40 percent of malpractice claims are for diagnostic errors

By Terry A. Rondberg, DC

Journal of the AMA - logoA commentary published in the July 28 issue of the Journal of the American Medical Association (JAMA) revealed that diagnostic errors are the single largest contributor to medical malpractice claims, accounting for about about 40% of all claims and costing approximately $300,000 per claim.

The authors — Mark Graber, MD, of Stony Brook University Medical Center; and Hardeep Singh, MD, MPH, of Baylor College of Medicine — pointed their fingers at everything BUT the practitioners themselves.

“The great majority of diagnostic errors have root causes that derive from the properties of the healthcare setting, organization and practice,” Dr. Graber said. “By working together, cognitive scientists, informaticians, clinicians, and human factors engineers have a unique opportunity to decrease the likelihood of diagnostic error to the extent that the five principles we outline in JAMA can be incorporated into every new medical home.”

The authors discussed a new model of primary care, called the patient-centered medical home, developed and endorsed by the American Academy of Family Physicians, the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association.

The model facilitates partnerships between individual patients, their personal physician, and, when appropriate, the patient’s family. Care is assisted by physician “extenders,” nurse empowerment, information technology, and other means to assure that patients get care when and where they need and want it in a culturally and linguistically appropriate manner.

The medical home model places emphasis on team-based care, and primary care teams could include not only physicians but also nurses, allied health professionals and personnel, the authors explained.

In this model, the medical doctor would be the gatekeeper and decide what role the “allied” health professions would have. “The physician could take a leadership role, while the entire group collectively takes care of the patient,” explained Dr. Singh.

It’s always heartening to see the medical profession recognize and admit the problems inherent in the current disease-oriented system, such as misdiagnoses, prescription errors, unnecessary surgeries, etc.

Still, I’ll continue to work toward the time when we supplant the old paradigm of labeling and treating conditions and symptoms with the new holistic view of the human body as a complex system of energy patterns that responds to non-invasive care such as chiropractic and other “energy medicine” approaches. And I especially look forward to the time when we don’t label all wellness and healing modalities as “medicine!”

The power of our touch

Power of touchWhen DD Palmer called our profession “chiropractic” — combining the Greek words cheir (hand) and praxis (action) — he couldn’t have chosen a better name. While there are a few doctors who substitute mechanical devices for their hands, even those practitioners have some hands-on work with patients — palpation, adjusting or just placing the hands on affected areas.

We, and our patients, have always known that the success of chiropractic has a great deal to do with the “personal touch” we provide (metaphorically as well as literally). Surveys on patient satisfaction almost always emphasize the influence of our personal involvement with those under our care, particularly when compared to the cold, impersonal treatment received from many medical providers.

A recent research study, sponsored by the National Cancer Institute and presented at the 6th International Conference of the Society for Integrative Oncology, reinforces our understanding of the importance of true “by hand” practice, whether it’s provided by a health care practitioner or a caretaker.

Researchers found that touch — particularly massage — administered by care partners significantly reduces the effects of cancer and the side-effects from its treatment while providing comfort and improvement in the quality of life.

In the study, 97 family caregivers learned touch and massage techniques from a 78-minute instructional DVD, called “Touch, Caring, and Cancer: Simple Instruction for Family and Friends.” They then used these touch techniques to safely care for people living with cancer. “The magnitude of the impact of family members was unexpected. Our research found significant reductions of pain, anxiety, fatigue, depression and nausea when massage was routinely administered at home by family and caregivers,” lead researcher William Collinge, PhD, revealed.

The study found massage by family members reduced stress/anxiety (44% reduction), pain (34%), fatigue (32%), depression (31%), and nausea (29%).

“The discovery that family members can learn and administer simple massage techniques that can consistently reduce stress is significant. Stress is a constant that negatively impacts the lives and wellbeing of cancer patients,” Collinge wrote. “Both cancer patients and caregivers benefit because massage appears to strengthen the relationship bond. Massage provides the caregiver a way to make a difference.”

This research not only reminds us of the significance of personal touch between doctor and patient, but might be a good incentive to bring a massage therapist into your practice. The synergistic effect of the two disciplines would no doubt benefit many patients and might increase patient volume.

You may even want to provide certain patients with the video used to train the participants in the study (it’s available from Amazon.com). I believe strongly that the “hands on” approach works for all people, regardless of the state of their health. Since it reduces stress — the primary cause of most health issues — it would be effective on most people, not just those with cancer.

How clean is your office?

By Terry A. Rondberg

Like many wellness practitioners, I don’t believe in the traditional “germ theory.” Of course I know germs exist, but I don’t think they “cause” illness. The true cause is the inability of the human body to deal with germs and counter their effects. After all, if germs were the actual root cause of illness, everyone who came into contact with them would be ill — that is, ALL of us!

Hand hygeineHaving said that, most of the people we see in our offices have impaired immune systems, to some degree or another. The existence of subluxations; the lack of proper diet or exercise; the overuse of antibiotics; and even physical, mental or emotional stress can all weaken the immune system to the point where the body is vulnerable to the impact of germs and viruses.

That’s why proper infection control procedures are critical in any wellness office. Unfortunately, this basic tenet of hygiene is often overlooked in medical settings. In fact, a report published in the June 9 issue of JAMA found that such lapses were common in many of the 70 ambulatory surgical centers studied. These centers are rapidly becoming the primary facility for a wide variety of medical and surgical procedures that don’t require hospitalization. In 2007, these facilities performed more than 6 million procedures including endoscopy, pain injections, and dental procedures.

The problem is, these places are often germ breeding environments where medical personnel don’t adhere to basic infection control procedures such as washing their hands.

Melissa K. Schaefer, MD, of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted the study and assessed procedures in five different categories: hand hygiene, injection safety and medication handling, equipment reprocessing, environmental cleaning, and handling of blood glucose monitoring equipment.

More than half of the facilities (67.6%) studied had at least one lapse in infection control noted by surveyors and 17.6% of the facilities had lapses identified in three or more categories.

Nearly one in five facilities (19.4%) didn’t properly apply “hand hygiene” (a euphemism for washing hands!) or use proper personal protective equipment such as gloves. More than one quarter of them (28.4%) had deficiencies related to injection practices or medication handling, primarily through use of single-dose vials for more than one patient.

Another 28.4% of these facilities failed to adhere to recommended practices regarding reprocessing of surgical equipment; and 18.8% didn’t properly clean high-touch surfaces in patient care areas.

Thankfully, chiropractors don’t have to be concerned with the high risk procedures involving injections and drugs, but tables and other high-touch surfaces need to be kept clean and disinfected.

The recommendations given by researchers from Parker Chiropractic College — published in Chiropractic & Osteopathy in 2007 — are excellent. They stated:

“Pathogenic microbes may be present on chiropractic treatment tables and can be effectively killed with proper disinfecting. Hand washing/sanitizing is an important measure in infection control as is table disinfecting. Rudimentary behavioral changes to improve chiropractic clinic infection control are needed. More comprehensive behavioral models are needed. All teaching clinics and private chiropractic offices should adopt infection control practices including routine table disinfecting and hand sanitizing. Effective measures can be put in place at minimal costs.”

References: JAMA. 2010;303[22]:2273-2279 — Abstract

“Assessment and risk reduction of infectious pathogens on chiropractic treatment tables,” Chiropractic & Osteopathy 2007

Study shows non-drug techniques reduce pain in hospitalized patients

In a study published in the Journal of Patient Safety, non-medical therapies were shown to relieve pain among a wide range of hospitalized patients as much as 50 percent. However, chiropractic was not among the approaches tested. Instead, researchers focused only on acupuncture, acupressure, massage therapy, healing touch, music therapy, aromatherapy, and reflexology.

Massage TherapyThe study showed that allowing patients to have access to drug-free care that reduces stress can have a significant impact on pain major challenge and eliminate the risk of negative side effects associated with the drugs normally given to patients.

“Roughly 80 percent of patients report moderate to severe pain levels after surgery,” said Gregory Plotnikoff, MD, one of the study’s authors and medical director of the Penny George Institute for Health and Healing at Abbott Northwestern Hospital.

“We struggle to provide effective pain control while trying to avoid the adverse effects of opioid medications, such as respiratory depression, nausea, constipation, dizziness, and falls.”

The study included 1,837 cardiovascular, medical, surgical, orthopedic, spine, rehabilitation, oncology, and women’s health patients between January 1, 2008, and June 30, 2009. They scored their pain verbally on a zero-to-ten scale before and after treatments.

“Earlier studies narrowly focused on whether specific integrative therapies manage pain in either cancer or surgical patients,” said Jeffery A. Dusek, PhD, research director for the George Institute. “Our real-world study broadly shows that these therapies effectively reduce pain by over 50 percent across numerous patient populations. Furthermore, they can be clinically implemented in real time, across, and under the operational and financial constraints within an acute care hospital.”

Lori Knutson, RN, BSN, HN-BC, executive director of the George Institute stated: “I think we will find that integrative approaches to pain management during the hospital stay will improve patient satisfaction and outcomes, and we will see cost savings from patients using fewer drugs and experiencing fewer adverse events.”

SOURCE: “The Impact of Integrative Medicine on Pain Management in a Tertiary Care Hospital,” March 5, 2010. Journal of Patient Safety.

Research and Public Perception

by Terry A. Rondberg, DC

The media constantly communicates to its vast audience the recent medical breakthroughs. Traditional medicine dominates our society. The recent medical mishaps such as dangerous prescription painkillers, are associated with the failures of regulators who ignore the apparent loopholes of allopathic medicine.

However, alternative health care is gaining attention. It is commonly utilized by the general population. A recent study by Hong at Ohio State University found that nearly three out of four adults over age 50 use some type of alternative medicine. Hong noted, “The most commonly used…was chiropractic, which about 43% of respondents had used.” [1]

Research and Public Perception - by Dr. Terry RondbergUnfortunately, the general public is unaware of chiropractic’s potential contribution to overall wellness.

According to the results of the World Federation of Chiropractic (WFC) survey titled, “Identity of the Chiropractic Profession,” only five percent of participating DCs believed the public considers that chiropractors are doctors who correct subluxations, while 81% believe the public defines chiropractic as doctors who help treat back and neck pain.” [2]

Eighty‑five percent of the chiropractors said the nervous system is essential to the practice of chiropractic, and 65% indicated the public should define chiropractic as stress and  subluxation correction.

In 2003, the Institute for Social Research at Ohio Northern University conducted a survey of  North American chiropractors.  The results showed that 89.8% of respondents felt adjustments should not be limited to musculoskeletal conditions and 88.1% felt that the term vertebral subluxation complex should be withheld. [3]

Some chiropractors have expressed that the public perception should identity the profession. Others wish to limit our role to musculoskeletal pain practitioners, justifying their position by claiming that only low back pain has sufficient research evidence and backing. Both sides are incorrect for reasons I have discussed elsewhere. [4,5]

A successful public relations approach should match the public’s interest with our vision of chiropractic. It is necessary for the public to be properly educated on how chiropractic meets their needs.

The success of this strategy came to light when Dr. Madeline Beherendt’s study on infertility was published in the Journal of Vertebral Subluxation Research, (JVSR) which resulted in positive and credible media coverage for chiropractic.

Among the television programs reporting the study’s results were: KBCI Boise, WCBS New York, KING Seattle, KYW Philadelphia, WTNH New Haven, KUTV Salt Lake City, WCPO Cincinnati, WOAI San Antonio, KOLD Tucson, and KPTM Omaha. On one of the specialized health news wire services, the press release was accessed by journalists more than 700 times by the end of March. [6]

Furthermore, Dr. Erin Elster, an upper cervical chiropractor in Boulder, Colo., gathered data from 44 MS patients and 37 PD patients treated during the span of five years. After treating upper neck injuries in 81 patients, 91% of MS patients and 92% of PD patients improved, suggesting that correction of neck injuries may reverse MS and PD.

The Chiropractic Journal reported, “The World Chiropractic Alliance (WCA), publisher of JVSR, distributed a press release on the research results, which was quickly picked up by major news media, including Reuter’s wire service. The news was relayed to newspapers and television stations around the world, and the story showed up in a wide array of media.

“Viewers watching CNN coverage of the Florida hurricanes saw the headline scroll by on the late breaking news crawl … readers saw all the details in The Washington Post … Internet browsers found the story on sites as varied as the National Institutes of Health’s MEDLINE and the Armenian Medical Network. Yahoo News featured the story and it even appeared on the Merck pharmaceutical company’s website.

“Within days, millions of people were exposed to information about chiropractic and how correction of subluxations might result in an improvement or reversal MS and PD. Although the research examined the two specific diseases, the press release emphasized that the role of chiropractic was not to diagnose or treat those diseases directly, but to correct subluxations and, in doing so, affect the progress of the diseases.” [7]

More recently, a collaborative study of chiropractic care, oxidative stress, and DNA repair has peeked the interests of medical news services and alternative health websites. [8, 9]

The public and journalists are not interested in “manipulation” for the treatment of low back pain. However, they are interested in learning about chiropractic as a focal point on wellness and quality‑of‑life issues often neglected by traditional medicine.

The answer is university-based research and not just a few studies focusing on small case histories. Although encouraging, a long‑term solution must be implemented. The university based research, should involve thousands of patients, and published in prestigious, medical journals. The group QOLR has embodied this challenge but your assistance is paramount.

References

1. Hong G‑S: “About 70 percent of older adults use alternative medicine.” News release. Ohio State University . April 9, 2005.
2. “Consultation on Identity: Quantitative Research Findings.” World Federation of Chiropractic, Dec. 7, 2004.
3. McDonald W, Durkin K, Iseman S, et al: “How Chiropractors Think and Practice.” Institute for Social Research. Ohio Northern University. Ada , OH . 2003.
4. Kent C: “A challenge and three myths.” The Chiropractic Journal. September 2004.
5. Kent C: “Where are we going?” The Chiropractic Journal. August 1997.
6. “Infertility research still a top news story in U.S.” The Chiropractic Journal. May 2004.
7. JVSR, WCA hit two more publicity home runs. The Chiropractic Journal. October 2004.
8. “Chiropractic Influence on Oxidative Stress and DNA Repair.” Medical News Today. March 7, 2005.
9. “Doctors crack code on chiropractic care.” Mercola.com. 4/27/05.

About the Author – Dr. Terry Rondberg
Terry A. Rondberg, DC, is a tireless advocate for drug-free chiropractic, chiropractic patients, wellness, and the mind-body connection for physical, mental, emotional and spiritual well-being. As CEO of the World Chiropractic Alliance, he is a global activist for the interests of doctors of chiropractic and their patients.