John Hickner, MD, MSc

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

Dr. Hickner’s editorial “Let’s talk about the evidence” (J Fam Pract. 2015;64:337) struck a chord with me. I am very supportive of evidence-based medicine (EBM), but am often dismayed by the lack of humility expressed by EBM leaders, including the US Preventive Services Task Force. We have so little evidence about much of what we do in family medicine, and most evidence comes from studies that are narrow by nature (reductionist research).

Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

For example, doing a physical exam is part of “laying on of hands” that is part of the art of medicine. Abraham Verghese, MD, MACP, has written and spoken about the importance of examining the patient and not just depending on data.¹ Yet elements of the physical exam, such as the pelvic exam example Dr. Hickner mentioned in his editorial, do not stand up well in EBM due to a lack of diagnostic accuracy. I’ll ask this: Who has studied the harm that may be caused by not examining our patients?

My physical exam “ritual” takes less than 10 minutes, and the value in the relationship I have with patients is more than a diagnostic exercise. Increasingly, I see patients become annoyed and critical of physicians who do not examine them.

Joseph E. Scherger, MD, MPH
Rancho Mirage, Calif

1. TED Talks. Abraham Verghese: A Doctor’s Touch. TED Web site. Available at: http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch. Accessed July 20, 2015.

Author’s response:
Dr. Scherger makes an excellent point about the importance of physical touch for the doctor-patient relationship. The question is: What touching is appropriate? In my own experience, I have noticed that most—but not all—of the women I see are quite relieved that they don’t need yearly pelvic exams, and women I see for pap smears do not seem put off if I do not do a bimanual exam. The data are actually quite strong that routine pelvic exams in asymptomatic women lead to more harm than good. They uncover way too many false positives and almost no true positive findings, leading to unnecessary testing and treatment.^1,2

John Hickner, MD, MSc
Chicago, Ill

Dr. Hickner is the editor-in-chief of The Journal of Family Practice

1. Ebell MH, Culp M, Lastinger K, et al. A systematic review of the bimanual examination as a test for ovarian cancer. Am J Prev Med. 2015;48:350–356.

2. Well-woman visit. Committee Opinion No. 534. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2012;120:421-424.

In this issue, Dr. Onysko discusses “alternative” pharmacologic approaches to painful peripheral neuropathy. (See “Targeting neuropathic pain: Consider these alternatives.”) Because so many of our patients use alternative therapies, I contend that alternative therapies are no longer “alternative.” Even the federal government has officially recognized the widespread use of alternative therapies by changing the name of the National Center for Complementary and Alternative Medicine in December 2014 to the National Center for Complementary and Integrative Health.

Alternative medicine had a bad name in mainstream medicine until 1991, when the National Institutes of Health established the Office of Alternative Medicine, officially recognizing that some alternative treatments might have a scientific basis and true therapeutic effects beyond the placebo effect. Over the years, hundreds of randomized controlled trials (RCTs) have emerged to investigate the value of various herbal treatments, vitamin therapies, magnet therapy, acupuncture, tai chi, aromatherapy, and other physical medicine and medicinal treatment modalities.

Last spring, as I prepared an evidence-based medicine talk, I was struck by the solid evidence supporting numerous therapies we used to consider alternative. Many trials of acupuncture, for instance, have shown positive effects for various musculoskeletal problems. But acupuncture is also effective for functional dyspepsia, according to a well-designed RCT.¹ In addition, it can relieve symptoms of irritable bowel syndrome (IBS), according to a Cochrane meta-analysis of 17 RCTs.²

We can now count acupuncture among the evidence-based treatment options for conditions such as functional dyspepsia and IBS.

One of the new kids on the block in alternative medicine is functional medicine, founded by nutritionist/biochemist Jeff Bland. According to the Institute of Functional Medicine Web site, functional medicine is a combination of holistic medicine principles and a belief that we can treat a wide variety of ailments with various dietary treatments, including supplements.³ Although research on the interaction between gut flora and human health is burgeoning, I’m wary of claims of effectiveness until we see evidence of improved patient-oriented outcomes from well-executed RCTs.

I’m keeping an open mind, however, about all forms of complementary and integrative therapies. After all, who would have guessed 30 years ago that peptic ulcer disease could be cured with antibiotics?

In this issue, Dr. Onysko discusses “alternative” pharmacologic approaches to painful peripheral neuropathy. (See “Targeting neuropathic pain: Consider these alternatives.”) Because so many of our patients use alternative therapies, I contend that alternative therapies are no longer “alternative.” Even the federal government has officially recognized the widespread use of alternative therapies by changing the name of the National Center for Complementary and Alternative Medicine in December 2014 to the National Center for Complementary and Integrative Health.

Alternative medicine had a bad name in mainstream medicine until 1991, when the National Institutes of Health established the Office of Alternative Medicine, officially recognizing that some alternative treatments might have a scientific basis and true therapeutic effects beyond the placebo effect. Over the years, hundreds of randomized controlled trials (RCTs) have emerged to investigate the value of various herbal treatments, vitamin therapies, magnet therapy, acupuncture, tai chi, aromatherapy, and other physical medicine and medicinal treatment modalities.

Last spring, as I prepared an evidence-based medicine talk, I was struck by the solid evidence supporting numerous therapies we used to consider alternative. Many trials of acupuncture, for instance, have shown positive effects for various musculoskeletal problems. But acupuncture is also effective for functional dyspepsia, according to a well-designed RCT.¹ In addition, it can relieve symptoms of irritable bowel syndrome (IBS), according to a Cochrane meta-analysis of 17 RCTs.²

We can now count acupuncture among the evidence-based treatment options for conditions such as functional dyspepsia and IBS.

One of the new kids on the block in alternative medicine is functional medicine, founded by nutritionist/biochemist Jeff Bland. According to the Institute of Functional Medicine Web site, functional medicine is a combination of holistic medicine principles and a belief that we can treat a wide variety of ailments with various dietary treatments, including supplements.³ Although research on the interaction between gut flora and human health is burgeoning, I’m wary of claims of effectiveness until we see evidence of improved patient-oriented outcomes from well-executed RCTs.

I’m keeping an open mind, however, about all forms of complementary and integrative therapies. After all, who would have guessed 30 years ago that peptic ulcer disease could be cured with antibiotics?

In this issue, Dr. Onysko discusses “alternative” pharmacologic approaches to painful peripheral neuropathy. (See “Targeting neuropathic pain: Consider these alternatives.”) Because so many of our patients use alternative therapies, I contend that alternative therapies are no longer “alternative.” Even the federal government has officially recognized the widespread use of alternative therapies by changing the name of the National Center for Complementary and Alternative Medicine in December 2014 to the National Center for Complementary and Integrative Health.

Alternative medicine had a bad name in mainstream medicine until 1991, when the National Institutes of Health established the Office of Alternative Medicine, officially recognizing that some alternative treatments might have a scientific basis and true therapeutic effects beyond the placebo effect. Over the years, hundreds of randomized controlled trials (RCTs) have emerged to investigate the value of various herbal treatments, vitamin therapies, magnet therapy, acupuncture, tai chi, aromatherapy, and other physical medicine and medicinal treatment modalities.

Last spring, as I prepared an evidence-based medicine talk, I was struck by the solid evidence supporting numerous therapies we used to consider alternative. Many trials of acupuncture, for instance, have shown positive effects for various musculoskeletal problems. But acupuncture is also effective for functional dyspepsia, according to a well-designed RCT.¹ In addition, it can relieve symptoms of irritable bowel syndrome (IBS), according to a Cochrane meta-analysis of 17 RCTs.²

We can now count acupuncture among the evidence-based treatment options for conditions such as functional dyspepsia and IBS.

One of the new kids on the block in alternative medicine is functional medicine, founded by nutritionist/biochemist Jeff Bland. According to the Institute of Functional Medicine Web site, functional medicine is a combination of holistic medicine principles and a belief that we can treat a wide variety of ailments with various dietary treatments, including supplements.³ Although research on the interaction between gut flora and human health is burgeoning, I’m wary of claims of effectiveness until we see evidence of improved patient-oriented outcomes from well-executed RCTs.

I’m keeping an open mind, however, about all forms of complementary and integrative therapies. After all, who would have guessed 30 years ago that peptic ulcer disease could be cured with antibiotics?

One of my favorite professional activities is teaching an evidence-based continuing medical education course each year at state Academy of Family Physicians meetings. In 12 intensive hours, 4 evidence-based medicine (EBM) experts guide family physicians, nurse practitioners, and physician assistants through nearly 400 abstracts that summarize recent studies that impact primary care practice.

In some cases, the new studies support current practice and standards of care, but for many topics, the new evidence suggests we ought to change our practice, either by stopping something we are currently doing or by starting to do something new. Who would have thought, for instance, that we should abandon the routine bimanual pelvic exam because the potential for harm is greater than the potential for benefit?

Frequently, however, we conclude a talk by describing the uncertainty surrounding particular issues and the need for more high-quality research. For example, there is scant evidence that vitamin D supplementation in healthy Americans leads to any positive outcomes compared to a decent diet and 15 minutes in the sun each day. Luckily, there are several large randomized trials currently underway that will evaluate vitamin D supplementation.

Who would have thought that we should abandon the routine bimanual pelvic exam? And yet, that is what the evidence tells us.

The strength of the scientific evidence to support screening tests and treatments is important to consider. A study examining changes in 11 American College of Cardiology/American Heart Association guidelines found that, out of 619 recommendations, 90% were unchanged in the updated version if supported by multiple randomized trials, and 74% were unchanged if supported by expert opinion.¹

In The Journal of Family Practice, we use the Strength of Recommendation Taxonomy (SORT) that was developed by family physician EBM experts² because it is an approach to grading evidence that takes into account “patient-oriented evidence that matters.” An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series.

We ask our authors to carefully select the level of evidence supporting their clinical recommendations. But your input—and the lively discussion that can often follow—is important, too. Just last month, we published a letter from 2 readers who challenged the evidence-based answer to a Clinical Inquiries question on breastfeeding.

Such ongoing dialogue is useful and enlightening. And we encourage you to write us if you disagree with any of the SORT ratings published in the journal. Let’s keep talking about what the evidence says.

One of my favorite professional activities is teaching an evidence-based continuing medical education course each year at state Academy of Family Physicians meetings. In 12 intensive hours, 4 evidence-based medicine (EBM) experts guide family physicians, nurse practitioners, and physician assistants through nearly 400 abstracts that summarize recent studies that impact primary care practice.

In some cases, the new studies support current practice and standards of care, but for many topics, the new evidence suggests we ought to change our practice, either by stopping something we are currently doing or by starting to do something new. Who would have thought, for instance, that we should abandon the routine bimanual pelvic exam because the potential for harm is greater than the potential for benefit?

Frequently, however, we conclude a talk by describing the uncertainty surrounding particular issues and the need for more high-quality research. For example, there is scant evidence that vitamin D supplementation in healthy Americans leads to any positive outcomes compared to a decent diet and 15 minutes in the sun each day. Luckily, there are several large randomized trials currently underway that will evaluate vitamin D supplementation.

Who would have thought that we should abandon the routine bimanual pelvic exam? And yet, that is what the evidence tells us.

The strength of the scientific evidence to support screening tests and treatments is important to consider. A study examining changes in 11 American College of Cardiology/American Heart Association guidelines found that, out of 619 recommendations, 90% were unchanged in the updated version if supported by multiple randomized trials, and 74% were unchanged if supported by expert opinion.¹

In The Journal of Family Practice, we use the Strength of Recommendation Taxonomy (SORT) that was developed by family physician EBM experts² because it is an approach to grading evidence that takes into account “patient-oriented evidence that matters.” An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series.

We ask our authors to carefully select the level of evidence supporting their clinical recommendations. But your input—and the lively discussion that can often follow—is important, too. Just last month, we published a letter from 2 readers who challenged the evidence-based answer to a Clinical Inquiries question on breastfeeding.

Such ongoing dialogue is useful and enlightening. And we encourage you to write us if you disagree with any of the SORT ratings published in the journal. Let’s keep talking about what the evidence says.

One of my favorite professional activities is teaching an evidence-based continuing medical education course each year at state Academy of Family Physicians meetings. In 12 intensive hours, 4 evidence-based medicine (EBM) experts guide family physicians, nurse practitioners, and physician assistants through nearly 400 abstracts that summarize recent studies that impact primary care practice.

In some cases, the new studies support current practice and standards of care, but for many topics, the new evidence suggests we ought to change our practice, either by stopping something we are currently doing or by starting to do something new. Who would have thought, for instance, that we should abandon the routine bimanual pelvic exam because the potential for harm is greater than the potential for benefit?

Frequently, however, we conclude a talk by describing the uncertainty surrounding particular issues and the need for more high-quality research. For example, there is scant evidence that vitamin D supplementation in healthy Americans leads to any positive outcomes compared to a decent diet and 15 minutes in the sun each day. Luckily, there are several large randomized trials currently underway that will evaluate vitamin D supplementation.

Who would have thought that we should abandon the routine bimanual pelvic exam? And yet, that is what the evidence tells us.

The strength of the scientific evidence to support screening tests and treatments is important to consider. A study examining changes in 11 American College of Cardiology/American Heart Association guidelines found that, out of 619 recommendations, 90% were unchanged in the updated version if supported by multiple randomized trials, and 74% were unchanged if supported by expert opinion.¹

In The Journal of Family Practice, we use the Strength of Recommendation Taxonomy (SORT) that was developed by family physician EBM experts² because it is an approach to grading evidence that takes into account “patient-oriented evidence that matters.” An A-level recommendation is based on consistent and good-quality patient-oriented evidence; a B-level recommendation is based on inconsistent or limited-quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion, disease-oriented evidence, or case series.

We ask our authors to carefully select the level of evidence supporting their clinical recommendations. But your input—and the lively discussion that can often follow—is important, too. Just last month, we published a letter from 2 readers who challenged the evidence-based answer to a Clinical Inquiries question on breastfeeding.

Such ongoing dialogue is useful and enlightening. And we encourage you to write us if you disagree with any of the SORT ratings published in the journal. Let’s keep talking about what the evidence says.

Missed case of group A strep results in amputation of limbs

A 53-YEAR-OLD WOMAN went to the emergency department (ED) with severe abdominal pain, a rapid heartbeat, and a 101.3° F fever. After 9 hours, the ED physician discharged her around midnight with instructions to contact her gynecologist in the morning for “fibroid issues.” Later that day, the patient collapsed at home and was transported back to the hospital. She was treated for septic shock from a group A Streptococcus infection and had all 4 of her limbs amputated.

Older patients with a fever and no definite source of infection must be handled with great caution.

PLAINTIFF’S CLAIM The ED physician, who discharged the patient with a 102.9° F fever, should have spotted the infection and should have spent more time with her—given the complexity of her case. The physician should have given the patient alternative diagnoses, which would have prompted her to pursue other treatment.

THE DEFENSE The defendants denied any negligence.

VERDICT $25.3 million Wisconsin verdict.

COMMENT Although we are not given many details of this case, I suspect there was a fairly thorough work-up with no specific source of infection discovered. While this was an emergency medicine case, it is a strong reminder that older patients with a fever and no definite source of infection must be handled with great caution.

Patient dies following "routine" warfarin change

AN 80-YEAR-OLD WOMAN was taking warfarin for chronic pulmonary emboli. She saw her physician for a follow-up visit after being hospitalized for heart failure and shortness of breath. He ordered lab work, which revealed an elevated international normalized ratio (INR) of 3.7. The physician e-mailed a nurse to contact the patient and tell her to reduce her warfarin dosage. The nurse documented that she told the patient and called in a new prescription. Five days later, the patient was admitted to the hospital with a significantly elevated INR and a spinal bleed that caused paralysis. The patient was transferred to a nursing home, where she died 6 months after her initial follow-up visit.

PLANTIFF’S CLAIM The physician’s instructions were ambiguous, and a repeat INR should have been performed in 2 or 3 days. The nurse did not properly instruct the decedent and should have notified the family and the visiting nurse of the medication change.

THE DEFENSE The instructions the physician gave were correct and the appropriate plan was to repeat the INR in 13 days. The decedent had managed her warfarin through 11 previous dose changes, so there was no reason to notify the family or visiting nurse.

VERDICT $40,000 settlement.

COMMENT This case is a reminder of the difficulties one can encounter with warfarin dose adjustments. In view of the small settlement, it does not appear there was much physician liability. Most patients do not bleed with an INR of 3.7. It certainly would have been prudent to recheck in 2 to 3 days, however.

Severe headache, but no CT scan results in death

A HOSPITALIZED 57-YEAR-OLD MAN complained of a severe headache that he described as a 10 on a scale of 1 to 10. At the time, he was taking warfarin. After 6 days, he died from a brain herniation and hemorrhage.

PLAINTIFF’S CLAIM Despite the patient’s complaint of severe headache, the physician failed to order a computed tomography scan of the head.

THE DEFENSE The patient’s headaches had waxed and waned and were associated with a fever of recent onset. There were no focal neurologic deficits to suggest that there was any problem with the brain. The brain hemorrhage was a sudden and acute event.

VERDICT $250,000 Illinois verdict.

COMMENT Have a high index of suspicion for intracranial hemorrhage in patients taking warfarin with severe headache. What more needs to be said?

Missed case of group A strep results in amputation of limbs

A 53-YEAR-OLD WOMAN went to the emergency department (ED) with severe abdominal pain, a rapid heartbeat, and a 101.3° F fever. After 9 hours, the ED physician discharged her around midnight with instructions to contact her gynecologist in the morning for “fibroid issues.” Later that day, the patient collapsed at home and was transported back to the hospital. She was treated for septic shock from a group A Streptococcus infection and had all 4 of her limbs amputated.

Older patients with a fever and no definite source of infection must be handled with great caution.

PLAINTIFF’S CLAIM The ED physician, who discharged the patient with a 102.9° F fever, should have spotted the infection and should have spent more time with her—given the complexity of her case. The physician should have given the patient alternative diagnoses, which would have prompted her to pursue other treatment.

THE DEFENSE The defendants denied any negligence.

VERDICT $25.3 million Wisconsin verdict.

COMMENT Although we are not given many details of this case, I suspect there was a fairly thorough work-up with no specific source of infection discovered. While this was an emergency medicine case, it is a strong reminder that older patients with a fever and no definite source of infection must be handled with great caution.

Patient dies following "routine" warfarin change

AN 80-YEAR-OLD WOMAN was taking warfarin for chronic pulmonary emboli. She saw her physician for a follow-up visit after being hospitalized for heart failure and shortness of breath. He ordered lab work, which revealed an elevated international normalized ratio (INR) of 3.7. The physician e-mailed a nurse to contact the patient and tell her to reduce her warfarin dosage. The nurse documented that she told the patient and called in a new prescription. Five days later, the patient was admitted to the hospital with a significantly elevated INR and a spinal bleed that caused paralysis. The patient was transferred to a nursing home, where she died 6 months after her initial follow-up visit.

PLANTIFF’S CLAIM The physician’s instructions were ambiguous, and a repeat INR should have been performed in 2 or 3 days. The nurse did not properly instruct the decedent and should have notified the family and the visiting nurse of the medication change.

THE DEFENSE The instructions the physician gave were correct and the appropriate plan was to repeat the INR in 13 days. The decedent had managed her warfarin through 11 previous dose changes, so there was no reason to notify the family or visiting nurse.

VERDICT $40,000 settlement.

COMMENT This case is a reminder of the difficulties one can encounter with warfarin dose adjustments. In view of the small settlement, it does not appear there was much physician liability. Most patients do not bleed with an INR of 3.7. It certainly would have been prudent to recheck in 2 to 3 days, however.

Severe headache, but no CT scan results in death

A HOSPITALIZED 57-YEAR-OLD MAN complained of a severe headache that he described as a 10 on a scale of 1 to 10. At the time, he was taking warfarin. After 6 days, he died from a brain herniation and hemorrhage.

PLAINTIFF’S CLAIM Despite the patient’s complaint of severe headache, the physician failed to order a computed tomography scan of the head.

THE DEFENSE The patient’s headaches had waxed and waned and were associated with a fever of recent onset. There were no focal neurologic deficits to suggest that there was any problem with the brain. The brain hemorrhage was a sudden and acute event.

VERDICT $250,000 Illinois verdict.

COMMENT Have a high index of suspicion for intracranial hemorrhage in patients taking warfarin with severe headache. What more needs to be said?

Missed case of group A strep results in amputation of limbs

A 53-YEAR-OLD WOMAN went to the emergency department (ED) with severe abdominal pain, a rapid heartbeat, and a 101.3° F fever. After 9 hours, the ED physician discharged her around midnight with instructions to contact her gynecologist in the morning for “fibroid issues.” Later that day, the patient collapsed at home and was transported back to the hospital. She was treated for septic shock from a group A Streptococcus infection and had all 4 of her limbs amputated.

Older patients with a fever and no definite source of infection must be handled with great caution.

PLAINTIFF’S CLAIM The ED physician, who discharged the patient with a 102.9° F fever, should have spotted the infection and should have spent more time with her—given the complexity of her case. The physician should have given the patient alternative diagnoses, which would have prompted her to pursue other treatment.

THE DEFENSE The defendants denied any negligence.

VERDICT $25.3 million Wisconsin verdict.

COMMENT Although we are not given many details of this case, I suspect there was a fairly thorough work-up with no specific source of infection discovered. While this was an emergency medicine case, it is a strong reminder that older patients with a fever and no definite source of infection must be handled with great caution.

Patient dies following "routine" warfarin change

AN 80-YEAR-OLD WOMAN was taking warfarin for chronic pulmonary emboli. She saw her physician for a follow-up visit after being hospitalized for heart failure and shortness of breath. He ordered lab work, which revealed an elevated international normalized ratio (INR) of 3.7. The physician e-mailed a nurse to contact the patient and tell her to reduce her warfarin dosage. The nurse documented that she told the patient and called in a new prescription. Five days later, the patient was admitted to the hospital with a significantly elevated INR and a spinal bleed that caused paralysis. The patient was transferred to a nursing home, where she died 6 months after her initial follow-up visit.

PLANTIFF’S CLAIM The physician’s instructions were ambiguous, and a repeat INR should have been performed in 2 or 3 days. The nurse did not properly instruct the decedent and should have notified the family and the visiting nurse of the medication change.

THE DEFENSE The instructions the physician gave were correct and the appropriate plan was to repeat the INR in 13 days. The decedent had managed her warfarin through 11 previous dose changes, so there was no reason to notify the family or visiting nurse.

VERDICT $40,000 settlement.

COMMENT This case is a reminder of the difficulties one can encounter with warfarin dose adjustments. In view of the small settlement, it does not appear there was much physician liability. Most patients do not bleed with an INR of 3.7. It certainly would have been prudent to recheck in 2 to 3 days, however.

Severe headache, but no CT scan results in death

A HOSPITALIZED 57-YEAR-OLD MAN complained of a severe headache that he described as a 10 on a scale of 1 to 10. At the time, he was taking warfarin. After 6 days, he died from a brain herniation and hemorrhage.

PLAINTIFF’S CLAIM Despite the patient’s complaint of severe headache, the physician failed to order a computed tomography scan of the head.

THE DEFENSE The patient’s headaches had waxed and waned and were associated with a fever of recent onset. There were no focal neurologic deficits to suggest that there was any problem with the brain. The brain hemorrhage was a sudden and acute event.

VERDICT $250,000 Illinois verdict.

COMMENT Have a high index of suspicion for intracranial hemorrhage in patients taking warfarin with severe headache. What more needs to be said?

The results of the 2015 National Residency Match Program were announced on March 20. For family medicine, the glass was either half empty or half full, depending on your point of view.

On the plus side, 84 more family medicine positions were offered compared to 2014 (3216 vs 3132) and 60 more positions were filled, for a total of 3060 new family medicine residents in 2015.¹ This was far more than matched in gloomy 2009, when only 2555 residents chose family medicine. On the negative side of the balance sheet, there will be 233 fewer family medicine residents this year than matched at the peak of medical student interest in family medicine in 1998.

I’m a glass half full kind of guy, so I am delighted that the trend of increased medical student interest in family medicine continues. According to Merritt Hawkins, a national recruitment firm, family medicine has been the top recruited specialty for several years. The firm reports that starting salaries for family physicians increased by nearly 12% from 2010/11 to 2013/14, which was a higher rate than that of most other specialties.² So there is reason to be optimistic about the future of our specialty.

Our monthly 5-question online quiz can help residents study for their certification exam.

However, to be card-carrying family physicians, our new residents must take the American Board of Family Medicine certification exam, and not all pass on their first attempt. A 2013 study of family medicine residency graduates found that only 86% of graduates passed the board exam on their first try.³

We can help. In addition to the evidence-based reviews published in The Journal of Family Practice (JFP), we have launched a new feature called Residents’ Rapid Review (RRR) to provide an additional resource for residents.

RRR is a monthly 5-question evidence-based quiz prepared by primary care faculty, including current and former residency program directors. After residents click on their answer, the system lets them know whether they’re right and provides the correct answer with an explanation and references. Monthly notifications are sent out to all jfponline.com registered users alerting them that a new quiz is available. (Not a registered user on the site? Sign up at jfponline.com/residents_reg.)

Getting ready for the recertification exam? The RRR quizzes can help you, too. Check out the latest quiz, today!

The results of the 2015 National Residency Match Program were announced on March 20. For family medicine, the glass was either half empty or half full, depending on your point of view.

On the plus side, 84 more family medicine positions were offered compared to 2014 (3216 vs 3132) and 60 more positions were filled, for a total of 3060 new family medicine residents in 2015.¹ This was far more than matched in gloomy 2009, when only 2555 residents chose family medicine. On the negative side of the balance sheet, there will be 233 fewer family medicine residents this year than matched at the peak of medical student interest in family medicine in 1998.

I’m a glass half full kind of guy, so I am delighted that the trend of increased medical student interest in family medicine continues. According to Merritt Hawkins, a national recruitment firm, family medicine has been the top recruited specialty for several years. The firm reports that starting salaries for family physicians increased by nearly 12% from 2010/11 to 2013/14, which was a higher rate than that of most other specialties.² So there is reason to be optimistic about the future of our specialty.

Our monthly 5-question online quiz can help residents study for their certification exam.

However, to be card-carrying family physicians, our new residents must take the American Board of Family Medicine certification exam, and not all pass on their first attempt. A 2013 study of family medicine residency graduates found that only 86% of graduates passed the board exam on their first try.³

We can help. In addition to the evidence-based reviews published in The Journal of Family Practice (JFP), we have launched a new feature called Residents’ Rapid Review (RRR) to provide an additional resource for residents.

RRR is a monthly 5-question evidence-based quiz prepared by primary care faculty, including current and former residency program directors. After residents click on their answer, the system lets them know whether they’re right and provides the correct answer with an explanation and references. Monthly notifications are sent out to all jfponline.com registered users alerting them that a new quiz is available. (Not a registered user on the site? Sign up at jfponline.com/residents_reg.)

Getting ready for the recertification exam? The RRR quizzes can help you, too. Check out the latest quiz, today!

The results of the 2015 National Residency Match Program were announced on March 20. For family medicine, the glass was either half empty or half full, depending on your point of view.

On the plus side, 84 more family medicine positions were offered compared to 2014 (3216 vs 3132) and 60 more positions were filled, for a total of 3060 new family medicine residents in 2015.¹ This was far more than matched in gloomy 2009, when only 2555 residents chose family medicine. On the negative side of the balance sheet, there will be 233 fewer family medicine residents this year than matched at the peak of medical student interest in family medicine in 1998.

I’m a glass half full kind of guy, so I am delighted that the trend of increased medical student interest in family medicine continues. According to Merritt Hawkins, a national recruitment firm, family medicine has been the top recruited specialty for several years. The firm reports that starting salaries for family physicians increased by nearly 12% from 2010/11 to 2013/14, which was a higher rate than that of most other specialties.² So there is reason to be optimistic about the future of our specialty.

Our monthly 5-question online quiz can help residents study for their certification exam.

However, to be card-carrying family physicians, our new residents must take the American Board of Family Medicine certification exam, and not all pass on their first attempt. A 2013 study of family medicine residency graduates found that only 86% of graduates passed the board exam on their first try.³

We can help. In addition to the evidence-based reviews published in The Journal of Family Practice (JFP), we have launched a new feature called Residents’ Rapid Review (RRR) to provide an additional resource for residents.

RRR is a monthly 5-question evidence-based quiz prepared by primary care faculty, including current and former residency program directors. After residents click on their answer, the system lets them know whether they’re right and provides the correct answer with an explanation and references. Monthly notifications are sent out to all jfponline.com registered users alerting them that a new quiz is available. (Not a registered user on the site? Sign up at jfponline.com/residents_reg.)

Getting ready for the recertification exam? The RRR quizzes can help you, too. Check out the latest quiz, today!

Stomach pain chalked up to flu; patient suffers fatal cardiac event

A 40-YEAR-OLD MAN went to the emergency department (ED) after 2 days of stomach discomfort. The ED physician who evaluated him released him after 4 or 5 hours without testing for levels of troponin or other cardiac enzymes. The patient’s discomfort continued, and about 3 days later, he told his wife to call 911. He was transported to the ED but did not survive.

PLAINTIFF’S CLAIM The decedent had been suffering from an acute cardiac event during the first ED visit. Testing to rule out cardiac problems should have been performed.

THE DEFENSE The patient had been suffering from a stomach flu during his initial ED visit. Any testing performed at that time would have been normal. The patient’s death was unrelated to the symptoms he was experiencing when he was first seen.

VERDICT $4 million Alabama verdict.

COMMENT Many questions come to mind with this case: How careful was the history? Did the patient’s discomfort get worse with activity? What were the characteristics of his pain? What were the patient’s cardiac risk factors? A colleague of mine missed a very similar case several years ago in a 67-year-old. The patient even had vomiting and diarrhea, but clearly had a myocardial infarction when diagnosed a few days later.

Follow-up failure on PSA results costs patient valuable Tx time

A PATIENT AT A GROUP PRACTICE underwent prostate specific antigen (PSA) screening, which revealed an abnormal result (4.1 ng/mL). The physician circled this value on the lab report, wrote, “Discuss next visit,” and placed the report in the patient’s chart. However, the patient switched to another physician in the group and was not told of the abnormal result for more than 2 years. When the patient went to a medical center for back pain, magnetic resonance imaging of his spine revealed the presence of cancer in his spine, shoulder blades, pelvis, and ribs. A PSA test performed at that time came back at 100 ng/mL. Two days later, a biopsy confirmed the diagnosis of prostate cancer (Gleason score, 9).

PLAINTIFF’S CLAIM In addition to failing to inform the patient of his abnormal PSA test result, the physician did not perform digital rectal exams.

THE DEFENSE Earlier treatment would not have made a difference in the outcome.

VERDICT $934,000 Florida verdict.

COMMENT If you order a PSA, you must follow up on it. When a patient transfers to your care, be sure to obtain and review past testing and provide follow-up on abnormal results. We now send all test results directly to patients so they can serve as a safety check for their own care. Despite fears of being inundated with calls, most organizations that have instituted such a policy have not turned back.

Stomach pain chalked up to flu; patient suffers fatal cardiac event

A 40-YEAR-OLD MAN went to the emergency department (ED) after 2 days of stomach discomfort. The ED physician who evaluated him released him after 4 or 5 hours without testing for levels of troponin or other cardiac enzymes. The patient’s discomfort continued, and about 3 days later, he told his wife to call 911. He was transported to the ED but did not survive.

PLAINTIFF’S CLAIM The decedent had been suffering from an acute cardiac event during the first ED visit. Testing to rule out cardiac problems should have been performed.

THE DEFENSE The patient had been suffering from a stomach flu during his initial ED visit. Any testing performed at that time would have been normal. The patient’s death was unrelated to the symptoms he was experiencing when he was first seen.

VERDICT $4 million Alabama verdict.

COMMENT Many questions come to mind with this case: How careful was the history? Did the patient’s discomfort get worse with activity? What were the characteristics of his pain? What were the patient’s cardiac risk factors? A colleague of mine missed a very similar case several years ago in a 67-year-old. The patient even had vomiting and diarrhea, but clearly had a myocardial infarction when diagnosed a few days later.

Follow-up failure on PSA results costs patient valuable Tx time

A PATIENT AT A GROUP PRACTICE underwent prostate specific antigen (PSA) screening, which revealed an abnormal result (4.1 ng/mL). The physician circled this value on the lab report, wrote, “Discuss next visit,” and placed the report in the patient’s chart. However, the patient switched to another physician in the group and was not told of the abnormal result for more than 2 years. When the patient went to a medical center for back pain, magnetic resonance imaging of his spine revealed the presence of cancer in his spine, shoulder blades, pelvis, and ribs. A PSA test performed at that time came back at 100 ng/mL. Two days later, a biopsy confirmed the diagnosis of prostate cancer (Gleason score, 9).

PLAINTIFF’S CLAIM In addition to failing to inform the patient of his abnormal PSA test result, the physician did not perform digital rectal exams.

THE DEFENSE Earlier treatment would not have made a difference in the outcome.

VERDICT $934,000 Florida verdict.

COMMENT If you order a PSA, you must follow up on it. When a patient transfers to your care, be sure to obtain and review past testing and provide follow-up on abnormal results. We now send all test results directly to patients so they can serve as a safety check for their own care. Despite fears of being inundated with calls, most organizations that have instituted such a policy have not turned back.

Stomach pain chalked up to flu; patient suffers fatal cardiac event

A 40-YEAR-OLD MAN went to the emergency department (ED) after 2 days of stomach discomfort. The ED physician who evaluated him released him after 4 or 5 hours without testing for levels of troponin or other cardiac enzymes. The patient’s discomfort continued, and about 3 days later, he told his wife to call 911. He was transported to the ED but did not survive.

PLAINTIFF’S CLAIM The decedent had been suffering from an acute cardiac event during the first ED visit. Testing to rule out cardiac problems should have been performed.

THE DEFENSE The patient had been suffering from a stomach flu during his initial ED visit. Any testing performed at that time would have been normal. The patient’s death was unrelated to the symptoms he was experiencing when he was first seen.

VERDICT $4 million Alabama verdict.

COMMENT Many questions come to mind with this case: How careful was the history? Did the patient’s discomfort get worse with activity? What were the characteristics of his pain? What were the patient’s cardiac risk factors? A colleague of mine missed a very similar case several years ago in a 67-year-old. The patient even had vomiting and diarrhea, but clearly had a myocardial infarction when diagnosed a few days later.

Follow-up failure on PSA results costs patient valuable Tx time

A PATIENT AT A GROUP PRACTICE underwent prostate specific antigen (PSA) screening, which revealed an abnormal result (4.1 ng/mL). The physician circled this value on the lab report, wrote, “Discuss next visit,” and placed the report in the patient’s chart. However, the patient switched to another physician in the group and was not told of the abnormal result for more than 2 years. When the patient went to a medical center for back pain, magnetic resonance imaging of his spine revealed the presence of cancer in his spine, shoulder blades, pelvis, and ribs. A PSA test performed at that time came back at 100 ng/mL. Two days later, a biopsy confirmed the diagnosis of prostate cancer (Gleason score, 9).

PLAINTIFF’S CLAIM In addition to failing to inform the patient of his abnormal PSA test result, the physician did not perform digital rectal exams.

THE DEFENSE Earlier treatment would not have made a difference in the outcome.

VERDICT $934,000 Florida verdict.

COMMENT If you order a PSA, you must follow up on it. When a patient transfers to your care, be sure to obtain and review past testing and provide follow-up on abnormal results. We now send all test results directly to patients so they can serve as a safety check for their own care. Despite fears of being inundated with calls, most organizations that have instituted such a policy have not turned back.

Failure to recognize impending MI has tragic consequences

A 55-YEAR-OLD WOMAN WENT TO HER MEDICAL CLINIC because she had heartburn and bilateral arm pain with numbness and tingling in her forearms. She said she’d had intermittent arm pain over the previous 7 to 10 days. A physician’s assistant diagnosed gastroesophageal reflux disease, gave the patient an antacid medication, and instructed her to return in 2 to 3 weeks. The patient came back to the clinic 10 days later with increased heartburn and continued arm pain with tingling. Because no clinicians were available to see her at that time, a prescription for ranitidine was called in and the patient was sent home. That evening, the patient died of a myocardial infarction (MI).

PLAINTIFF’S CLAIM There were specific, objective signs of an impending MI that were not recognized.

The patient should have been seen by a medical provider on the day of her death or referred to an emergency department.

THE DEFENSE No information about the defense is available.

VERDICT $275,000 California settlement.

COMMENT There was clearly an opportunity to make the correct diagnosis for this woman, especially when she returned a second time. The one lesson I have learned from reviewing malpractice cases for 15 years is that if a patient returns unimproved, you must up the ante with the evaluation. Start all over again and think through the entire history very carefully; you are likely to find a clue to the correct diagnosis.

Pulmonary embolism mistaken for respiratory infection

A 40-YEAR-OLD MAN SOUGHT TREATMENT FOR SYMPTOMS OF A COLD. He also complained of shortness of breath, dizziness, and pain in his left calf. His family physician (FP) treated him for a respiratory infection. Three days later, the patient returned to the office with continued shortness of breath. The FP scheduled a cardiac work-up. Two days before the work-up, the patient died from a pulmonary embolism (PE).

PLAINTIFF'S CLAIM No information about the plaintiff’s claim is available.

If a patient returns unimproved, start the evaluation over again and think through the entire history; you’ll likely find a clue to the correct diagnosis.

THE DEFENSE No information about the defense is available.

VERDICT $1.1 million Virginia settlement.

COMMENT PE has clearly unseated syphilis as “The Great Masquerader.” We cannot tell from this short synopsis how significant the patient’s calf pain was and whether or not there were any physical findings of deep vein thrombosis. However, when the patient returned 3 days later with increasing shortness of breath, PE should have been toward the top of the differential diagnosis.

Back spasms—or something far more serious?

A 47-YEAR-OLD WOMAN WENT TO THE EMERGENCY DEPARTMENT (ED) seeking treatment for severe back and abdominal pain. The patient had previously undergone gastric bypass surgery. The ED physician diagnosed back spasms, but admitted her to the hospital for observation. The next day, the patient died from a bowel obstruction.

PLAINTIFF'S CLAIM The ED physician failed to order testing and consult with a specialist to diagnose bowel obstruction, which is a known complication of gastric bypass surgery.

THE DEFENSE No information about the defense is available.

VERDICT $2.4 million Illinois verdict.

COMMENT Bowel obstruction with back pain only? And dead the next day from bowel obstruction? I can only presume the history was inadequate, which led to a failure to do an abdominal exam.

Failure to recognize impending MI has tragic consequences

A 55-YEAR-OLD WOMAN WENT TO HER MEDICAL CLINIC because she had heartburn and bilateral arm pain with numbness and tingling in her forearms. She said she’d had intermittent arm pain over the previous 7 to 10 days. A physician’s assistant diagnosed gastroesophageal reflux disease, gave the patient an antacid medication, and instructed her to return in 2 to 3 weeks. The patient came back to the clinic 10 days later with increased heartburn and continued arm pain with tingling. Because no clinicians were available to see her at that time, a prescription for ranitidine was called in and the patient was sent home. That evening, the patient died of a myocardial infarction (MI).

PLAINTIFF’S CLAIM There were specific, objective signs of an impending MI that were not recognized.

The patient should have been seen by a medical provider on the day of her death or referred to an emergency department.

THE DEFENSE No information about the defense is available.

VERDICT $275,000 California settlement.

COMMENT There was clearly an opportunity to make the correct diagnosis for this woman, especially when she returned a second time. The one lesson I have learned from reviewing malpractice cases for 15 years is that if a patient returns unimproved, you must up the ante with the evaluation. Start all over again and think through the entire history very carefully; you are likely to find a clue to the correct diagnosis.

Pulmonary embolism mistaken for respiratory infection

A 40-YEAR-OLD MAN SOUGHT TREATMENT FOR SYMPTOMS OF A COLD. He also complained of shortness of breath, dizziness, and pain in his left calf. His family physician (FP) treated him for a respiratory infection. Three days later, the patient returned to the office with continued shortness of breath. The FP scheduled a cardiac work-up. Two days before the work-up, the patient died from a pulmonary embolism (PE).

PLAINTIFF'S CLAIM No information about the plaintiff’s claim is available.

If a patient returns unimproved, start the evaluation over again and think through the entire history; you’ll likely find a clue to the correct diagnosis.

THE DEFENSE No information about the defense is available.

VERDICT $1.1 million Virginia settlement.

COMMENT PE has clearly unseated syphilis as “The Great Masquerader.” We cannot tell from this short synopsis how significant the patient’s calf pain was and whether or not there were any physical findings of deep vein thrombosis. However, when the patient returned 3 days later with increasing shortness of breath, PE should have been toward the top of the differential diagnosis.

Back spasms—or something far more serious?

A 47-YEAR-OLD WOMAN WENT TO THE EMERGENCY DEPARTMENT (ED) seeking treatment for severe back and abdominal pain. The patient had previously undergone gastric bypass surgery. The ED physician diagnosed back spasms, but admitted her to the hospital for observation. The next day, the patient died from a bowel obstruction.

PLAINTIFF'S CLAIM The ED physician failed to order testing and consult with a specialist to diagnose bowel obstruction, which is a known complication of gastric bypass surgery.

THE DEFENSE No information about the defense is available.

VERDICT $2.4 million Illinois verdict.

COMMENT Bowel obstruction with back pain only? And dead the next day from bowel obstruction? I can only presume the history was inadequate, which led to a failure to do an abdominal exam.

Failure to recognize impending MI has tragic consequences

A 55-YEAR-OLD WOMAN WENT TO HER MEDICAL CLINIC because she had heartburn and bilateral arm pain with numbness and tingling in her forearms. She said she’d had intermittent arm pain over the previous 7 to 10 days. A physician’s assistant diagnosed gastroesophageal reflux disease, gave the patient an antacid medication, and instructed her to return in 2 to 3 weeks. The patient came back to the clinic 10 days later with increased heartburn and continued arm pain with tingling. Because no clinicians were available to see her at that time, a prescription for ranitidine was called in and the patient was sent home. That evening, the patient died of a myocardial infarction (MI).

PLAINTIFF’S CLAIM There were specific, objective signs of an impending MI that were not recognized.

The patient should have been seen by a medical provider on the day of her death or referred to an emergency department.

THE DEFENSE No information about the defense is available.

VERDICT $275,000 California settlement.

COMMENT There was clearly an opportunity to make the correct diagnosis for this woman, especially when she returned a second time. The one lesson I have learned from reviewing malpractice cases for 15 years is that if a patient returns unimproved, you must up the ante with the evaluation. Start all over again and think through the entire history very carefully; you are likely to find a clue to the correct diagnosis.

Pulmonary embolism mistaken for respiratory infection

A 40-YEAR-OLD MAN SOUGHT TREATMENT FOR SYMPTOMS OF A COLD. He also complained of shortness of breath, dizziness, and pain in his left calf. His family physician (FP) treated him for a respiratory infection. Three days later, the patient returned to the office with continued shortness of breath. The FP scheduled a cardiac work-up. Two days before the work-up, the patient died from a pulmonary embolism (PE).

PLAINTIFF'S CLAIM No information about the plaintiff’s claim is available.

If a patient returns unimproved, start the evaluation over again and think through the entire history; you’ll likely find a clue to the correct diagnosis.

THE DEFENSE No information about the defense is available.

VERDICT $1.1 million Virginia settlement.

COMMENT PE has clearly unseated syphilis as “The Great Masquerader.” We cannot tell from this short synopsis how significant the patient’s calf pain was and whether or not there were any physical findings of deep vein thrombosis. However, when the patient returned 3 days later with increasing shortness of breath, PE should have been toward the top of the differential diagnosis.

Back spasms—or something far more serious?

A 47-YEAR-OLD WOMAN WENT TO THE EMERGENCY DEPARTMENT (ED) seeking treatment for severe back and abdominal pain. The patient had previously undergone gastric bypass surgery. The ED physician diagnosed back spasms, but admitted her to the hospital for observation. The next day, the patient died from a bowel obstruction.

PLAINTIFF'S CLAIM The ED physician failed to order testing and consult with a specialist to diagnose bowel obstruction, which is a known complication of gastric bypass surgery.

THE DEFENSE No information about the defense is available.

VERDICT $2.4 million Illinois verdict.

COMMENT Bowel obstruction with back pain only? And dead the next day from bowel obstruction? I can only presume the history was inadequate, which led to a failure to do an abdominal exam.

Team care is not a new idea. For many years, our office teams have included physicians, nurse practitioners, physician assistants, nurses, medical assistants, front office staff, and administrative staff who functioned quite well in caring for our patients.

But primary care changed drastically after the publication of 2 landmark Institute of Medicine reports: To Err is Human: Building a Safer Health System¹ (in 1999) and Crossing the Quality Chasm: A New Health System for the 21st Century² (in 2001). These scathing reports told us we were providing inadequate care to our patients, and they contained plenty of truth. What followed is that expectations increased exponentially, and we found our offices were not prepared to deal with the new mandates for computerized medical records, high performance on quality and patient satisfaction measures, and population management.

It’s time to consider whether your team would benefit from the addition of a nurse care coordinator, a “navigator,” a clinical pharmacist, or maybe even a practice facilitator.

Addressing these expanded expectations requires redefining roles and adding new players to our office teams, including nurse care coordinators, “navigators,” clinical pharmacists, psychologists, information technologists, and who knows what else. One innovative role that has seen limited testing is what some call practice facilitators.³ These are trained agents who do some of the heavy lifting required to change things like office systems and work flow.

I think that expanding the role of nurses and medical assistants is one of best ways to ensure that all of our patients get the care they deserve. Each office is unique, however, and physicians need to do the hard work of selecting the best team configuration to care for their patients. One of the more successful team-based practices is the Nuka System of Care in Alaska, which was crafted in collaboration with the tribal council. Read this fascinating story at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752290 and then create your own story of a successful, high-quality primary care office.

Team care is not a new idea. For many years, our office teams have included physicians, nurse practitioners, physician assistants, nurses, medical assistants, front office staff, and administrative staff who functioned quite well in caring for our patients.

But primary care changed drastically after the publication of 2 landmark Institute of Medicine reports: To Err is Human: Building a Safer Health System¹ (in 1999) and Crossing the Quality Chasm: A New Health System for the 21st Century² (in 2001). These scathing reports told us we were providing inadequate care to our patients, and they contained plenty of truth. What followed is that expectations increased exponentially, and we found our offices were not prepared to deal with the new mandates for computerized medical records, high performance on quality and patient satisfaction measures, and population management.

It’s time to consider whether your team would benefit from the addition of a nurse care coordinator, a “navigator,” a clinical pharmacist, or maybe even a practice facilitator.

Addressing these expanded expectations requires redefining roles and adding new players to our office teams, including nurse care coordinators, “navigators,” clinical pharmacists, psychologists, information technologists, and who knows what else. One innovative role that has seen limited testing is what some call practice facilitators.³ These are trained agents who do some of the heavy lifting required to change things like office systems and work flow.

I think that expanding the role of nurses and medical assistants is one of best ways to ensure that all of our patients get the care they deserve. Each office is unique, however, and physicians need to do the hard work of selecting the best team configuration to care for their patients. One of the more successful team-based practices is the Nuka System of Care in Alaska, which was crafted in collaboration with the tribal council. Read this fascinating story at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752290 and then create your own story of a successful, high-quality primary care office.

Team care is not a new idea. For many years, our office teams have included physicians, nurse practitioners, physician assistants, nurses, medical assistants, front office staff, and administrative staff who functioned quite well in caring for our patients.

But primary care changed drastically after the publication of 2 landmark Institute of Medicine reports: To Err is Human: Building a Safer Health System¹ (in 1999) and Crossing the Quality Chasm: A New Health System for the 21st Century² (in 2001). These scathing reports told us we were providing inadequate care to our patients, and they contained plenty of truth. What followed is that expectations increased exponentially, and we found our offices were not prepared to deal with the new mandates for computerized medical records, high performance on quality and patient satisfaction measures, and population management.

It’s time to consider whether your team would benefit from the addition of a nurse care coordinator, a “navigator,” a clinical pharmacist, or maybe even a practice facilitator.

Addressing these expanded expectations requires redefining roles and adding new players to our office teams, including nurse care coordinators, “navigators,” clinical pharmacists, psychologists, information technologists, and who knows what else. One innovative role that has seen limited testing is what some call practice facilitators.³ These are trained agents who do some of the heavy lifting required to change things like office systems and work flow.

I think that expanding the role of nurses and medical assistants is one of best ways to ensure that all of our patients get the care they deserve. Each office is unique, however, and physicians need to do the hard work of selecting the best team configuration to care for their patients. One of the more successful team-based practices is the Nuka System of Care in Alaska, which was crafted in collaboration with the tribal council. Read this fascinating story at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752290 and then create your own story of a successful, high-quality primary care office.