6 Red Flags It’s Time to End the Doctor Patient Relationship

Physician-patient relationships end for numerous reasons. The reality is often a mundane affair.

Objectives change. The patient’s care develops. Sometimes a change of scenery is necessary. Still – physicians are human, and humans are bound by limitations. We have a limited amount of time. We have limited resources. Limited patience. Some relationships can be salvaged. Some should. But sometimes the most professional course of action is to terminate the relationship. Knowing when to take such action can be healthful for a physician and his patient.

The article will help you make a sound judgement.

 

Crap, It’s Always Something


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Sometimes the little things matter just as much as the big ones. They can create downstream problems that were never anticipated.  

We recently heard from a surgeon in Ohio. He was performing an office-based procedure. An employee was looking for the doctor. She quickly opened the door to the room where the surgeon was working. In a high-decibel, shrill voice she said something like “There you are!”

The surgeon was not expecting the intrusion of the cacophony. His hand moved. An extra unintended snip. Now this outcome will require additional treatment / repair.  

The first webinar I presented from my office, I was ten minutes into the discussion when someone barged into my office. An unexpected interruption. Now I put a sign on the door before any webinar putting everyone on notice that quiet is the order of the day. 

At a later webinar, I was in a heated discussion with a co-presenter. My phone went off. Multiple times. It was spam marketing. Yes, it was a distraction for me. Even more of a distraction for the people listening. Now I turn my phone off before getting started. 

None of these details are earth shattering. They require no effort. But, we don’t think about them unless and until something bad happens. Or unless someone else tells us to think about X, Y, or Z. 

So, help out your colleagues. Please give us some pearls of wisdom in your routines. Pearls that are obvious in retrospect. But pearls we really don’t think about until something hits the fan. 

What do you think? 


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About the Author

Jeffrey Segal, MD, JD

Dr. Jeffrey Segal, Chief Executive Officer and Founder of Medical Justice, is a board-certified neurosurgeon. In the process of conceiving, funding, developing, and growing Medical Justice, Dr. Segal has established himself as one of the country’s leading authorities on medical malpractice issues, counterclaims, and internet-based assaults on reputation.

Dr. Segal holds a M.D. from Baylor College of Medicine, where he also completed a neurosurgical residency. Dr. Segal served as a Spinal Surgery Fellow at The University of South Florida Medical School. He is a member of Phi Beta Kappa as well as the AOA Medical Honor Society. Dr. Segal received his B.A. from the University of Texas and graduated with a J.D. from Concord Law School with highest honors.

If you have a medico-legal question, write to Medical Justice at infonews@medicaljustice-staging.shfpvdx8-liquidwebsites.com.


 

British Hairdresser Sentenced to Life in Prison for Infecting Men with HIV


The Center for HIV Law and Policy recently published an illustrative (though not exhaustive) list of 332 arrests and prosecutions for HIV exposure in the US between 2008-2017. ‘

To illustrate but a handful:

October 2017: a 28 year old man was arrested in Florida for allegedly not disclosing to sexual partners he was living with HIV.

October 2017: A 29 year old man pleaded no contest to felony charge of knowingly exposing another person to HIV and faced up to 30 years in prison.

September 2017: A woman was arrested in Florida for allegedly threatening to spit in the eyes of a nurse.

September 2017: A 32 year old woman was arrested in Kansas for aggravated assault on a law enforcement officer after she attempted to rub blood on an officer.

Now across the pond in the United Kingdom.

Daryll Rowe is a 27 year old hairdresser from Brighton. In court it was revealed he deliberately tried to infect at least 10 men with HIV. For that, he was handed a life sentence, and will have to serve a minimum of 12 years for the “determined, hateful campaign of sly violence.”

After being diagnosed with HIV in April 2015, Rowe met men through the gay dating app Grindr. He had sex with ten of them.

During the six-week trial, the court learned he refused treatment and ignored advice from doctors. More importantly, he insisted on having unprotected sex with the men he met, claiming that he was “clean.” When they refused, he tampered with his condoms, tricking his partners into thinking that he was practicing safe sex. By tampering, I mean he cut off the ends of the condoms.

To add insult to injury, days after the encounter he would send taunting messages to his victims, such as:

“Maybe you have the fever…I have HIV. Whoops.”
“I ripped the condom. I got you.”
“I have HIV. LOL. Whoops!”

At sentencing, here is what the judge said:

“Many of those men were young men in their 20s at the time they had the misfortune to meet you. Given the facts of this case and your permissive, predatory behaviour, I cannot see when you would no longer be a danger to gay men. In my judgment, the offences, taken together, are so serious that a life sentence is justified.”

During the trial, Rowe defended by arguing he believed he had been cured, having started drinking his own urine, supplemented with natural remedies.

Five of Rowe’s targets were ultimately infected with HIV.

Given Rowe’s malicious intent, I am not surprised by the judgment or sentence.

Still, HIV is not unique in terms of potentially causing a chronic or fatal illness.

Arguably the same sentence could be handed down for any number of illnesses knowingly transmitted by one person to another. The law places a great deal of weight on a defendant’s state of mind, even if the outcome is the same. To take an extreme example, if a person has temporal lobe epilepsy and via an automatism, kills his roommate, that is treated very differently than pre-meditated intent to kill murder. In both cases, the roommate is now dead. But, in one, the defendant INTENDED that outcome. Does it really matter substantively if a person intends to kill another via an infectious disease or poison?

Interestingly, in California, effective 2018, the penalty for knowingly or intentionally exposing others to HIV was lowed from a felony to a misdemeanor. The act of knowingly donating HIV-infected blood, which was previously a felony, is now decriminalized. Supporters of the California bill pointed out that intentional transmission of any other communicable disease in California, such as SARS, Ebola, or TB was treated only as misdemeanors, so the goal was to level the playing field.

Is it possible there may have been more than one way to level the playing field?

What do you think?

Informed Consent and Facial Fillers: Risk versus Reward 


In May, the FDA issued a report called: Unintentional Injection of Soft Tissue Filler into Blood Vessels in the Face: FDA Safety Communication.  For our general audience, fillers are approved to reduce the appearance of wrinkles or augment hollowed-out areas, such as lips or cheeks. When injected by trained and experienced practitioners, the safety record is quite good. On rare occasion, complications can be horrific. I have seen pictures presented at plastic surgery conferences of skin slough. I have seen reports of patients becoming blind. In such circumstances, it is believed the filler can block blood vessels directly and/or embolize to distal vessels – including those of the eye or brain.  If it happens to your patient, you’ll never forget it.  

The FDA reasonably counsels:  

Do not inject soft tissue fillers if you do not have the appropriate training or experience. 

Make sure that you are familiar with the anatomy at and around the site of injection, keeping in mind that blood vessel anatomy can vary among patients. 

Know the signs and symptoms associated with injection into blood vessels, and have an updated plan detailing how you plan to treat the patient if this should this occur. This may include on-site treatment and/or immediate referral to another health care provider for treatment. 

Immediately stop the injection if a patient exhibits any signs or symptoms associated with injection into a blood vessel, such as changes in vision, signs of a stroke, white appearance (or blanching) of the skin, or unusual pain during or shortly after the procedure. 

All good advice. 

The FDA also advises: 

Before injection, thoroughly inform the patient of all risks of the procedure and the specific product you intend to use. 

Tell patients that they should seek immediate medical attention after the procedure if they experience signs and symptoms associated with injection into a blood vessel. 

It’s easy to forget that cosmetic procedures are medical procedures; with risks and potential complications – some irreversible. I can imagine it’s difficult informing a patient who wants his/her appearance improved by fillers that there’s a risk of blindness, stroke, or death – albeit rare. And full informed consent would include educating patients on identifying complications as soon as possible to enable intervention, if possible.  

For those who perform such cosmetic injections, do you explain these rare ischemic complications in advance of the patient saying “yes”? If so, how do you do it? Do some patients rethink their decision and go home?

Please weigh in using the comments box below. 


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Dodging a Bullet. Occupational Hazards of Healthcare.


If you practice in an operating room, sooner or later you will get stuck with a needle. We all try to follow best practices. But, when you have sharp tools, on occasion, the unfortunate does happen.

Last year, an ophthalmologist in Oregon relayed this tale. He had used a syringe and needle to aspirate and irrigate fluid over the cornea. He passed the syringe back to his scrub tech. The needle pricked the scrub tech’s finger and drew blood.

The ophthalmologist told the story to the patient, a 64 year old woman. She agreed to be tested for the usual stuff. Hep B, Hep C, and HIV. The patient had screening tests done and that afternoon, the lab reported a positive test for HIV.

Now what?

First, the patient had no discernible risk factors for HIV. Next, the prevalence of HIV in this community was low. Likely, the screening test was a false positive. And a screening test is just that – a prelude to a more definitive test, if positive. Even if a test is highly sensitive and highly specific, if the prevalence rate for the tested disease is low, there will be a fair number of false positives.

The CDC stated that there had been no known cases of HIV transmission from patient to healthcare workers in the US over the past decade. Cold comfort indeed.

More calls to infectious disease physicians; pathologists who run labs; etc.

Meanwhile, the recommendation was to consider prophylactic HIV medication sooner rather than later. So, such medication would need to be started before a confirmatory test returned.

This was a difficult conversation with the scrub tech.

Looking at this through the cool lens of statistics, the odds of this patient being HIV positive were low. The likelihood a single stick from a surface that contained no blood transmitting HIV to the scrub tech was even lower. And the opportunity to use prophylactic medication during this window should neutralize any infection taking hold.

Yes, all medications have side effects.

And people are not statistics.

Still, this was a tense time operating room team.

The patient’s follow-up HIV test was negative. Crisis aborted.

Winston Churchill once said, “there’s nothing so exhilarating as being shot at without effect.”

What do you think? Share your comments below.


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Why are so many neurosurgeons in – or potentially headed to – jail?


It’s been an active year for neurosurgeons and the criminal justice system. 

Dr. Christopher Duntsch was sentenced to life in prison for knowingly and recklessly injuring patients. Thirty two patients were involved. Two were killed. Two were paralyzed. Duntsch’s attorneys argued he was not a criminal; just a bad surgeon. Admitted into evidence was an email he sent his girlfriend…

“What I am being is what I am, one of kind, a mother f***ing stone cold killer that can buy or own or steal or ruin or build whatever he wants.” 

This probably did not help his case.

D Magazine published an extensive investigative piece called Dr. Death…The story of a madman with a scalpel. It’s a long read. Someday it will be made into a movie.  

Then we have Aria Sabit, a spinal surgeon who admitted to unnecessary and fake operations. He was sentenced to 20 years. Nearly 30 of his California patients – operated on over an 18 month stretch – later sued him for malpractice. During those 18 months he accounted for 70% of all patients unexpectedly re-admitted to his hospital following surgery. In early 2011, he moved from California to Detroit. There, he “performed” spinal fusion surgery with metal instrumentation, but subsequent diagnostic imaging revealed that he never installed the hardware, just bone dowels, and never achieved fusion. Now, that’s an oversight. 

Dr. Sabit apparently did express remorse. “I came from absolutely nothing to become a neurosurgeon and squandered the opportunity,” Dr Sabit said. “I do not deny my guilt.”  

And, finally we have Dr. James Kohut, a California neurosurgeon who was allegedly accused of 10 child molestation charges, including 6 sex acts with children under the age of 10. At his first court appearance, his attorney denied the allegations. No details were disclosed. And, who knows, a jury may ultimately find him not guilty by the standard of “beyond a reasonable doubt.”  

We’re getting close to a quorum for journal club. 

So, what do you think? Why are so many neurosurgeons in – or potentially headed to – jail?


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