Medicolegal Issues

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

Performance enhancement in sports (“doping”) dates back to Ancient Greece. This was an era when Olympic athletes would attempt to improve their physical performance by consuming magic potions, herbal medications, and even exotic meats such as sheep testicles—a delicacy high in testosterone. Advances in medical and pharmaceutical technologies have increased both the range of enhancement agents available and their efficacy, leading to the development of anti-doping agencies and routine screening for doping in athletics. This has led to the renouncement of titles, medals, and financial sponsorship of athletes found to have been using prohibited substances during competition.

While doping in elite athletes often forms the nidus of media attention, the pressure to compete and perform at, or even beyond, one’s potential extends into many facets of today’s achievementfocused society. In the face of these pressures, individuals are increasingly seeking medications to enhance their performance across numerous domains, including cognitive, athletic, and artistic endeavors. Medication classes used to enhance performance include stimulants, which increase attention, executive function, and energy; cholinesterase inhibitors, which may ameliorate age-related memory decline; and beta-blockers, which decrease physiologic symptoms of anxiety and have been demonstrated to be beneficial for musical performance.¹ Fifty-three percent of college athletes report using prescription medications to enhance athletic performance,² and most college students who take stimulants without a prescription use them to study (84%) or stay awake (51%).³

Pharmacologic performance enhancement is the use of medications by healthy individuals to improve function in the absence of mental illness. Psychiatrists are increasingly finding themselves in the controversial position of “gatekeeper” of these medications for enhancement purposes. In this article we:

• outline arguments that support the use of psychopharmacology for performance enhancement, as well as some serious concerns with this practice
• discuss special considerations for pediatric populations and the risk of malpractice when prescribing for performance enhancement
• offer practice guidelines for approaching requests for psychopharmacologic performance enhancement.

Performance enhancement: The wave of the future?

The ethical principle that supports providing medication for performance enhancement is beneficence, the promotion of the patient’s well-being. In other words, it is a physician’s duty to help his or her patient in need. Individuals seeking performance enhancement typically present with suffering, and the principle of beneficence would call upon the psychiatrist to help ameliorate that suffering. Furthermore, patients who seek performance enhancement may present with impairing “subsyndromal” psychiatric symptoms (for example, low-grade attentional difficulty that occurs only in one setting), which, even if they do not rise to the threshold of a DSM diagnosis, may improve with psychiatric medications.

Using medical knowledge and skills beyond the traditional physician duty to diagnose and treat medical conditions is not unprecedented (eg, when surgeons perform cosmetic enhancement). Might elective enhancement of cognition and psychological performance through the judicious use of medication be part of the future of psychiatry? If cognitive and emotional enhancement becomes a more widely accepted standard of care, might this increase both individual and societal innovation and productivity?

Dilemma: Cautions against performance enhancement

One of the major cautions against prescribing psychotropics for the purpose of performance enhancement is the lack of clearly supported efficacy. Psychiatric medications generally are studied in individuals who meet criteria for mental illness, and they are FDA-approved for use in ill persons. It may be erroneous to extrapolate that a medication that improves symptoms in a patient with an illness would achieve the same target effect in a healthy individual. For example, data on whether stimulants provide neurocognitive enhancement in healthy individuals without attention-deficit/hyperactivity disorder is mixed, and these agents may even promote risky behavior in healthy controls.⁴ Furthermore, dopamine agonism may compress cognitive performance in both directions,⁵ as it has been observed that methylphenidate improves executive function in healthy controls, but is less beneficial for those with strong executive function at baseline.⁶

In the face of unclear benefit, it is particularly important to consider the risk of medications used for performance enhancement. Pharmacologic performance enhancement in individuals without psychopathology can be considered an “elective” intervention, for which individuals typically tolerate less risk. Physical risks, including medication-related adverse effects, must be considered, particularly in settings where there may be temptation to use more than prescribed, or to divert medication to others who may use it without medical monitoring. In addition to physical harm, there may be psychological harm associated with prescribing performance enhancers, such as pathologizing variants of “normal,” diminishing one’s sense of self-efficacy, or decreasing one’s ability to bear failure.

Continue to: Finally, there are ethical quandaries

Finally, there are ethical quandaries regarding using medications for performance enhancement. Widespread adoption of pharmacologic performance enhancement may lead to implicit coercion for all individuals to enhance their abilities. As a greater proportion of society receives pharmacologic enhancement, society as a whole faces stronger pressures to seek pharmacologic enhancement, ultimately constricting an individual’s freedom of choice to enhance.⁶ In this setting, distributive justice would become a consideration, because insurance companies are unlikely to reimburse for medications used for enhancement,⁷ which would give an advantage to individuals with higher socioeconomic status. Research shows that children from higher socioeconomic communities and from states with higher academic standards are more likely to use stimulants.⁸

Areas of controversy

Pediatric populations. There are special considerations when prescribing performance-enhancing medications for children and adolescents. First, such prescribing may inhibit normal child development, shifting the focus away from the normative tasks of social and emotional development that occur through leisure and creativity, experimentation, and play to an emphasis on performance and outcomes-based achievement.⁹ Second, during childhood and adolescence, one develops a sense of his or her identity, morals, and values. Taking a medication during childhood to enhance performance may inhibit the process of learning to tolerate failure, become aware of one’s weaknesses, and value effort in addition to outcome.

Malpractice risk. Practicing medicine beyond the scope of one’s expertise is unethical and unlawful. In the past 30 years, medical malpractice has become one of the most difficult health care issues in the U.S.¹⁰ In addition to billions of dollars in legal fees and court costs, medical malpractice premiums in the U.S. total more than $5 billion annually,¹¹ and “defensive medicine”— procedures performed to protect against litigation—is estimated to cost more than $14 billion a year.¹²

When considering performance-enhancing treatment, it is the physician’s duty to conduct a diagnostic assessment, including noting target symptoms that are interfering with the patient’s function, and to tailor such treatment toward measurable goals and outcomes. Aside from medication, this could include a therapeutic approach to improving performance that might include cognitive-behavioral therapy and promotion of a healthy diet and exercise.

Treatment rises to the level of malpractice when there is a dereliction of duty that directly leads to damages.¹³ Part of a physician’s duty is to educate patients about the pros and cons of different treatment options. For performance-enhancing medications, the risks of addiction and dependence are adverse effects that require discussion. And for a pediatric patient, this would require the guardian’s engagement and understanding.

Continue to: What to do if you decide to prescribe

Inevitably, the decision to prescribe psychotropic medications for performance enhancement is a physician-specific one. Certainly, psychiatrists should not feel obligated to prescribe performance enhancers. Given our current state of pharmacology, it is unclear whether medications would be helpful in the absence of psychopathology. When deciding whether to prescribe for performance enhancement in the absence of psychopathology, we suggest first carefully considering how to maintain the ethical value of nonmaleficence by weighing both the potential physical and psychologic harms of prescribing as well as the legal risks and rules of applicable sport governing bodies.

For a psychiatrist who chooses to prescribe for performance enhancement, we recommend conducting a thorough psychiatric assessment to determine whether the patient has a treatable mental illness. If so, then effective treatment of that illness should take priority. Before prescribing, the psychiatrist and patient should discuss the patient’s specific performance goals and how to measure them.

Any prescription for a performance-enhancing medication should be given in conjunction with nonpharmacologic approaches, including optimizing diet, exercise, and sleep. Therapy to address problem-solving techniques and skills to cope with stress may also be appropriate. The patient and psychiatrist should engage in regular follow-up to assess the efficacy of the medication, as well as its safety and tolerability. Finally, if a medication is not efficacious as a performance enhancer, then both the patient and psychiatrist should be open to re-evaluating the treatment plan, and when appropriate, stopping the medication.

A 42-year-old man presented to the ED with a cut to his left forearm from a piece of metal. The patient only complained of pain at the site of injury; he had no numbness or weakness of the left hand. The patient was otherwise in good health, was taking no medications, and was current with his tetanus immunization.

On physical examination, the patient’s vital signs were normal. The emergency physician (EP) documented a vertical laceration of the mid-left forearm on the dorsal aspect, measuring 6 x 2 cm. The wound edges could be easily approximated. The distal motor and sensory exams were normal.

The EP anesthetized the area with local infiltration using 1% plain xylocaine. The EP then picked up a bottle of CaviCide that had been sitting on the counter and sprayed it on the patient’s wound. The patient immediately complained of burning pain, but the EP continued to spray the wound before suturing it closed with 4.0 nylon.

The patient, however, stated the pain was unbearable. He showed the ED manager the bottle of CaviCide and asked if it was an appropriate sterilizing solution for wounds. When informed it was not, the patient demanded the sutures be removed and the wound re-opened and irrigated with an appropriate solution. The EP re-opened the wound, irrigated it with sterile normal saline, and closed it once again using 4.0 nylon. The EP apologized to the patient, admitted that he made a mistake, and discharged the patient home with instructions to have the sutures removed in 10 days.

The patient developed severe pain at the site a few hours later, prompting him to go to a different ED. They applied lidocaine gel to the area and recommended ibuprofen by mouth for pain. The patient was discharged home.

The patient sued the EP, the nurse, and the hospital for negligence. The plaintiff alleged that under no circumstances should CaviCide be used on humans. The plaintiff’s EM expert testified that the error represented gross negligence. The hospital admitted the nurse violated the standard of care for not properly storing the CaviCide. The EP expert for the defense argued the patient did not suffer any new injury or pain, and that his symptoms were due to the laceration. A second defense expert (toxicology) explained that CaviCide is not toxic and that it would only cause short-term irritation. The plaintiff’s counsel asked for $172,800 in damages, explaining that he was requesting $1 per second for the time the patient experienced intense pain.  After deliberating for five hours, the jury found in favor of the defense.

DISCUSSION

Over the years, I have seen variations of this case: hemoccult solution placed in the eye under the impression it was a topical anesthetic, and 1:1000 epinephrine given intravenously (IV) when it was thought to be 1:10,000 concentration.

The way to avoid this mistake is to force yourself to take a good look at whatever medication you are administering to a patient, be it by mouth or IV, on the eye or skin, in a muscle, or up the rectum. Read the name of the medication before giving it. It is fortunate for all involved in this case that no serious or permanent injury occurred.

According to the manufacturer of CaviCide (Metrex), it is a “convenient, ready-to-use, intermediate-level surface disinfectant which is effective against tuberculosis, HBV, HCV, viruses (hydrophilic and lipophilic), bacteria (including MRSA and VRE), and fungi. It is safe for use on non-porous surfaces, and for cleaning environmental and medical device surfaces.” While it sounds great for cleaning surfaces and objects, it is clearly not the right product to spray on a wound.

This accident falls under the general heading of a medication error. This category includes: selecting the wrong medication or dosage; giving the medication at the wrong frequency; administration to the wrong patient or via the wrong route; or failure to monitor the patients’ response to the medication. In the risk management world, it is recommended that providers consistently perform the “five rights” of medication administration: right patient; right drug; right dosage; right time; and right route. This case illustrates the problem of “right drug.” Clearly, CaviCide was not the right drug for this patient. Given different circumstances, the harm could have been significant.

SUMMARY

Fortunately, this is a relatively simple take-home message: know what drug you are giving your patient, always.

A 42-year-old man presented to the ED with a cut to his left forearm from a piece of metal. The patient only complained of pain at the site of injury; he had no numbness or weakness of the left hand. The patient was otherwise in good health, was taking no medications, and was current with his tetanus immunization.

On physical examination, the patient’s vital signs were normal. The emergency physician (EP) documented a vertical laceration of the mid-left forearm on the dorsal aspect, measuring 6 x 2 cm. The wound edges could be easily approximated. The distal motor and sensory exams were normal.

The EP anesthetized the area with local infiltration using 1% plain xylocaine. The EP then picked up a bottle of CaviCide that had been sitting on the counter and sprayed it on the patient’s wound. The patient immediately complained of burning pain, but the EP continued to spray the wound before suturing it closed with 4.0 nylon.

The patient, however, stated the pain was unbearable. He showed the ED manager the bottle of CaviCide and asked if it was an appropriate sterilizing solution for wounds. When informed it was not, the patient demanded the sutures be removed and the wound re-opened and irrigated with an appropriate solution. The EP re-opened the wound, irrigated it with sterile normal saline, and closed it once again using 4.0 nylon. The EP apologized to the patient, admitted that he made a mistake, and discharged the patient home with instructions to have the sutures removed in 10 days.

The patient developed severe pain at the site a few hours later, prompting him to go to a different ED. They applied lidocaine gel to the area and recommended ibuprofen by mouth for pain. The patient was discharged home.

The patient sued the EP, the nurse, and the hospital for negligence. The plaintiff alleged that under no circumstances should CaviCide be used on humans. The plaintiff’s EM expert testified that the error represented gross negligence. The hospital admitted the nurse violated the standard of care for not properly storing the CaviCide. The EP expert for the defense argued the patient did not suffer any new injury or pain, and that his symptoms were due to the laceration. A second defense expert (toxicology) explained that CaviCide is not toxic and that it would only cause short-term irritation. The plaintiff’s counsel asked for $172,800 in damages, explaining that he was requesting $1 per second for the time the patient experienced intense pain.  After deliberating for five hours, the jury found in favor of the defense.

DISCUSSION

Over the years, I have seen variations of this case: hemoccult solution placed in the eye under the impression it was a topical anesthetic, and 1:1000 epinephrine given intravenously (IV) when it was thought to be 1:10,000 concentration.

The way to avoid this mistake is to force yourself to take a good look at whatever medication you are administering to a patient, be it by mouth or IV, on the eye or skin, in a muscle, or up the rectum. Read the name of the medication before giving it. It is fortunate for all involved in this case that no serious or permanent injury occurred.

According to the manufacturer of CaviCide (Metrex), it is a “convenient, ready-to-use, intermediate-level surface disinfectant which is effective against tuberculosis, HBV, HCV, viruses (hydrophilic and lipophilic), bacteria (including MRSA and VRE), and fungi. It is safe for use on non-porous surfaces, and for cleaning environmental and medical device surfaces.” While it sounds great for cleaning surfaces and objects, it is clearly not the right product to spray on a wound.

This accident falls under the general heading of a medication error. This category includes: selecting the wrong medication or dosage; giving the medication at the wrong frequency; administration to the wrong patient or via the wrong route; or failure to monitor the patients’ response to the medication. In the risk management world, it is recommended that providers consistently perform the “five rights” of medication administration: right patient; right drug; right dosage; right time; and right route. This case illustrates the problem of “right drug.” Clearly, CaviCide was not the right drug for this patient. Given different circumstances, the harm could have been significant.

SUMMARY

Fortunately, this is a relatively simple take-home message: know what drug you are giving your patient, always.

A 42-year-old man presented to the ED with a cut to his left forearm from a piece of metal. The patient only complained of pain at the site of injury; he had no numbness or weakness of the left hand. The patient was otherwise in good health, was taking no medications, and was current with his tetanus immunization.

On physical examination, the patient’s vital signs were normal. The emergency physician (EP) documented a vertical laceration of the mid-left forearm on the dorsal aspect, measuring 6 x 2 cm. The wound edges could be easily approximated. The distal motor and sensory exams were normal.

The EP anesthetized the area with local infiltration using 1% plain xylocaine. The EP then picked up a bottle of CaviCide that had been sitting on the counter and sprayed it on the patient’s wound. The patient immediately complained of burning pain, but the EP continued to spray the wound before suturing it closed with 4.0 nylon.

The patient, however, stated the pain was unbearable. He showed the ED manager the bottle of CaviCide and asked if it was an appropriate sterilizing solution for wounds. When informed it was not, the patient demanded the sutures be removed and the wound re-opened and irrigated with an appropriate solution. The EP re-opened the wound, irrigated it with sterile normal saline, and closed it once again using 4.0 nylon. The EP apologized to the patient, admitted that he made a mistake, and discharged the patient home with instructions to have the sutures removed in 10 days.

The patient developed severe pain at the site a few hours later, prompting him to go to a different ED. They applied lidocaine gel to the area and recommended ibuprofen by mouth for pain. The patient was discharged home.

The patient sued the EP, the nurse, and the hospital for negligence. The plaintiff alleged that under no circumstances should CaviCide be used on humans. The plaintiff’s EM expert testified that the error represented gross negligence. The hospital admitted the nurse violated the standard of care for not properly storing the CaviCide. The EP expert for the defense argued the patient did not suffer any new injury or pain, and that his symptoms were due to the laceration. A second defense expert (toxicology) explained that CaviCide is not toxic and that it would only cause short-term irritation. The plaintiff’s counsel asked for $172,800 in damages, explaining that he was requesting $1 per second for the time the patient experienced intense pain.  After deliberating for five hours, the jury found in favor of the defense.

DISCUSSION

Over the years, I have seen variations of this case: hemoccult solution placed in the eye under the impression it was a topical anesthetic, and 1:1000 epinephrine given intravenously (IV) when it was thought to be 1:10,000 concentration.

The way to avoid this mistake is to force yourself to take a good look at whatever medication you are administering to a patient, be it by mouth or IV, on the eye or skin, in a muscle, or up the rectum. Read the name of the medication before giving it. It is fortunate for all involved in this case that no serious or permanent injury occurred.

According to the manufacturer of CaviCide (Metrex), it is a “convenient, ready-to-use, intermediate-level surface disinfectant which is effective against tuberculosis, HBV, HCV, viruses (hydrophilic and lipophilic), bacteria (including MRSA and VRE), and fungi. It is safe for use on non-porous surfaces, and for cleaning environmental and medical device surfaces.” While it sounds great for cleaning surfaces and objects, it is clearly not the right product to spray on a wound.

This accident falls under the general heading of a medication error. This category includes: selecting the wrong medication or dosage; giving the medication at the wrong frequency; administration to the wrong patient or via the wrong route; or failure to monitor the patients’ response to the medication. In the risk management world, it is recommended that providers consistently perform the “five rights” of medication administration: right patient; right drug; right dosage; right time; and right route. This case illustrates the problem of “right drug.” Clearly, CaviCide was not the right drug for this patient. Given different circumstances, the harm could have been significant.

SUMMARY

Fortunately, this is a relatively simple take-home message: know what drug you are giving your patient, always.

The 2017−2018 term of the Supreme Court of the United States (SCOTUS) was momentous. Justice Anthony Kennedy, who had been the deciding vote in most of the 5 to 4 cases for a generation, announced his retirement as of July 31, 2018. In addition, the Court decided a number of cases of interest to ObGyns. In this article we review some of those cases, as well as consider the future of the Court without Justice Kennedy. In selecting cases, we have given special attention to those in which national medical organizations filed amicus briefs. These “amicus curiae” or “friend of the court” briefs are filed by an entity who is not party to a case but wants to provide information or views to the court.

1. Abortion rulings

The Court decided 2 abortion cases and rejected a request to hear a third.

National Institute of Family and Life Advocates v Becerra

In this case,¹ the Court struck down a California law that required pregnancy crisis centers not offering abortions (generally operated by pro-life groups) to provide special notices to clients.²

At stake. These notices would inform clients that California provides free or low-cost services, including abortions, and provide a phone number to call for those services.

There were many amicus briefs filed in this case, including those by the American College of Obstetricians and Gynecologists (ACOG) and other specialty boards,³ as well as the American Association of Pro-Life Obstetricians and Gynecologists and other pro-life organizations.⁴ ACOG’s brief argued that the California-required notice facilitates the goal of allowing women to receive medical services without harmful delay.

Final ruling. The Court held that the law required clinics to engage in speech with which the clinics disagreed (known as “compelled speech”). It also noted that California disclosure requirements were “wildly underinclusive” because they apply only to some clinics. The majority felt that there was no strong state interest in compelling this speech because there were other alternatives for the state to provide information about the availability of abortion and other services. The Court found that the clinics were likely to succeed on the merits of their claims of a First Amendment (free speech) violation.

Right to abortion for illegal immigrants in custody

A very unusual abortion case involved “Jane Doe,” a minor who was at 8 weeks’ gestation when she illegally crossed the border into the United States.⁵ She was placed in a federally-funded shelter where she requested an abortion. The facility denied that request.

At stake. Legal argument ensued about releasing her to another facility for an abortion, as the argument was made that pregnant minors who are apprehended crossing into the United States illegally and placed into the custody of federal officials should have abortion access. A lower Court of Appeals ruled against the Trump Administration’s policy of denying abortions to undocumented minors in federal custody. During the process of the federal government taking the case to the Supreme Court, the attorneys for Doe moved appointments around and, without notice, the abortion was performed. Government attorneys said that Doe’s attorneys made “what appear to be material misrepresentations and omissions” designed to “thwart [the Supreme Court’s] review” of the case.⁵ The government requested that the Court vacate the order of the Court of Appeals so that it could not be used as precedent.

Final ruling. The Court granted the governments request to vacate the lower court’s order because the minor was no longer pregnant and the order was therefore moot. The basic issue in this case (the right of in-custody minors to access abortions) remains unresolved. It is likely to appear before the Court in the future.

Continue to: Access to medical abortions

An Arkansas law requires that a physician administering medical abortions contract with a physician who has admitting privileges at a hospital (a “contracted physician”).

At stake. Planned Parenthood filed suit challenging the requirement as unnecessary and harmful because it would result in the closure of 2 of the 3 abortion providers in Arkansas. ACOG filed an amicus brief urging the Supreme Court to consider the case.⁶ (Technically this was a petition for a Writ of Certiorari, the procedure by which the Court accepts cases. It accepts only about 1% of applications.) ACOG argued that there was no medical reason for the contracted physician requirement, and noted the harm it would do to women who would not have access to abortions.

Final ruling. On May 29, 2018, the Court declined to hear the case. This case is still active in the lower courts and may eventually return to the Supreme Court.

2. The patent system

The medical profession depends on the patent system to encourage the discovery of new patents efficiently and effectively. In 2012, Congress passed the America Invents Act⁷ that authorizes a petition by anyone other than the patent holder to the Patent and Trademark Office (PTO) for an “inter partes review” to assess a challenge to the patent’s legitimacy. If the PTO determines that there may be merit to the claim, the Patent Trial and Appeal Board undertakes a trial-like review process that may validate, invalidate, or amend the patent. The Board’s decision is subject to appellate court review.

At stake. This term, the inter partes review was challenged as unconstitutional on technical bases.⁸

Final ruling. The Court rejected this claim and approved the current administrative inter partes review process. The Court determined that once the Patent Office takes a petition challenging a patent, it must decide all of the claims against the patent, not pick and choose which elements of the challenge to evaluate.⁹ The Court’s decision upheld patent-review reform, but will require the Patent Office to tweak its procedures.

3. The travel ban

ACOG, the American Medical Association (AMA), the Association of American Medical Colleges, and more than 30 other health care and specialty associations filed an amicus brief regarding one of the most anticipated cases of the term—the “travel ban.”¹⁰

At stake. The essential argument of these organizations was that the US health care system depends on professionals from other countries. An efficient and fair immigration program is, therefore, important to advance the nation’s “health security.” During the 2016−2017 term, the Court considered but then removed the issue from its calendar when the Trump Administration issued a revised travel ban.¹¹

In September 2017, President Trump’s proclamation imposed a range of entry restrictions on the citizens of 8 countries, most (but not all) of which are predominantly Muslim. The government indicated that, in a study by Homeland Security and the State Department, these countries were identified as having especially deficient information-sharing practices and presented national security concerns. Trump v Hawaii¹² challenged this proclamation.

Final ruling. The majority of the Court upheld the travel ban. For the 5-Justice majority led by Chief Justice Roberts, the case came down to 3 things:

1. The Constitution and the laws passed by Congress of necessity give the President great authority to engage in foreign policy, including policies regarding entry into the country.
2. The courts are very reluctant to get into the substance of foreign affairs—they are not equipped to know in detail what the facts are, and things change very fast.
3. If courts start tinkering with foreign policy and things turn bad, it will appear that the courts are to blame and were interfering in an area about which they are not competent.

Continue to: 4. Did a credit card case add risk to health insurance markets?

It was just a credit card case, but one in which the AMA saw a real risk to regulation of the health insurance markets.

At stake. Technically, Ohio v American Express concerned a claim that American Express (AmEx) violated antitrust laws when it prohibited merchants taking its credit card from “steering” customers to cards with lower fees.¹³ AmEx maintained that, because credit cards were a special kind of “2-sided” market (connecting merchants on one side and customers on the other), antitrust laws should not be strictly enforced.

The AMA noticed that special rules regarding 2-sided markets might apply to health insurance, and it submitted an amicus brief¹⁴ that noted: “dominant health insurance networks … have imposed and could further impose rules or effectively erect barriers that prohibit physicians from referring patients to certain specialists, particularly out-of-network specialists, for innovative and even necessary medical tests.”¹⁴ It concluded that the antitrust rule AmEx was suggesting would make it nearly impossible to challenge these unfair provisions in health insurance arrangements.

Final ruling. The Court, however, accepted the AmEx position, making it very difficult to develop an antitrust case against 2-sided markets. It remains to be seen the degree to which the AMA concern about health insurance markets will be realized.

5. Gay wedding and a bakeshop

At stake. In Masterpiece Cakeshop v Colorado, a cakemaker declined to design a cake for a gay wedding and had been disciplined under Colorado law for discriminating against the couple based on sexual orientation.¹⁵

Final ruling. The Court, however, found that the Colorado regulators had, ironically, shown such religious animus in the way they treated the baker that the regulators themselves had discriminated on the basis of religion. As a result, the Court reversed the sanctions against the baker.

This decision was fairly narrow. It does not, for example, stand for the proposition that there may be a general religious exception to antidiscrimination laws. The question of broader religious or free-speech objections to antidiscrimination laws remains for another time.

Amicus brief. It was interesting that the American College of Pediatricians, American Association of Pro-Life Obstetricians and Gynecologists, and others, filed an amicus brief to report with concern the “demands that individual medical professionals must perform, assist with, or facilitate abortions, without regard to the teachings of their own faiths, consciences, and convictions.”¹⁶ The brief also noted that “issues in the present case implicate the fundamental rights of health care professionals, and to respectfully urge that the Court should by no means permit any weakening or qualification of well-established protections against compelled speech, and of free exercise” of religion.¹⁶

Clues to the future

During the term that ran from October 2, 2017, through June 27, 2018, the Court issued 72 decisions. An unusually high proportion of cases (26%; 19 cases) were decided on a 5 to 4 vote. Last term, the rate of 5 to 4 decisions was 10%; the 6-year average was 18%. The unanimous decision rate was 39% this term, compared with 59% last term, and 50% on average.

The rate of 5 to 4 cases provides a clue about the Court’s general direction. The number of times each Justice was in the majority in those nineteen 5 to 4 decisions included: Chief Justice Roberts, 17; and Justices Kennedy, 16; Gorsuch, 16; Thomas, 15; and Alito, 15; compared with Justices Ginsburg, 5; Breyer, 4; Sotomayor, 4; and Kagan, 3.

The Court convened on October 1, 2018. At this writing, whether the new term starts with 8 or 9 justices remains a question. President Trump nominated Brett Kavanaugh, JD, to take Justice Kennedy’s place on the Court. His professional qualifications and experience appear to make him qualified for a position on the Court, but as we have seen, there are many other elements that go into confirming a Justice’s nomination.

Next term, the Court is scheduled to hear cases regarding pharmaceutical liability, double jeopardy, sex-offender registration, expert witnesses, Social Security disability benefits, and the Age Discrimination in Employment Act. There will be at least 3 arbitration cases. Health care and reproductive rights will continue to be an important part of the Court’s docket.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

The 2017−2018 term of the Supreme Court of the United States (SCOTUS) was momentous. Justice Anthony Kennedy, who had been the deciding vote in most of the 5 to 4 cases for a generation, announced his retirement as of July 31, 2018. In addition, the Court decided a number of cases of interest to ObGyns. In this article we review some of those cases, as well as consider the future of the Court without Justice Kennedy. In selecting cases, we have given special attention to those in which national medical organizations filed amicus briefs. These “amicus curiae” or “friend of the court” briefs are filed by an entity who is not party to a case but wants to provide information or views to the court.

1. Abortion rulings

The Court decided 2 abortion cases and rejected a request to hear a third.

National Institute of Family and Life Advocates v Becerra

In this case,¹ the Court struck down a California law that required pregnancy crisis centers not offering abortions (generally operated by pro-life groups) to provide special notices to clients.²

At stake. These notices would inform clients that California provides free or low-cost services, including abortions, and provide a phone number to call for those services.

There were many amicus briefs filed in this case, including those by the American College of Obstetricians and Gynecologists (ACOG) and other specialty boards,³ as well as the American Association of Pro-Life Obstetricians and Gynecologists and other pro-life organizations.⁴ ACOG’s brief argued that the California-required notice facilitates the goal of allowing women to receive medical services without harmful delay.

Final ruling. The Court held that the law required clinics to engage in speech with which the clinics disagreed (known as “compelled speech”). It also noted that California disclosure requirements were “wildly underinclusive” because they apply only to some clinics. The majority felt that there was no strong state interest in compelling this speech because there were other alternatives for the state to provide information about the availability of abortion and other services. The Court found that the clinics were likely to succeed on the merits of their claims of a First Amendment (free speech) violation.

Right to abortion for illegal immigrants in custody

A very unusual abortion case involved “Jane Doe,” a minor who was at 8 weeks’ gestation when she illegally crossed the border into the United States.⁵ She was placed in a federally-funded shelter where she requested an abortion. The facility denied that request.

At stake. Legal argument ensued about releasing her to another facility for an abortion, as the argument was made that pregnant minors who are apprehended crossing into the United States illegally and placed into the custody of federal officials should have abortion access. A lower Court of Appeals ruled against the Trump Administration’s policy of denying abortions to undocumented minors in federal custody. During the process of the federal government taking the case to the Supreme Court, the attorneys for Doe moved appointments around and, without notice, the abortion was performed. Government attorneys said that Doe’s attorneys made “what appear to be material misrepresentations and omissions” designed to “thwart [the Supreme Court’s] review” of the case.⁵ The government requested that the Court vacate the order of the Court of Appeals so that it could not be used as precedent.

Final ruling. The Court granted the governments request to vacate the lower court’s order because the minor was no longer pregnant and the order was therefore moot. The basic issue in this case (the right of in-custody minors to access abortions) remains unresolved. It is likely to appear before the Court in the future.

Continue to: Access to medical abortions

An Arkansas law requires that a physician administering medical abortions contract with a physician who has admitting privileges at a hospital (a “contracted physician”).

At stake. Planned Parenthood filed suit challenging the requirement as unnecessary and harmful because it would result in the closure of 2 of the 3 abortion providers in Arkansas. ACOG filed an amicus brief urging the Supreme Court to consider the case.⁶ (Technically this was a petition for a Writ of Certiorari, the procedure by which the Court accepts cases. It accepts only about 1% of applications.) ACOG argued that there was no medical reason for the contracted physician requirement, and noted the harm it would do to women who would not have access to abortions.

Final ruling. On May 29, 2018, the Court declined to hear the case. This case is still active in the lower courts and may eventually return to the Supreme Court.

2. The patent system

The medical profession depends on the patent system to encourage the discovery of new patents efficiently and effectively. In 2012, Congress passed the America Invents Act⁷ that authorizes a petition by anyone other than the patent holder to the Patent and Trademark Office (PTO) for an “inter partes review” to assess a challenge to the patent’s legitimacy. If the PTO determines that there may be merit to the claim, the Patent Trial and Appeal Board undertakes a trial-like review process that may validate, invalidate, or amend the patent. The Board’s decision is subject to appellate court review.

At stake. This term, the inter partes review was challenged as unconstitutional on technical bases.⁸

Final ruling. The Court rejected this claim and approved the current administrative inter partes review process. The Court determined that once the Patent Office takes a petition challenging a patent, it must decide all of the claims against the patent, not pick and choose which elements of the challenge to evaluate.⁹ The Court’s decision upheld patent-review reform, but will require the Patent Office to tweak its procedures.

3. The travel ban

ACOG, the American Medical Association (AMA), the Association of American Medical Colleges, and more than 30 other health care and specialty associations filed an amicus brief regarding one of the most anticipated cases of the term—the “travel ban.”¹⁰

At stake. The essential argument of these organizations was that the US health care system depends on professionals from other countries. An efficient and fair immigration program is, therefore, important to advance the nation’s “health security.” During the 2016−2017 term, the Court considered but then removed the issue from its calendar when the Trump Administration issued a revised travel ban.¹¹

In September 2017, President Trump’s proclamation imposed a range of entry restrictions on the citizens of 8 countries, most (but not all) of which are predominantly Muslim. The government indicated that, in a study by Homeland Security and the State Department, these countries were identified as having especially deficient information-sharing practices and presented national security concerns. Trump v Hawaii¹² challenged this proclamation.

Final ruling. The majority of the Court upheld the travel ban. For the 5-Justice majority led by Chief Justice Roberts, the case came down to 3 things:

1. The Constitution and the laws passed by Congress of necessity give the President great authority to engage in foreign policy, including policies regarding entry into the country.
2. The courts are very reluctant to get into the substance of foreign affairs—they are not equipped to know in detail what the facts are, and things change very fast.
3. If courts start tinkering with foreign policy and things turn bad, it will appear that the courts are to blame and were interfering in an area about which they are not competent.

Continue to: 4. Did a credit card case add risk to health insurance markets?

It was just a credit card case, but one in which the AMA saw a real risk to regulation of the health insurance markets.

At stake. Technically, Ohio v American Express concerned a claim that American Express (AmEx) violated antitrust laws when it prohibited merchants taking its credit card from “steering” customers to cards with lower fees.¹³ AmEx maintained that, because credit cards were a special kind of “2-sided” market (connecting merchants on one side and customers on the other), antitrust laws should not be strictly enforced.

The AMA noticed that special rules regarding 2-sided markets might apply to health insurance, and it submitted an amicus brief¹⁴ that noted: “dominant health insurance networks … have imposed and could further impose rules or effectively erect barriers that prohibit physicians from referring patients to certain specialists, particularly out-of-network specialists, for innovative and even necessary medical tests.”¹⁴ It concluded that the antitrust rule AmEx was suggesting would make it nearly impossible to challenge these unfair provisions in health insurance arrangements.

Final ruling. The Court, however, accepted the AmEx position, making it very difficult to develop an antitrust case against 2-sided markets. It remains to be seen the degree to which the AMA concern about health insurance markets will be realized.

5. Gay wedding and a bakeshop

At stake. In Masterpiece Cakeshop v Colorado, a cakemaker declined to design a cake for a gay wedding and had been disciplined under Colorado law for discriminating against the couple based on sexual orientation.¹⁵

Final ruling. The Court, however, found that the Colorado regulators had, ironically, shown such religious animus in the way they treated the baker that the regulators themselves had discriminated on the basis of religion. As a result, the Court reversed the sanctions against the baker.

This decision was fairly narrow. It does not, for example, stand for the proposition that there may be a general religious exception to antidiscrimination laws. The question of broader religious or free-speech objections to antidiscrimination laws remains for another time.

Amicus brief. It was interesting that the American College of Pediatricians, American Association of Pro-Life Obstetricians and Gynecologists, and others, filed an amicus brief to report with concern the “demands that individual medical professionals must perform, assist with, or facilitate abortions, without regard to the teachings of their own faiths, consciences, and convictions.”¹⁶ The brief also noted that “issues in the present case implicate the fundamental rights of health care professionals, and to respectfully urge that the Court should by no means permit any weakening or qualification of well-established protections against compelled speech, and of free exercise” of religion.¹⁶

Clues to the future

During the term that ran from October 2, 2017, through June 27, 2018, the Court issued 72 decisions. An unusually high proportion of cases (26%; 19 cases) were decided on a 5 to 4 vote. Last term, the rate of 5 to 4 decisions was 10%; the 6-year average was 18%. The unanimous decision rate was 39% this term, compared with 59% last term, and 50% on average.

The rate of 5 to 4 cases provides a clue about the Court’s general direction. The number of times each Justice was in the majority in those nineteen 5 to 4 decisions included: Chief Justice Roberts, 17; and Justices Kennedy, 16; Gorsuch, 16; Thomas, 15; and Alito, 15; compared with Justices Ginsburg, 5; Breyer, 4; Sotomayor, 4; and Kagan, 3.

The Court convened on October 1, 2018. At this writing, whether the new term starts with 8 or 9 justices remains a question. President Trump nominated Brett Kavanaugh, JD, to take Justice Kennedy’s place on the Court. His professional qualifications and experience appear to make him qualified for a position on the Court, but as we have seen, there are many other elements that go into confirming a Justice’s nomination.

Next term, the Court is scheduled to hear cases regarding pharmaceutical liability, double jeopardy, sex-offender registration, expert witnesses, Social Security disability benefits, and the Age Discrimination in Employment Act. There will be at least 3 arbitration cases. Health care and reproductive rights will continue to be an important part of the Court’s docket.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

The 2017−2018 term of the Supreme Court of the United States (SCOTUS) was momentous. Justice Anthony Kennedy, who had been the deciding vote in most of the 5 to 4 cases for a generation, announced his retirement as of July 31, 2018. In addition, the Court decided a number of cases of interest to ObGyns. In this article we review some of those cases, as well as consider the future of the Court without Justice Kennedy. In selecting cases, we have given special attention to those in which national medical organizations filed amicus briefs. These “amicus curiae” or “friend of the court” briefs are filed by an entity who is not party to a case but wants to provide information or views to the court.

1. Abortion rulings

The Court decided 2 abortion cases and rejected a request to hear a third.

National Institute of Family and Life Advocates v Becerra

In this case,¹ the Court struck down a California law that required pregnancy crisis centers not offering abortions (generally operated by pro-life groups) to provide special notices to clients.²

At stake. These notices would inform clients that California provides free or low-cost services, including abortions, and provide a phone number to call for those services.

There were many amicus briefs filed in this case, including those by the American College of Obstetricians and Gynecologists (ACOG) and other specialty boards,³ as well as the American Association of Pro-Life Obstetricians and Gynecologists and other pro-life organizations.⁴ ACOG’s brief argued that the California-required notice facilitates the goal of allowing women to receive medical services without harmful delay.

Final ruling. The Court held that the law required clinics to engage in speech with which the clinics disagreed (known as “compelled speech”). It also noted that California disclosure requirements were “wildly underinclusive” because they apply only to some clinics. The majority felt that there was no strong state interest in compelling this speech because there were other alternatives for the state to provide information about the availability of abortion and other services. The Court found that the clinics were likely to succeed on the merits of their claims of a First Amendment (free speech) violation.

Right to abortion for illegal immigrants in custody

A very unusual abortion case involved “Jane Doe,” a minor who was at 8 weeks’ gestation when she illegally crossed the border into the United States.⁵ She was placed in a federally-funded shelter where she requested an abortion. The facility denied that request.

At stake. Legal argument ensued about releasing her to another facility for an abortion, as the argument was made that pregnant minors who are apprehended crossing into the United States illegally and placed into the custody of federal officials should have abortion access. A lower Court of Appeals ruled against the Trump Administration’s policy of denying abortions to undocumented minors in federal custody. During the process of the federal government taking the case to the Supreme Court, the attorneys for Doe moved appointments around and, without notice, the abortion was performed. Government attorneys said that Doe’s attorneys made “what appear to be material misrepresentations and omissions” designed to “thwart [the Supreme Court’s] review” of the case.⁵ The government requested that the Court vacate the order of the Court of Appeals so that it could not be used as precedent.

Final ruling. The Court granted the governments request to vacate the lower court’s order because the minor was no longer pregnant and the order was therefore moot. The basic issue in this case (the right of in-custody minors to access abortions) remains unresolved. It is likely to appear before the Court in the future.

Continue to: Access to medical abortions

An Arkansas law requires that a physician administering medical abortions contract with a physician who has admitting privileges at a hospital (a “contracted physician”).

At stake. Planned Parenthood filed suit challenging the requirement as unnecessary and harmful because it would result in the closure of 2 of the 3 abortion providers in Arkansas. ACOG filed an amicus brief urging the Supreme Court to consider the case.⁶ (Technically this was a petition for a Writ of Certiorari, the procedure by which the Court accepts cases. It accepts only about 1% of applications.) ACOG argued that there was no medical reason for the contracted physician requirement, and noted the harm it would do to women who would not have access to abortions.

Final ruling. On May 29, 2018, the Court declined to hear the case. This case is still active in the lower courts and may eventually return to the Supreme Court.

2. The patent system

The medical profession depends on the patent system to encourage the discovery of new patents efficiently and effectively. In 2012, Congress passed the America Invents Act⁷ that authorizes a petition by anyone other than the patent holder to the Patent and Trademark Office (PTO) for an “inter partes review” to assess a challenge to the patent’s legitimacy. If the PTO determines that there may be merit to the claim, the Patent Trial and Appeal Board undertakes a trial-like review process that may validate, invalidate, or amend the patent. The Board’s decision is subject to appellate court review.

At stake. This term, the inter partes review was challenged as unconstitutional on technical bases.⁸

Final ruling. The Court rejected this claim and approved the current administrative inter partes review process. The Court determined that once the Patent Office takes a petition challenging a patent, it must decide all of the claims against the patent, not pick and choose which elements of the challenge to evaluate.⁹ The Court’s decision upheld patent-review reform, but will require the Patent Office to tweak its procedures.

3. The travel ban

ACOG, the American Medical Association (AMA), the Association of American Medical Colleges, and more than 30 other health care and specialty associations filed an amicus brief regarding one of the most anticipated cases of the term—the “travel ban.”¹⁰

At stake. The essential argument of these organizations was that the US health care system depends on professionals from other countries. An efficient and fair immigration program is, therefore, important to advance the nation’s “health security.” During the 2016−2017 term, the Court considered but then removed the issue from its calendar when the Trump Administration issued a revised travel ban.¹¹

In September 2017, President Trump’s proclamation imposed a range of entry restrictions on the citizens of 8 countries, most (but not all) of which are predominantly Muslim. The government indicated that, in a study by Homeland Security and the State Department, these countries were identified as having especially deficient information-sharing practices and presented national security concerns. Trump v Hawaii¹² challenged this proclamation.

Final ruling. The majority of the Court upheld the travel ban. For the 5-Justice majority led by Chief Justice Roberts, the case came down to 3 things:

1. The Constitution and the laws passed by Congress of necessity give the President great authority to engage in foreign policy, including policies regarding entry into the country.
2. The courts are very reluctant to get into the substance of foreign affairs—they are not equipped to know in detail what the facts are, and things change very fast.
3. If courts start tinkering with foreign policy and things turn bad, it will appear that the courts are to blame and were interfering in an area about which they are not competent.

Continue to: 4. Did a credit card case add risk to health insurance markets?

It was just a credit card case, but one in which the AMA saw a real risk to regulation of the health insurance markets.

At stake. Technically, Ohio v American Express concerned a claim that American Express (AmEx) violated antitrust laws when it prohibited merchants taking its credit card from “steering” customers to cards with lower fees.¹³ AmEx maintained that, because credit cards were a special kind of “2-sided” market (connecting merchants on one side and customers on the other), antitrust laws should not be strictly enforced.

The AMA noticed that special rules regarding 2-sided markets might apply to health insurance, and it submitted an amicus brief¹⁴ that noted: “dominant health insurance networks … have imposed and could further impose rules or effectively erect barriers that prohibit physicians from referring patients to certain specialists, particularly out-of-network specialists, for innovative and even necessary medical tests.”¹⁴ It concluded that the antitrust rule AmEx was suggesting would make it nearly impossible to challenge these unfair provisions in health insurance arrangements.

Final ruling. The Court, however, accepted the AmEx position, making it very difficult to develop an antitrust case against 2-sided markets. It remains to be seen the degree to which the AMA concern about health insurance markets will be realized.

5. Gay wedding and a bakeshop

At stake. In Masterpiece Cakeshop v Colorado, a cakemaker declined to design a cake for a gay wedding and had been disciplined under Colorado law for discriminating against the couple based on sexual orientation.¹⁵

Final ruling. The Court, however, found that the Colorado regulators had, ironically, shown such religious animus in the way they treated the baker that the regulators themselves had discriminated on the basis of religion. As a result, the Court reversed the sanctions against the baker.

This decision was fairly narrow. It does not, for example, stand for the proposition that there may be a general religious exception to antidiscrimination laws. The question of broader religious or free-speech objections to antidiscrimination laws remains for another time.

Amicus brief. It was interesting that the American College of Pediatricians, American Association of Pro-Life Obstetricians and Gynecologists, and others, filed an amicus brief to report with concern the “demands that individual medical professionals must perform, assist with, or facilitate abortions, without regard to the teachings of their own faiths, consciences, and convictions.”¹⁶ The brief also noted that “issues in the present case implicate the fundamental rights of health care professionals, and to respectfully urge that the Court should by no means permit any weakening or qualification of well-established protections against compelled speech, and of free exercise” of religion.¹⁶

Clues to the future

During the term that ran from October 2, 2017, through June 27, 2018, the Court issued 72 decisions. An unusually high proportion of cases (26%; 19 cases) were decided on a 5 to 4 vote. Last term, the rate of 5 to 4 decisions was 10%; the 6-year average was 18%. The unanimous decision rate was 39% this term, compared with 59% last term, and 50% on average.

The rate of 5 to 4 cases provides a clue about the Court’s general direction. The number of times each Justice was in the majority in those nineteen 5 to 4 decisions included: Chief Justice Roberts, 17; and Justices Kennedy, 16; Gorsuch, 16; Thomas, 15; and Alito, 15; compared with Justices Ginsburg, 5; Breyer, 4; Sotomayor, 4; and Kagan, 3.

The Court convened on October 1, 2018. At this writing, whether the new term starts with 8 or 9 justices remains a question. President Trump nominated Brett Kavanaugh, JD, to take Justice Kennedy’s place on the Court. His professional qualifications and experience appear to make him qualified for a position on the Court, but as we have seen, there are many other elements that go into confirming a Justice’s nomination.

Next term, the Court is scheduled to hear cases regarding pharmaceutical liability, double jeopardy, sex-offender registration, expert witnesses, Social Security disability benefits, and the Age Discrimination in Employment Act. There will be at least 3 arbitration cases. Health care and reproductive rights will continue to be an important part of the Court’s docket.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

Hemorrhage; bladder laceration during hysterectomy

A 46-year-old woman reported increasingly frequent and painful menstrual periods to her Gyn. Estrogen-progestin contraceptives were relatively contraindicated because of the patient’s hypertension. The Gyn performed hysteroscopic resection of a submucosal fibroid, dilation and curettage, and endometrial ablation. He attempted to morcellate the 2-cm fibroid from the anterior wall. Blood loss during surgery was noted to be less than 100 mL.

The patient began to hemorrhage immediately after surgery; nurses informed the Gyn of this multiple times over the next several hours. After 7 hours, the Gyn examined the patient, found that she was in hemorrhagic shock, and advised a hysterectomy was necessary. During surgery, the Gyn lacerated the patient’s bladder twice, which required a urologist to repair. Postoperatively, the patient had a stroke, respiratory failure, and kidney failure.

PATIENT'S CLAIM: The Gyn’s morcellation technique was negligent. He did not respond to the nurses for 7 hours. If he had responded earlier, she might not have lost her uterus. He was also negligent for injuring the patient’s bladder during the second surgery.

PHYSICIAN'S DEFENSE: The case was settled during mediation.

VERDICT: A confidential North Carolina settlement was reached.

Bowel injured during BSO

In 2013, a 52-year-old woman underwent bilateral salpingo-oophorectomy (BSO) performed by a Gyn. Postoperatively, she was found to have a 1.5-cm bowel perforation. After surgical repair, she developed a wound infection and wound breakdown. She was treated with a vacuum-assisted wound closure device. She later developed a ventral hernia and an intra-abdominal abscess leading to a colostomy, which eventually was reversed. At trial, she had a low-output bowel-to-skin fistula and extensive abdominal scarring.

PATIENT'S CLAIM: The surgeon should have known to perform open BSO rather than laparoscopic surgery based on her 3 prior abdominal surgeries that would have left severe adhesions. He caused a perforation and/or thermal injury to the sigmoid colon during the BSO. He should have consulted a general surgeon when encountering the adhesions. The surgeon failed to readmit her on a timely basis for treatment of the suspected bowel injury.

PHYSICIAN'S DEFENSE: The severe adhesions encountered during BSO surgery could not have been predicted; no adhesions were noted during a 2004 surgery. The adhesions precluded procedure completion. He attempted to lyse the adhesions to create a visual field for removing the ovaries but they could not be visualized. After using a harmonic scalpel for lysis, he inspected the bowel portions that he could see and found no thermal injury or perforation.

VERDICT: An Illinois defense verdict was returned.

Multiple injuries after LVH

A woman was found to have a 4-cm uterine fibroid in April 2007. She received medical management.

In May 2008, she reported left lower quadrant pain to her Gyn. A pelvic ultrasound showed an increase in the fibroid’s diameter to 5.8 cm. On December 4 she underwent laparoscopic-assisted vaginal hysterectomy (LVH). The Gyn performed intraoperative cystoscopy. The patient was discharged the following day.

Over the next several weeks, the patient experienced urinary tract symptoms that progressed to rust-colored urine and incontinence. On December 31 she was found to have bilateral vesicovaginal fistulas. By early April 2009, urologists had placed ureteral stents on 2 separate occasions and performed 2 bilateral reimplantation procedures. On April 28, 2009, a urologist placed a stent in the right ureter but was unable to place a stent in the left ureter. The right stent was removed prior to another reconstructive surgery on August 18. Two stents were also placed on August 26 and were removed on October 6. She underwent annual ultrasounds that revealed minimal hydronephrosis. Except for urinary frequency, the patient’s symptoms had subsided by trial.

PATIENT'S CLAIM: The Gyn fell below the standard of care during the LVH when he negligently cauterized and/or burned the patient’s ureters.

PHYSICIAN'S DEFENSE: The Gyn denied negligence. She argued that, following the cystoscopy, both of the patient’s ureteral orifices discharged indigo carmine–stained urine, an indication that there was no injury to the ureters.

VERDICT: A Nevada defense verdict was returned.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

Hemorrhage; bladder laceration during hysterectomy

A 46-year-old woman reported increasingly frequent and painful menstrual periods to her Gyn. Estrogen-progestin contraceptives were relatively contraindicated because of the patient’s hypertension. The Gyn performed hysteroscopic resection of a submucosal fibroid, dilation and curettage, and endometrial ablation. He attempted to morcellate the 2-cm fibroid from the anterior wall. Blood loss during surgery was noted to be less than 100 mL.

The patient began to hemorrhage immediately after surgery; nurses informed the Gyn of this multiple times over the next several hours. After 7 hours, the Gyn examined the patient, found that she was in hemorrhagic shock, and advised a hysterectomy was necessary. During surgery, the Gyn lacerated the patient’s bladder twice, which required a urologist to repair. Postoperatively, the patient had a stroke, respiratory failure, and kidney failure.

PATIENT'S CLAIM: The Gyn’s morcellation technique was negligent. He did not respond to the nurses for 7 hours. If he had responded earlier, she might not have lost her uterus. He was also negligent for injuring the patient’s bladder during the second surgery.

PHYSICIAN'S DEFENSE: The case was settled during mediation.

VERDICT: A confidential North Carolina settlement was reached.

Bowel injured during BSO

In 2013, a 52-year-old woman underwent bilateral salpingo-oophorectomy (BSO) performed by a Gyn. Postoperatively, she was found to have a 1.5-cm bowel perforation. After surgical repair, she developed a wound infection and wound breakdown. She was treated with a vacuum-assisted wound closure device. She later developed a ventral hernia and an intra-abdominal abscess leading to a colostomy, which eventually was reversed. At trial, she had a low-output bowel-to-skin fistula and extensive abdominal scarring.

PATIENT'S CLAIM: The surgeon should have known to perform open BSO rather than laparoscopic surgery based on her 3 prior abdominal surgeries that would have left severe adhesions. He caused a perforation and/or thermal injury to the sigmoid colon during the BSO. He should have consulted a general surgeon when encountering the adhesions. The surgeon failed to readmit her on a timely basis for treatment of the suspected bowel injury.

PHYSICIAN'S DEFENSE: The severe adhesions encountered during BSO surgery could not have been predicted; no adhesions were noted during a 2004 surgery. The adhesions precluded procedure completion. He attempted to lyse the adhesions to create a visual field for removing the ovaries but they could not be visualized. After using a harmonic scalpel for lysis, he inspected the bowel portions that he could see and found no thermal injury or perforation.

VERDICT: An Illinois defense verdict was returned.

Multiple injuries after LVH

A woman was found to have a 4-cm uterine fibroid in April 2007. She received medical management.

In May 2008, she reported left lower quadrant pain to her Gyn. A pelvic ultrasound showed an increase in the fibroid’s diameter to 5.8 cm. On December 4 she underwent laparoscopic-assisted vaginal hysterectomy (LVH). The Gyn performed intraoperative cystoscopy. The patient was discharged the following day.

Over the next several weeks, the patient experienced urinary tract symptoms that progressed to rust-colored urine and incontinence. On December 31 she was found to have bilateral vesicovaginal fistulas. By early April 2009, urologists had placed ureteral stents on 2 separate occasions and performed 2 bilateral reimplantation procedures. On April 28, 2009, a urologist placed a stent in the right ureter but was unable to place a stent in the left ureter. The right stent was removed prior to another reconstructive surgery on August 18. Two stents were also placed on August 26 and were removed on October 6. She underwent annual ultrasounds that revealed minimal hydronephrosis. Except for urinary frequency, the patient’s symptoms had subsided by trial.

PATIENT'S CLAIM: The Gyn fell below the standard of care during the LVH when he negligently cauterized and/or burned the patient’s ureters.

PHYSICIAN'S DEFENSE: The Gyn denied negligence. She argued that, following the cystoscopy, both of the patient’s ureteral orifices discharged indigo carmine–stained urine, an indication that there was no injury to the ureters.

VERDICT: A Nevada defense verdict was returned.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

Hemorrhage; bladder laceration during hysterectomy

A 46-year-old woman reported increasingly frequent and painful menstrual periods to her Gyn. Estrogen-progestin contraceptives were relatively contraindicated because of the patient’s hypertension. The Gyn performed hysteroscopic resection of a submucosal fibroid, dilation and curettage, and endometrial ablation. He attempted to morcellate the 2-cm fibroid from the anterior wall. Blood loss during surgery was noted to be less than 100 mL.

The patient began to hemorrhage immediately after surgery; nurses informed the Gyn of this multiple times over the next several hours. After 7 hours, the Gyn examined the patient, found that she was in hemorrhagic shock, and advised a hysterectomy was necessary. During surgery, the Gyn lacerated the patient’s bladder twice, which required a urologist to repair. Postoperatively, the patient had a stroke, respiratory failure, and kidney failure.

PATIENT'S CLAIM: The Gyn’s morcellation technique was negligent. He did not respond to the nurses for 7 hours. If he had responded earlier, she might not have lost her uterus. He was also negligent for injuring the patient’s bladder during the second surgery.

PHYSICIAN'S DEFENSE: The case was settled during mediation.

VERDICT: A confidential North Carolina settlement was reached.

Bowel injured during BSO

In 2013, a 52-year-old woman underwent bilateral salpingo-oophorectomy (BSO) performed by a Gyn. Postoperatively, she was found to have a 1.5-cm bowel perforation. After surgical repair, she developed a wound infection and wound breakdown. She was treated with a vacuum-assisted wound closure device. She later developed a ventral hernia and an intra-abdominal abscess leading to a colostomy, which eventually was reversed. At trial, she had a low-output bowel-to-skin fistula and extensive abdominal scarring.

PATIENT'S CLAIM: The surgeon should have known to perform open BSO rather than laparoscopic surgery based on her 3 prior abdominal surgeries that would have left severe adhesions. He caused a perforation and/or thermal injury to the sigmoid colon during the BSO. He should have consulted a general surgeon when encountering the adhesions. The surgeon failed to readmit her on a timely basis for treatment of the suspected bowel injury.

PHYSICIAN'S DEFENSE: The severe adhesions encountered during BSO surgery could not have been predicted; no adhesions were noted during a 2004 surgery. The adhesions precluded procedure completion. He attempted to lyse the adhesions to create a visual field for removing the ovaries but they could not be visualized. After using a harmonic scalpel for lysis, he inspected the bowel portions that he could see and found no thermal injury or perforation.

VERDICT: An Illinois defense verdict was returned.

Multiple injuries after LVH

A woman was found to have a 4-cm uterine fibroid in April 2007. She received medical management.

In May 2008, she reported left lower quadrant pain to her Gyn. A pelvic ultrasound showed an increase in the fibroid’s diameter to 5.8 cm. On December 4 she underwent laparoscopic-assisted vaginal hysterectomy (LVH). The Gyn performed intraoperative cystoscopy. The patient was discharged the following day.

Over the next several weeks, the patient experienced urinary tract symptoms that progressed to rust-colored urine and incontinence. On December 31 she was found to have bilateral vesicovaginal fistulas. By early April 2009, urologists had placed ureteral stents on 2 separate occasions and performed 2 bilateral reimplantation procedures. On April 28, 2009, a urologist placed a stent in the right ureter but was unable to place a stent in the left ureter. The right stent was removed prior to another reconstructive surgery on August 18. Two stents were also placed on August 26 and were removed on October 6. She underwent annual ultrasounds that revealed minimal hydronephrosis. Except for urinary frequency, the patient’s symptoms had subsided by trial.

PATIENT'S CLAIM: The Gyn fell below the standard of care during the LVH when he negligently cauterized and/or burned the patient’s ureters.

PHYSICIAN'S DEFENSE: The Gyn denied negligence. She argued that, following the cystoscopy, both of the patient’s ureteral orifices discharged indigo carmine–stained urine, an indication that there was no injury to the ureters.

VERDICT: A Nevada defense verdict was returned.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

Psychiatry is a field of passion. The reward of experiencing growth and change alongside our patients is what bolsters us through years of difficult training, overnight shifts, endless paperwork, regulatory mandates, and frequent worry about our patients. As physicians, we don’t live for weekends as many other professionals do. To the contrary, we spend them on call, moonlighting, laboring over journal articles, and perfecting lectures.

That passion is what makes us trusted clinicians and experts in our field. It can also make it difficult for us to disconnect from our work, frequently leading to burnout. Physician self-care, support, and professional development are critical topics that modern-day medicine minimizes at the peril of physicians and public health.¹

Psychiatry lends itself to a deep and intimate understanding of another human being. The therapist delves into the lives of his or her patients, hears their stories, and holds their secrets. In some cases, we might be the only ones who truly see patients for who they uniquely are, and come to understand them on a deeper level than their closest family and friends. This can be both thrilling and intense. As we delve into the psyche of another individual, contemplate which interpretation we should share, and resonate with our patients, it is easy to become bogged down with our own countertransference, sentiment, and worry, and to become consumed by our work. A professional hazard, some might quip.

Therefore, personal restoration—a tool that keeps our clinical skills sharp—is vitally important to caring for oneself and one’s patient. Surprisingly, this can be neglected until we begin to experience burnout, which over time could transform into impairment, thus endangering ourselves, our patients, and our profession.

Over the past decade, physician impairment has been exhaustively described, researched, and addressed. However, most analyses have focused on identifying impairment, and offering guidance on how to properly report it. How do we shift from managing the crisis to preventing it? To answer this question, this article:

• reviews the dilemma of physician impairment
• explores the duty we have to patients, ourselves, and the profession
• discusses shifting the focus on impairment to prevention through well-being.

Continue to: Dilemma

The cornerstone for well-being is a balanced life. No matter how much one loves his or her work, there must be balance between work, relationships, and hobbies. Without that equilibrium, everyone is put at risk.²

Just as our patients, we are not immune to mental illness, cognitive decline, or substance abuse.³ We might even be more susceptible. For many physicians, their identity is intimately tied to their work.⁴ Dr. Robin Weiss captured that intimate relationship⁵:

“… [A] therapist may spend hundreds of hours, perhaps more than a thousand, hearing about a patient’s most exalted aspirations and most murderous, hateful fantasies. During this time, the patient may endure excruciating losses, unbearable shame, bitter sadness and great triumphs. You may accompany patients through torturous adolescence into adulthood. Or you may meet them in middle age and be with them as they age and eventually die. You collaborate in a deep process of discovery. Few encounters are this deeply honest, and therefore intimate.”

Given the stories we hear and the resulting intimacy and countertransference that inevitably arise, psychiatrists are even more prone to burnout than other physicians.⁶ Physician impairment is a public health issue that affects not just physicians but also their families, colleagues, and patients.

“Impairment” for the purpose of this article means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.⁷ Predisposing factors for physician impairment include an obsessive-compulsive personality type, a family history of mental illness, sensation-seeking behavior, denial of personal problems, perfectionism, and idealism.^8,9 Also, work stress becomes a significant factor in already vulnerable physicians, leading to a greater risk for mental illness.¹⁰

Continue to: Some warning signs of impairment include...

Duty: To ourselves, our colleagues, and our patients

There has been much discussion on how to report impaired colleagues, but little on how to help and support ourselves and our colleagues before things escalate into serious problems. And this lack of discussion is at the detriment of individual practitioners, their families, and patients. Physicians-in-training, including psychiatric residents, are at particularly high risk for developing stress-related problems, depression, and substance misuse.¹² Occupational demands, self-criticism, and denial of one’s distress are common among physicians, as is self-treatment with drugs and alcohol.¹³

We all know by now that doctors and physician health programs (PHPs) have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. There are an abundance of PHPs that are in place to assist with such situations. The American Medical Association’s official position on reporting impairment is outlined in Policy H-275.952.⁷ There also is the Federation of State Medical Boards. Its policy states that PHPs have “a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track of record of ensuring safety to the public and reveal deficiencies if they occur.”¹⁴

Legal and ethical issues, however, complicate interventions for colleagues who need assistance.¹⁵ Despite the existence of PHPs, it would be much easier—not to mention helpful—to help a colleague by carrying out early interventions.

Discussion: Prevention as a solution

More emphasis should be placed on prevention. That’s where self-care and well-being come into play. Awareness of and sensitivity to physician vulnerability, early detection, and prevention of impairment are important.

Continue to: There has been a paradigm shift in focus...

There has been a paradigm shift in focus across medical boards, professional societies, and medical colleges. They are recognizing that personal well-being can help prevent burnout and, in turn, change the landscape of medicine from endless work to balanced lives that yield more satisfying and joyful work. It is becoming an accepted fact in medicine that well-being is just as important as integrity, professionalism, and patient safety. For example, the American Academy of Medical Colleges (AAMC) issued a statement emphasizing the importance of clinician well-being and dedicated its June 2016 Leadership Forum to a range of topics addressing depression, resilience, burnout, and suicide in academic medicine.¹⁶

Anita Everett, MD, put the spotlight on physician well-being during her term as American Psychiatric Association President (2017 to 2018). She formed a specific workgroup on Physician Wellness and Burnout where there is a community focus on prevention and self-care.¹⁷ A strong sense of community and purpose is almost always part of the prescription for promoting greater well-being.²

The importance of this issue is also trickling down from policymakers into hospitals and community health centers. Consider an initiative at Minneapolis’s Hennepin County Medical Center. Leaders there created a “reset room” for physicians to quietly decompress. The room is complete with LED lights, flameless candles, a sound machine, comfortable chairs, several plants, and an “in use” sign on the door.¹⁸ Other personal strategies to help prevent burnout include making environmental changes, encouraging hobbies, and streamlining burdensome tasks such as paperwork and electronic medical record systems.

As physician health and well-being are finally emerging as a “hot topic,”² educational and treatment resources are increasingly available for any of us to explore. Consider a simple Google search to look into your State’s PHPs, and get involved in your professional societies to make change.

The culture is starting to shift, and leading by example will be a key to propelling further progress in this area. Model our own self-care for colleagues and patients alike. As Mark Twain said, we might love our work, but we must remember that being solely defined by work comes to the detriment of our health. Maintaining balance is what will allow us to sustain long careers ahead doing what we love.

A 44-year-old woman presented to the ED complaining of crampy lower abdominal pain with nausea and vomiting. The patient described gradual onset 2 days prior, with symptoms worsening over the previous 12 hours. She denied diarrhea, constipation, or blood in her stool. She did admit to frequency of urination, but no dysuria or hematuria. She was gravida 2, para 2, aborta 0, with a last menstrual period 3 weeks prior. She denied vaginal bleeding or discharge. Her past medical history was unremarkable, she was on no medications, and denied alcohol use. She did admit to smoking one pack of cigarettes per day.

On physical examination, the patient’s vital signs were: blood pressure, 132/68 mm Hg; heart rate, 96 beats/min; respiratory rate, 18 breaths/min; and temperature, 99.8°F. Oxygen saturation was 99% on room air.

The head, ears, eyes, nose, and throat (HEENT) examination was completely normal, as was the heart and lung examination. The patient was tender to palpation in the lower abdomen, but without guarding or rebound. Bowel sounds were present and normoactive. A pelvic examination, including a bimanual examination, demonstrated mild left ovarian tenderness but without mass or cervical motion tenderness. The patient did not exhibit any costovertebral angle tenderness bilaterally. No rectal examination was performed.

The emergency physicians (EPs) ordered a complete blood count (CBC), basic metabolic profile (BMP), urinalysis, urine pregnancy test, and a vaginal wet preparation. In addition, the patient was administered 500 cc’s of normal saline intravenously (IV) and ondansetron (Zofran) 4 mg IV.

The urine pregnancy test result came back negative. The urinalysis was remarkable for positive leukocyte esterase, with five to 10 white cells and bacteria present. The CBC showed a mild leukocytosis, but with a normal hemoglobin and hematocrit. The BMP and vaginal wet preparation were completely normal.

The EP was concerned the patient might have something more serious than a simple urinary tract infection (UTI), so she ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast.

The radiologist interpreted the CT scan as normal. The patient was discharged home with a prescription for an antibiotic for her UTI, encouraged to drink liquids, and instructed to follow-up with her primary care physician in 1 week.

The patient returned to the same ED approximately 48 hours later with worsening abdominal pain. On this presentation, she was tachycardic (110 beats/min) with a temperature of 101°F. The abdominal examination was remarkable for diffuse tenderness and voluntary guarding. The patient was administered IV fluids, morphine, and ondansetron. A repeat CT scan of the abdomen and pelvis with IV contrast showed a perforated sigmoid colon, with leakage of bowel contents into the peritoneum. The EP immediately started IV fluid resuscitation and administered IV antibiotics. The patient was taken emergently to the operating room by general surgery. The colon was repaired and a colostomy placed. The patient was able to be discharged home on day number 5.

The patient sued the hospital and the treating EP for failure to make the proper diagnosis on the initial ED visit, resulting in the patient having a long and difficult recovery, and the need for a colostomy. At trial, the jury returned a defense verdict.

Discussion

Diverticulitis, and its complications, account for a significant number of ED visits. It is the third most common inpatient gastrointestinal diagnosis in the United States, costing two billion dollars annually.¹It is defined as clinically evident microscopic inflammation of a diverticulum or diverticula, and occurs in approximately 4% of patients with diverticulosis.¹It is estimated that roughly 15% of these patients will experience a complication, defined as an abscess, perforation, fistula, or colonic obstruction; 15% to 30% will experience a recurrence.

The mean age of patients admitted to the hospital for diverticulitis is 63 years. While considered a disease of older patients, it should be included in the differential diagnosis for younger patients, as approximately 16% of admissions for acute diverticulitis are in patients less than 45 years.²Risk factors include poor diet (ie, low fiber, high fat, red meat), obesity, and smoking. The clinical presentation of diverticulitis has sometimes been referred to as “left-sided appendicitis” because of the similarities between the two entities. Patients will frequently complain of anorexia, change in bowel habits (either diarrhea or constipation), crampy abdominal pain (primarily in the left lower quadrant), low grade fever, and nausea with vomiting. Interestingly, 10% to 15% of patients with acute diverticulitis will complain of dysuria, urgency, or frequency (as in this patient) due to irritation of the bladder from an inflamed sigmoid colon.

Physical examination may reveal a low grade fever and tachycardia, if significant vomiting has been present. The abdomen is tender primarily in the left lower quadrant. The presence of severe tachycardia, hypotension, or a rigid abdomen with guarding and rebound suggests perforation. A pelvic examination should be performed on all women of child-bearing age. The rectal examination may reveal hemoccult positive stool; gross blood is rare.

Laboratory testing should include a CBC, BMP, urinalysis, and a urine pregnancy test (for women of child-bearing age). The CBC will usually reveal a mild leukocytosis. The urinalysis may reveal sterile pyuria for the reason previously described. Additional testing may be indicated by the history and physical examination.

A CT scan of the abdomen and pelvis is considered the gold standard with regards to imaging, with a reported sensitivity of 94% and specificity of 99%.³ Ideally, the CT scan should include both oral and IV contrast; however, IV alone is frequently used. In addition to identifying diverticulitis, CT can also visualize complications, including abscesses, perforation, and bowel obstruction. Ultrasound using high-resolution, graded compassion has a similar sensitivity and specificity as CT, with the advantage of less cost, can be performed at the bedside, and avoids radiation exposure.³ However, it is operator dependent and inferior to CT regarding visualizing complications.

Historically, antibiotics have been considered the treatment of choice for patients with acute uncomplicated diverticulitis, usually as an outpatient. Typically, this involves prescribing ciprofloxacin (or trimethoprim-sulfamethoxazole) plus metronidazole for 7 to 10 days. Monotherapy consisting of either moxifloxacin or amoxicillin/clavulanic acid is also acceptable. However, as our understanding of the important role of inflammation in this disease process, combined with the negative effects associated with antibiotic use, the role of antibiotics in uncomplicated diverticulitis has been called into question. In one recent study of 155 patients with acute uncomplicated diverticulitis, 97% were managed successfully as outpatients without antibiotics, admission, or complications.⁴ The American Gastroenterological Association (AGA) recommends that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. However, this is considered a “conditional recommendation with a low quality of evidence.”¹In other words, this recommendation could easily change based on newer studies. Similarly, other “conditional recommendations” by the AGA include suggesting a fiber-rich diet, or fiber supplementation, and no need to avoid the consumption of nuts and popcorn.¹ The majority of these patients begin to feel better in 2 to 3 days and have a good outcome.

Summary

For patients that appear ill, have significant comorbidities, are immunocompromised, or have a complication of acute diverticulitis, admission to the hospital with surgery consultation is recommended. For abscesses, interventional radiology has been used with success for CT-guided percutaneous drainage of diverticular abscesses. Intravenous antibiotics should be initiated; appropriate medications include metronidazole plus a third-generation cephalosporin (such as ceftriaxone or cefotaxime) or a fluoroquinolone (such as ciprofloxacin or levofloxacin). Monotherapy for the moderately ill patient includes piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, and imipenem. In addition, these patients should be placed at bowel rest (ie, nothing by mouth) with IV fluid resuscitation and hydration.

A 44-year-old woman presented to the ED complaining of crampy lower abdominal pain with nausea and vomiting. The patient described gradual onset 2 days prior, with symptoms worsening over the previous 12 hours. She denied diarrhea, constipation, or blood in her stool. She did admit to frequency of urination, but no dysuria or hematuria. She was gravida 2, para 2, aborta 0, with a last menstrual period 3 weeks prior. She denied vaginal bleeding or discharge. Her past medical history was unremarkable, she was on no medications, and denied alcohol use. She did admit to smoking one pack of cigarettes per day.

On physical examination, the patient’s vital signs were: blood pressure, 132/68 mm Hg; heart rate, 96 beats/min; respiratory rate, 18 breaths/min; and temperature, 99.8°F. Oxygen saturation was 99% on room air.

The head, ears, eyes, nose, and throat (HEENT) examination was completely normal, as was the heart and lung examination. The patient was tender to palpation in the lower abdomen, but without guarding or rebound. Bowel sounds were present and normoactive. A pelvic examination, including a bimanual examination, demonstrated mild left ovarian tenderness but without mass or cervical motion tenderness. The patient did not exhibit any costovertebral angle tenderness bilaterally. No rectal examination was performed.

The emergency physicians (EPs) ordered a complete blood count (CBC), basic metabolic profile (BMP), urinalysis, urine pregnancy test, and a vaginal wet preparation. In addition, the patient was administered 500 cc’s of normal saline intravenously (IV) and ondansetron (Zofran) 4 mg IV.

The urine pregnancy test result came back negative. The urinalysis was remarkable for positive leukocyte esterase, with five to 10 white cells and bacteria present. The CBC showed a mild leukocytosis, but with a normal hemoglobin and hematocrit. The BMP and vaginal wet preparation were completely normal.

The EP was concerned the patient might have something more serious than a simple urinary tract infection (UTI), so she ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast.

The radiologist interpreted the CT scan as normal. The patient was discharged home with a prescription for an antibiotic for her UTI, encouraged to drink liquids, and instructed to follow-up with her primary care physician in 1 week.

The patient returned to the same ED approximately 48 hours later with worsening abdominal pain. On this presentation, she was tachycardic (110 beats/min) with a temperature of 101°F. The abdominal examination was remarkable for diffuse tenderness and voluntary guarding. The patient was administered IV fluids, morphine, and ondansetron. A repeat CT scan of the abdomen and pelvis with IV contrast showed a perforated sigmoid colon, with leakage of bowel contents into the peritoneum. The EP immediately started IV fluid resuscitation and administered IV antibiotics. The patient was taken emergently to the operating room by general surgery. The colon was repaired and a colostomy placed. The patient was able to be discharged home on day number 5.

The patient sued the hospital and the treating EP for failure to make the proper diagnosis on the initial ED visit, resulting in the patient having a long and difficult recovery, and the need for a colostomy. At trial, the jury returned a defense verdict.

Discussion

Diverticulitis, and its complications, account for a significant number of ED visits. It is the third most common inpatient gastrointestinal diagnosis in the United States, costing two billion dollars annually.¹It is defined as clinically evident microscopic inflammation of a diverticulum or diverticula, and occurs in approximately 4% of patients with diverticulosis.¹It is estimated that roughly 15% of these patients will experience a complication, defined as an abscess, perforation, fistula, or colonic obstruction; 15% to 30% will experience a recurrence.

The mean age of patients admitted to the hospital for diverticulitis is 63 years. While considered a disease of older patients, it should be included in the differential diagnosis for younger patients, as approximately 16% of admissions for acute diverticulitis are in patients less than 45 years.²Risk factors include poor diet (ie, low fiber, high fat, red meat), obesity, and smoking. The clinical presentation of diverticulitis has sometimes been referred to as “left-sided appendicitis” because of the similarities between the two entities. Patients will frequently complain of anorexia, change in bowel habits (either diarrhea or constipation), crampy abdominal pain (primarily in the left lower quadrant), low grade fever, and nausea with vomiting. Interestingly, 10% to 15% of patients with acute diverticulitis will complain of dysuria, urgency, or frequency (as in this patient) due to irritation of the bladder from an inflamed sigmoid colon.

Physical examination may reveal a low grade fever and tachycardia, if significant vomiting has been present. The abdomen is tender primarily in the left lower quadrant. The presence of severe tachycardia, hypotension, or a rigid abdomen with guarding and rebound suggests perforation. A pelvic examination should be performed on all women of child-bearing age. The rectal examination may reveal hemoccult positive stool; gross blood is rare.

Laboratory testing should include a CBC, BMP, urinalysis, and a urine pregnancy test (for women of child-bearing age). The CBC will usually reveal a mild leukocytosis. The urinalysis may reveal sterile pyuria for the reason previously described. Additional testing may be indicated by the history and physical examination.

A CT scan of the abdomen and pelvis is considered the gold standard with regards to imaging, with a reported sensitivity of 94% and specificity of 99%.³ Ideally, the CT scan should include both oral and IV contrast; however, IV alone is frequently used. In addition to identifying diverticulitis, CT can also visualize complications, including abscesses, perforation, and bowel obstruction. Ultrasound using high-resolution, graded compassion has a similar sensitivity and specificity as CT, with the advantage of less cost, can be performed at the bedside, and avoids radiation exposure.³ However, it is operator dependent and inferior to CT regarding visualizing complications.

Historically, antibiotics have been considered the treatment of choice for patients with acute uncomplicated diverticulitis, usually as an outpatient. Typically, this involves prescribing ciprofloxacin (or trimethoprim-sulfamethoxazole) plus metronidazole for 7 to 10 days. Monotherapy consisting of either moxifloxacin or amoxicillin/clavulanic acid is also acceptable. However, as our understanding of the important role of inflammation in this disease process, combined with the negative effects associated with antibiotic use, the role of antibiotics in uncomplicated diverticulitis has been called into question. In one recent study of 155 patients with acute uncomplicated diverticulitis, 97% were managed successfully as outpatients without antibiotics, admission, or complications.⁴ The American Gastroenterological Association (AGA) recommends that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. However, this is considered a “conditional recommendation with a low quality of evidence.”¹In other words, this recommendation could easily change based on newer studies. Similarly, other “conditional recommendations” by the AGA include suggesting a fiber-rich diet, or fiber supplementation, and no need to avoid the consumption of nuts and popcorn.¹ The majority of these patients begin to feel better in 2 to 3 days and have a good outcome.

Summary

For patients that appear ill, have significant comorbidities, are immunocompromised, or have a complication of acute diverticulitis, admission to the hospital with surgery consultation is recommended. For abscesses, interventional radiology has been used with success for CT-guided percutaneous drainage of diverticular abscesses. Intravenous antibiotics should be initiated; appropriate medications include metronidazole plus a third-generation cephalosporin (such as ceftriaxone or cefotaxime) or a fluoroquinolone (such as ciprofloxacin or levofloxacin). Monotherapy for the moderately ill patient includes piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, and imipenem. In addition, these patients should be placed at bowel rest (ie, nothing by mouth) with IV fluid resuscitation and hydration.

A 44-year-old woman presented to the ED complaining of crampy lower abdominal pain with nausea and vomiting. The patient described gradual onset 2 days prior, with symptoms worsening over the previous 12 hours. She denied diarrhea, constipation, or blood in her stool. She did admit to frequency of urination, but no dysuria or hematuria. She was gravida 2, para 2, aborta 0, with a last menstrual period 3 weeks prior. She denied vaginal bleeding or discharge. Her past medical history was unremarkable, she was on no medications, and denied alcohol use. She did admit to smoking one pack of cigarettes per day.

On physical examination, the patient’s vital signs were: blood pressure, 132/68 mm Hg; heart rate, 96 beats/min; respiratory rate, 18 breaths/min; and temperature, 99.8°F. Oxygen saturation was 99% on room air.

The head, ears, eyes, nose, and throat (HEENT) examination was completely normal, as was the heart and lung examination. The patient was tender to palpation in the lower abdomen, but without guarding or rebound. Bowel sounds were present and normoactive. A pelvic examination, including a bimanual examination, demonstrated mild left ovarian tenderness but without mass or cervical motion tenderness. The patient did not exhibit any costovertebral angle tenderness bilaterally. No rectal examination was performed.

The emergency physicians (EPs) ordered a complete blood count (CBC), basic metabolic profile (BMP), urinalysis, urine pregnancy test, and a vaginal wet preparation. In addition, the patient was administered 500 cc’s of normal saline intravenously (IV) and ondansetron (Zofran) 4 mg IV.

The urine pregnancy test result came back negative. The urinalysis was remarkable for positive leukocyte esterase, with five to 10 white cells and bacteria present. The CBC showed a mild leukocytosis, but with a normal hemoglobin and hematocrit. The BMP and vaginal wet preparation were completely normal.

The EP was concerned the patient might have something more serious than a simple urinary tract infection (UTI), so she ordered a computed tomography (CT) scan of the abdomen and pelvis with IV contrast.

The radiologist interpreted the CT scan as normal. The patient was discharged home with a prescription for an antibiotic for her UTI, encouraged to drink liquids, and instructed to follow-up with her primary care physician in 1 week.

The patient returned to the same ED approximately 48 hours later with worsening abdominal pain. On this presentation, she was tachycardic (110 beats/min) with a temperature of 101°F. The abdominal examination was remarkable for diffuse tenderness and voluntary guarding. The patient was administered IV fluids, morphine, and ondansetron. A repeat CT scan of the abdomen and pelvis with IV contrast showed a perforated sigmoid colon, with leakage of bowel contents into the peritoneum. The EP immediately started IV fluid resuscitation and administered IV antibiotics. The patient was taken emergently to the operating room by general surgery. The colon was repaired and a colostomy placed. The patient was able to be discharged home on day number 5.

The patient sued the hospital and the treating EP for failure to make the proper diagnosis on the initial ED visit, resulting in the patient having a long and difficult recovery, and the need for a colostomy. At trial, the jury returned a defense verdict.

Discussion

Diverticulitis, and its complications, account for a significant number of ED visits. It is the third most common inpatient gastrointestinal diagnosis in the United States, costing two billion dollars annually.¹It is defined as clinically evident microscopic inflammation of a diverticulum or diverticula, and occurs in approximately 4% of patients with diverticulosis.¹It is estimated that roughly 15% of these patients will experience a complication, defined as an abscess, perforation, fistula, or colonic obstruction; 15% to 30% will experience a recurrence.

The mean age of patients admitted to the hospital for diverticulitis is 63 years. While considered a disease of older patients, it should be included in the differential diagnosis for younger patients, as approximately 16% of admissions for acute diverticulitis are in patients less than 45 years.²Risk factors include poor diet (ie, low fiber, high fat, red meat), obesity, and smoking. The clinical presentation of diverticulitis has sometimes been referred to as “left-sided appendicitis” because of the similarities between the two entities. Patients will frequently complain of anorexia, change in bowel habits (either diarrhea or constipation), crampy abdominal pain (primarily in the left lower quadrant), low grade fever, and nausea with vomiting. Interestingly, 10% to 15% of patients with acute diverticulitis will complain of dysuria, urgency, or frequency (as in this patient) due to irritation of the bladder from an inflamed sigmoid colon.

Physical examination may reveal a low grade fever and tachycardia, if significant vomiting has been present. The abdomen is tender primarily in the left lower quadrant. The presence of severe tachycardia, hypotension, or a rigid abdomen with guarding and rebound suggests perforation. A pelvic examination should be performed on all women of child-bearing age. The rectal examination may reveal hemoccult positive stool; gross blood is rare.

Laboratory testing should include a CBC, BMP, urinalysis, and a urine pregnancy test (for women of child-bearing age). The CBC will usually reveal a mild leukocytosis. The urinalysis may reveal sterile pyuria for the reason previously described. Additional testing may be indicated by the history and physical examination.

A CT scan of the abdomen and pelvis is considered the gold standard with regards to imaging, with a reported sensitivity of 94% and specificity of 99%.³ Ideally, the CT scan should include both oral and IV contrast; however, IV alone is frequently used. In addition to identifying diverticulitis, CT can also visualize complications, including abscesses, perforation, and bowel obstruction. Ultrasound using high-resolution, graded compassion has a similar sensitivity and specificity as CT, with the advantage of less cost, can be performed at the bedside, and avoids radiation exposure.³ However, it is operator dependent and inferior to CT regarding visualizing complications.

Historically, antibiotics have been considered the treatment of choice for patients with acute uncomplicated diverticulitis, usually as an outpatient. Typically, this involves prescribing ciprofloxacin (or trimethoprim-sulfamethoxazole) plus metronidazole for 7 to 10 days. Monotherapy consisting of either moxifloxacin or amoxicillin/clavulanic acid is also acceptable. However, as our understanding of the important role of inflammation in this disease process, combined with the negative effects associated with antibiotic use, the role of antibiotics in uncomplicated diverticulitis has been called into question. In one recent study of 155 patients with acute uncomplicated diverticulitis, 97% were managed successfully as outpatients without antibiotics, admission, or complications.⁴ The American Gastroenterological Association (AGA) recommends that antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. However, this is considered a “conditional recommendation with a low quality of evidence.”¹In other words, this recommendation could easily change based on newer studies. Similarly, other “conditional recommendations” by the AGA include suggesting a fiber-rich diet, or fiber supplementation, and no need to avoid the consumption of nuts and popcorn.¹ The majority of these patients begin to feel better in 2 to 3 days and have a good outcome.

Summary

For patients that appear ill, have significant comorbidities, are immunocompromised, or have a complication of acute diverticulitis, admission to the hospital with surgery consultation is recommended. For abscesses, interventional radiology has been used with success for CT-guided percutaneous drainage of diverticular abscesses. Intravenous antibiotics should be initiated; appropriate medications include metronidazole plus a third-generation cephalosporin (such as ceftriaxone or cefotaxime) or a fluoroquinolone (such as ciprofloxacin or levofloxacin). Monotherapy for the moderately ill patient includes piperacillin/tazobactam, ampicillin/sulbactam, ticarcillin/clavulanic acid, and imipenem. In addition, these patients should be placed at bowel rest (ie, nothing by mouth) with IV fluid resuscitation and hydration.