This is an important point in malpractice cases: Failure to follow "standard of care" (and I am assuming that simply for the sake of argument) in one aspect of patient care is often imputed to other aspects of patient care. That isn't the way the law is supposed to work; that isn't the way logic is supposed to work, but that is often an argument that a jury will buy.
10 million dollar malpractice verdict for IM doc due to patient suicide.
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This is an important point in malpractice cases: Failure to follow "standard of care" (and I am assuming that simply for the sake of argument) in one aspect of patient care is often imputed to other aspects of patient care. That isn't the way the law is supposed to work; that isn't the way logic is supposed to work, but that is often an argument that a jury will buy.
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Well the most recent piece of bad information someone hears can be decades old.
When Xanax came to market it was explicitly marketed as being for "anxiety associated with depressive symptoms." It was advertised as better than longer-acting benzos because it wouldn't cause depression like longer-acting benzos. I can't find the ad now, but I remember seeing one that made that point about not being "hungover" or groggy the next day. I wish I could find the ad—it was a long form ad that I think was in a medical journal geared toward doctors rather than patients. They somehow turned the short half-life into a positive but I don't recall exactly how they managed it.
Also Xanax is one of the newest benzodiazepines (even though it's almost forty years old), and that makes a difference in prescribing. I've heard the marketing speak regarding newer benzos from doctors about them being "cleaner" than Valium. And it is the number one prescribed benzo right now. Plus there's Xanax-XR, which came out in 2003—not terribly long ago. Besides the short-lived Klonopin Wafers and the new nasal forms of Ativan (for epilepsy), there haven't been too many other recent benzo approvals.
As an aside, I hated the way Klonopin made me feel, and that was before I was benzo tolerant. It was different than both Ativan and Valium. Really made me irritable and much more amnesic than other benzos. Which isn't to say that's universal, but I really hated that drug which is kind of weird because you'd think they'd all have fairly similar effects since the mechanism of action is so similar. I think any of these drugs have the potential to worsen depression.
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Not sure how it is where you live, but here, he wouldn't even get a psychiatry appointment for 8-12 weeks. This was a very quick decompensation. In fact, would the patient even meet criteria for MDD? I doubt it. It was that fast. I think we're all jumping to conclusions. First of all, he wasn't on any antidepressant long enough to determine that it "didn't work" as someone said. Second, we don't know how he responded to the Xanax or how he was instructed to take it. Honestly, the only egregious thing here is the Ambien script. Should have been something else or better evaluated for sleep problems. I can't see anything else the doctor did that would assign him blame. He could have sent him to the ED, but unless the patient WANTED an inpatient psych admission, he likely would have been sent home.
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Aaaaaand this is why closed ICUs are taking off so rapidly.
Yes, I was wondering about this... Are there different rules for admittance to inpatient units based upon states? Where I am from, if a patient does not willingly go to an inpatient unit they can be admitted still but only with the blessing of a judge, and it would have to be considered an emergency detainment. Judges also will not admit a patient where I am from unless the patient actually verbalized suicidal thoughts, has a plan, and intent, and the means to do so. So.....
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Wildly variable from State to state. Involuntary requires (initially, anyway) requires, attributable to a psychiatric condition, intent to seriously injute or kill self with an act of furtherance, HI with an active of furtherance, or failure to care of self to the extent that you anticipate death or serious injury in the next 30 days. Physicians at specific facilities can do an exam and uphold initial petition. This is good for 120 hours but must have a hearing within 72. Even mention substances in the petition and it is likely to be overturned at the hearing
By contrast forcing medications on someone committed involuntarily is distressingly easy from a legal perspective.
I think there are only two states that require a judge to initiate an inpatient hospitalization (Virginia and Oregon).
The biggest issue clinically is that as a physician you can justify a reason for admission, but the admission itself will often be contingent on patient self reports. So if they disavow SI in the emergency room, chances are they’ll deny it inpatient, and it’s going to be a short hospitalization, voluntary or involuntary (assuming there isn’t overt psychosis, mania or some other justification).
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Same here.
Louie the vampire from Interview with the Vampire was made one by L'estat. L'estat wanted to manipulate and control Louie so he didn't teach him how to be a vampire. e.g. Louis had a conscience, and didn't know if he could avoid killing people by using the blood of animals. L'estat wouldn't tell him, and what he did tell he did it to keep him controlled within a box.
I know a psychiatrist who went to a program with very bad training and it shows in his clinical performance, and he is very aware of this and regrets it.
My own training I was not satisfied with even though it wasn't bad, but so much of what I learned I had to learn afterwards, through a forensic fellowship, by continuing learning in a different academic program that was much better, and because I had a self-interest in it that burned far brighter than my colleagues. I remember by 3rd year I knew I was better than some of the attendings teaching me, and while that could sound narcissistic it was incredibly frustrating for me. I even battled what my intellect was telling me because it sounded absurd to be that I could have more knowledge than a practicing licensed physician of several years, and then by 4th year as chief the head of the department basically told me upfront that about half the attendings were terrible and I was better than many of them by the end of my first year. She added that many of them were problematic residents who were terrible but and she was forced to hire them because there's a shortage of psychiatrists. The pay at that hospital for a psychiatrist was low compared to private practice and they had no real academic interest. Their real interest was in letting residents do all the work while they watched The Price is Right in the doctor's lounge (I'm not joking).
Add to that by 4th year in residency I encountered an attending (this was in 2005) who was still only prescribing typical antipsychotics, TCAs, and MAOIs. Yes these days this is now unheard of but back in 2005 while this was still about 20 years behind the times this was actually quite common to see. I still see doctors about 20 years behind to be quite common but the 20 years behind now is more 11 years ahead of 2005.
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In PA while SI is part of criteria for initial involuntary hospitalization, if the initial petition is upheld, the criteria for continuing the admission actually does not require any demonstration of or evidence for lethality. The standard is whether the patient continues to have symptoms of the psychiatric disorder that led to initial hospitalization and whether they would benefit from continued treatment.
As a practical matter insurance often begs to differ about this being a good reason for keeping someone in the hospital for lengthy periods.
That actually sounds like a good, well-intentioned law, but again falls apart when you’re dealing with self reported symptoms in illnesses that never completely resolve (or take months to do so). Marginally psychotic patients will learn to seal over when they want discharge, same with the depressed. The exceptions may be floridly manic individuals or severely decompensated borderline patients, but again you only need partial resolution to gain the wherewithal to tell clinicians (and insurance companies) what they want to hear, or schizophrenia with residual negative symptoms (which we don’t have phenomenal acute treatment for anyway).
Also, if Pennsylvania actually held to that standard in practice, every psych admission for depression would have a 4 to 6 week LOS for the purported time it takes to “treat” a depressive episode.
So in this article it says "The lawyer said Strange had asked Shouldis if he was going to hurt himself, and the decedent said he would not and would be OK."
I am honestly just floored. No reported SI, a denial of self-harming thoughts. He would have been screened through the ER and/or psych inpatient unit and told to go home if the doctor had actually made the immediate referral.
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....I really hope in a psych ER or inpatient setting you are doing a slightly more detailed risk assessment than that because that would be shocking.
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I would hope so too, but the point is still there. Even in a comprehensive assessment, with endorsed hopelessness and some other positive signs, if someone denies active SI and also denies intent or worry about self harm, most inpatient units will not admit. Especially not involuntarily.
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If you send them to the ER the ER will do a more thorough evaluation but trust me from experience. Even patients that have SI are often times discharged quickly. Having SI doesn't simply mean you're dangerous. I've had several chronically suicidal patients but are able to work full time and have lived with their SI for literally decades that unfortunately is treatment-resistant. Yes of course the SI is bad but they've learned to live with it. The real thing is if they have SI and are willing to act upon it.
In the ER typically a social worker, psychiatrist or psych nurse will call the family or friends to get verification of safety. They can also hold the person for up to 24 hrs and observe them.
And if you send someone to the ER for a reported SI most of them will be discharged quickly and now with a bill. Many acute exacerbations literally are solved with the person simply just having time to think it through. Most people who end up in the ER for psych reasons are ultimately discharged with a big bill and the ER doc muttering "who was this loser doctor who told them to go to the ER and waste my time?"
As I wrote above the article doesn't really present the case well enough for us to judge.
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Yes that is right.. And the article did say he left with his wife, and his wife later "had no idea" he was going to kill himself.
At the place I work we would have allowed him to walk most likely. Based on the information provided he would not meet criteria for an inpatient unit stay and we could not have ED'd him.
There is also something to be said about the fact that they are blaming the doctor for not diagnosing this patient with MDD, when the doctor had diagnosed him with "depression and anxiety." The article says the patient had a recent onset of these symptoms and deteriorated quickly, hence the multiple visits. He would not even have met the time frame required to be diagnosed with MDD. Some professionals would say this wasn't even a mental health issue at all, but rather a stress response from losing his job or the threat of losing his job or whatever it was. There is a time component to these diagnoses, even generalized anxiety (6 mo. symptoms). This doctor did his due diligence to prescribe medication but I know people who might not have even done that considering the short amount of time he exhibited symptoms etc. because if you do not meet the time frame for the disorder, you cannot have the disorder, therefore what are you prescribing medication for?
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We don't know if he ever delved deeper than asking him superficially about sx and then about SI. Sorry but 6 lb weight loss in a week is quite unusual and is alarming. A deeper probing would almost certainly uncovered the seriousness/depth of depression and I think this is where the PMD "faultered" or maybe it wasn't in his comfort zone and the pt should have been referred to a psychiatrist before.
Yes, you would be doing a more detailed risk assessment than that but based on what had been reported he would have been screened out at my inpatient unit and told to go home. We did not keep people for 24 hr observation either.
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It's not unusual, really. 5 pound fluctuations are within the normal range for day to day fluctuations for people of average size mostly due to shifts in water retention and a few other factors. w 5 pound fluctuation within a week is nothing. Now if this sustained itself into 10+ pounds in a couple weeks and trending down, now you have something.
This entire issue had developed within a weeks time. The patient had been treated by this doctor for years and it appears the first mention of anything mental health related had occurred on May 30th with the last appointment being June 6th.
Even if he had referred to psychiatry, he wouldn't have got in that quickly. Actually he wouldn't have even gotten into the psychologist that quickly either, which this doctor did refer to. I think a referral to the psychologist was appropriate, as often doctors who refer should collaborate on patient care and treatment. ROIs should be obtained, and if the depression was way worse than Dr. Strange thought (a psychologist would be able to ask those questions) then he could adjust accordingly then refer out to psychiatry at that point.
Also you're saying a deeper probing would "almost certainly" uncovered depth of depression... That is $10 million dollars worth of assuming.
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This article keeps being mis-read.
There was court testimony, but none of it is in the article. The wife is never quoted in the article.
The quotes are from the lawyers on each side. They each claim she said completely opposite things about her husband's suicidality.
It's possible due to the nature of cross-examination she did in fact technically make two statements that contradict each other.
"Mrs. Shouldis testified she had no inkling her husband might commit suicide, Belair said." (Defendant's lawyer)
"Charlene Shouldis testified at trial she was concerned her husband would kill himself, and he should have been admitted to the hospital right away, Cannavo said." (Accuser's lawyer)
There are no quotations from the wife, only allegations by the lawyers on what she said in court.
So it's not what the wife said. It's what the defense attorney said about the wife based on a line of questioning that was surely intended to get her to say something like what he claims she said.
Even if she did not say any of these things... He still left with her. That's a safety plan. He had support leaving the office, and I still do not think this doctor could have seen any of this coming. So he had two visits quickly, back to back. Some reported exacerbation of symptoms. Denied thoughts of harming himself. Just based on what the article reports I do not think an exacerbation in symptoms is enough to consider a doctor recommending an immediate evaluation to an ER or psych inpatient unit. This is the only way he could have been given immediate intervention anyway unless there is some magical place where patients get straight into see psychiatry and psychologists for an intake appt (none exist where I am from).
I believe this is a great example of why our healthcare is so expensive. Everyone tries to sue every chance they get. Americans go across seas to have surgeries because it is too expensive to get their needs met here.
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Yes, other countries are less lawsuit-happy, but according to this article the combined effect of lawsuits and defensive medicine is only 2.4% of US healthcare expenditure:
The True Cost Of Medical Malpractice - It May Surprise You
I think the balkanization of healthcare markets along with medicine being a privately funded initiative (paying for medical school) is the core problem.
You have to lay out a huge investment to get into medicine. And not only do we not have a single payer system, we have multiple public health payers in addition to private ones. Medicaid in my state has now gone public-private with 6 different commercial payers.
Imagine a system where the government pays to fund medical education—allowing for more competition and for more people to join due to merit. And then imagine that same government being the monolithic negotiator with (nearly) all providers. You reduce the need to recoup costs on the one side, and you reduce price gouging on the other.
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This is a classic case of poor documentation. The prosecution gets to make their own narrative and the doctor violated the standard of care by prescribing medications and not documenting his insistence on the patients taking a higher level of care whether or not he did.
This is a terrible outcome but suicides are not Doctor’s faults unless you make the mistakes that this doctor did
Also if I’m not mistaken New York is one of the most liberal civil commitment states in the United States. His family could’ve civilly committed him without the doctors assistance at all....
...I think this verdict will be overturned on appeal
This is a terrible outcome but suicides are not Doctor’s faults unless you make the mistakes that this doctor did
Also if I’m not mistaken New York is one of the most liberal civil commitment states in the United States. His family could’ve civilly committed him without the doctors assistance at all....
...I think this verdict will be overturned on appeal
6
675015
S.I. doctor springs into action at NYC Marathon; revives unconscious woman
The same guy just saved someone's life while running the New York City marathon!
The same guy just saved someone's life while running the New York City marathon!
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This will look really good on appeal!
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Not to turn this into a system debate, but that's only a direct measure. Fear of lawsuits causes doctors to practice defensive medicine, order tests to CYA when they're completely inapproptiate, prescribe unnecessary meds, etc. Last report I saw (2015) showed that $100 billion dollars was spent on unnecessary labs and imaging, which basically means $100billion in waste spending. Pass comprehensive tort reform and I guarantee you'd see a decrease in the extent of unnecessary testing and wasteful spending.
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I won't argue that profit driving isn't a factor, but I will argue against defensive medicine not playing a role. I can't begin to count the number of times I've argued with/questioned an attending that a test was unnecessary and the response is always "well if we miss it are you going to take responsibility?!?!" And in the end we almost always order the test. Part of it is lawsuits, part of it Ian just fear of missing something (d/t fear of either undertreating or lawsuits).
There's a 200 page document from 2015 (I'll try and find it if I can) which shows over-utilization is our primary form of wasted expenditures and accounts for about 30% of healthcare waste. If you're going to tell me that all or almost all of that is purely for greed and profit, I'll tell you to go work in more acute care settings and count the number of times something is ordered "just in case" and get back to me.
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I would fully agree that defensive medicine adds a HUGE burden to healthcare costs, just based on what I've seen and how I practice in the NE myself..
Yup.
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But how do you know that the fear of lawsuits isn't only a minor factor? Don't we have data from states that have passed tort reform, comparing practices before and after?
How much does tort reform (caps on non economic damages) actually reduce the number of lawsuits? And even if getting sued becomes less common, or potential payouts are capped, I still don’t want to get sued at all because it’s extremely stressful and you’re looking at 2-5 years of worry and maybe facing a jury who awards economic damages in excess of your policy limits. And then you have to report the lawsuit on every piece of paperwork you ever fill out for credentialling or licensing forever. I may be misinformed about what tort reform actually is, but in its current state I wouldnt expect tort reform to change defensive medicine practice habits. There needs to be another solution.
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In the end though, every physician has passed USMLE Step 1, 2, 3 OSCE CSA, NBME shelf exams for every rotation, and many also have Board Certification. That's a very good base.
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That was quite the resurrection, this thread has been dead about a year and a half. I see the point, but passing a test that can be crammed for is very different than having a solid base of training in certain subjects, or a measure of uniformity of training.
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To correct a misconception: the USMLE/LEVEL exams are NOT exams you can just cram for. If one doesn't take the first 2 years of med school seriously and put the hours in during that time, it's highly unlikely that they'd pass. The weeks of "cramming" before USMLE (especially Step 1) you may hear med students talking about is not really cramming, it's an extended review period with possible cramming of stuff that was missed/not remembered at all from months earlier.
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Fair enough, I'll gladly concede that to a degree. But the uniformity piece remains suspect. From my experience both in taking med school coursework at different institutions and teaching med students, I have not seen this uniformity. Granted, this is not unique to MD/DO training in the doctoral world.
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the doctor doesn’t make any money from ordering that extra test or admitting when it’s a borderline discharge..so I don’t know why he’s saying that it’s all profit motive when much of the day to day we don’t see any profit from what we do, I agree a big portion is I don’t want to miss something and be sued ..
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The case was tossed . $10-million malpractice verdict against prominent doctor tossed
I'm shocked a neurologist (Dr. Lawrence Shields Dr. Lawrence Shields, MD – Hewlett, NY | Neurology on Doximity) was retained as the plaintiff expert to testify regarding suicide risk assessment and managing a suicidal patient. What does a neurologist know about this...how did defense let this guy through voir dire as an expert on mental health? And the guy finished residency in 1975, so he's gotta be about 80 years old now, and is just testifying against doctors trying to help their patients. This is a case I'd want a state medical board to look at...a neurologist providing expert testimony for a psychiatric issue...sheesh
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that is pretty absurd
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That's ridiculous. Jeez. At least get a psychiatrist expert witness, there's plenty forensically trained!
Who knows but I’d suspect they couldn’t find a psychiatrist to support their case.
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The article doesn't give me enough information to form a strong opinion.
I can point out some obvious details many already mentioned.
1-Almost never do you prescribe Zolpidem and Alprazolam together. If you don't know why either you're not a medical student, physician and you don't know what I'm talking about. Anyone who knows anything in medicine knows this is a dangerous mix.
2-If the decedent's wife said she had "no inkling" the decendent would commit suicide this should if anything added a layer of defense to the doctor. Doctors can't see their patients 24/7 in outpatient. Family members such as spouses who see the person everyday are in more of a position to tell what's going on. If anything then the defense attorney could argue, "if his wife couldn't tell then how is the doctor supposed to tell?"
3-The article points to things that could've been better done by the physician such as better documentation, but it doesn't give anything out that's damning to the point where IMHO he should've been found guilty.
Juries don't know as well as we do that this guy likely doesn't evaluate suicide anywhere near as much as an actual psychiatrist. Lawyers know this too. Now do I know for a fact that this is what happened with Dr. Shields? No, but this type of thing happens quite a lot in forensic medicine. There too are other factors. E.g. maybe the doctor who testified was going to testify for a lot less and the lawyer didn't want to pay as much (not likely given the $$ of the case), maybe the lawyer couldn't get a good forensic psychiatrist in time (unlikely too).
It could also be that Dr. Shields really was good at suicide evaluation (despite his credential as a neurologist). We don't know.
I can point out some obvious details many already mentioned.
1-Almost never do you prescribe Zolpidem and Alprazolam together. If you don't know why either you're not a medical student, physician and you don't know what I'm talking about. Anyone who knows anything in medicine knows this is a dangerous mix.
2-If the decedent's wife said she had "no inkling" the decendent would commit suicide this should if anything added a layer of defense to the doctor. Doctors can't see their patients 24/7 in outpatient. Family members such as spouses who see the person everyday are in more of a position to tell what's going on. If anything then the defense attorney could argue, "if his wife couldn't tell then how is the doctor supposed to tell?"
3-The article points to things that could've been better done by the physician such as better documentation, but it doesn't give anything out that's damning to the point where IMHO he should've been found guilty.
It's a perfect world argument assuming people are actually wanting justice. I've been in a few high-profile cases where I told the lawyer I couldn't provide a strong argument to back them up. The lawyer would often times respond something to the effect of...-don't worry doctor, I already asked more than 10 doctors and I know many that will back anything I want them to back up. We chose you first because we always want the one with the honest and good reputation first. If that one doesn't work out we sink lower. We keep sinking lower until someone grabs for the $1000 an hour paycheck.-
Juries don't know as well as we do that this guy likely doesn't evaluate suicide anywhere near as much as an actual psychiatrist. Lawyers know this too. Now do I know for a fact that this is what happened with Dr. Shields? No, but this type of thing happens quite a lot in forensic medicine. There too are other factors. E.g. maybe the doctor who testified was going to testify for a lot less and the lawyer didn't want to pay as much (not likely given the $$ of the case), maybe the lawyer couldn't get a good forensic psychiatrist in time (unlikely too).
It could also be that Dr. Shields really was good at suicide evaluation (despite his credential as a neurologist). We don't know.
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If you read the article with his testimony (snippet of testimony to be fair) it doesn’t sound like he knows anything about managing suicide risk saying the patient should have been sent to an ED, or if not that level of care "or a psychiatrist or any other doctor knowledgeable about suicide patients". That last part in quotes is a completely impractical thing to expect a PCP to do. How do you send someone to a psychiatrist from your primary care office, I assume that same day? Where are these magical clinics with psychiatrists available to see a suicidal patient the same day. To me this is telling of the "expert's" complete lack of knowledge of how the real world of mental health care works. He's acting like a neurologist who would expect a vascular surgeon or ophthalmologist to add on an appointment for someone with an urgent issue...which is much more realistic for those specialties. If he thinks you can just get a patient into a psychiatrist same day I really doubt he's any sort of mental health expert.
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Isn't this the MO with juries, though? You can't expect 12 average Joe's from off the street - not being derogatory, that's literally who jurors are - to be well-informed or rational. Heck, you can't expect a judge to be well-informed or rational either. The whole process is fraught.
A mentor of mine was involved in a lawsuit where the hospital settled on a ridiculous case where they were clearly not at fault simply because they thought the diagnostic issues in the case would go over the heads of a jury and the defendant "looked pathetic."
Also, a pet peeve of mine is the question "do you want to hurt yourself?" That doesn't get at the issue of suicide. Hurt does not equal kill. Non-psychiatrists are afraid to ask about kill. Yet the patient could answer perfectly truthfully that they don't want to hurt themselves, and yet have desire and intent to kill themselves. This is one thing I try to impress on all the trainees that come through my service. If they take nothing else away from psychiatry, at least let them take away *that.* Ok, end rant. I still think the verdict is ridiculous.
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Standard of care, standard of anything, with 10 minute appointments, or 7 minutes or whatever it is in primary care these days? Don't make me laugh.
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Or, when these services are available, this type of fear often results in PCPs sending patients to Primary Care Mental Health for a suicide risk evaluation just because they're, like, feeling sad.
Speaking as someone who used to see warm handoffs in PCMHI...
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I agree.
There aren't many facts in the article. The winning lawyer is just making grandstanding, media-friendly statements. Without seeing the court transcript or any video deposition, it's hard to tell how the doctor appeared to the jury. Maybe he contradicted himself, came off arrogant etc. Juries are known to punish people for that.
It wouldn't be very hard to trip up PCPs on the witness stand about suicide assessment. PCPs often like to say they deal with depressed patients all the time, but then their HPI, A/P are 10 characters.
