Active surveillance for prostate cancer: The trader won the bet

Mike Steskal, a commodities trader who lives and works just outside Philadelphia, is 55 and was told last summer that he had prostate cancer after his doctor ordered a blood test for flu-like symptoms that happened to include a PSA test.  The PSA test looks for a protein linked to prostate cancers.  His PSA level was slightly elevated, which led to more tests, including a biopsy that showed a Gleason 6 cancer.  

He spent months seeing different doctors, most of whom recommended aggressive treatment because he is so young.  He also researched prostate cancer on the Internet and talked to men who had gone through various treatments.  Finally he chose active surveillance.

As part of the surveillance, he had two more PSA tests.  They came back with levels so low that no one would ever have suspected prostate cancer.  His higher level last summer was probably due to an infection, which can cause PSA levels to rise.  

“It was pure chance” that he got a prostate cancer diagnosis, Mr. Steskal said.  “That’s another thing that went into my decision.”  

Dr. Alan J. Wein, the Chief of Urology at the Perelman School of Medicine, advocates active surveillance for most men with low-risk cancers.  But he emphasizes that they should have a second biopsy within a year, followed by regular biopsies every year or two and regular PSA tests.  

“I tell patients, ‘This is a bet’”, he said. “You are betting that the disease is not going to progress, or if it progresses, you will be able to tell before it progresses to a situation where it less treatable.  You enhance the chances of winning the bet by doing a confirmatory biopsy.”

Ken’s comment:  The false positive PSA test led to a scary misdiagnosis, but Mike was wise to carefully consider the alternative to surgery.  

Thanks to Gina Kolata of the New York Times for the source story on May 24, “The Latest Trend in How to Treat Prostate Cancer:  Don’t.”  Read another story about decision-making on prostate cancer.

YourCity.MD: A good way to give back

Joe Benza’s story: 

I’m an entrepreneur, with several successful businesses over the years.  My book called "Preventing Aids" published in 1985 by JALSCO, Inc.  is in 40 countries.  I also bought and sold Internet domain names as a rewarding hobby.  I come from a medical family:  I have a brother who’s a surgeon, and we have dentists, dental hygienists and a urologist in the family as well. 

My father had Parkinson’s, and his hand would shake a little.  He was a proud man, so he wanted medication to stop that from happening as he was very self-conscious.  He ended up getting leukemia, which was one of the rare side effects of taking his partiular drug.  My whole family missed it; we didn’t look at the drugs he was taking to see if the risk outweighed the reward; none of us looked.  The drug was somewhat controversial, and my Dad told me two of his doctors argued about the use of the drug.  One of the doctors stated the other doctor was getting a kickback or had a financial interest of some kind in prescribing the drug! 

Experiencing side effects, he was misdiagnosed by his doctors for four months, and then he passed away.  We were really angry but took on most all of the blame ourselves...at least, I know I did.

About a year and a half later, a business opportunity developed.  I’d realized that the name www.YourCity.MD was available as a Web domain name with the "Local" city names as well.  The Gannett company encouraged me to build the websites to help people like my Dad and my family.  They were prepared to collaborate with me on making YourCity.MD into a business. They ultimately bowed out, but I kept with it.  In light of what had happened to my father, it seemed a good way to give back to everyone else so they can avoid our guilt by using our free resources to make the best decisions for their own families.  

Today, we’re helping people in 100% of the USA to find good local doctors and the best healthcare information available.  We are the only "local" platform on the Internet in any industry with a national footprint. 

Read another entrepreneur’s entrepreneurial patient safety story.  Thanks to Joe for the interview, and to Joelle Caputa of CPR Communications for connecting us. 

There's so much of this going around: Co-production of a diagnosis

Mrs. R: I'm here because I just feel rotten.

Provider: What kind of symptoms are you having?

Mrs. R: Really high fevers. Last night it was 102. I just ache all over. And I've got this cough...It started the day before yesterday, all of a sudden in the afternoon, something just hit me like a ton of bricks.

Provider: It sounds like you have influenza. There's already a lot of this going around.

Mrs. R: I don't see how this could just be the flu. I've never had anything like this, and I can't ever remember feeling so sick.

Provider: What you have is more than just the run of the mill flu....Have you been under a lot of stress lately?

Mrs. R: Things have been tougher at home lately....My husband and I aren't getting along so well...we fight about money and he parties too much.

Provider: Let's get back to the medical reasons for the visit, but if you ever want to talk about the personal issues, I'm available.

Mrs. R: I'm just worried that this virus or whatever will keep hanging on.

Provider: There's so much of this going around. Everybody's got it this week.



In Provider-Patient Partnerships, Helen Meldrum and her co-author, Dr. Mary Hardy, discuss the case study summarized here in a section entitled, "What is it you're not telling me?" in their chapter about sensitive issues. In this case, the provider didn't learn about Mrs. R's husband's IV drug use, and so couldn't detect her possible exposure to HIV from her husband. Mrs. R had spoken quite indirectly, as many patients do, and the provider didn't understand what she hadn't told him.

Using many rich scenarios like this one, Helen Meldrum's book discusses how providers can improve their communication with patients. The book respects the messy complexity of patients' medical issues, and the frequently indirect communication by patients about their problems. The book is a practical and insightful guide for providers. Its specific prescriptions for seeing the truth among patients' murky comments are much needed.

Ken's advice for patients with sensitive issues to discuss: Rehearse what you'll say to the doctor ahead of time to clarify your concerns.

For more ways to improve communication of providers and patients, read the chapter on "Interacting with Your Doctor" in my book, Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

I thought this was an odd response: A father’s intuition on misdiagnosis

John James' story:
Early in my son's failed diagnosis I told his lead cardiologist that I could get a previous electrocardiogram [which produces graphs of the heart's electrical activity over time] done a few months before my son's non-fatal collapse. That cardiologist wasn't interested in this previous EKG. Since I carried a small card in my wallet with my EKG, I thought this was an odd response from the cardiologist if he knew what he was doing. My intuition said I need to find another hospital for my son. Unfortunately, I did not follow my intuition and my son lost his life to incompetent medical care. The changes in my son's EKG would have pointed the way to the proper diagnosis, which was acquired long QT syndrome [a rare heart condition].

John James' Advice: If I could tell patients only one thing it would be to follow your intuition. If you think there is something wrong where you or a loved one is being diagnosed or treated then take charge, get a second opinion, or just get out.

Read a happier story about the role of a patient’s intuition in choosing medical treatment. Thanks to John James for this story.

Click here to get John’s book and e-newsletter subscription.

If you would have come earlier: A cancer misdiagnosis

National patient safety expert Dr. Peter Pronovost describes what got him started on his crusade:

My father died at age 50 of cancer. He had lymphoma. But he was diagnosed with leukemia. When I was a first-year medical student, I took him to one of our experts for a second opinion. The specialist said, "If you would have come earlier, you would have been eligible for a bone marrow transplant, but the cancer is too advanced now." The word "error" was never spoken. But it was crystal clear. I was devastated. I was angry at the clinicians and myself. I kept thinking, "Medicine has to do better than this."

Advice: Get a second opinion promptly upon receiving a crucial diagnosis.

Read a very different story about the need for a second opinion. Thanks to Claudia Dreifus for the source interview in the New York Times of March 9.

Overmedicated and misunderstood: Appropriate care for the elderly

Candy Schulman's story:

July 2, 2009
To the Editor:
My 96-year-old mother, who died two weeks ago, had difficulty finding physicians trained in geriatric medicine, even though she lived in Florida.

She was overmedicated and misunderstood. Early symptoms – and potential treatments – were missed. A robust woman who drove and played golf until she was 90, she felt infuriated whenever presenting a symptom, only to hear many doctors respond, "What do you expect…at your age?"

Once a year I took her for a checkup with the head of geriatrics at a leading New York teaching hospital, a gifted physician who reduced her medications. But the geriatrics department was eliminated. My mother never found another geriatric physician with the same insight and sensitivity until she was in hospice care. She received better medical care when she was dying than when she was living.

We desperately need to fill this huge gap in medical care between middle-age patients and the elderly at the final stage in their lives.

Advice: There are many electronic databases now that assist in the choice of a doctor. If you have trouble finding them, get the help of a professional patient advocate.

Read a story about drug interactions in the elderly.

Thanks to Candy for her letter, reprinted from the July 8 issue of the New York Times.

A Sea of Broken Hearts: Fatal errors in a young athlete’s medical treatment

Dr. John James tells the heart-breaking story of his son's medical treatment:

I lost my 19-year old son several years ago in Texas due to multiple medical errors. He had collapsed while running, self-recovered, but was taken by ambulance to a hospital in his college town. There cardiologists evaluated him for 5 days and could not find any cause of his collapse. They delegated his followup to a physician in training in family medicine, she gave him a clean bill of health, and two weeks later he collapsed and died while running.

There were several catastrophic medical errors. First his cardiologists failed to apply a national, widely published guideline for potassium replacement in a person with cardiac arrhythmias, they failed to make an obvious diagnosis of acquired long QT syndrome, and they failed to warn him properly that running would be hazardous to his life. They wrote in the medical record that they warned him against running just after they gave him a second dose of Versed, a drug widely used as a sedative and known to cause amnesia. His discharge summary gave the only written instruction: do not drive for 24 hours.

I have written a book called "A Sea of Broken Hearts" that chronicles my son's botched care, the cardiologists' clumsy tampering with evidence in the medical record, and why we need a national patient bill of rights.

Dr. James' Advice: What should I have done differently? First, I had an intuition that his college-town hospital and especially the cardiologist assigned to his case were in over their head. I sensed this when his cardiologist was not interested in me getting my son's previous electrocardiogram that the Air Force had done a few months before. I should have followed my intuition.

I was not aware of how easily one can be manipulated by fear. In my son's case we were told the woeful story of Pete Maravich who collapsed and died suddenly. At the time, we did not know what informed consent really ought to be, and so we were frightened into allowing invasive testing. In my book I give good (but not absolutely conclusive) evidence that the invasive testing set my son up for death. This was combined with Alex's untreated, severe potassium depletion.

 I should never have been so trusting. I should have asked to see the details of the results of every test that was done. This way I might have found out that the hospital had screwed up his cardiac MRI. I should also have demanded to see his medical records at least twice a day. I really did not know much cardiology at the time, but I might have seen the major change in his electrocardiogram that showed that three risk factors for sudden death had disappeared...temporarily. There is no evidence in the record that his cardiologists ever looked at this second electrocardiogram.

As Julia Hallisey DDS wrote in her book "The Empowered Patient": never trust your heart to a single cardiologist; get a second opinion. I would add: make certain it is an independent second opinion rendered without knowledge of the first opinion.

Read about the organization Dr. James has launched, Patient Safety America.

Thanks to Dr. James, a patient safety hero, for forming a nonprofit organization to help others, and writing his son's painful story.

With significant potential financial gain: Unnecessary cardiac surgery

Father John Corapi went to Dr. M. for a diagnosis, and the doctor recommended surgery. Father Corapi then got second, third, fourth and fifth opinions, all of which disagreed with Dr. M.'s diagnosis and recommendation for cardiac surgery. He was so struck by these additional opinions that he went to the FBI.

The FBI performed a three-month investigation, interviewing medical staff at the local medical center in California, other patients of Dr. M., some of his colleagues, Dr. Gerald Rogan, and outside cardiologists as far away as the Cleveland Clinic. The FBI produced a 67-page affidavit that led to a search warrant authorizing an FBI raid on Dr. M.'s office. The affidavit contained a description of Dr. M.'s interaction with patients: the doctor bullied patients, and scared them. He would consistently tell patients, many of whom had ambiguous symptoms and no history of coronary disease, that he needed to perform an angiogram to determine whether the patient required invasive treatment. (An angiogram is a diagnostic test that takes X-ray pictures of the heart arteries, highlighted by an injected dye, via a soft catheter tube that the surgeon threads into the heart from an incision in the patient's groin. )

If the angiogram failed to document treatable disease, or as was frequently the case with Dr. M., was unreadable, he would perform an intravascular ultrasound, which at the time was new, and unfamiliar to many cardiologists. By improperly setting the gain on the ultrasound too high, Dr. M. guaranteed the appearance but not the reality of significant arterial blockages. Dr. M. would then lean over the supine patient and tell him in dire tones that without immediate bypass surgery, he would die. In such a stressful situation, few patients were sufficiently confident, rational, or sophisticated to ask for a second opinion. For the few who did, Dr. M. typically referred the patient to another doctor in his practice, who would confirm the diagnosis, relying on Dr. M.'s recommendation, and perform the surgery.

The California Medical Board sought a restraining order against the two doctors, finding that:

"Both have fraudulently misrepresented the findings of tests to induce and/or scare patients into having unnecessary surgeries or interventions. At best, this can be viewed as incompetent and/or grossly negligent as well as dishonest and corrupt. [They] misled, lied to or attempted to frighten patients into consenting to invasive coronary surgical procedures, at significant risk to the patient and with significant potential financial gain."

Advice: Work to reform the payment system that rewards unscrupulous doctors for unnecessary and dangerous surgery.

Read another story about unnecessary bypass surgery.

Thanks to Drs. Gerald Rogan, Frank Sebat and Ian Grady for the source, Disaster Analysis Redding Medical Center Congressional Report, June 1, 2008, and to Helen Haskell.

Remind your daughters: Mariana Bridi da Costa's misdiagnosed fatal infection

The 20-year-old Brazilian beauty queen Mariana Bridi da Costa died early this morning in the hospital. She had had a urinary tract infection (UTI), which was initially misdiagnosed, delaying the routine antibiotic treatment that probably would have saved her life.

The bacterial infection progressed rapidly, snowballing into more serious conditions. First, it spread to her blood ("septicemia"). The septicemia then caused an insufficient blood flow that triggered the quick deadening of tissue ("necrosis"), first in Mariana's hands and feet. But even the prompt amputation of her hands and feet could not save her life, as the septicemia (also called bacteremia or sepsis) apparently led to organ failure and her death.

As of now, it's not known whether she had acquired the UTI at home or in the hospital. Her boyfriend said she had felt ill in late December, perhaps from a UTI, and that her doctor had misdiagnosed the problem as a kidney stone, and prescribed medicine for that. This incorrect diagnosis evoked a wrong-drug error. The type of bacterial infection she had - Pseudomonas aeruginosa - is usually acquired in the hospital, not at home. A hospital-acquired infection, whose detection was delayed, may well have led to her death.

Mariana had been a finalist to represent Brazil in the Miss World contest.

Advice to mothers: Remind your daughters that they can prevent some UTIs by wiping themselves from front to back after using the toilet. Doctors can prevent some hospital-acquired UTIs by washing their hands before touching patients.

Read another Pseudomonas aeruginos story.

Thanks to Shari Roan for the source article in yesterday's Los Angeles Times.

Eric has been reading a lot: Medical schoolitis and cyberchondria

Eric Horvitz is an artificial intelligence researcher at Microsoft Research. He remembers, years ago, while in medical school, "sitting on a cold seat with my legs dangling off the examination table," convinced that he was suffering from a rare and incurable skin disease. While the doctor was out of the room, Eric took a look at his medical chart and saw that the doctor's note read, "Eric is in medical school and he has been reading a lot."

In medical school, the common "diagnosis" by medical students of very rare conditions is called "second year syndrome" or "medical schoolitis." Medical students, according to the well-known joke, often jump to the conclusion that hoofbeats and whinnies are the signs of a zebra rather than a horse. Patients often make the same mistake, fearing they have a rare and dread disease when, much more often than not, they have a less serious condition.

On the Internet, the large number of stories on any topic often indicate to the lay reader a very wide variety of diagnoses, and many patients latch onto the most serious, even if very rare, condition. "Cyberchondria" is the name of this new malady.

Advice to those searching the Web for medical information: Take it with a grain of salt.

Read a story of a misdiagnosis of a harmless condition.

Thanks to John Markoff for the source story in today's New York Times.

We can still do some good: Public learning from a fatal misdiagnosed aortic dissection

This story was the subject of a particularly popular seminar at the conference today of the American Society for Healthcare Risk Management in Boston. It was so popular that the room was filled to capacity, leaving many others outside – like me. So this story comes from Michael O’Connor of the Omaha World-Herald, rather than from the presentation by lawyer Sara Juster, Vice President of the hospital:

Watch a new video produced by Methodist Hospital and you'll see Tyler Kahle looking just like he did the weeks before he died: chiseled face, short brown hair and a big smile.

The death of the 19-year-old Omahan five years ago resulted in a lawsuit against Methodist and an out-of-court settlement that included creation of the video.

Parts of the 20-minute video are a tribute to the young man. It shows him graduating from high school, skateboarding, wave-boarding and doing the high-energy activities he loved.

Other parts carry messages that legal experts say are surprising and uncommon.

In the video, initiated by Methodist, the hospital's doctors acknowledge the mistakes that Methodist made in diagnosing the medical problem that caused his death. Legal experts say it's rare for doctors and hospitals to publicly acknowledge mistakes after a settlement.

"It's more common that they don't parade around [saying] that we made a mistake," said Craig Dallon, a professor at the Creighton University School of Law.

What's also unusual, he said, is that Methodist has posted the video, made in cooperation with Tyler's family, on its Web site and plans to distribute it as a DVD nationally to educate other hospitals and doctors about the aortic dissection that led to Tyler's death.

"It was a way to memorialize Tyler, and we hope to prevent this from happening again," said Sara Juster, a vice president for Nebraska Methodist Health System, whose duties include overseeing the hospital's legal cases.

During negotiations for the settlement with the man's family, Methodist raised the idea of the video and the family backed it, said Juster and Deb McMillan, Tyler's mother.

Deb said the video provided the justice she wanted for her son. She wanted Methodist to publicly admit its mistakes. She also wanted the hospital to help educate other health care providers and prevent deaths.

"If I can't have my son back, we [can still do] some good," she said.

During an eight-day span in fall 2002, Tyler went twice with chest pains to the Methodist emergency room and once to his family doctor at Methodist Physicians Clinic.

All three times, Methodist physicians diagnosed and treated Tyler for upper respiratory problems.

Deb repeatedly told Methodist doctors about her son's family history of aortic dissection, but he was never given a scan for the ailment. He died four days after his last trip to the Methodist emergency room.

Aortic dissection — deadly if not diagnosed quickly — is a tear in the lining of the main artery for blood leaving the heart. It can be spotted with medical imaging equipment and can be treated. The ailment, which killed actor John Ritter, runs in families, including Tyler's.

In the video, Methodist doctors say Methodist did not take into account Tyler's family history of aortic dissection and did not consider the fact that it can occur in young people.

Dr. Anton Piskac, Methodist vice president for quality improvement, said in the video: "We had multiple opportunities to do the right thing and repeatedly neglected to do so."

Dallon, the law professor, said the video may reflect the frustration some doctors and hospitals have with defense attorneys who typically advise not to acknowledge any mistakes. The "I'm sorry" laws in Nebraska and more than 25 other states are another sign, he said.

Nebraska's law, approved in the last session, makes a health care provider's expression of apology, sympathy or compassion inadmissible as evidence of liability in a lawsuit.

Juster said Methodist wanted to share its experience because hospitals across the country have lacked an understanding that young patients with a family history of aortic dissection can suffer from it.

She said Methodist did not offer to produce the video as a way to reduce the financial payment to Tyler's family that was part of the settlement. Both sides declined to reveal the amount.

Omaha attorney Jeffrey Welch, who represented Tyler's family, said money wasn't the family's priority. They wanted to keep the young man's memory alive and prevent other deaths.

Advice to parents: If you disbelieve a doctor's diagnosis, ask what else it could be. If you know an inheritable condition may be involved, ask if that can be ruled out as a diagnosis, and why.

See a short video by a survivor about an instructive medical error.

I had gone to the doctors too many times: Patient's research for misdiagnosed restless legs syndrome

Often patients begin doing health research because their own doctors don't seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Texas, suffered from leg pain and poor sleep; her gynecologist told her she had "extreme PMS." But by searching the medical literature for "adult growing pains," she learned about restless legs syndrome and a doctor who had studied it.

"I had gone to the doctors too many times and gotten no help and no results," she said. She is now a volunteer patient advocate for the web site WhatIsRLS.org. The new doctor she found "really pushed me to educate myself further and pushed me to look for support.

Tara Parker-Pope’s Advice: Tell your doctor about your research.

Read another delayed diagnosis story.

Thanks to Tara Parker-Pope for the source article in today's New York Times.

Despite the antibiotics: Strep throat and a missed diagnosis

"I – can't - breathe," the boy gasped. There was panic in his voice and face. He moved restlessly in his hospital bed, tugging at the clear plastic mask that covered his mouth and nose. It was unusual for a 17-year old boy to be in the pediatric intensive care unit.

Earlier that morning, the boy had a fever, but otherwise looked well. Now his condition had deteriorated: he was breathing at three times the normal rate, he had bone-wrenching chills, and was spiking fevers up to 105 degrees. There was very little oxygen in his blood.

Six days earlier, the boy had awakened with a fever and sore throat. His family doctor had diagnosed strep throat the next day, and had begun azythromycin, an antibiotic that is usually effective against strep. The diagnosis was obvious, and no strep test was done.

Despite the antibiotics, the boy continued to spike fevers up to 102 degrees, and pain and swelling had migrated from his throat to the right side of his neck. The boy's parents took him to the hospital because something scared them; his responses were slow and strangely deliberate.

During three days in the hospital, doctors and other clinicians performed a variety of consultations and diagnostic tests. A blood culture developed a strange bacteria – Fusobacterium necrophorum – which enabled the diagnosis of Lemierre's disease, which is treatable through antibiotics. In the meantime, however, the boy’s condition had worsened, and he had to be put on a ventilator to get him enough oxygen.

His lungs never recovered, and he died in the intensive care unit three weeks later.

The family doctor, heartbroken over his missed diagnosis, now says that every patient in his practice with suspected strep will have a throat culture.

Advice to parents with children who may have strep: Ask to have a strep test or throat culture to confirm the diagnosis.


Thanks to Dr. Lisa Sanders for the source story in today's New York Times Magazine.

Thrilled to be a pitcher and not a patient: Carl Pavano's shoulder misdiagnosis

The scar still looks fresh, 15 months later, on the inside of Carl Pavano's right elbow. Usually, after Tommy John surgery, it settles into a flesh-colored zipper, visible but not so obvious. Carl is actually progressing quite well.

As he comes to the end of his four-year, $40 million contract, Carl is thrilled to be a pitcher and not a patient. But he also has wounds from a bitter comeback trail that are hard for him to forget.

Carl said he was bruised by the belief among fans, reporters and some teammates that he was not dedicated to his craft. When he reflects on four lost seasons, he said he thought it could have been different if the Yankees' team doctor had recommended reconstructive elbow surgery sooner.

Carl shares some of the blame. He said he should have reported his back problems early in the 2005 season, when he made 17 starts through the end of June. Those issues brought about everything else, he says.

"I wish I had been smart enough to just get it right," Carl said. "Say something, make sure something was taken care of, instead of just keeping pitching and thinking it was going to get better."

A daily massage at his apartment helped for a while, Carl said, but pitching with back pain affected his arm. He went on the disabled list that July, and the Yankees announced that he had right shoulder tendonitis.

He made two rehabilitation starts after a month of rest and was re-evaluated by the team physician and a doctor whom Carl had known and trusted for years. The new diagnosis was rotator cuff tendonitis and associated pain in the humerus.

"When they reported I had rotator cuff tendonitis, I actually had a stress fracture in my humerus bone," Carl said. "It wasn't rotator cuff tendonitis. It was just misdiagnosed."

By May, Carl was back on a minor league pitching mound, but he left a start for Class AA Trenton with elbow discomfort. This, Carl said, was a pivotal point.

Six years earlier, when Carl pitched for Montreal, a doctor had removed bone chips from his elbow. He did it again in May 2006, removing a chip the size of a marble. (Carl kept is as a souvenir, he said, until it turned to mold and dust.) The procedure was a temporary fix. It helped for a while, but when Carl broke his ribs in a car accident that August, he aggravated the elbow by trying to keep pitching without telling the Yankees about the injury. In hindsight, Carl said, he could have had Tommy John surgery that summer, but the Yankees did not recommend it.

"I think I could have, but we'll never know," Carl said. The doctor "was told not to. He was told to take the bone chips out and rehab it."

Two starts into the 2007 season, the elbow pain returned, and Carl insisted on major surgery as the only way to heal everything. It took four doctors to find one who agreed definitively. That was the Mets team doctor.

"They had to go through all that red tape; that's why I had to go get all these opinions," Carl said. "It was crazy. And I had to walk around with my heart in my throat: 'Are you serious? You're messing with my career here.' You think I wanted to have Tommy John surgery? But I knew I needed it and I knew I could come back from it. That's why I was all for it."

The Mets team physician told Carl he had done everything he could to come back from the 2006 operation. His only choice was Tommy John surgery, in which a tendon from Carl's knee was used to replace an elbow ligament.

It took place June 5, 2007, nearly two months after he had last pitched a game. Carl said he wished he had the operation sooner.

"I would have been back seven weeks earlier this year," Carl said. "That would have been a considerable amount of time to help the team."

Advice: If you don't agree with a doctor's diagnosis, ask what else it could be. If the answer and the recommended treatment are still unsatisfactory, consider getting another doctor's opinion.

Read another Yankee pitcher's misdiagnosis story.

Thanks to Tyler Kepner for the source article in yesterday's New York Times.

Is it better to bring 8,000 individual cases?: Pathology errors in breast and prostate cancer biopsies

Patients impacted by a misdiagnosis and the quality of service at the Miramichi Regional Hospital will file a class-action suit on Tuesday.

Halifax lawyer Raymond Wagner will file the proposed lawsuit in Miramichi on Tuesday. It is available to any patients who had a biopsy or other procedure at the Miramichi Regional Hospital between 1995 and February 2007, regardless of their test results.

"They suffered great mental distress, frustration, and needless anxiety while awaiting confirmation that the original results were correct," he said.

The province is reviewing more than 23,700 cases from the hospital dating from 1995 to 2007 while a public commission is examining the rate of breast and prostate cancer misdiagnoses.

An independent audit of 227 cases of breast and prostate cancer biopsies from 2004-05 found 18% had incomplete results and 3% had been misdiagnosed at the health authority in northeastern New Brunswick, which was being served by a now-suspended pathologist.

Filing a lawsuit will hold the system accountable, Wagner said, adding that arguments revolve around allegations of negligent hiring and poor quality control at the pathology department.

"The suit of course is to assist the people in the community surrounding the Miramichi with respect to their health care," he said. "It is to bring to account the hospital administration with respect to oversight and quality control and to assure the community that their health care is of sufficient quality for them to have confidence in that health care."

A judge will have to decide if the suit will go ahead, which will involve testing whether the lawsuit is the most efficient way to proceed, Wagner said.

"Is it more appropriate and more efficient to have the case determined in one case, or is it better for everybody to bring their own individual cases, in other words 8,000 cases?" he said.

The Halifax law firm, Wagners, is working in co-operation with Newfoundland and Labrador firm Ches Crosbie Barristers.

Advice: Pathologists have to use very subjective judgments in assessing biopsies. Ask the pathologist how certain s/he is about the findings of your biopsy.

Read another Pathology error story.

The source article comes from a posting today on the Canadian Broadcasting Corporation's website.

I got my mother back: Overuse of antipsychotic drugs in nursing homes

Last fall, Theresa Lamascola of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor, who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.

She was moved to a nursing home to get the problems under control. But things only got worse. She "was screaming and out of it, drooling on herself and twitching," said her daughter, a nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.

"I knew the drugs were doing this to her," said her daughter. "I told him to stop the medications and stay away from Mom."

Not until another doctor took her off the drugs did she begin to improve. He prescribed Aricept. "It's not clear whether it was getting her hypothyroid and other medical issues finally under control or getting rid of the offending medications. But she had a miraculous turnaround," said the new doctor.

She still has dementia but she went from confinement in a wheelchair – unable to sit still and screaming out in fear – to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversation and even make jokes.

Or, as her daughter put it, "I got my mother back."

Researchers estimate that one third of all nursing home patients have been given antipsychotic drugs.

Advice to people with elderly relatives in a nursing home: Ask the doctor about alternatives to antipsychotic medicines.

Read another story about drug side-effects in the elderly.

Thanks to Laurie Tarkan for the source article in today's NY Times.

A buffer and enabler for the patient: VIP care

Dr. Victoria McEvoy on VIP care:
One Emergency Room doctor told me recently about a VIP patient who came to the ER complaining of chest pain. The patient's visit triggered a cascade of events at the hospital administration level. The "VIP Office" sent a delegate to smooth the way, and the patient came with his own personal physician, who was there to serve as a buffer and enabler for the patient. Not only was the "physician bodyguard" not in the right specialty for the complaint and age of the patient, but the physician gave orders: "Call the cardiologist and get an echocardiogram."

Both the resident and the responsible physician thought the patient's problem was gastro-intestinal: he had swallowed a huge antibiotic pill without water, and the esophagus was irritated enough to cause the chest pain. Instead of quickly looking at the patient's esophagus, hours were wasted getting cardiology and cardiac tests which were not needed. His VIP status delayed him getting proper care.

Advice to Very Important Persons: If you bring in your personal physician, make sure they will listen to other doctors' opinions.

Read a celebrity drug error story.

Thanks to Dr. Victoria McEvoy for the source article in yesterday's Boston Globe.

I killed her: My first malpractice suit

I stared down at my name neatly typed next to the word "Defendant." And just below the heading: "Complaint: Wrongful Death Based on Medical Negligence."

Oh my God. Deceased. It was me. I killed her. That's how I heard about my first malpractice suit.

I was the new doctor in the group. I had joined fresh out of residency two years before. I was the first woman doctor in the clinic, and one of only a handful of women physicians in semi-rural Clackamas County.

My last note in Helen Simmons' chart [not her real name] was from last August, a visit for chest pain. I had first met her in my first year in the practice, in December of the year before she died. She had gone to the Emergency Room of the local community hospital with chest pain, and had been admitted overnight for observation by one of my senior partners. Covering for him, I met Helen the next day.

Her chest pain had not been a heart attack, according to blood tests overnight. Her pain was gone. But she was a time bomb, I realized. She had heart disease up and down her family tree, she smoked, and her blood pressure was high.

I told her I was glad she hadn't had a heart attack, but that I was worried she was going to, sooner or later. She could save her own life, I said, by quitting smoking and taking care of herself. She wasn't worried about all that. She wanted to go home and have Christmas with her family.

Her EKG (electrocardiogram) showed she may well have had a prior heart attack, not previously discovered, but that she had not had one just now. Heartburn was the more likely diagnosis, so I sent her home with a prescription for medicine to block stomach acid.

She had scheduled her two-week post-hospital visit with my partner, who had admitted her to the hospital. She told him her pain was better, and the way she described it fit the heartburn pattern. A special X-ray called a barium swallow confirmed acid irritation of the stomach, so my partner gave her another acid blocker prescription.

Two weeks later her time bomb went off. In mid-January she came to clinic with bad chest pain, and I sent her right up to the hospital. It was her first official heart attack. She had quit smoking a few days before. Trying to change her lifestyle, she had tried to exercise.

A few days later, the cardiologists reopened a cholesterol-plugged artery in her heart. After that she could exercise without chest pain and joined a health club. She lost some weight and stayed off tobacco. I saw her every month or two through the winter, spring and summer, congratulating her at every visit for her progress. She was 44.

She came in for a final visit in August, complaining of chest pain. It fit the pattern of stomach pain rather than heart pain. I ran an EKG on her at that last visit, and it was normal – normal for her, that is; it showed nothing new, and even some improvement. I switched her to an even stronger acid blocker. And I never saw her again.

Ten days after that last appointment with me, Helen had died in her sleep. What probably killed Helen was her heart suddenly jumping into a bad rhythm, that didn’t pump blood forward – sudden cardiac death. We don't have any good way of predicting whose damaged hearts are more likely to do that, or when. I couldn't have diagnosed, predicted, or prevented it.

At the trial, there were some surprises. Helen had quit smoking. But her family and friends hadn't, exposing her to secondhand smoke that can increase the risk of abnormal heart rhythms. And in her last visit with me Helen had said she had been able to work out in the gym for hours without chest pain. But her daughter and a friend testified that Helen could only stay on those exercise machines a few minutes before she had to stop and rest until the chest pain went away.

She lied to me. She was playing a role, the role of a good patient. She was telling me what she thought I wanted to hear. Maybe she wanted to hear me congratulate her again on how well she was doing.

I didn't see through Helen's performance. That was the mistake I made. That was my negligence.

I "won" the case and went back to work. I say it was my first malpractice suit. There hasn't been a second – yet – but I don’t want to get overconfident.

Advice: Always tell the truth to doctors.

Browse for related stories in the index at the very bottom of this page, or read a patient-doctor miscommunication story.

Thanks to Dr. Merilee Karr for the source article in Creative Nonfiction, issue #33, 2007.

He used an alias: A lawsuit on John Ritter's misdiagnosis

When actor John Ritter checked into a Burbank, California hospital the day he died, he used an alias, "Edwin Marcus," to protect his privacy. He died of an aortic tear, which might have been diagnosed by an X-ray. His widow, Amy Yasbeck, is suing two of the doctors who treated him, saying they misdiagnosed his condition, and did not order an X-ray. The doctors' attorneys say the name change created confusion at the hospital, for which John is responsible.

John Ritter was 54 years old when he died of an aortic tear in 2003. His widow is seeking $67 million in damages.

Advice: Patients using aliases, or their advocates, should carefully track their care against the hospital's checklist to ensure all necessary physician orders are performed.

Browse for similar stories in our index at the very bottom of this page, or read a celebrity story.

Thanks to ContactMusic.com for the source story yesterday.

He retired at 34: Concussions in football receiver Wayne Chrebet

At age 34, Wayne Chrebet retired from his football career with the New York Jets because of post-concussion syndrome, after suffering at least six concussions. He sometimes had returned to games in which he had been knocked unconscious. He was the third star pass receiver on the New York Jets to retire because of post-concussion syndrome, along with Laveranues Coles and Al Toon.

Wayne has recently acknowledged he has bouts of depression and memory problems so severe that he cannot make the routine drive from his home in New Jersey to his restaurant in Long Island without a global positioning system.

The Jets' team physician has drawn criticism because he is both the leader of the National Football League’s commission on concussions and because under his care, three of his team's star receivers have had multiple concussions that ended their careers and left them with permanent disabilities. The team physician's desire to both help his team win and care for the players' health poses an innate conflict of interest.

Advice to parents of football players: Make sure you get your son's family physician to independently verify the team physician's clearance for him to resume play.

Browse for related stories in the index at the very bottom of this page, or read another football story.

Thanks to Alan Schwarz for the source story in the NY Times of Dec. 22.