any kind should use these experiences explicitly. These are sources of strength, not something to be forgiven or tolerated or accommodated.”
The same goes for physicians who do not have disabilities but who have lived through hardship, pain, struggle, or adversity, he emphasized.
“Find a way to learn from them, find a way to own them,” he said. “Use them as a source of strength and the rest of the world will respond to you differently.”
A version of this article first appeared on Medscape.com.
My patient is having an affair and has an STI. I’m treating both partners. What would you do?
A psychiatrist was treating a couple individually, one of whom was HIV-positive. During a session, the infected partner revealed he was having sex with other men outside the relationship and not using safe sex practices.
“He was being treated for major depression and anxiety at the time,” explained the anonymous psychiatrist. “I strongly encouraged him to tell his partner, but he was scared of doing so. He stated that they had not been using safe sex practices between the two of them, but he was willing to start at that point.”
At a session with the HIV-negative partner, the psychiatrist inquired about the couple’s current sex practices. The HIV-negative partner reported no changes and said the two continued to have sex without condoms, said the psychiatrist, who shared the experience in Medscape’s Ethics 2020 Survey open-ended questions.
“My dilemma now was whether or not to inform him about his partner’s ‘extracurricular sex behavior,’ the psychiatrist said. “Since he was now at greater risk of contracting HIV, I felt compelled to do something to intervene.”
What would you do in this situation?
according to responses from the Ethics 2020 Report. When asked to share their toughest ethical dilemma, one internist for example, wrote, “I have couples as patients, and it is very challenging if they reveal infidelity or separate/divorce; I cannot reveal info to the spouse, but it makes me very uncomfortable caring for both.” Similarly, an obstetrician-gynecologist wrote about her experience counseling patients who reveal extramarital affairs.
“Women confide deeply with their gynecologist, and although I was not successful in rescuing 100% of them, the majority accepted my counseling and saved their marriages,” the anonymous ob/gyn wrote. “In every case in which my patient was willing to resume her marital relationship, I always ensured that she advised her spouse of the infidelity, and the couple was referred to a qualified provider for marriage counseling.”
When a sexually transmitted infection (STI) comes into play however, physicians describe a deeper level of internal conflict. A family physician wrote her top ethical dilemma was “Cheating spouses and STIs: how do you get the other spouse treated?” An ob-gyn stated that, “disclosure of STI status in couples when this may indicate infidelity,” was a frequent ethical issue in her specialty. Commenters on Medscape’s recent story, “The Secret I’ll Take to my Grave: Doc Reveals,” also raised the uncomfortable topic. One physician recalled a deaf female patient who requested in writing not to test for syphilis and not to discuss the issue with her husband. “Patient knew that she had syphilis, but she did not want her husband to know,” the physician wrote.
It’s not uncommon for physicians to encounter such scenarios when treating long-term couples, especially in the digital era, said Shannon Dowler, MD, chief medical officer for North Carolina Medicaid and a family physician at the Buncombe County STI Clinic.
“This is definitely something I think we see more of in our age of ‘hookup apps’ and easier access to casual sexual connections than we did before,” said Dr. Dowler, who serves on the CDC Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment.
The topic is particularly timely because of the pandemic’s impact on STI testing and the expected rise in sexually transmitted infection rates over the next year, Dr. Dowler notes.
“People weren’t necessarily coming in for routine screening or testing during the pandemic because they didn’t want to take a chance on being exposed to COVID,” she said. “But also, the reagent used for testing for certain types of transmitted infections was in short supply because they use that same reagent for the COVID test. We had shortages of STI testing in many parts of the country. I expect what we’re going to see over the next year are a lot of diagnoses that were missed during the pandemic and a lot of asymptomatic spread.”
What do the experts suggest?
Caring for spouses or two partners when an STI is discovered can be challenging for physicians, particularly in small towns where many people know each other, said Kenneth Goodman, PhD, founder and director of the Institute for Bioethics and Health Policy at the University of Miami.
“This can be a real challenge for family physicians and others in a small town,” he said. “If you discover one partner is positive for a sexually transmitted infection and the other is negative, then you’ve got a challenge to manage. The way to do that is to start with moral persuasion, namely you tell your patient, ‘You really need to disclose this. Because when he or she gets it, chances are, you’re going to be the prime suspect.’ “
Dr. Dowler, who practices in an STI clinic, said she once diagnosed a sexually transmitted infection in a patient who was married to one of Dowler’s coworkers. The patient would not allow the partner to be notified, she said. In this case, Dr. Dowler practiced expedited partner therapy (EPT), the clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by giving the patient prescriptions or medications to take to the partner without having first examined the partner. The practice is legal to some extent in all states, Dr. Dowler said, but some states have different rules about how the practice can be utilized.
Physicians are obligated to report communicable diseases to their local health department, Dr. Goodman said. The health department would then do contract tracing and be responsible for conveying the STI diagnosis to any relevant parties. Even so, Dr. Goodman said physicians have a moral obligation to strongly encourage patients to divulge the infection to their partner.
“Doctors should work on being persuasive to change behavior,” he said. “Tell your patients to do the right thing and follow up with them. You should tell patients they have a responsibility to disclose a sexually transmitted infection to any of their partners and a responsibility not to have unprotected sex. Doctors can be very powerful advocates for that.”
Dr. Dowler said if she is treating two partners, and one is diagnosed with a sexually transmitted infection, she generally asks the patient for their consent to disclose the diagnosis to the partner. She ensures a witness, usually a nurse, is present when she asks. If consent is refused, Dr. Dowler guides her treatment to be as protective as possible, she said. A helpful resource for patients is Tellyourpartner.org, a website that sends an anonymous text or email about infection exposure and provides guidance on treatment locations and options.
Of course, if the sexually transmitted infection is HIV, another set of rules apply. As of 2021, 35 states have laws that criminalize HIV exposure. Laws vary, but many hold patients criminally liable if they knowingly expose another party to HIV. Many states and some cities also have ‘partner notification’ laws that require health providers to disclose an HIV diagnosis to the patient’s sex partners or to report the names of sex partners to the health department, if known.
However, case law on a physician’s duty to warn is mixed, and doctors’ responsibility for STI reporting and partner notification is determined by individual states. Making matters more complex is the fact that some states have recently changed their HIV control requirements, Dr. Dowler said. In North Carolina for example, patients living with HIV who have been virally suppressed for 6 months and who are adherent to medications, are no longer in violation of the control measure if they do not disclose their HIV diagnosis to sex partners or if they don’t wear a condom.
“This means physicians would not have to report a virally suppressed, adequately treated HIV-positive patient who is having unprotected sex or take measures to inform any known sex partners of the diagnosis,” she said. “The landscape is constantly changing so physicians have to be vigilant about their state public health statutes. It’s a tricky area. It takes an already complicated topic and makes it just a little more complicated.”
Consider drafting a policy
It’s a good idea to have a policy in place at your practice that addresses such ethical dilemmas before they occur, says Michael Heitt, PsyD, a clinical psychologist on the faculty of Loyola University Maryland in Baltimore, and a member of the Maryland Psychological Association’s Ethics Committee. Dr. Heitt developed a model of ethical reasoning called CLEAR Lenses, which stands for Clinical, Legal, Ethical, Administrative, and Risk management. The approach encourages clinicians to identify often competing factors in the decision-making process before choosing a course of action to take.
In the situation of an unfaithful spouse who contracted an STI for example, the physician should consider clinical issues such as the medical likelihood the unaware partner has the STI, and legal issues such as maintaining the confidentiality of all patient information and possible mandated reporting of STI data, Dr. Heitt said. The lenses overlap since confidentiality is also a key ethical issue, and other ethical issues involve the balance of helping the unaware spouse and not harming the infected spouse, he explained. Administrative issues might include how medical records are maintained and whether the physician documents information about patients’ family members in the medical record, while risk management elements may include informed consent, documentation, and consultation.
“So, if the physician has a policy about how such matters are dealt with, and patients are informed about this when they come to the practice, this can guide the physician much more easily through this sticky situation,” Dr. Heitt said. “Documentation of the decision-making process in the medical record demonstrates the physician’s thought process should it ever be challenged in the future, and consultation with peers (while disguising the identity of the patients, of course) sets a foundation of what a ‘reasonable standard’ might be in such situations.”
There is also the conflict-avoidant approach, Dr. Heitt said, in which the physician could perform “routine” STI testing if the unaware spouse was due for an appointment soon.
“But of course, this is far from avoiding any conflict; it just kicks the can down the road as there will surely be conflict — and plenty of confusion — if the wife tests positive for an STI,” he said. “In most situations, it is usually best to be brave, do the hard work upfront, and deal with the tough situation then, rather than trying to avoid the probable inevitable difficult conversation.”
As for the psychiatrist who was treating the cheating HIV-positive partner, the physician ultimately convinced both patients to come in for a couple’s session. The doctor allowed for a 2-hour timeframe to encourage discussion of any conflicts and unresolved issues, the psychiatrist said. After several more couple’s sessions, it was apparent the HIV-positive partner wanted out of the relationship, according to the psychiatrist’s account. The physician referred them to a couples’ therapist for ongoing treatment.
“During that same session, the HIV positive partner disclosed his recent behaviors and, as a result, they decided not to have further sexual contact until they could explore this further in therapy,” the psychiatrist wrote. “At last communication the couple decided to end the relationship, and the HIV negative partner remained negative.”
A version of this article first appeared on Medscape.com.
A psychiatrist was treating a couple individually, one of whom was HIV-positive. During a session, the infected partner revealed he was having sex with other men outside the relationship and not using safe sex practices.
“He was being treated for major depression and anxiety at the time,” explained the anonymous psychiatrist. “I strongly encouraged him to tell his partner, but he was scared of doing so. He stated that they had not been using safe sex practices between the two of them, but he was willing to start at that point.”
At a session with the HIV-negative partner, the psychiatrist inquired about the couple’s current sex practices. The HIV-negative partner reported no changes and said the two continued to have sex without condoms, said the psychiatrist, who shared the experience in Medscape’s Ethics 2020 Survey open-ended questions.
“My dilemma now was whether or not to inform him about his partner’s ‘extracurricular sex behavior,’ the psychiatrist said. “Since he was now at greater risk of contracting HIV, I felt compelled to do something to intervene.”
What would you do in this situation?
according to responses from the Ethics 2020 Report. When asked to share their toughest ethical dilemma, one internist for example, wrote, “I have couples as patients, and it is very challenging if they reveal infidelity or separate/divorce; I cannot reveal info to the spouse, but it makes me very uncomfortable caring for both.” Similarly, an obstetrician-gynecologist wrote about her experience counseling patients who reveal extramarital affairs.
“Women confide deeply with their gynecologist, and although I was not successful in rescuing 100% of them, the majority accepted my counseling and saved their marriages,” the anonymous ob/gyn wrote. “In every case in which my patient was willing to resume her marital relationship, I always ensured that she advised her spouse of the infidelity, and the couple was referred to a qualified provider for marriage counseling.”
When a sexually transmitted infection (STI) comes into play however, physicians describe a deeper level of internal conflict. A family physician wrote her top ethical dilemma was “Cheating spouses and STIs: how do you get the other spouse treated?” An ob-gyn stated that, “disclosure of STI status in couples when this may indicate infidelity,” was a frequent ethical issue in her specialty. Commenters on Medscape’s recent story, “The Secret I’ll Take to my Grave: Doc Reveals,” also raised the uncomfortable topic. One physician recalled a deaf female patient who requested in writing not to test for syphilis and not to discuss the issue with her husband. “Patient knew that she had syphilis, but she did not want her husband to know,” the physician wrote.
It’s not uncommon for physicians to encounter such scenarios when treating long-term couples, especially in the digital era, said Shannon Dowler, MD, chief medical officer for North Carolina Medicaid and a family physician at the Buncombe County STI Clinic.
“This is definitely something I think we see more of in our age of ‘hookup apps’ and easier access to casual sexual connections than we did before,” said Dr. Dowler, who serves on the CDC Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment.
The topic is particularly timely because of the pandemic’s impact on STI testing and the expected rise in sexually transmitted infection rates over the next year, Dr. Dowler notes.
“People weren’t necessarily coming in for routine screening or testing during the pandemic because they didn’t want to take a chance on being exposed to COVID,” she said. “But also, the reagent used for testing for certain types of transmitted infections was in short supply because they use that same reagent for the COVID test. We had shortages of STI testing in many parts of the country. I expect what we’re going to see over the next year are a lot of diagnoses that were missed during the pandemic and a lot of asymptomatic spread.”
What do the experts suggest?
Caring for spouses or two partners when an STI is discovered can be challenging for physicians, particularly in small towns where many people know each other, said Kenneth Goodman, PhD, founder and director of the Institute for Bioethics and Health Policy at the University of Miami.
“This can be a real challenge for family physicians and others in a small town,” he said. “If you discover one partner is positive for a sexually transmitted infection and the other is negative, then you’ve got a challenge to manage. The way to do that is to start with moral persuasion, namely you tell your patient, ‘You really need to disclose this. Because when he or she gets it, chances are, you’re going to be the prime suspect.’ “
Dr. Dowler, who practices in an STI clinic, said she once diagnosed a sexually transmitted infection in a patient who was married to one of Dowler’s coworkers. The patient would not allow the partner to be notified, she said. In this case, Dr. Dowler practiced expedited partner therapy (EPT), the clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by giving the patient prescriptions or medications to take to the partner without having first examined the partner. The practice is legal to some extent in all states, Dr. Dowler said, but some states have different rules about how the practice can be utilized.
Physicians are obligated to report communicable diseases to their local health department, Dr. Goodman said. The health department would then do contract tracing and be responsible for conveying the STI diagnosis to any relevant parties. Even so, Dr. Goodman said physicians have a moral obligation to strongly encourage patients to divulge the infection to their partner.
“Doctors should work on being persuasive to change behavior,” he said. “Tell your patients to do the right thing and follow up with them. You should tell patients they have a responsibility to disclose a sexually transmitted infection to any of their partners and a responsibility not to have unprotected sex. Doctors can be very powerful advocates for that.”
Dr. Dowler said if she is treating two partners, and one is diagnosed with a sexually transmitted infection, she generally asks the patient for their consent to disclose the diagnosis to the partner. She ensures a witness, usually a nurse, is present when she asks. If consent is refused, Dr. Dowler guides her treatment to be as protective as possible, she said. A helpful resource for patients is Tellyourpartner.org, a website that sends an anonymous text or email about infection exposure and provides guidance on treatment locations and options.
Of course, if the sexually transmitted infection is HIV, another set of rules apply. As of 2021, 35 states have laws that criminalize HIV exposure. Laws vary, but many hold patients criminally liable if they knowingly expose another party to HIV. Many states and some cities also have ‘partner notification’ laws that require health providers to disclose an HIV diagnosis to the patient’s sex partners or to report the names of sex partners to the health department, if known.
However, case law on a physician’s duty to warn is mixed, and doctors’ responsibility for STI reporting and partner notification is determined by individual states. Making matters more complex is the fact that some states have recently changed their HIV control requirements, Dr. Dowler said. In North Carolina for example, patients living with HIV who have been virally suppressed for 6 months and who are adherent to medications, are no longer in violation of the control measure if they do not disclose their HIV diagnosis to sex partners or if they don’t wear a condom.
“This means physicians would not have to report a virally suppressed, adequately treated HIV-positive patient who is having unprotected sex or take measures to inform any known sex partners of the diagnosis,” she said. “The landscape is constantly changing so physicians have to be vigilant about their state public health statutes. It’s a tricky area. It takes an already complicated topic and makes it just a little more complicated.”
Consider drafting a policy
It’s a good idea to have a policy in place at your practice that addresses such ethical dilemmas before they occur, says Michael Heitt, PsyD, a clinical psychologist on the faculty of Loyola University Maryland in Baltimore, and a member of the Maryland Psychological Association’s Ethics Committee. Dr. Heitt developed a model of ethical reasoning called CLEAR Lenses, which stands for Clinical, Legal, Ethical, Administrative, and Risk management. The approach encourages clinicians to identify often competing factors in the decision-making process before choosing a course of action to take.
In the situation of an unfaithful spouse who contracted an STI for example, the physician should consider clinical issues such as the medical likelihood the unaware partner has the STI, and legal issues such as maintaining the confidentiality of all patient information and possible mandated reporting of STI data, Dr. Heitt said. The lenses overlap since confidentiality is also a key ethical issue, and other ethical issues involve the balance of helping the unaware spouse and not harming the infected spouse, he explained. Administrative issues might include how medical records are maintained and whether the physician documents information about patients’ family members in the medical record, while risk management elements may include informed consent, documentation, and consultation.
“So, if the physician has a policy about how such matters are dealt with, and patients are informed about this when they come to the practice, this can guide the physician much more easily through this sticky situation,” Dr. Heitt said. “Documentation of the decision-making process in the medical record demonstrates the physician’s thought process should it ever be challenged in the future, and consultation with peers (while disguising the identity of the patients, of course) sets a foundation of what a ‘reasonable standard’ might be in such situations.”
There is also the conflict-avoidant approach, Dr. Heitt said, in which the physician could perform “routine” STI testing if the unaware spouse was due for an appointment soon.
“But of course, this is far from avoiding any conflict; it just kicks the can down the road as there will surely be conflict — and plenty of confusion — if the wife tests positive for an STI,” he said. “In most situations, it is usually best to be brave, do the hard work upfront, and deal with the tough situation then, rather than trying to avoid the probable inevitable difficult conversation.”
As for the psychiatrist who was treating the cheating HIV-positive partner, the physician ultimately convinced both patients to come in for a couple’s session. The doctor allowed for a 2-hour timeframe to encourage discussion of any conflicts and unresolved issues, the psychiatrist said. After several more couple’s sessions, it was apparent the HIV-positive partner wanted out of the relationship, according to the psychiatrist’s account. The physician referred them to a couples’ therapist for ongoing treatment.
“During that same session, the HIV positive partner disclosed his recent behaviors and, as a result, they decided not to have further sexual contact until they could explore this further in therapy,” the psychiatrist wrote. “At last communication the couple decided to end the relationship, and the HIV negative partner remained negative.”
A version of this article first appeared on Medscape.com.
A psychiatrist was treating a couple individually, one of whom was HIV-positive. During a session, the infected partner revealed he was having sex with other men outside the relationship and not using safe sex practices.
“He was being treated for major depression and anxiety at the time,” explained the anonymous psychiatrist. “I strongly encouraged him to tell his partner, but he was scared of doing so. He stated that they had not been using safe sex practices between the two of them, but he was willing to start at that point.”
At a session with the HIV-negative partner, the psychiatrist inquired about the couple’s current sex practices. The HIV-negative partner reported no changes and said the two continued to have sex without condoms, said the psychiatrist, who shared the experience in Medscape’s Ethics 2020 Survey open-ended questions.
“My dilemma now was whether or not to inform him about his partner’s ‘extracurricular sex behavior,’ the psychiatrist said. “Since he was now at greater risk of contracting HIV, I felt compelled to do something to intervene.”
What would you do in this situation?
according to responses from the Ethics 2020 Report. When asked to share their toughest ethical dilemma, one internist for example, wrote, “I have couples as patients, and it is very challenging if they reveal infidelity or separate/divorce; I cannot reveal info to the spouse, but it makes me very uncomfortable caring for both.” Similarly, an obstetrician-gynecologist wrote about her experience counseling patients who reveal extramarital affairs.
“Women confide deeply with their gynecologist, and although I was not successful in rescuing 100% of them, the majority accepted my counseling and saved their marriages,” the anonymous ob/gyn wrote. “In every case in which my patient was willing to resume her marital relationship, I always ensured that she advised her spouse of the infidelity, and the couple was referred to a qualified provider for marriage counseling.”
When a sexually transmitted infection (STI) comes into play however, physicians describe a deeper level of internal conflict. A family physician wrote her top ethical dilemma was “Cheating spouses and STIs: how do you get the other spouse treated?” An ob-gyn stated that, “disclosure of STI status in couples when this may indicate infidelity,” was a frequent ethical issue in her specialty. Commenters on Medscape’s recent story, “The Secret I’ll Take to my Grave: Doc Reveals,” also raised the uncomfortable topic. One physician recalled a deaf female patient who requested in writing not to test for syphilis and not to discuss the issue with her husband. “Patient knew that she had syphilis, but she did not want her husband to know,” the physician wrote.
It’s not uncommon for physicians to encounter such scenarios when treating long-term couples, especially in the digital era, said Shannon Dowler, MD, chief medical officer for North Carolina Medicaid and a family physician at the Buncombe County STI Clinic.
“This is definitely something I think we see more of in our age of ‘hookup apps’ and easier access to casual sexual connections than we did before,” said Dr. Dowler, who serves on the CDC Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment.
The topic is particularly timely because of the pandemic’s impact on STI testing and the expected rise in sexually transmitted infection rates over the next year, Dr. Dowler notes.
“People weren’t necessarily coming in for routine screening or testing during the pandemic because they didn’t want to take a chance on being exposed to COVID,” she said. “But also, the reagent used for testing for certain types of transmitted infections was in short supply because they use that same reagent for the COVID test. We had shortages of STI testing in many parts of the country. I expect what we’re going to see over the next year are a lot of diagnoses that were missed during the pandemic and a lot of asymptomatic spread.”
What do the experts suggest?
Caring for spouses or two partners when an STI is discovered can be challenging for physicians, particularly in small towns where many people know each other, said Kenneth Goodman, PhD, founder and director of the Institute for Bioethics and Health Policy at the University of Miami.
“This can be a real challenge for family physicians and others in a small town,” he said. “If you discover one partner is positive for a sexually transmitted infection and the other is negative, then you’ve got a challenge to manage. The way to do that is to start with moral persuasion, namely you tell your patient, ‘You really need to disclose this. Because when he or she gets it, chances are, you’re going to be the prime suspect.’ “
Dr. Dowler, who practices in an STI clinic, said she once diagnosed a sexually transmitted infection in a patient who was married to one of Dowler’s coworkers. The patient would not allow the partner to be notified, she said. In this case, Dr. Dowler practiced expedited partner therapy (EPT), the clinical practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by giving the patient prescriptions or medications to take to the partner without having first examined the partner. The practice is legal to some extent in all states, Dr. Dowler said, but some states have different rules about how the practice can be utilized.
Physicians are obligated to report communicable diseases to their local health department, Dr. Goodman said. The health department would then do contract tracing and be responsible for conveying the STI diagnosis to any relevant parties. Even so, Dr. Goodman said physicians have a moral obligation to strongly encourage patients to divulge the infection to their partner.
“Doctors should work on being persuasive to change behavior,” he said. “Tell your patients to do the right thing and follow up with them. You should tell patients they have a responsibility to disclose a sexually transmitted infection to any of their partners and a responsibility not to have unprotected sex. Doctors can be very powerful advocates for that.”
Dr. Dowler said if she is treating two partners, and one is diagnosed with a sexually transmitted infection, she generally asks the patient for their consent to disclose the diagnosis to the partner. She ensures a witness, usually a nurse, is present when she asks. If consent is refused, Dr. Dowler guides her treatment to be as protective as possible, she said. A helpful resource for patients is Tellyourpartner.org, a website that sends an anonymous text or email about infection exposure and provides guidance on treatment locations and options.
Of course, if the sexually transmitted infection is HIV, another set of rules apply. As of 2021, 35 states have laws that criminalize HIV exposure. Laws vary, but many hold patients criminally liable if they knowingly expose another party to HIV. Many states and some cities also have ‘partner notification’ laws that require health providers to disclose an HIV diagnosis to the patient’s sex partners or to report the names of sex partners to the health department, if known.
However, case law on a physician’s duty to warn is mixed, and doctors’ responsibility for STI reporting and partner notification is determined by individual states. Making matters more complex is the fact that some states have recently changed their HIV control requirements, Dr. Dowler said. In North Carolina for example, patients living with HIV who have been virally suppressed for 6 months and who are adherent to medications, are no longer in violation of the control measure if they do not disclose their HIV diagnosis to sex partners or if they don’t wear a condom.
“This means physicians would not have to report a virally suppressed, adequately treated HIV-positive patient who is having unprotected sex or take measures to inform any known sex partners of the diagnosis,” she said. “The landscape is constantly changing so physicians have to be vigilant about their state public health statutes. It’s a tricky area. It takes an already complicated topic and makes it just a little more complicated.”
Consider drafting a policy
It’s a good idea to have a policy in place at your practice that addresses such ethical dilemmas before they occur, says Michael Heitt, PsyD, a clinical psychologist on the faculty of Loyola University Maryland in Baltimore, and a member of the Maryland Psychological Association’s Ethics Committee. Dr. Heitt developed a model of ethical reasoning called CLEAR Lenses, which stands for Clinical, Legal, Ethical, Administrative, and Risk management. The approach encourages clinicians to identify often competing factors in the decision-making process before choosing a course of action to take.
In the situation of an unfaithful spouse who contracted an STI for example, the physician should consider clinical issues such as the medical likelihood the unaware partner has the STI, and legal issues such as maintaining the confidentiality of all patient information and possible mandated reporting of STI data, Dr. Heitt said. The lenses overlap since confidentiality is also a key ethical issue, and other ethical issues involve the balance of helping the unaware spouse and not harming the infected spouse, he explained. Administrative issues might include how medical records are maintained and whether the physician documents information about patients’ family members in the medical record, while risk management elements may include informed consent, documentation, and consultation.
“So, if the physician has a policy about how such matters are dealt with, and patients are informed about this when they come to the practice, this can guide the physician much more easily through this sticky situation,” Dr. Heitt said. “Documentation of the decision-making process in the medical record demonstrates the physician’s thought process should it ever be challenged in the future, and consultation with peers (while disguising the identity of the patients, of course) sets a foundation of what a ‘reasonable standard’ might be in such situations.”
There is also the conflict-avoidant approach, Dr. Heitt said, in which the physician could perform “routine” STI testing if the unaware spouse was due for an appointment soon.
“But of course, this is far from avoiding any conflict; it just kicks the can down the road as there will surely be conflict — and plenty of confusion — if the wife tests positive for an STI,” he said. “In most situations, it is usually best to be brave, do the hard work upfront, and deal with the tough situation then, rather than trying to avoid the probable inevitable difficult conversation.”
As for the psychiatrist who was treating the cheating HIV-positive partner, the physician ultimately convinced both patients to come in for a couple’s session. The doctor allowed for a 2-hour timeframe to encourage discussion of any conflicts and unresolved issues, the psychiatrist said. After several more couple’s sessions, it was apparent the HIV-positive partner wanted out of the relationship, according to the psychiatrist’s account. The physician referred them to a couples’ therapist for ongoing treatment.
“During that same session, the HIV positive partner disclosed his recent behaviors and, as a result, they decided not to have further sexual contact until they could explore this further in therapy,” the psychiatrist wrote. “At last communication the couple decided to end the relationship, and the HIV negative partner remained negative.”
A version of this article first appeared on Medscape.com.
Medical power couple launch robot that helps in the labor room
Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.
Julie Shah, PhD, and Neel Shah, MD
Ob.gyn. Neel Shah was telling his wife how challenging it was for labor and delivery nurses to make room assignments: to delegate available beds, predict the timing of patient progression from one room to another, and pair patients with staff nurses, equipment, and resources.
Julie Shah, a roboticist with Massachusetts Institute of Technology, Cambridge, compared the head nurses to air traffic controllers, but without near the decision support. Julie had previously worked for aerospace giant Boeing, where she helped design a set of algorithmic techniques to give decision support to manufacturing personnel and embed robots to aid their work.
Suddenly the Shahs had an idea.
The robot, tested in 2018 at a Boston tertiary care center, produced high-quality recommendations accepted by nurses and physicians 90% of the time. The android was taught to observe actual performances of human tasks – what was done and not done in certain situations – and develop a scheduling policy. The Shahs and their team were the first to field a robotic system on a labor and delivery unit to aid in the coordination of resources required for patient care.
“For the first time, we were able to develop a novel machine-learning technique that could learn from demonstration or observation, heuristics, or strategies for solving resource allocation and scheduling problems, which was really exciting,” Julie said. “We were able to show also how that system could be embedded to offer decision support to reduce the cognitive burden of nurses.”
Neel and Julie joke that their first collaboration dates back to middle school when they sang together in chorus. The Shahs grew up in the same small New Jersey town and met as 14-year-olds.
Though the Shahs have known each other more than half their lives, they haven’t always lived side by side. After they married, Julie accepted an opportunity in Seattle, while Neel remained 3,000 miles away in Boston.
“He does all the cooking, so I did not eat well,” Julie recalled with a laugh. “It was not great.”
“I don’t self-regulate well,” Neel adds. “I just worked 24/7. I started a nonprofit that year, so externally, it looked like I was crushing it, but …”
“He was lonely,” Julie says.
Now back in the same city, the Shahs are doting parents to two toddlers aged 2 and 4, and also serve as heads of house at an MIT graduate dorm.
Julie, 39, is an associate professor in the department of aeronautics and astronautics at MIT and leads the Interactive Robotics Group of the Computer Science and Artificial Intelligence Laboratory. She is renowned for her innovative methods for enabling fluid human-robot teamwork in time- and safety-critical environments such as surgery, manufacturing, and space exploration. In 2014, she was recognized by the MIT Technology Review as one of the world’s top innovators under 35, and her work on industrial human-robot collaboration was recognized as one of the 10 breakthrough technologies of 2013.
Neel, 39, is an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston and chief medical officer of Maven Clinic, a virtual clinic for women’s and family health. A scientist and entrepreneur, Neel is globally recognized for designing solutions to improve health care. He is founder of Costs of Care, an NGO that curates insights from clinicians and patients to help delivery systems provide better care.
He also cofounded the March for Moms Association, a coalition of organizations that works to raise public and private investment in mothers’ well-being. Most recently, Neel and his team designed TeamBirth, an intrapartum care process that aims to improve the safety and dignity of childbirth care and promote communication and teamwork.
The Shahs say their personalities are sometimes opposite, but that they balance each other well.
“Julie thinks in lists, which sometimes drives me crazy, and I think in exploding clouds, which I think drives her crazy, but the combination usually works out,” Neel said. “We seem to be good complements for each other.”
In their own words
What is one food that your spouse eats that you can’t stand?
Neel: She eats raisins, and I hate raisins. Raisins are a crime against humanity. They’re wrong. The chocolate-covered raisins are even grosser.
What is one parenting difference you have?
Julie: Safety. I hover around the kids around safety hazards, and Neel is very relaxed.
What’s one quirky thing about your partner?
Neel: She has a parrot that predates our marriage. He started out as an illegal dorm bird. He just screeches and poops. If you’re developing a character in a book or a movie and you want to make them seem slightly off, you make them a bird owner. Think about it.
Julie: He’s 19 and his name is Bolivar, after the South American revolutionary. He’s very sweet.
Neel: I live in a Hitchcock movie.
If you weren’t a physician/scientist, what is a dream job you might have?
Julie: I would be a dolphin trainer. That was my childhood dream.
Neel: I’d want to do something creative. I’ve always wanted to be a better musician. I play the guitar and piano.
A version of this article first appeared on Medscape.com.
Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.
Julie Shah, PhD, and Neel Shah, MD
Ob.gyn. Neel Shah was telling his wife how challenging it was for labor and delivery nurses to make room assignments: to delegate available beds, predict the timing of patient progression from one room to another, and pair patients with staff nurses, equipment, and resources.
Julie Shah, a roboticist with Massachusetts Institute of Technology, Cambridge, compared the head nurses to air traffic controllers, but without near the decision support. Julie had previously worked for aerospace giant Boeing, where she helped design a set of algorithmic techniques to give decision support to manufacturing personnel and embed robots to aid their work.
Suddenly the Shahs had an idea.
The robot, tested in 2018 at a Boston tertiary care center, produced high-quality recommendations accepted by nurses and physicians 90% of the time. The android was taught to observe actual performances of human tasks – what was done and not done in certain situations – and develop a scheduling policy. The Shahs and their team were the first to field a robotic system on a labor and delivery unit to aid in the coordination of resources required for patient care.
“For the first time, we were able to develop a novel machine-learning technique that could learn from demonstration or observation, heuristics, or strategies for solving resource allocation and scheduling problems, which was really exciting,” Julie said. “We were able to show also how that system could be embedded to offer decision support to reduce the cognitive burden of nurses.”
Neel and Julie joke that their first collaboration dates back to middle school when they sang together in chorus. The Shahs grew up in the same small New Jersey town and met as 14-year-olds.
Though the Shahs have known each other more than half their lives, they haven’t always lived side by side. After they married, Julie accepted an opportunity in Seattle, while Neel remained 3,000 miles away in Boston.
“He does all the cooking, so I did not eat well,” Julie recalled with a laugh. “It was not great.”
“I don’t self-regulate well,” Neel adds. “I just worked 24/7. I started a nonprofit that year, so externally, it looked like I was crushing it, but …”
“He was lonely,” Julie says.
Now back in the same city, the Shahs are doting parents to two toddlers aged 2 and 4, and also serve as heads of house at an MIT graduate dorm.
Julie, 39, is an associate professor in the department of aeronautics and astronautics at MIT and leads the Interactive Robotics Group of the Computer Science and Artificial Intelligence Laboratory. She is renowned for her innovative methods for enabling fluid human-robot teamwork in time- and safety-critical environments such as surgery, manufacturing, and space exploration. In 2014, she was recognized by the MIT Technology Review as one of the world’s top innovators under 35, and her work on industrial human-robot collaboration was recognized as one of the 10 breakthrough technologies of 2013.
Neel, 39, is an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston and chief medical officer of Maven Clinic, a virtual clinic for women’s and family health. A scientist and entrepreneur, Neel is globally recognized for designing solutions to improve health care. He is founder of Costs of Care, an NGO that curates insights from clinicians and patients to help delivery systems provide better care.
He also cofounded the March for Moms Association, a coalition of organizations that works to raise public and private investment in mothers’ well-being. Most recently, Neel and his team designed TeamBirth, an intrapartum care process that aims to improve the safety and dignity of childbirth care and promote communication and teamwork.
The Shahs say their personalities are sometimes opposite, but that they balance each other well.
“Julie thinks in lists, which sometimes drives me crazy, and I think in exploding clouds, which I think drives her crazy, but the combination usually works out,” Neel said. “We seem to be good complements for each other.”
In their own words
What is one food that your spouse eats that you can’t stand?
Neel: She eats raisins, and I hate raisins. Raisins are a crime against humanity. They’re wrong. The chocolate-covered raisins are even grosser.
What is one parenting difference you have?
Julie: Safety. I hover around the kids around safety hazards, and Neel is very relaxed.
What’s one quirky thing about your partner?
Neel: She has a parrot that predates our marriage. He started out as an illegal dorm bird. He just screeches and poops. If you’re developing a character in a book or a movie and you want to make them seem slightly off, you make them a bird owner. Think about it.
Julie: He’s 19 and his name is Bolivar, after the South American revolutionary. He’s very sweet.
Neel: I live in a Hitchcock movie.
If you weren’t a physician/scientist, what is a dream job you might have?
Julie: I would be a dolphin trainer. That was my childhood dream.
Neel: I’d want to do something creative. I’ve always wanted to be a better musician. I play the guitar and piano.
A version of this article first appeared on Medscape.com.
Medical Power Couples is a new series highlighting spouses or domestic partners prominent in health care. Both have achieved high-level professional success and have made significant contributions to their respective fields.
Julie Shah, PhD, and Neel Shah, MD
Ob.gyn. Neel Shah was telling his wife how challenging it was for labor and delivery nurses to make room assignments: to delegate available beds, predict the timing of patient progression from one room to another, and pair patients with staff nurses, equipment, and resources.
Julie Shah, a roboticist with Massachusetts Institute of Technology, Cambridge, compared the head nurses to air traffic controllers, but without near the decision support. Julie had previously worked for aerospace giant Boeing, where she helped design a set of algorithmic techniques to give decision support to manufacturing personnel and embed robots to aid their work.
Suddenly the Shahs had an idea.
The robot, tested in 2018 at a Boston tertiary care center, produced high-quality recommendations accepted by nurses and physicians 90% of the time. The android was taught to observe actual performances of human tasks – what was done and not done in certain situations – and develop a scheduling policy. The Shahs and their team were the first to field a robotic system on a labor and delivery unit to aid in the coordination of resources required for patient care.
“For the first time, we were able to develop a novel machine-learning technique that could learn from demonstration or observation, heuristics, or strategies for solving resource allocation and scheduling problems, which was really exciting,” Julie said. “We were able to show also how that system could be embedded to offer decision support to reduce the cognitive burden of nurses.”
Neel and Julie joke that their first collaboration dates back to middle school when they sang together in chorus. The Shahs grew up in the same small New Jersey town and met as 14-year-olds.
Though the Shahs have known each other more than half their lives, they haven’t always lived side by side. After they married, Julie accepted an opportunity in Seattle, while Neel remained 3,000 miles away in Boston.
“He does all the cooking, so I did not eat well,” Julie recalled with a laugh. “It was not great.”
“I don’t self-regulate well,” Neel adds. “I just worked 24/7. I started a nonprofit that year, so externally, it looked like I was crushing it, but …”
“He was lonely,” Julie says.
Now back in the same city, the Shahs are doting parents to two toddlers aged 2 and 4, and also serve as heads of house at an MIT graduate dorm.
Julie, 39, is an associate professor in the department of aeronautics and astronautics at MIT and leads the Interactive Robotics Group of the Computer Science and Artificial Intelligence Laboratory. She is renowned for her innovative methods for enabling fluid human-robot teamwork in time- and safety-critical environments such as surgery, manufacturing, and space exploration. In 2014, she was recognized by the MIT Technology Review as one of the world’s top innovators under 35, and her work on industrial human-robot collaboration was recognized as one of the 10 breakthrough technologies of 2013.
Neel, 39, is an assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School in Boston and chief medical officer of Maven Clinic, a virtual clinic for women’s and family health. A scientist and entrepreneur, Neel is globally recognized for designing solutions to improve health care. He is founder of Costs of Care, an NGO that curates insights from clinicians and patients to help delivery systems provide better care.
He also cofounded the March for Moms Association, a coalition of organizations that works to raise public and private investment in mothers’ well-being. Most recently, Neel and his team designed TeamBirth, an intrapartum care process that aims to improve the safety and dignity of childbirth care and promote communication and teamwork.
The Shahs say their personalities are sometimes opposite, but that they balance each other well.
“Julie thinks in lists, which sometimes drives me crazy, and I think in exploding clouds, which I think drives her crazy, but the combination usually works out,” Neel said. “We seem to be good complements for each other.”
In their own words
What is one food that your spouse eats that you can’t stand?
Neel: She eats raisins, and I hate raisins. Raisins are a crime against humanity. They’re wrong. The chocolate-covered raisins are even grosser.
What is one parenting difference you have?
Julie: Safety. I hover around the kids around safety hazards, and Neel is very relaxed.
What’s one quirky thing about your partner?
Neel: She has a parrot that predates our marriage. He started out as an illegal dorm bird. He just screeches and poops. If you’re developing a character in a book or a movie and you want to make them seem slightly off, you make them a bird owner. Think about it.
Julie: He’s 19 and his name is Bolivar, after the South American revolutionary. He’s very sweet.
Neel: I live in a Hitchcock movie.
If you weren’t a physician/scientist, what is a dream job you might have?
Julie: I would be a dolphin trainer. That was my childhood dream.
Neel: I’d want to do something creative. I’ve always wanted to be a better musician. I play the guitar and piano.
A version of this article first appeared on Medscape.com.
I did peer review: I saw turf wars, ego, and unfairness
After making an insulting comment to a surgery scheduler, a surgeon become the subject of a peer review investigation.
The surgeon had been called in on a Saturday morning for surgery, but when he arrived at the hospital, staff informed him that the operating room had been incorrectly booked and asked him to come back that afternoon. When the surgeon returned, the room still wasn’t ready, recounted David Beran, DO, a peer reviewer and medical director for the emergency department at University Medical Center New Orleans, in Louisiana. After more waiting and staff uncertainty about which operating room was going to open, the surgeon became frustrated and said to the scheduler: “Any idiot could figure this out!”
During his peer review, the surgeon acknowledged that he shouldn’t have made the rude remark to the scheduler, Dr. Beran said. His exasperation stemmed from an ongoing problem – operating rooms at the hospital were being inefficiently managed.
“The surgeon acknowledged that even though there was a systems issue at the root, that’s not justification to speak to people unprofessionally,” Dr. Beran said. “So, there was education for the surgeon, but the surgeon was also able to explain the frustration that led to that point.”
System problems are commonly encountered by peer reviewers, said Dr. Beran.
“There’s a huge gap between administration and clinical professionals when it comes to peer review,” he said. “So many times, bad situations, whether they’re clinical or behavioral, often boil down to systems issues or some inadequacy, whether it’s an EMR [electronic medical record] problem, an inefficacy, or how complicated a process is for an end user. But having a peer review situation that then leads to a system-level change that prevents that problem from happening again is really unlikely. There’s a huge disconnect between those two.”
Peer review is generally a process that goes on behind closed doors. Although structures may differ, peer review is generally described as the process by which physicians assess the quality of their peers’ work to ensure that standards of care are being met. The process is often used to evaluate issues regarding clinical care as well as behavioral complaints against physicians.
Doctors who undergo peer review frequently share their experiences, but reviewers themselves rarely speak out. For this story,
“Peer review processes are in place to build stronger institutions and stronger practices, and they’re supposed to be helpful,” Dr. Beran said. “But because of how opaque they are, it immediately puts physicians on the defensive, and it doesn’t always succeed in what it’s trying to do. I think that’s one of the biggest challenges.”
Biased reviewers taint evaluations
A peer reviewer on and off throughout her career, Indiana family physician Lana Patch, MD, said she always strived to be fair when evaluating fellow physicians. But not every reviewer she encountered operated the same way, she said. Some were biased.
In one case, Dr. Patch peer reviewed a general surgeon who had performed a hysterectomy on a 16-year-old girl. The surgeon believed the teenager likely had an acute appendicitis, but it turned out she had a uterine pathology, Dr. Patch said. The surgeon saved the girl’s life, but the case came under review because of the patient’s age and the fact that her uterus was removed. A local obstetrician-gynecologist weighed in on the case.
“The local ob.gyn. saw it as a turf battle,” recalled Dr. Patch, who is now retired after 30 years of practice in eastern Indiana. “The doctor had nothing but bad to say about the surgeon. He was a competitor.”
Because it was a small hospital, the committee sometimes had trouble finding a specialist who was qualified to give an opinion and who wasn’t in competition with the physician in question, said Dr. Patch. Eventually they found an outside pediatric gynecologist who reviewed the case and concluded that the surgeon had followed the standard of care.
Personal agendas in can come from different directions, said Robert Marder, MD, the author of several books on peer review. Dr. Marder is a consultant who assists with peer review redesign. He has worked with hundreds of medical staff leaders and is a former vice president at the Greeley Company, a consulting firm in Danvers, Mass., that performs peer review redesign. Dr. Marder is president of Robert J. Marder Consulting.
“It goes both ways,” Dr. Marder said. “I’ve seen where somebody with a personal view decides to bring things to the peer review committee specifically because they want the peer review committee to have an adverse view of this person and get them off the medical staff. And I’ve seen hospitals that are uncomfortable with a certain person for whatever reason and want the peer review committee to address it, as opposed to addressing it from a human resource standpoint.”
Dr. Patch recalled a case in which reviewers and hospital leaders were at odds over the credentialing of a physician. Fifteen years earlier, while driving in California, the psychiatrist had been pulled over and was found with an ounce of marijuana, she said.
“We wanted to privilege him,” Dr. Patch said. “As staff physicians, we felt that was 15 years ago, people change over time. Doctors are human beings, too. He seemed to have good credentials and good training. The hospital said, ‘Oh no, we can’t have somebody like this.’ “
The psychiatrist was placed on probation and had to undergo a review every 90 days for about 3 years. Eventually, he was privileged, Dr. Patch said.
Bias among reviewers, including unintentional bias, is also a challenge, Dr. Marder noted. Some initial reviewers score a physician too harshly, he said, whereas others underscore.
“Underscoring is more insidious and more difficult to deal with,” Dr. Marder said. “Underscoring is where the reviewer is too nice. They tend to dismiss things from their colleagues rather than recognize them as an opportunity to help them improve. With underscoring, a lot of committees, if the initial reviewer says the care was appropriate, they don’t even look at the case. They just take that one person’s word for it.”
Reviewers: Looks can be deceiving
When first examining the documented details of a case, it can be easy for peer reviewers to make a quick judgment about what happened, Dr. Beran said.
“You get these complaints, and you read through it, and you think, ‘Oh man, this person really messed up,’ “ he said. “Then you hear the doctor’s side of it, and you realize, ‘No, there’s a much bigger picture at play.’ You realize both sides have valid perspectives on it.”
In one case, for example, Dr. Beran recalled a complaint against a physician who made a snarky remark to a nurse. The doctor had asked the nurse for a piece of equipment, and the nurse said she was busy preparing the room for a patient. The doctor made a comment along the lines of, “Well, would you like me to do that for you and also intubate the patient while you do some charting?!”
At first glance, it appeared that the physician lashed out inappropriately at the nurse. But when reviewers heard from the doctor, they learned that the nurses knew that a trauma patient was coming by ambulance and that he would likely require a ventilator, Dr. Beran said. As the minutes ticked by, however, the nurses were seen in the break room chatting. Nothing had been prepared in the room, including any airway supply.
“The patient had a prolonged course and a very difficult intubation and could have very easily wound up with a much worse outcome for something the nurses had been warned about prior to the patient’s arrival,” he said. “I can see anybody getting upset in that situation if I warned them 5 or 10 minutes beforehand, ‘Get this stuff ready,’ and then nothing was done.”
There was no direct penalty for the physician.
Just as some complaints can be misleading, the clinical record in some peer review cases can also lead reviewers astray.
Physicians frequently include too much irrelevant information in the record, which can cloud a peer review, said Hans Duvefelt, MD, a family physician at Pines Health Services, in Van Buren, Maine. Dr. Duvefelt is a former medical director at Bucksport Regional Health Center, in Ellsworth, Maine. Both facilities are federally qualified health centers where continuous, random peer reviews are required.
In one case, Dr. Duvefelt was peer reviewing a physician’s office note regarding an elderly patient with a low-grade fever. The final diagnosis was urinary tract infection. Dr. Duvefelt said he had trouble following the doctor’s line of thinking because of a plethora of unnecessary data in the 10-page document. The office note included past medical history, prior lab and imaging test results, and an extensive narrative section that included a mixture of active medical problems and ongoing relationships with specialists, he said.
After reading through the printout three times, Dr. Duvefelt said he finally found mention of increased urinary dribbling and details about an enlarged prostate. He also spotted a same-day urinalysis among nearly a dozen other previous lab tests that had no connection to body temperature. Dr. Duvefelt gave the physician a passing grade but also left a scathing note about all the irrelevant information.
“It’s very common,” Dr. Duvefelt said. “It’s a disaster. Other doctors can’t follow your thinking. A reviewer has a hard time determining whether the doctor acted reasonably.”
Slackers make bad reviewers
Although dedicated reviewers work hard to get to the bottom of cases, it’s not uncommon for some committee members to hardly work at all, according to experts.
Dr. Marder said he’s seen many instances in which reviewers were assigned a review but did not complete it for months. Most committees have set time frames in which reviewers must complete their review.
“That delays that review, and by that time, the review is older and it’s harder to remember things,” he said. “It’s not fair to the physician. If there was a problem the physician could fix and you don’t tell him for 3 or 4 months what it is, he may do the same thing again. The case might come before the committee again and it looks like he’s repeated something, but you never gave him the opportunity to improve.”
Other reviewers fail to attend meetings regularly. Peer review committee members are generally volunteers, and meetings are usually held in the early mornings or late evenings.
“There are reasons for not attending occasionally, but some people put on a committee just don’t take it seriously,” Dr. Marder said. “They don’t fulfill their responsibilities as well as they should. If you accept the job, do the job.”
For physicians considering becoming a peer reviewer, Dr. Beran offers these tips: Be transparent, help physicians understand next steps, and make yourself as available as allowed to answer questions.
Know your committee’s policies and procedures, and follow them, added Dr. Marder. It’s also a good idea to work with your hospital’s quality staff, he said.
Reviewers should keep in mind that they may not always be the one assessing someone else, Dr. Beran said.
“Realize very easily you could be on the other side of that table for things that are outside your control,” he said. “How would you want to be treated?”
A version of this article first appeared on Medscape.com.
After making an insulting comment to a surgery scheduler, a surgeon become the subject of a peer review investigation.
The surgeon had been called in on a Saturday morning for surgery, but when he arrived at the hospital, staff informed him that the operating room had been incorrectly booked and asked him to come back that afternoon. When the surgeon returned, the room still wasn’t ready, recounted David Beran, DO, a peer reviewer and medical director for the emergency department at University Medical Center New Orleans, in Louisiana. After more waiting and staff uncertainty about which operating room was going to open, the surgeon became frustrated and said to the scheduler: “Any idiot could figure this out!”
During his peer review, the surgeon acknowledged that he shouldn’t have made the rude remark to the scheduler, Dr. Beran said. His exasperation stemmed from an ongoing problem – operating rooms at the hospital were being inefficiently managed.
“The surgeon acknowledged that even though there was a systems issue at the root, that’s not justification to speak to people unprofessionally,” Dr. Beran said. “So, there was education for the surgeon, but the surgeon was also able to explain the frustration that led to that point.”
System problems are commonly encountered by peer reviewers, said Dr. Beran.
“There’s a huge gap between administration and clinical professionals when it comes to peer review,” he said. “So many times, bad situations, whether they’re clinical or behavioral, often boil down to systems issues or some inadequacy, whether it’s an EMR [electronic medical record] problem, an inefficacy, or how complicated a process is for an end user. But having a peer review situation that then leads to a system-level change that prevents that problem from happening again is really unlikely. There’s a huge disconnect between those two.”
Peer review is generally a process that goes on behind closed doors. Although structures may differ, peer review is generally described as the process by which physicians assess the quality of their peers’ work to ensure that standards of care are being met. The process is often used to evaluate issues regarding clinical care as well as behavioral complaints against physicians.
Doctors who undergo peer review frequently share their experiences, but reviewers themselves rarely speak out. For this story,
“Peer review processes are in place to build stronger institutions and stronger practices, and they’re supposed to be helpful,” Dr. Beran said. “But because of how opaque they are, it immediately puts physicians on the defensive, and it doesn’t always succeed in what it’s trying to do. I think that’s one of the biggest challenges.”
Biased reviewers taint evaluations
A peer reviewer on and off throughout her career, Indiana family physician Lana Patch, MD, said she always strived to be fair when evaluating fellow physicians. But not every reviewer she encountered operated the same way, she said. Some were biased.
In one case, Dr. Patch peer reviewed a general surgeon who had performed a hysterectomy on a 16-year-old girl. The surgeon believed the teenager likely had an acute appendicitis, but it turned out she had a uterine pathology, Dr. Patch said. The surgeon saved the girl’s life, but the case came under review because of the patient’s age and the fact that her uterus was removed. A local obstetrician-gynecologist weighed in on the case.
“The local ob.gyn. saw it as a turf battle,” recalled Dr. Patch, who is now retired after 30 years of practice in eastern Indiana. “The doctor had nothing but bad to say about the surgeon. He was a competitor.”
Because it was a small hospital, the committee sometimes had trouble finding a specialist who was qualified to give an opinion and who wasn’t in competition with the physician in question, said Dr. Patch. Eventually they found an outside pediatric gynecologist who reviewed the case and concluded that the surgeon had followed the standard of care.
Personal agendas in can come from different directions, said Robert Marder, MD, the author of several books on peer review. Dr. Marder is a consultant who assists with peer review redesign. He has worked with hundreds of medical staff leaders and is a former vice president at the Greeley Company, a consulting firm in Danvers, Mass., that performs peer review redesign. Dr. Marder is president of Robert J. Marder Consulting.
“It goes both ways,” Dr. Marder said. “I’ve seen where somebody with a personal view decides to bring things to the peer review committee specifically because they want the peer review committee to have an adverse view of this person and get them off the medical staff. And I’ve seen hospitals that are uncomfortable with a certain person for whatever reason and want the peer review committee to address it, as opposed to addressing it from a human resource standpoint.”
Dr. Patch recalled a case in which reviewers and hospital leaders were at odds over the credentialing of a physician. Fifteen years earlier, while driving in California, the psychiatrist had been pulled over and was found with an ounce of marijuana, she said.
“We wanted to privilege him,” Dr. Patch said. “As staff physicians, we felt that was 15 years ago, people change over time. Doctors are human beings, too. He seemed to have good credentials and good training. The hospital said, ‘Oh no, we can’t have somebody like this.’ “
The psychiatrist was placed on probation and had to undergo a review every 90 days for about 3 years. Eventually, he was privileged, Dr. Patch said.
Bias among reviewers, including unintentional bias, is also a challenge, Dr. Marder noted. Some initial reviewers score a physician too harshly, he said, whereas others underscore.
“Underscoring is more insidious and more difficult to deal with,” Dr. Marder said. “Underscoring is where the reviewer is too nice. They tend to dismiss things from their colleagues rather than recognize them as an opportunity to help them improve. With underscoring, a lot of committees, if the initial reviewer says the care was appropriate, they don’t even look at the case. They just take that one person’s word for it.”
Reviewers: Looks can be deceiving
When first examining the documented details of a case, it can be easy for peer reviewers to make a quick judgment about what happened, Dr. Beran said.
“You get these complaints, and you read through it, and you think, ‘Oh man, this person really messed up,’ “ he said. “Then you hear the doctor’s side of it, and you realize, ‘No, there’s a much bigger picture at play.’ You realize both sides have valid perspectives on it.”
In one case, for example, Dr. Beran recalled a complaint against a physician who made a snarky remark to a nurse. The doctor had asked the nurse for a piece of equipment, and the nurse said she was busy preparing the room for a patient. The doctor made a comment along the lines of, “Well, would you like me to do that for you and also intubate the patient while you do some charting?!”
At first glance, it appeared that the physician lashed out inappropriately at the nurse. But when reviewers heard from the doctor, they learned that the nurses knew that a trauma patient was coming by ambulance and that he would likely require a ventilator, Dr. Beran said. As the minutes ticked by, however, the nurses were seen in the break room chatting. Nothing had been prepared in the room, including any airway supply.
“The patient had a prolonged course and a very difficult intubation and could have very easily wound up with a much worse outcome for something the nurses had been warned about prior to the patient’s arrival,” he said. “I can see anybody getting upset in that situation if I warned them 5 or 10 minutes beforehand, ‘Get this stuff ready,’ and then nothing was done.”
There was no direct penalty for the physician.
Just as some complaints can be misleading, the clinical record in some peer review cases can also lead reviewers astray.
Physicians frequently include too much irrelevant information in the record, which can cloud a peer review, said Hans Duvefelt, MD, a family physician at Pines Health Services, in Van Buren, Maine. Dr. Duvefelt is a former medical director at Bucksport Regional Health Center, in Ellsworth, Maine. Both facilities are federally qualified health centers where continuous, random peer reviews are required.
In one case, Dr. Duvefelt was peer reviewing a physician’s office note regarding an elderly patient with a low-grade fever. The final diagnosis was urinary tract infection. Dr. Duvefelt said he had trouble following the doctor’s line of thinking because of a plethora of unnecessary data in the 10-page document. The office note included past medical history, prior lab and imaging test results, and an extensive narrative section that included a mixture of active medical problems and ongoing relationships with specialists, he said.
After reading through the printout three times, Dr. Duvefelt said he finally found mention of increased urinary dribbling and details about an enlarged prostate. He also spotted a same-day urinalysis among nearly a dozen other previous lab tests that had no connection to body temperature. Dr. Duvefelt gave the physician a passing grade but also left a scathing note about all the irrelevant information.
“It’s very common,” Dr. Duvefelt said. “It’s a disaster. Other doctors can’t follow your thinking. A reviewer has a hard time determining whether the doctor acted reasonably.”
Slackers make bad reviewers
Although dedicated reviewers work hard to get to the bottom of cases, it’s not uncommon for some committee members to hardly work at all, according to experts.
Dr. Marder said he’s seen many instances in which reviewers were assigned a review but did not complete it for months. Most committees have set time frames in which reviewers must complete their review.
“That delays that review, and by that time, the review is older and it’s harder to remember things,” he said. “It’s not fair to the physician. If there was a problem the physician could fix and you don’t tell him for 3 or 4 months what it is, he may do the same thing again. The case might come before the committee again and it looks like he’s repeated something, but you never gave him the opportunity to improve.”
Other reviewers fail to attend meetings regularly. Peer review committee members are generally volunteers, and meetings are usually held in the early mornings or late evenings.
“There are reasons for not attending occasionally, but some people put on a committee just don’t take it seriously,” Dr. Marder said. “They don’t fulfill their responsibilities as well as they should. If you accept the job, do the job.”
For physicians considering becoming a peer reviewer, Dr. Beran offers these tips: Be transparent, help physicians understand next steps, and make yourself as available as allowed to answer questions.
Know your committee’s policies and procedures, and follow them, added Dr. Marder. It’s also a good idea to work with your hospital’s quality staff, he said.
Reviewers should keep in mind that they may not always be the one assessing someone else, Dr. Beran said.
“Realize very easily you could be on the other side of that table for things that are outside your control,” he said. “How would you want to be treated?”
A version of this article first appeared on Medscape.com.
After making an insulting comment to a surgery scheduler, a surgeon become the subject of a peer review investigation.
The surgeon had been called in on a Saturday morning for surgery, but when he arrived at the hospital, staff informed him that the operating room had been incorrectly booked and asked him to come back that afternoon. When the surgeon returned, the room still wasn’t ready, recounted David Beran, DO, a peer reviewer and medical director for the emergency department at University Medical Center New Orleans, in Louisiana. After more waiting and staff uncertainty about which operating room was going to open, the surgeon became frustrated and said to the scheduler: “Any idiot could figure this out!”
During his peer review, the surgeon acknowledged that he shouldn’t have made the rude remark to the scheduler, Dr. Beran said. His exasperation stemmed from an ongoing problem – operating rooms at the hospital were being inefficiently managed.
“The surgeon acknowledged that even though there was a systems issue at the root, that’s not justification to speak to people unprofessionally,” Dr. Beran said. “So, there was education for the surgeon, but the surgeon was also able to explain the frustration that led to that point.”
System problems are commonly encountered by peer reviewers, said Dr. Beran.
“There’s a huge gap between administration and clinical professionals when it comes to peer review,” he said. “So many times, bad situations, whether they’re clinical or behavioral, often boil down to systems issues or some inadequacy, whether it’s an EMR [electronic medical record] problem, an inefficacy, or how complicated a process is for an end user. But having a peer review situation that then leads to a system-level change that prevents that problem from happening again is really unlikely. There’s a huge disconnect between those two.”
Peer review is generally a process that goes on behind closed doors. Although structures may differ, peer review is generally described as the process by which physicians assess the quality of their peers’ work to ensure that standards of care are being met. The process is often used to evaluate issues regarding clinical care as well as behavioral complaints against physicians.
Doctors who undergo peer review frequently share their experiences, but reviewers themselves rarely speak out. For this story,
“Peer review processes are in place to build stronger institutions and stronger practices, and they’re supposed to be helpful,” Dr. Beran said. “But because of how opaque they are, it immediately puts physicians on the defensive, and it doesn’t always succeed in what it’s trying to do. I think that’s one of the biggest challenges.”
Biased reviewers taint evaluations
A peer reviewer on and off throughout her career, Indiana family physician Lana Patch, MD, said she always strived to be fair when evaluating fellow physicians. But not every reviewer she encountered operated the same way, she said. Some were biased.
In one case, Dr. Patch peer reviewed a general surgeon who had performed a hysterectomy on a 16-year-old girl. The surgeon believed the teenager likely had an acute appendicitis, but it turned out she had a uterine pathology, Dr. Patch said. The surgeon saved the girl’s life, but the case came under review because of the patient’s age and the fact that her uterus was removed. A local obstetrician-gynecologist weighed in on the case.
“The local ob.gyn. saw it as a turf battle,” recalled Dr. Patch, who is now retired after 30 years of practice in eastern Indiana. “The doctor had nothing but bad to say about the surgeon. He was a competitor.”
Because it was a small hospital, the committee sometimes had trouble finding a specialist who was qualified to give an opinion and who wasn’t in competition with the physician in question, said Dr. Patch. Eventually they found an outside pediatric gynecologist who reviewed the case and concluded that the surgeon had followed the standard of care.
Personal agendas in can come from different directions, said Robert Marder, MD, the author of several books on peer review. Dr. Marder is a consultant who assists with peer review redesign. He has worked with hundreds of medical staff leaders and is a former vice president at the Greeley Company, a consulting firm in Danvers, Mass., that performs peer review redesign. Dr. Marder is president of Robert J. Marder Consulting.
“It goes both ways,” Dr. Marder said. “I’ve seen where somebody with a personal view decides to bring things to the peer review committee specifically because they want the peer review committee to have an adverse view of this person and get them off the medical staff. And I’ve seen hospitals that are uncomfortable with a certain person for whatever reason and want the peer review committee to address it, as opposed to addressing it from a human resource standpoint.”
Dr. Patch recalled a case in which reviewers and hospital leaders were at odds over the credentialing of a physician. Fifteen years earlier, while driving in California, the psychiatrist had been pulled over and was found with an ounce of marijuana, she said.
“We wanted to privilege him,” Dr. Patch said. “As staff physicians, we felt that was 15 years ago, people change over time. Doctors are human beings, too. He seemed to have good credentials and good training. The hospital said, ‘Oh no, we can’t have somebody like this.’ “
The psychiatrist was placed on probation and had to undergo a review every 90 days for about 3 years. Eventually, he was privileged, Dr. Patch said.
Bias among reviewers, including unintentional bias, is also a challenge, Dr. Marder noted. Some initial reviewers score a physician too harshly, he said, whereas others underscore.
“Underscoring is more insidious and more difficult to deal with,” Dr. Marder said. “Underscoring is where the reviewer is too nice. They tend to dismiss things from their colleagues rather than recognize them as an opportunity to help them improve. With underscoring, a lot of committees, if the initial reviewer says the care was appropriate, they don’t even look at the case. They just take that one person’s word for it.”
Reviewers: Looks can be deceiving
When first examining the documented details of a case, it can be easy for peer reviewers to make a quick judgment about what happened, Dr. Beran said.
“You get these complaints, and you read through it, and you think, ‘Oh man, this person really messed up,’ “ he said. “Then you hear the doctor’s side of it, and you realize, ‘No, there’s a much bigger picture at play.’ You realize both sides have valid perspectives on it.”
In one case, for example, Dr. Beran recalled a complaint against a physician who made a snarky remark to a nurse. The doctor had asked the nurse for a piece of equipment, and the nurse said she was busy preparing the room for a patient. The doctor made a comment along the lines of, “Well, would you like me to do that for you and also intubate the patient while you do some charting?!”
At first glance, it appeared that the physician lashed out inappropriately at the nurse. But when reviewers heard from the doctor, they learned that the nurses knew that a trauma patient was coming by ambulance and that he would likely require a ventilator, Dr. Beran said. As the minutes ticked by, however, the nurses were seen in the break room chatting. Nothing had been prepared in the room, including any airway supply.
“The patient had a prolonged course and a very difficult intubation and could have very easily wound up with a much worse outcome for something the nurses had been warned about prior to the patient’s arrival,” he said. “I can see anybody getting upset in that situation if I warned them 5 or 10 minutes beforehand, ‘Get this stuff ready,’ and then nothing was done.”
There was no direct penalty for the physician.
Just as some complaints can be misleading, the clinical record in some peer review cases can also lead reviewers astray.
Physicians frequently include too much irrelevant information in the record, which can cloud a peer review, said Hans Duvefelt, MD, a family physician at Pines Health Services, in Van Buren, Maine. Dr. Duvefelt is a former medical director at Bucksport Regional Health Center, in Ellsworth, Maine. Both facilities are federally qualified health centers where continuous, random peer reviews are required.
In one case, Dr. Duvefelt was peer reviewing a physician’s office note regarding an elderly patient with a low-grade fever. The final diagnosis was urinary tract infection. Dr. Duvefelt said he had trouble following the doctor’s line of thinking because of a plethora of unnecessary data in the 10-page document. The office note included past medical history, prior lab and imaging test results, and an extensive narrative section that included a mixture of active medical problems and ongoing relationships with specialists, he said.
After reading through the printout three times, Dr. Duvefelt said he finally found mention of increased urinary dribbling and details about an enlarged prostate. He also spotted a same-day urinalysis among nearly a dozen other previous lab tests that had no connection to body temperature. Dr. Duvefelt gave the physician a passing grade but also left a scathing note about all the irrelevant information.
“It’s very common,” Dr. Duvefelt said. “It’s a disaster. Other doctors can’t follow your thinking. A reviewer has a hard time determining whether the doctor acted reasonably.”
Slackers make bad reviewers
Although dedicated reviewers work hard to get to the bottom of cases, it’s not uncommon for some committee members to hardly work at all, according to experts.
Dr. Marder said he’s seen many instances in which reviewers were assigned a review but did not complete it for months. Most committees have set time frames in which reviewers must complete their review.
“That delays that review, and by that time, the review is older and it’s harder to remember things,” he said. “It’s not fair to the physician. If there was a problem the physician could fix and you don’t tell him for 3 or 4 months what it is, he may do the same thing again. The case might come before the committee again and it looks like he’s repeated something, but you never gave him the opportunity to improve.”
Other reviewers fail to attend meetings regularly. Peer review committee members are generally volunteers, and meetings are usually held in the early mornings or late evenings.
“There are reasons for not attending occasionally, but some people put on a committee just don’t take it seriously,” Dr. Marder said. “They don’t fulfill their responsibilities as well as they should. If you accept the job, do the job.”
For physicians considering becoming a peer reviewer, Dr. Beran offers these tips: Be transparent, help physicians understand next steps, and make yourself as available as allowed to answer questions.
Know your committee’s policies and procedures, and follow them, added Dr. Marder. It’s also a good idea to work with your hospital’s quality staff, he said.
Reviewers should keep in mind that they may not always be the one assessing someone else, Dr. Beran said.
“Realize very easily you could be on the other side of that table for things that are outside your control,” he said. “How would you want to be treated?”
A version of this article first appeared on Medscape.com.
The secret I’ll take to my grave: Doc reveals
An internist will never forget the dark secret his patient revealed during a routine visit – or the grim aftermath.
The patient, who had a progressive, incurable neurological condition, confided that he planned to kill himself. The patient intended to conceal the true manner and make the death look natural.
“[He planned to do it] very carefully at home so no one would know,” said the internist, who remains anonymous. “[He shared] the methods he would use.”
Perhaps more shocking than the patient’s confession was the physician’s response.
“He did not require my help to do what he planned, and I did not try to stop him,” said the internist. “I reported his death as ‘natural causes’ and never told anyone.”
An ob.gyn., for instance, wrote about struggling with whether to tell a father that his newborn baby was not his genetic child. The newborn had a blood type that made it impossible for the father to be biologically related to the infant, the anonymous doctor wrote.
“I told the wife who then informed me she had a lover,” the ob.gyn. said. “I never told the husband.”
It’s uncertain whether carrying the burden of such hidden knowledge affected the physicians involved in these cases. However, in general, secrets can weigh heavily on the minds of those who keep them and can contribute to stress, said Malia Mason, PhD, a psychologist and dean of research at Columbia Business School in New York. Holding onto secrets can cause depression and anxiety, research shows. The more often people think about the secret, the greater the impact, according to a recent study coauthored by Dr. Mason.
“Keeping a secret diminishes well-being,” Dr. Mason said. “It makes people feel socially distant. It lowers relationship satisfaction, and it leads people to feel inauthentic. The reason that secrets do this is because people think about them all the time. The more you think about it, the more you see these consequences.”
Feelings that stem from a secret depend on the content. The more immoral a secret is thought to be, the more people feel ashamed, according to a 2021 analysis of thousands of secrets, reported by Michael L. Slepian, PhD, and Alex Koch, PhD. However, secrets more related to a person’s profession are often internalized differently, the study found. The more a secret fell higher on the profession/goal-oriented dimension, the more people felt they had insight into the secret, according to the analysis. For example, having clear thinking about the secret and/or knowing how to handle it.
“The more shame participants felt from their secret, the more they indicated the secret hurt their well-being,” Dr. Slepian and Dr. Koch wrote in the study. “The more insight participants felt they had into their secret, the less they indicated the secret hurt their well-being.”
Suspicious deaths exposed after investigations
The internist’s account of keeping his patient’s suicide a secret raises many questions, such as how the patient masked his manner of death. The internist did not share any more details about the incident.
Suicides are among the most challenging manners of deaths to certify, according to James Gill, MD, a pathologist and president of the National Association of Medical Examiners. Death investigators must demonstrate intent, meaning the individuals caused the injury to intentionally harm themselves. Fewer than half of people who die by suicide leave a note, Dr. Gill said, so investigators can’t rely on the absence or the presence of a note in making their determination.
A decedent who had cancer or a severe neurological disorder presents further challenges, said Dr. Gill, who serves as chief medical examiner for the state of Connecticut.
“These [deaths] may not be unexpected and may not be reported to the medical examiner/coroner,” Dr. Gill said. “If there is no suspicion and the treating doctor is willing to sign the death certificate, the death will not come under the jurisdiction of the medical examiner.”
Dr. Gill recalled a death his colleague once investigated that appeared to be natural but emerged as something else after a deeper look.
A woman with metastatic breast cancer was about to be discharged from a hospital into hospice the next morning. The night before, she had a “going away” party with friends who came to visit her in the hospital. Shortly after the friends left, the woman was found dead. Because of her condition, she could have died at any time, Dr. Gill said, but she also had a history of depression and hospital staff were suspicious. The death was reported to the medical examiner’s office.
Toxicology testing found markedly elevated concentrations of phenytoin and pentobarbital, neither of which were prescribed during her hospital stay. Dr. Gill said it turned out that the woman and her friends worked at a veterinarian’s office, and the medication they used to euthanize dogs was a combination of phenytoin and pentobarbital.
“The death was certified as a homicide because of the direct actions of another, but a reasonable argument could be made for suicide,” Dr. Gill said.
In a similar case reported in the journal Science & Justice, a 64-year-old cardiologist was found lifeless by his wife after he collapsed near the stairs of his home. Next to his body was a bottle of whiskey and two cups, one that appeared to be used for the alcohol and one with a yellowish liquid smelling of honey. The wife reported that her husband always drank whiskey with honey before bed. The death was initially classified as natural, but after vehement protest by the family, a forensic autopsy was performed.
Prior to the autopsy, death investigators learned the decedent, who was a well-known and successful practitioner in his community, had Parkinson’s disease. At times, he could not sign his prescriptions because of the increasing tremor in his hands, according to the case study. Investigators learned the patient’s mother had also suffered from Parkinson’s, and that her son had witnessed her decline.
The autopsy revealed only nonspecific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral edema, and moderate generalized atheromatosis. Histological examinations did not yield any unusual findings.
An analysis of the beverage containers detected pentobarbital in the yellowish syrup residue of the second cup. Testing of the doctor’s peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol, and traces of phenobarbital. In addition, a urine analysis showed the presence of venlafaxine, an antidepressant, as well as the benzophenone of lorazepam, a sedating benzodiazepine, and metoclopramide, an antiemetic.
Lead author C. Brandt-Casadevall, MD, and colleagues wrote that the levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome.
“... It is obvious that the victim attempted to hide his suicide from his family circle,” Dr. Brandt-Casadevall and colleagues wrote. “Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal, and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim.”
What to do when a terminally ill patient talks suicide
When a terminally ill patient expresses the desire to end his or her life, it’s important to understand that desire is often a result of existential suffering, a sense of hopelessness, and lack of social support, said Lynn A. Jansen, PhD, a bioethicist at the University of Arizona in Tucson.
“The duty of beneficence requires that physicians attempt to provide the support and care that is needed,” said Dr. Jansen. “Here, interdisciplinary teamwork is important and should be utilized. Physicians should refer patients to professionals, such as social workers, pastoral care, psychologists, etc., who are better able to address these issues.”
The rate of desire for a hastened death among terminally ill patients ranges from 17% to 45%, depending on the population studied and how the desire is evaluated, according to an analysis in the Primary Care Companion to the Journal of Clinical Psychiatry. In one study, 14% of about 130 palliative care patients with cancer had a strong desire to quicken the dying process.
In addition, patients with neurologic disorders have a significantly higher suicide rate than that of those without neurologic disorders, a recent JAMA study found. About 1 in 150 patients diagnosed with a neurological disorder dies by suicide, the analysis determined.
A tricky point to remember is that a desire by a terminally ill patient to hasten his or her death by suicide should not be taken by itself to indicate depression, Dr. Jansen noted.
“In principle, such patients can make an autonomous decision to end their lives,” she said. “However, the expression of such a desire is very often associated with depression and forms of suffering that can be effectively addressed by the health care team.”
Physicians can also explore other avenues with the patient such as palliative care or making sure adequate pain relief is available, added Robert Klitzman, MD, professor of psychiatry and academic director of the master of science in bioethics program at Columbia University, New York.
“If they are saying it’s because they are distressed, ethically, a doctor can and should find ways to decrease their distress,” he said.
Of course, those who practice in the U.S. jurisdictions that have physician-assisted-dying laws have different legal and ethical elements to consider. Physicians in these areas have no ethical duty to participate in the process, Dr. Jansen said, but they have a duty to refer patients who express a desire to pursue physician aid-in-dying to another provider who can assist them.
Physician aid-in-dying laws vary somewhat so it’s important that physicians in these areas be aware of their specific statute, Dr. Klitzman said. California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington, and the District of Columbia have these laws.
“In these states, if a terminally ill patient says they don’t want to live anymore, a physician would first decide if this is a result of depression or if it’s a request for physician aid-in-dying,” he said. “Even then, in most cases, the patient would be evaluated by not one, but two different health professionals at two different points. We want to see if it is a consistent decision that the person has made that they want physician aid-in-dying, and not just that they’ve had a bad day or a setback in their treatment.”
In the case of the internist who told no one of his patient’s suicide plan, Dr. Klitzman said he would have dug deeper into the patient’s mindset.
“Not knowing anything about the patient or the doctor, I would have responded differently,” he said. “I think a physician should address why a patient feels that way. They may feel their pain is unbearable, and we potentially offer more pain relief. Maybe the patient shows evidence of having depression, which may be treatable [with medication]. The patient would then feel better and be able to spend quality time with family and loved ones, make sure their affairs are in order, and have a chance to say goodbye.”
A version of this article first appeared on Medscape.com.
An internist will never forget the dark secret his patient revealed during a routine visit – or the grim aftermath.
The patient, who had a progressive, incurable neurological condition, confided that he planned to kill himself. The patient intended to conceal the true manner and make the death look natural.
“[He planned to do it] very carefully at home so no one would know,” said the internist, who remains anonymous. “[He shared] the methods he would use.”
Perhaps more shocking than the patient’s confession was the physician’s response.
“He did not require my help to do what he planned, and I did not try to stop him,” said the internist. “I reported his death as ‘natural causes’ and never told anyone.”
An ob.gyn., for instance, wrote about struggling with whether to tell a father that his newborn baby was not his genetic child. The newborn had a blood type that made it impossible for the father to be biologically related to the infant, the anonymous doctor wrote.
“I told the wife who then informed me she had a lover,” the ob.gyn. said. “I never told the husband.”
It’s uncertain whether carrying the burden of such hidden knowledge affected the physicians involved in these cases. However, in general, secrets can weigh heavily on the minds of those who keep them and can contribute to stress, said Malia Mason, PhD, a psychologist and dean of research at Columbia Business School in New York. Holding onto secrets can cause depression and anxiety, research shows. The more often people think about the secret, the greater the impact, according to a recent study coauthored by Dr. Mason.
“Keeping a secret diminishes well-being,” Dr. Mason said. “It makes people feel socially distant. It lowers relationship satisfaction, and it leads people to feel inauthentic. The reason that secrets do this is because people think about them all the time. The more you think about it, the more you see these consequences.”
Feelings that stem from a secret depend on the content. The more immoral a secret is thought to be, the more people feel ashamed, according to a 2021 analysis of thousands of secrets, reported by Michael L. Slepian, PhD, and Alex Koch, PhD. However, secrets more related to a person’s profession are often internalized differently, the study found. The more a secret fell higher on the profession/goal-oriented dimension, the more people felt they had insight into the secret, according to the analysis. For example, having clear thinking about the secret and/or knowing how to handle it.
“The more shame participants felt from their secret, the more they indicated the secret hurt their well-being,” Dr. Slepian and Dr. Koch wrote in the study. “The more insight participants felt they had into their secret, the less they indicated the secret hurt their well-being.”
Suspicious deaths exposed after investigations
The internist’s account of keeping his patient’s suicide a secret raises many questions, such as how the patient masked his manner of death. The internist did not share any more details about the incident.
Suicides are among the most challenging manners of deaths to certify, according to James Gill, MD, a pathologist and president of the National Association of Medical Examiners. Death investigators must demonstrate intent, meaning the individuals caused the injury to intentionally harm themselves. Fewer than half of people who die by suicide leave a note, Dr. Gill said, so investigators can’t rely on the absence or the presence of a note in making their determination.
A decedent who had cancer or a severe neurological disorder presents further challenges, said Dr. Gill, who serves as chief medical examiner for the state of Connecticut.
“These [deaths] may not be unexpected and may not be reported to the medical examiner/coroner,” Dr. Gill said. “If there is no suspicion and the treating doctor is willing to sign the death certificate, the death will not come under the jurisdiction of the medical examiner.”
Dr. Gill recalled a death his colleague once investigated that appeared to be natural but emerged as something else after a deeper look.
A woman with metastatic breast cancer was about to be discharged from a hospital into hospice the next morning. The night before, she had a “going away” party with friends who came to visit her in the hospital. Shortly after the friends left, the woman was found dead. Because of her condition, she could have died at any time, Dr. Gill said, but she also had a history of depression and hospital staff were suspicious. The death was reported to the medical examiner’s office.
Toxicology testing found markedly elevated concentrations of phenytoin and pentobarbital, neither of which were prescribed during her hospital stay. Dr. Gill said it turned out that the woman and her friends worked at a veterinarian’s office, and the medication they used to euthanize dogs was a combination of phenytoin and pentobarbital.
“The death was certified as a homicide because of the direct actions of another, but a reasonable argument could be made for suicide,” Dr. Gill said.
In a similar case reported in the journal Science & Justice, a 64-year-old cardiologist was found lifeless by his wife after he collapsed near the stairs of his home. Next to his body was a bottle of whiskey and two cups, one that appeared to be used for the alcohol and one with a yellowish liquid smelling of honey. The wife reported that her husband always drank whiskey with honey before bed. The death was initially classified as natural, but after vehement protest by the family, a forensic autopsy was performed.
Prior to the autopsy, death investigators learned the decedent, who was a well-known and successful practitioner in his community, had Parkinson’s disease. At times, he could not sign his prescriptions because of the increasing tremor in his hands, according to the case study. Investigators learned the patient’s mother had also suffered from Parkinson’s, and that her son had witnessed her decline.
The autopsy revealed only nonspecific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral edema, and moderate generalized atheromatosis. Histological examinations did not yield any unusual findings.
An analysis of the beverage containers detected pentobarbital in the yellowish syrup residue of the second cup. Testing of the doctor’s peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol, and traces of phenobarbital. In addition, a urine analysis showed the presence of venlafaxine, an antidepressant, as well as the benzophenone of lorazepam, a sedating benzodiazepine, and metoclopramide, an antiemetic.
Lead author C. Brandt-Casadevall, MD, and colleagues wrote that the levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome.
“... It is obvious that the victim attempted to hide his suicide from his family circle,” Dr. Brandt-Casadevall and colleagues wrote. “Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal, and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim.”
What to do when a terminally ill patient talks suicide
When a terminally ill patient expresses the desire to end his or her life, it’s important to understand that desire is often a result of existential suffering, a sense of hopelessness, and lack of social support, said Lynn A. Jansen, PhD, a bioethicist at the University of Arizona in Tucson.
“The duty of beneficence requires that physicians attempt to provide the support and care that is needed,” said Dr. Jansen. “Here, interdisciplinary teamwork is important and should be utilized. Physicians should refer patients to professionals, such as social workers, pastoral care, psychologists, etc., who are better able to address these issues.”
The rate of desire for a hastened death among terminally ill patients ranges from 17% to 45%, depending on the population studied and how the desire is evaluated, according to an analysis in the Primary Care Companion to the Journal of Clinical Psychiatry. In one study, 14% of about 130 palliative care patients with cancer had a strong desire to quicken the dying process.
In addition, patients with neurologic disorders have a significantly higher suicide rate than that of those without neurologic disorders, a recent JAMA study found. About 1 in 150 patients diagnosed with a neurological disorder dies by suicide, the analysis determined.
A tricky point to remember is that a desire by a terminally ill patient to hasten his or her death by suicide should not be taken by itself to indicate depression, Dr. Jansen noted.
“In principle, such patients can make an autonomous decision to end their lives,” she said. “However, the expression of such a desire is very often associated with depression and forms of suffering that can be effectively addressed by the health care team.”
Physicians can also explore other avenues with the patient such as palliative care or making sure adequate pain relief is available, added Robert Klitzman, MD, professor of psychiatry and academic director of the master of science in bioethics program at Columbia University, New York.
“If they are saying it’s because they are distressed, ethically, a doctor can and should find ways to decrease their distress,” he said.
Of course, those who practice in the U.S. jurisdictions that have physician-assisted-dying laws have different legal and ethical elements to consider. Physicians in these areas have no ethical duty to participate in the process, Dr. Jansen said, but they have a duty to refer patients who express a desire to pursue physician aid-in-dying to another provider who can assist them.
Physician aid-in-dying laws vary somewhat so it’s important that physicians in these areas be aware of their specific statute, Dr. Klitzman said. California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington, and the District of Columbia have these laws.
“In these states, if a terminally ill patient says they don’t want to live anymore, a physician would first decide if this is a result of depression or if it’s a request for physician aid-in-dying,” he said. “Even then, in most cases, the patient would be evaluated by not one, but two different health professionals at two different points. We want to see if it is a consistent decision that the person has made that they want physician aid-in-dying, and not just that they’ve had a bad day or a setback in their treatment.”
In the case of the internist who told no one of his patient’s suicide plan, Dr. Klitzman said he would have dug deeper into the patient’s mindset.
“Not knowing anything about the patient or the doctor, I would have responded differently,” he said. “I think a physician should address why a patient feels that way. They may feel their pain is unbearable, and we potentially offer more pain relief. Maybe the patient shows evidence of having depression, which may be treatable [with medication]. The patient would then feel better and be able to spend quality time with family and loved ones, make sure their affairs are in order, and have a chance to say goodbye.”
A version of this article first appeared on Medscape.com.
An internist will never forget the dark secret his patient revealed during a routine visit – or the grim aftermath.
The patient, who had a progressive, incurable neurological condition, confided that he planned to kill himself. The patient intended to conceal the true manner and make the death look natural.
“[He planned to do it] very carefully at home so no one would know,” said the internist, who remains anonymous. “[He shared] the methods he would use.”
Perhaps more shocking than the patient’s confession was the physician’s response.
“He did not require my help to do what he planned, and I did not try to stop him,” said the internist. “I reported his death as ‘natural causes’ and never told anyone.”
An ob.gyn., for instance, wrote about struggling with whether to tell a father that his newborn baby was not his genetic child. The newborn had a blood type that made it impossible for the father to be biologically related to the infant, the anonymous doctor wrote.
“I told the wife who then informed me she had a lover,” the ob.gyn. said. “I never told the husband.”
It’s uncertain whether carrying the burden of such hidden knowledge affected the physicians involved in these cases. However, in general, secrets can weigh heavily on the minds of those who keep them and can contribute to stress, said Malia Mason, PhD, a psychologist and dean of research at Columbia Business School in New York. Holding onto secrets can cause depression and anxiety, research shows. The more often people think about the secret, the greater the impact, according to a recent study coauthored by Dr. Mason.
“Keeping a secret diminishes well-being,” Dr. Mason said. “It makes people feel socially distant. It lowers relationship satisfaction, and it leads people to feel inauthentic. The reason that secrets do this is because people think about them all the time. The more you think about it, the more you see these consequences.”
Feelings that stem from a secret depend on the content. The more immoral a secret is thought to be, the more people feel ashamed, according to a 2021 analysis of thousands of secrets, reported by Michael L. Slepian, PhD, and Alex Koch, PhD. However, secrets more related to a person’s profession are often internalized differently, the study found. The more a secret fell higher on the profession/goal-oriented dimension, the more people felt they had insight into the secret, according to the analysis. For example, having clear thinking about the secret and/or knowing how to handle it.
“The more shame participants felt from their secret, the more they indicated the secret hurt their well-being,” Dr. Slepian and Dr. Koch wrote in the study. “The more insight participants felt they had into their secret, the less they indicated the secret hurt their well-being.”
Suspicious deaths exposed after investigations
The internist’s account of keeping his patient’s suicide a secret raises many questions, such as how the patient masked his manner of death. The internist did not share any more details about the incident.
Suicides are among the most challenging manners of deaths to certify, according to James Gill, MD, a pathologist and president of the National Association of Medical Examiners. Death investigators must demonstrate intent, meaning the individuals caused the injury to intentionally harm themselves. Fewer than half of people who die by suicide leave a note, Dr. Gill said, so investigators can’t rely on the absence or the presence of a note in making their determination.
A decedent who had cancer or a severe neurological disorder presents further challenges, said Dr. Gill, who serves as chief medical examiner for the state of Connecticut.
“These [deaths] may not be unexpected and may not be reported to the medical examiner/coroner,” Dr. Gill said. “If there is no suspicion and the treating doctor is willing to sign the death certificate, the death will not come under the jurisdiction of the medical examiner.”
Dr. Gill recalled a death his colleague once investigated that appeared to be natural but emerged as something else after a deeper look.
A woman with metastatic breast cancer was about to be discharged from a hospital into hospice the next morning. The night before, she had a “going away” party with friends who came to visit her in the hospital. Shortly after the friends left, the woman was found dead. Because of her condition, she could have died at any time, Dr. Gill said, but she also had a history of depression and hospital staff were suspicious. The death was reported to the medical examiner’s office.
Toxicology testing found markedly elevated concentrations of phenytoin and pentobarbital, neither of which were prescribed during her hospital stay. Dr. Gill said it turned out that the woman and her friends worked at a veterinarian’s office, and the medication they used to euthanize dogs was a combination of phenytoin and pentobarbital.
“The death was certified as a homicide because of the direct actions of another, but a reasonable argument could be made for suicide,” Dr. Gill said.
In a similar case reported in the journal Science & Justice, a 64-year-old cardiologist was found lifeless by his wife after he collapsed near the stairs of his home. Next to his body was a bottle of whiskey and two cups, one that appeared to be used for the alcohol and one with a yellowish liquid smelling of honey. The wife reported that her husband always drank whiskey with honey before bed. The death was initially classified as natural, but after vehement protest by the family, a forensic autopsy was performed.
Prior to the autopsy, death investigators learned the decedent, who was a well-known and successful practitioner in his community, had Parkinson’s disease. At times, he could not sign his prescriptions because of the increasing tremor in his hands, according to the case study. Investigators learned the patient’s mother had also suffered from Parkinson’s, and that her son had witnessed her decline.
The autopsy revealed only nonspecific lesions such as acute stasis of the viscera, moderate pulmonary and cerebral edema, and moderate generalized atheromatosis. Histological examinations did not yield any unusual findings.
An analysis of the beverage containers detected pentobarbital in the yellowish syrup residue of the second cup. Testing of the doctor’s peripheral blood revealed the presence of a metabolite of pentobarbital, ethanol, and traces of phenobarbital. In addition, a urine analysis showed the presence of venlafaxine, an antidepressant, as well as the benzophenone of lorazepam, a sedating benzodiazepine, and metoclopramide, an antiemetic.
Lead author C. Brandt-Casadevall, MD, and colleagues wrote that the levels were clearly compatible with a scenario of a pentobarbital overdose with a lethal outcome.
“... It is obvious that the victim attempted to hide his suicide from his family circle,” Dr. Brandt-Casadevall and colleagues wrote. “Thus, we obtained no evidence indicating that he might have spoken at any point of putting an end to his life. There was no written note. The victim did not wait to be alone at home. Instead, he committed his act in a routine situation: his wife was watching television late at night and he was upstairs, presumably going to sleep. Thus, he had one to two hours at his disposal, and he ingested a very fast-acting drug which would make any attempt at reanimation impossible, even after a brief period of time. This may have induced the physician in charge to believe that the cause of death was cardiac origin, a likely hypothesis given the age of the victim.”
What to do when a terminally ill patient talks suicide
When a terminally ill patient expresses the desire to end his or her life, it’s important to understand that desire is often a result of existential suffering, a sense of hopelessness, and lack of social support, said Lynn A. Jansen, PhD, a bioethicist at the University of Arizona in Tucson.
“The duty of beneficence requires that physicians attempt to provide the support and care that is needed,” said Dr. Jansen. “Here, interdisciplinary teamwork is important and should be utilized. Physicians should refer patients to professionals, such as social workers, pastoral care, psychologists, etc., who are better able to address these issues.”
The rate of desire for a hastened death among terminally ill patients ranges from 17% to 45%, depending on the population studied and how the desire is evaluated, according to an analysis in the Primary Care Companion to the Journal of Clinical Psychiatry. In one study, 14% of about 130 palliative care patients with cancer had a strong desire to quicken the dying process.
In addition, patients with neurologic disorders have a significantly higher suicide rate than that of those without neurologic disorders, a recent JAMA study found. About 1 in 150 patients diagnosed with a neurological disorder dies by suicide, the analysis determined.
A tricky point to remember is that a desire by a terminally ill patient to hasten his or her death by suicide should not be taken by itself to indicate depression, Dr. Jansen noted.
“In principle, such patients can make an autonomous decision to end their lives,” she said. “However, the expression of such a desire is very often associated with depression and forms of suffering that can be effectively addressed by the health care team.”
Physicians can also explore other avenues with the patient such as palliative care or making sure adequate pain relief is available, added Robert Klitzman, MD, professor of psychiatry and academic director of the master of science in bioethics program at Columbia University, New York.
“If they are saying it’s because they are distressed, ethically, a doctor can and should find ways to decrease their distress,” he said.
Of course, those who practice in the U.S. jurisdictions that have physician-assisted-dying laws have different legal and ethical elements to consider. Physicians in these areas have no ethical duty to participate in the process, Dr. Jansen said, but they have a duty to refer patients who express a desire to pursue physician aid-in-dying to another provider who can assist them.
Physician aid-in-dying laws vary somewhat so it’s important that physicians in these areas be aware of their specific statute, Dr. Klitzman said. California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont, Washington, and the District of Columbia have these laws.
“In these states, if a terminally ill patient says they don’t want to live anymore, a physician would first decide if this is a result of depression or if it’s a request for physician aid-in-dying,” he said. “Even then, in most cases, the patient would be evaluated by not one, but two different health professionals at two different points. We want to see if it is a consistent decision that the person has made that they want physician aid-in-dying, and not just that they’ve had a bad day or a setback in their treatment.”
In the case of the internist who told no one of his patient’s suicide plan, Dr. Klitzman said he would have dug deeper into the patient’s mindset.
“Not knowing anything about the patient or the doctor, I would have responded differently,” he said. “I think a physician should address why a patient feels that way. They may feel their pain is unbearable, and we potentially offer more pain relief. Maybe the patient shows evidence of having depression, which may be treatable [with medication]. The patient would then feel better and be able to spend quality time with family and loved ones, make sure their affairs are in order, and have a chance to say goodbye.”
A version of this article first appeared on Medscape.com.
Doctor wins restraining order against CVS after prescription ban
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
In an Aug. 11 decision, District Court Judge William Bertelsman ordered CVS to stop refusing prescriptions written by Kendall E. Hansen, MD. Judge Bertelsman ruled that Dr. Hansen is likely to succeed in his claim that CVS barred his prescriptions without evidence that he violated any law or professional protocol. The restraining order will remain in place while Dr. Hansen’s lawsuit against CVS Pharmacy proceeds.
Ronald W. Chapman II, an attorney representing Dr. Hansen, said the order is groundbreaking and that, to his knowledge, it’s the first time a federal court has overturned a pharmacy’s decision to block a prescriber.
“We believe that CVS’ decision was based solely on algorithms they use to analyze prescriber practices and not an any individual review of patient records,” Mr. Chapman said. “In fact, we invited CVS to come out to Dr. Hansen’s practice and look at how he was treating patients and ensure things were compliant, but they refused. Instead, they had a phone call with him then cut his patients off.”
Michael DeAngelis, a spokesman for CVS, said the court’s order illustrates the proverbial rock and hard place that pharmacies are placed between in the country’s fight against the misuse of prescription opioids.
“It is alleged in many lawsuits that pharmacies fill too many opioid prescriptions and should operate programs that use data to block prescriptions written by some doctors,” Mr. DeAngelis told this news organization. “And yet other lawsuits, including this one, argue that we should not operate programs that may block prescriptions. Such contradictions are grossly unfair to the pharmacy profession.”
Mr. DeAngelis declined to comment about Dr. Hansen’s claims or specify what led CVS to refuse his prescriptions.
Dr. Hansen declined to comment for this story through his attorney.
Dr. Hansen is no stranger to the spotlight. The Northern Kentucky pain doctor made headlines in 2012 when two of his horses, Fast and Accurate, and Hansen, ran in the Kentucky Derby. In February 2019, he drew media attention when his practice, Interventional Pain Specialists in Crestview Hills, Ky., was raided by federal agents. Dr. Hansen owns and operates the facility, which serves patients in Kentucky, Ohio, and Indiana.
The search yielded no findings, and no charges were filed, according to Mr. Chapman. Scott Hardcorn, director of the Northern Kentucky Drug Strike Force, confirmed that his agency assisted in the operation but said he was unaware of the outcome and that his officers generated no reports from the investigation. A spokesperson for the Drug Enforcement Administration would not comment about the investigation and directed a reporter for this news organization to the DEA website where enforcement actions are listed. No records or actions against Dr. Hansen can be found.
The CVS complaint stems from actions taken by the pharmacy against Dr. Hansen earlier this year. In June, a pharmacy representative allegedly contacted Dr. Hansen by phone and asked him questions about his practice and his prescribing practices, according to his lawsuit filed in U.S. District Court for the Eastern District of Kentucky. During the call, the representative did not inform Dr. Hansen that any of his prescriptions were in question or were suspected of being medically unnecessary, the complaint alleges.
On July 28, 2021, CVS sent Dr. Hansen a letter announcing that its pharmacies would no longer be honoring his prescriptions. The letter, entered as an exhibit in the lawsuit, states that CVS contacted Dr. Hansen twice in 2021 about his prescribing practices, once in May and again in June.
“Despite our attempts to resolve the concerns with your controlled substance prescribing patterns, these concerns persist,” Kahra Lutkiewicz, director of CVS’ retail pharmacy professional practice, wrote in the letter. “Thus, we are writing to inform you that effective Aug. 5, 2021, CVS/pharmacy stores will no longer be able to fill prescriptions that you write for controlled substances. We take our compliance obligations very seriously, and after careful consideration, find it necessary to take this action.”
The letter does not explain the details behind CVS’ concerns.
Dr. Hansen sued CVS on Aug. 4 for tortious interference with a business relationship and defamation, among other claims. His complaint alleges that Dr. Hansen and his patients will suffer irreparable injury if the prescription decision stands. More than 250 of Dr. Hansen’s patients use CVS pharmacies for their prescriptions, and some are locked into using the pharmacy because of insurance contracts, Mr. Chapman said.
“There really is nowhere else for these patients to go,” Mr. Chapman said. “They would have to go to a new doctor and establish a new relationship, and obviously that has devastating consequences when we’re talking about people who need their medication.”
CVS has not yet issued a written response to the lawsuit. In his order, Judge Bertelsman stated that a preliminary conference was held in which all parties were represented and stated their positions to the judge.
“Plaintiffs are likely to succeed on the merits of their claims that defendant has interfered with plaintiffs’ relationships with their patients by refusing to fill prescriptions written by plaintiffs, and defendant has done so without evidence that plaintiffs have violated any law or professional protocol related to such prescriptions,” Judge Bertelsman wrote. “The balance of the hardships between the parties weighs in favor of issuing a temporary restraining order inasmuch as defendant’s actions pose a threat to plaintiffs’ professional reputation and livelihood and ... because plaintiffs’ patients’ medical care is implicated by defendant’s actions, the public interest weighs in favor of issuance of the temporary restraining order.”
Dr. Hansen is currently embroiled in several other legal battles as both a plaintiff and a defendant.
In 2019, a patient sued him for negligence and fraud for allegedly performing medically unnecessary and excessive injection therapy. The suit claims the patient was required to undergo injection therapy on a continuing basis in order to receive her narcotic pain medication, according to the lawsuit filed in Kenton Circuit Court. The complaint alleges that Dr. Hansen made false representations to the patient and to her insurers that the injections were necessary for the treatment of the patient’s chronic pain.
The federal government is not involved in the case.
The negligence lawsuit is in the discovery stage, and attorneys plan to collect Dr. Hansen’s deposition soon, said Eric Deters, a spokesman for Deters Law, a law firm based in Independence, Ky., that is representing the patient.
“The crux is that he performs unnecessary pain procedures and forces you to get an unnecessary procedure before giving you your medication,” Mr. Deters said.
However, Dr. Hansen’s and Mr. Deters’ history together includes a recent riff, according to an August 2021 lawsuit filed by Dr. Hansen against the law firm. Dr. Hansen was a former medical expert in cases for Deters and Associates, but the relationship turned sour when attorneys believed Dr. Hansen was retained as an expert in a case against their clients, according to Dr. Hansen’s suit. Dr. Hansen claims that as retribution, Deters and Associates issued a medical malpractice lawsuit against him in 2020, even though attorneys allegedly knew the statute of limitations had run out. A trial court dismissed the 2020 lawsuit against Dr. Hansen as being untimely filed. Dr. Hansen’s lawsuit alleges wrongful use of civil proceedings and requests compensatory, punitive damages and court costs from the law firm.
The law firm has faced trouble in the past. In August 2021, the Ohio Supreme Court ordered that Mr. Deters pay a $6,500 fine for engaging in the unauthorized practice of law. Mr. Deters’ Kentucky law license has been suspended since 2013 for ethics infractions, according to court records. He retired from law in 2014 and now acts as a spokesperson and office manager for the law firm. The fine resulted from legal advice given by Mr. Deters to two clients at the law firm, according to the Ohio Supreme Court decision.
As for the CVS lawsuit, an upcoming hearing will determine whether the federal court issues a permanent injunction against CVS’s actions. CVS officials have not said whether they will fight the temporary restraining order or the withdrawal of their prescription ban against Dr. Hansen.
A version of this article first appeared on Medscape.com.
Doctor, PA, face lawsuit after patient dies of COVID-19
, claiming the health providers failed to properly test the man and rendered improper care that led to his demise.
Shirley Dimoh of Memphis alleges her husband Peter Dimoh, 66, received inadequate care when he presented with COVID-19 symptoms to May Medical Group in Munford, Tenn., on November 19, 2020. Physician assistant Robert Moody ordered a COVID-19 blood test for Mr. Dimoh, rather than a nasal swab test, which was sent to an Atlanta lab for analysis, according to the lawsuit.
By the time the Dimohs were informed of the positive result on November 23, Mr. Dimoh was seriously ill and showed signs of severe infection, the claim alleges. Family physician David Krapf, DO, then prescribed methocarbamol, a muscle relaxant, which the complaint claims exacerbated Mr. Dimoh’s infection, caused serious adverse reactions, and led to his death on December 16, 2020.
“Mr. Dimoh had multiple comorbid conditions and he had a positive test, he should have been referred to a specialist at a higher level of care,” said Duncan E. Ragsdale, a Memphis-based attorney representing Shirley Dimoh. “This is not something for a family physician or a physician assistant to be attempting to handle. It’s my belief this was a preventable death.”
Shirley Dimoh filed a lawsuit against May Medical Group, Moody, Krapf, and several others on June 23, 2021, in the Circuit Court of Tennessee, 13th Judicial District. She accuses the group of negligence, failure to refer, and failure to supervise, among other claims. She is requesting $5 million in damages.
May Medical Group did not return phone or email messages seeking comment for this story. The group had not issued a reply to the lawsuit as of this article’s deadline. An attorney for the practice is not yet listed in court records.
Wife had COVID-19 first, treated by same PA
Shirley Dimoh was the first of the couple to contract COVID-19. She visited May Medical Group with COVID-19 symptoms on November 9, according to the lawsuit. The same physician assistant allegedly prescribed antibiotics and sent Shirley Dimoh to the health department for a rapid nasal swab test. After a positive test resulted, she was prescribed more antibiotics, steroids, and other medications, according to the claim. She recovered without complications.
The plaintiff alleges the medical practice did not warn Peter Dimoh of the risk of contracting COVID-19 from contact with Shirley Dimoh or offer prophylactics against infection. Peter Dimoh had underlying conditions that included diabetes and kidney failure, according to Mr. Ragsdale.
It’s unclear why Peter Dimoh may have been prescribed methocarbamol after his positive COVID-19 test on November 23. The same day, Shirley Dimoh went to the pharmacy to pick up her husband’s prescription because he was too sick to go himself, the complaint states. Mr. Dimoh took the medication three times a day as prescribed. The methocarbamol was “unreasonably dangerous” for Mr. Dimoh at the time and caused an injury he would have not incurred otherwise, the suit claims.
On November 28, Mr. Dimoh collapsed and was taken by ambulance to Methodist Hospital in Memphis. He was treated for COVID-19 as well as bacterial pneumonia, severe sepsis, and sytemic inflammatory response syndrome, according to the complaint. He died December 16 from respiratory and heart failure.
“What’s interesting about this case is that you’ve got a good example and a bad example together,” Mr. Ragsdale said. “In other words, the good example is they treated her appropriately, she recovered. They didn’t treat him at all, he died. I don’t know how you could have a better counter position established by the same practice.”
Family has sued for malpractice before
Before his death, Peter Dimoh was the plaintiff in another medical negligence suit. In 2013, he sued the Center for Oral and Facial Surgery of Memphis and two oral surgeons for allegedly operating on him improperly and causing an adverse outcome.
Mr. Dimoh underwent oral surgery on February 8, 2012, at the center. The day of his operation, Mr. Dimoh’s A1c and glucose levels were grossly elevated, according to the claim, which was also represented by Mr. Ragsdale. Surgeons concluded, incorrectly, that Mr. Dimoh’s diabetes was under control, the complaint alleges, failed to order preoperative antibiotics, operated on him, and caused a bacterial infection at the operative site. The infection allegedly resulted in osteomyelitis of Mr. Dimoh’s left mandible with a pathologic fracture.
The complaint also alleges that although Mr. Dimoh signed a consent form for the surgery, the defendants failed to obtain his consent because they were unaware his diabetes was not under control and they did not explain the risks of surgery while in such a condition. The suit alleges lack of informed consent, negligence, and gross negligence by the practice and requests $2 million in damages.
Court documents show the suit was voluntarily withdrawn in 2018 without prejudice and reissued in 2019. In January 2021, the court was given notice of Mr. Dimoh’s death, and a motion was made to substitute another plaintiff, according to Shelby County court records.
An attorney for the Center for Oral and Facial Surgery of Memphis did not return a message seeking comment.
A version of this article first appeared on Medscape.com.
, claiming the health providers failed to properly test the man and rendered improper care that led to his demise.
Shirley Dimoh of Memphis alleges her husband Peter Dimoh, 66, received inadequate care when he presented with COVID-19 symptoms to May Medical Group in Munford, Tenn., on November 19, 2020. Physician assistant Robert Moody ordered a COVID-19 blood test for Mr. Dimoh, rather than a nasal swab test, which was sent to an Atlanta lab for analysis, according to the lawsuit.
By the time the Dimohs were informed of the positive result on November 23, Mr. Dimoh was seriously ill and showed signs of severe infection, the claim alleges. Family physician David Krapf, DO, then prescribed methocarbamol, a muscle relaxant, which the complaint claims exacerbated Mr. Dimoh’s infection, caused serious adverse reactions, and led to his death on December 16, 2020.
“Mr. Dimoh had multiple comorbid conditions and he had a positive test, he should have been referred to a specialist at a higher level of care,” said Duncan E. Ragsdale, a Memphis-based attorney representing Shirley Dimoh. “This is not something for a family physician or a physician assistant to be attempting to handle. It’s my belief this was a preventable death.”
Shirley Dimoh filed a lawsuit against May Medical Group, Moody, Krapf, and several others on June 23, 2021, in the Circuit Court of Tennessee, 13th Judicial District. She accuses the group of negligence, failure to refer, and failure to supervise, among other claims. She is requesting $5 million in damages.
May Medical Group did not return phone or email messages seeking comment for this story. The group had not issued a reply to the lawsuit as of this article’s deadline. An attorney for the practice is not yet listed in court records.
Wife had COVID-19 first, treated by same PA
Shirley Dimoh was the first of the couple to contract COVID-19. She visited May Medical Group with COVID-19 symptoms on November 9, according to the lawsuit. The same physician assistant allegedly prescribed antibiotics and sent Shirley Dimoh to the health department for a rapid nasal swab test. After a positive test resulted, she was prescribed more antibiotics, steroids, and other medications, according to the claim. She recovered without complications.
The plaintiff alleges the medical practice did not warn Peter Dimoh of the risk of contracting COVID-19 from contact with Shirley Dimoh or offer prophylactics against infection. Peter Dimoh had underlying conditions that included diabetes and kidney failure, according to Mr. Ragsdale.
It’s unclear why Peter Dimoh may have been prescribed methocarbamol after his positive COVID-19 test on November 23. The same day, Shirley Dimoh went to the pharmacy to pick up her husband’s prescription because he was too sick to go himself, the complaint states. Mr. Dimoh took the medication three times a day as prescribed. The methocarbamol was “unreasonably dangerous” for Mr. Dimoh at the time and caused an injury he would have not incurred otherwise, the suit claims.
On November 28, Mr. Dimoh collapsed and was taken by ambulance to Methodist Hospital in Memphis. He was treated for COVID-19 as well as bacterial pneumonia, severe sepsis, and sytemic inflammatory response syndrome, according to the complaint. He died December 16 from respiratory and heart failure.
“What’s interesting about this case is that you’ve got a good example and a bad example together,” Mr. Ragsdale said. “In other words, the good example is they treated her appropriately, she recovered. They didn’t treat him at all, he died. I don’t know how you could have a better counter position established by the same practice.”
Family has sued for malpractice before
Before his death, Peter Dimoh was the plaintiff in another medical negligence suit. In 2013, he sued the Center for Oral and Facial Surgery of Memphis and two oral surgeons for allegedly operating on him improperly and causing an adverse outcome.
Mr. Dimoh underwent oral surgery on February 8, 2012, at the center. The day of his operation, Mr. Dimoh’s A1c and glucose levels were grossly elevated, according to the claim, which was also represented by Mr. Ragsdale. Surgeons concluded, incorrectly, that Mr. Dimoh’s diabetes was under control, the complaint alleges, failed to order preoperative antibiotics, operated on him, and caused a bacterial infection at the operative site. The infection allegedly resulted in osteomyelitis of Mr. Dimoh’s left mandible with a pathologic fracture.
The complaint also alleges that although Mr. Dimoh signed a consent form for the surgery, the defendants failed to obtain his consent because they were unaware his diabetes was not under control and they did not explain the risks of surgery while in such a condition. The suit alleges lack of informed consent, negligence, and gross negligence by the practice and requests $2 million in damages.
Court documents show the suit was voluntarily withdrawn in 2018 without prejudice and reissued in 2019. In January 2021, the court was given notice of Mr. Dimoh’s death, and a motion was made to substitute another plaintiff, according to Shelby County court records.
An attorney for the Center for Oral and Facial Surgery of Memphis did not return a message seeking comment.
A version of this article first appeared on Medscape.com.
, claiming the health providers failed to properly test the man and rendered improper care that led to his demise.
Shirley Dimoh of Memphis alleges her husband Peter Dimoh, 66, received inadequate care when he presented with COVID-19 symptoms to May Medical Group in Munford, Tenn., on November 19, 2020. Physician assistant Robert Moody ordered a COVID-19 blood test for Mr. Dimoh, rather than a nasal swab test, which was sent to an Atlanta lab for analysis, according to the lawsuit.
By the time the Dimohs were informed of the positive result on November 23, Mr. Dimoh was seriously ill and showed signs of severe infection, the claim alleges. Family physician David Krapf, DO, then prescribed methocarbamol, a muscle relaxant, which the complaint claims exacerbated Mr. Dimoh’s infection, caused serious adverse reactions, and led to his death on December 16, 2020.
“Mr. Dimoh had multiple comorbid conditions and he had a positive test, he should have been referred to a specialist at a higher level of care,” said Duncan E. Ragsdale, a Memphis-based attorney representing Shirley Dimoh. “This is not something for a family physician or a physician assistant to be attempting to handle. It’s my belief this was a preventable death.”
Shirley Dimoh filed a lawsuit against May Medical Group, Moody, Krapf, and several others on June 23, 2021, in the Circuit Court of Tennessee, 13th Judicial District. She accuses the group of negligence, failure to refer, and failure to supervise, among other claims. She is requesting $5 million in damages.
May Medical Group did not return phone or email messages seeking comment for this story. The group had not issued a reply to the lawsuit as of this article’s deadline. An attorney for the practice is not yet listed in court records.
Wife had COVID-19 first, treated by same PA
Shirley Dimoh was the first of the couple to contract COVID-19. She visited May Medical Group with COVID-19 symptoms on November 9, according to the lawsuit. The same physician assistant allegedly prescribed antibiotics and sent Shirley Dimoh to the health department for a rapid nasal swab test. After a positive test resulted, she was prescribed more antibiotics, steroids, and other medications, according to the claim. She recovered without complications.
The plaintiff alleges the medical practice did not warn Peter Dimoh of the risk of contracting COVID-19 from contact with Shirley Dimoh or offer prophylactics against infection. Peter Dimoh had underlying conditions that included diabetes and kidney failure, according to Mr. Ragsdale.
It’s unclear why Peter Dimoh may have been prescribed methocarbamol after his positive COVID-19 test on November 23. The same day, Shirley Dimoh went to the pharmacy to pick up her husband’s prescription because he was too sick to go himself, the complaint states. Mr. Dimoh took the medication three times a day as prescribed. The methocarbamol was “unreasonably dangerous” for Mr. Dimoh at the time and caused an injury he would have not incurred otherwise, the suit claims.
On November 28, Mr. Dimoh collapsed and was taken by ambulance to Methodist Hospital in Memphis. He was treated for COVID-19 as well as bacterial pneumonia, severe sepsis, and sytemic inflammatory response syndrome, according to the complaint. He died December 16 from respiratory and heart failure.
“What’s interesting about this case is that you’ve got a good example and a bad example together,” Mr. Ragsdale said. “In other words, the good example is they treated her appropriately, she recovered. They didn’t treat him at all, he died. I don’t know how you could have a better counter position established by the same practice.”
Family has sued for malpractice before
Before his death, Peter Dimoh was the plaintiff in another medical negligence suit. In 2013, he sued the Center for Oral and Facial Surgery of Memphis and two oral surgeons for allegedly operating on him improperly and causing an adverse outcome.
Mr. Dimoh underwent oral surgery on February 8, 2012, at the center. The day of his operation, Mr. Dimoh’s A1c and glucose levels were grossly elevated, according to the claim, which was also represented by Mr. Ragsdale. Surgeons concluded, incorrectly, that Mr. Dimoh’s diabetes was under control, the complaint alleges, failed to order preoperative antibiotics, operated on him, and caused a bacterial infection at the operative site. The infection allegedly resulted in osteomyelitis of Mr. Dimoh’s left mandible with a pathologic fracture.
The complaint also alleges that although Mr. Dimoh signed a consent form for the surgery, the defendants failed to obtain his consent because they were unaware his diabetes was not under control and they did not explain the risks of surgery while in such a condition. The suit alleges lack of informed consent, negligence, and gross negligence by the practice and requests $2 million in damages.
Court documents show the suit was voluntarily withdrawn in 2018 without prejudice and reissued in 2019. In January 2021, the court was given notice of Mr. Dimoh’s death, and a motion was made to substitute another plaintiff, according to Shelby County court records.
An attorney for the Center for Oral and Facial Surgery of Memphis did not return a message seeking comment.
A version of this article first appeared on Medscape.com.