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How Doctors Think
Posted by: Paul W. Cutrone
April 30, 2008
Topic: How Doctors Think

In his insightful and engaging best seller How Doctors Think (First Mariner Books 2007), Jerome Groopman, M.D. describes his discomfort with his conclusion that "very bright and very affable medical students, interns, and residents all too often failed to question cogently or listen carefully or observe keenly." He wrote this book because he was disturbed that they were not thinking deeply about their patient's problems, and because he thought there was something profoundly wrong with the way they were learning to solve clinical puzzles and to care for people. He found that doctors too often had no insight into the thought process that led them to their diagnostic conclusions.

He explores the shift to preset algorithms and decision trees, and the siren call of "evidence based medicine". His observation about how misdiagnoses occur are complex, and nuanced, and do not lend themselves to a simplistic summary in this blog. He dares to explore how a doctor's emotions color his judgement, and how the economics that drive medical practices affect patient outcomes. The book focuses long and hard on the failure of doctors to listen to their patients and to truly absorb and think about the stories of their illnesses.

An equally compelling book, Complications (Metropolitan Books 2002), written by Atul Gawande, M.D., is about the rarefied world of surgeons. It also focuses on the human factors and cognitive errors that lead to disastrous consequences. It points out the differences in the approach to error of industries like aviation in which there is no tolerance for any error, and medicine, which tolerates far too many avoidable systemic errors. One of his insights is that "not only do all human beings err, but they err frequently and in predictable, patterned ways. And systems that do not adjust for these realities end up exacerbating rather that eliminating errors." He gives examples of how it is not usually a single error that harms a patient, but instead a series of undetected errors that ultimately combine to cause an injury.

Why does this blogger-attorney read books like these? It is important to be able to deconstruct the way doctors think in order to learn how they make the errors that cause harm to their patients. An attorney must be able to follow their cognitive processes in order to be able to construct the questioning that takes place at depositions and during trial. I began my legal career defending doctors, and know first hand how the failure to listen to patients' stories, and to follow the steps of differential diagnosis, can lead to malpractice. As a plaintiff's attorney I have heard the stories of parents who have had a child injured at birth because a doctor came into a delivery room tired and angry for some unknown reason. Doctors are fallible, and often, when they err through negligence, the harm they cause is staggering and irreparable. It is our job, as attorneys for these harmed patients, to understand to the best of our ability why and how malpractice occurs.

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Breast Cancer Detection and Digital Mammograms
Posted by: Paul W. Cutrone
April 14, 2008
Topic: Breast Cancer Detection and Digital Mammograms

A front page article in today's New York Times calls attention to the ongoing change-over from traditional x-ray film mammograms to digital mammograms. This article calls attention to the fact that because of the increased clarity of the images and the improvement in the ability to detect calcium deposits, that there has been an increase in the amount of women being asked to return for further testing that ultimately are found not to have breast cancer. Another factor in the increased rate of recalls of patients is that radiologists are in the early stages of the learning curve with respect to the interpretation of digital mammograms.

In an article entitled "Issues to Consider in Switching To Digital Mammography", published in Sept. 07 by the journal Radiologic Clinics of North America, the authors discussed the results of the "Oslo II" medical study, which studies over 25,000 women who were randomly assigned to either film or digital mammography. They also discussed the "DMIST" study, which studied over 49,000 women who had both digital and film mammography. The DMIST study found that for women who had dense breasts, or were under 50, or who were pre- or peri-menopausal, digital mammography was statistically significantly better at detecting cancers. Both studies found that in comparing the results over the general population, however, that there was no significant difference between digital and film mammography in detecting breast cancers.

The American Cancer Society has published guidelines that call for the following steps to detect breast cancer at an early stage;

1) Clinical breast exams by your physician should be performed every three years in women 20 to 39 years of age, then annually beginning at age 40.

2) Women at average risk for breast cancer should begin regular annual mammography at age 40, and should be informed of the benefits, limitations, and potential harms associated with screening.

Breast cancer may be seen on a mammogram up to 2 years before it can be felt with a breast exam. Early detection means that the cancer then can be treated early, which can greatly increase the success in treating the cancer.

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Heart Attacks, Lack of Sleep, and Bloggin
Posted by: Paul W. Cutrone
April 08, 2008
Topic: Heart Attacks, Lack Of Sleep, And Blogging

The New York Times, in its Sunday Edition for April 6, 2008, reported on the death of two prominent technology bloggers at age 50 and 60 respectively, from heart attacks. It reported that a third blogger, Om Malik, age 41, survived a heart attack that he suffered in December of 2007.

The necessity for a blogger to be the first out with a story in order to be read, relevant, and to ultimately be paid, contributes to high levels of stress, and to low levels of sleep. The Times article did not presume to draw a direct link between these occupational hazards and the cardiac events suffered by these three bloggers. It did, however call attention to the often unhealthy life styles of those locked into a 24/7 news cycle.

Coincidently, one of the lead stories reported earlier in the week by mdconsult.com concerned a study associating a change in sleep duration during midlife with a huge increase in risk of death from cardiovascular events. Dr. Francesco Cappucio of Warwick Medical School, Coventry , England, reported upon a study known as "Whitehall II" at a conference of the American Heart Association. The study's subjects were over 10,000 white-collar British civil servants between the ages of 35-55. The study concluded that cardiovascular mortality was increased 2.4 fold when persons who normally slept 6-8 hours decreased their time sleeping to 5 hours during the five-year follow up period of the study.

It is was already known that sleep deprivation was associated with diseases such as hypertension, weight gain, and diabetes. What this study makes clear, is that those who are seriously sleep deprived are also placing themselves at risk for early, sudden, cardiac death.

If you or a loved one is suffering from sleep deprivation for any period of time, please seek the help and advice of your physician. There is no reason to place yourself at risk when there are safe medical therapies available to help you get the rest your body needs.

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Tower Cranes and Construction Site Accidents
Posted by: Paul Cutrone
March 17, 2008
Topic: Construction Site Accidents

New York mourns the loss of life and destruction caused by the collapse of the tower crane used in constructing a new apartment tower at 303 East 51st Street on March 15, 2008.

New York State and New York City have long recognized the dangers inherent in high-rise construction. They have in place laws and regulations that were put in place for the protection not only of the construction workers who are most frequently harmed in these incidents, but also to protect the citizens who live and work in the area around the construction site.

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TIA's, and The Importance Of Immediate Stroke Prevention Measures
Posted by: Paul Cutrone
March 12, 2008
Topic: Stroke Prevention Measures

Elsevier Global Medical News has reported on the findings of Dr. Anthony S. Kim, in a March 6, 2008 article, that mortality is high in the two years following an emergency room visit for transient ischemic attacks. Transient ischemic attacks (TIA's), are defined as an acute loss of focal cerebral or ocular (eye) function with symptoms that last less than 24 hours and that are attributed to inadequate blood supply to the brain. Most of these patient deaths were attributable to cardiovascular or cerebrovascular causes. Dr. Kim reported his findings at the International Stroke Conference which took place in New Orleans.

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