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General Medicine

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Tacrolimus-Associated Diabetic Ketoacidosis: A Case Report and Literature 
   Review
Nursing Magnet Hospitals Have Better CMS Hospital Compare Ratings
Publish or Perish: Tools for Survival
Is Quality of Healthcare Improving in the US?
Survey Shows Support for the Hospital Executive Compensation Act
The Disruptive Administrator: Tread with Care
A Qualitative Systematic Review of the Professionalization of the 
   Vice Chair for Education
Nurse Practitioners' Substitution for Physicians
National Health Expenditures: The Past, Present, Future and Solutions
Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative
   Case Study of Physician-Faculty Perspectives
Special Article: Physician Burnout-The Experience of Three Physicians
Brief Review: Dangers of the Electronic Medical Record
Finding a Mentor: The Complete Examination of an Online Academic 
   Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
   Conviction
Comparisons between Medicare Mortality, Readmission and 
   Complications
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 

 

Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.

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Friday
Aug092013

Profiles in Medical Courage: John Snow and the Courage of Conviction

Richard A. Robbins, M.D.1

Stephen A. Klotz, M.D.2 

1Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ

2Division of Infectious Diseases, University of Arizona, Tucson, AZ

 

Abstract

The story of John Snow’s removal of the handle of the Broad Street pump stopping the London cholera outbreak of 1854 has reached near legendary status. In this review we examine Snow’s life and conclude that the removal of the pump handle causing the end of the epidemic is largely myth. However, Snow was a clever man with eclectic medical interests. He not only founded the field of epidemiology but did early pioneering work in resuscitation and anesthesia. It is likely that his self-experimentation with anesthetic gases may have contributed to his early death at age 45. Largely forgotten during his own time, he is now correctly remembered as a smart physician and scientist with the conviction to pursue what he believed to be right.

 

Introduction

A poll taken by a UK medical magazine for hospital doctors named John Snow (Figure 1) the greatest physician of all time (1).

Figure 1. John Snow in 1857.

Hippocrates was second. However, a recent equally unscientific poll of medical students revealed that none had heard of Snow (Robbins RA, unpublished observations) prompting the writing of this Profile in Medical Courage. Snow’s work was largely ignored in his own time (2). The 19th century British medical establishment was in general fiercely opposed to his views on cholera and favored the “miasma” or bad air theory of how cholera was spread (2,3). His somewhat less than friendly personality and early death contributed to his lack of recognition. However, starting in the 1930’s with republication of Snow’s most famous text, “On the Mode of Communication of Cholera” the story of John Snow and cholera has become a founding chronicle of public health (4). Snow’s contributions have been so important that he has been termed the founder of epidemiology (2-4).

Many have heard the famous story of the Broad Street pump and how the removal of the pump handle stopped the cholera epidemic of 1854, although apparently not our medical students. Snow's rise to iconic status originated not only because of his founding the science of epidemiology, but also his pioneering work on resuscitation and anesthesia (2). During his short lifetime, Snow contributed 107 publications to the scientific literature (2). In this review, we examine the life of Snow, his publications and his work on cholera, anesthesia and resuscitation.

 

Early Years

John Snow was born into a family of modest means on March 15, 1813 in York, England (2). His father was a laborer in the neighboring coal yard. Beginning about age 6, Snow attended a private, common day school in York. There were few public schools and common day schools were intended to educate the poor. He attended school until he was 14 and received basic education in reading, writing, arithmetic and the Scriptures. He was noted to be a good student with mathematics and natural history his favorite subjects.

Usually the children of poor families left home as early as possible to earn their own livings. How Snow’s family afforded to send him to a private school, even one intended for the poor, remains a mystery. Some suggest that money may have come from his maternal uncle, Charles Empson, a prosperous book merchant first in Newcastle-upon-Tyne and later in Bath (2).  However, others suggest Snow's ambitious father, William, was the likely source (2). At about the time he began school, his father began delivering goods by horse-drawn carriage that arrived by river. He saved his money and purchased rental property and eventually a farm.  Such upward financial mobility was unusual in 19th century England.

 

Medical Apprenticeships

Medical education in the early 1800’s was markedly different from today (2). Only two universities, Oxford and Cambridge, granted medical degrees leading to licensure. Snow’s modest means meant he could attend neither. The other route to licensure, and the one taken by Snow, was to apprentice with a surgeon and apothecary (pharmacist). Eventually the apprentice could take the licensing test given by the Royal Colleges of Physicians and of Surgeons and the Worshipful Society of Apothecaries to obtain medical licensure. 

Snow did 3 apprenticeships beginning at age 14 that lasted 9 years. His first was in Newcastle- upon-Tyne with William Hardcastle, a general practitioner. Newcastle was 90 miles from York, a fair distance in the first half of the 19th Century. Why Snow was sent so far from home for his first apprenticeship is likely explained by Hardcastle’s friendship with Snow's uncle, Charles Empson. Empson was a witness at Hardcastle’s wedding and executor of his will. Hardcastle was an established practitioner of good reputation in the Newcastle area who was thirty-one years old at the outset of Snow's apprenticeship.  

Snow's apprenticeship with Hardcastle lasted six years. Not only were the foundations of his medical training developed but the first indications of his independent nature became evident. During the third year of his apprenticeship when he was 17 years old, he became a vegetarian and teetotaler. Snow found time to attend classes at what would eventually become a modern medical school. He also developed his interest in cholera. In 1831, when he was 18 years old, Hardcastle sent Snow to provide medical assistance to the local coal miners and their families who were victims of a cholera outbreak. Years later Snow wrote, "That the men [who work in coal pits] are occasionally attacked whilst at work I know, from having seen them brought up from some of the coal-pits ... after having had profuse discharges from the stomach and bowels, and when fast approaching to a state of collapse” (2).

At age 20 Snow went to Burnop Field, a neighboring village near Newcastle and became an assistant to John Watson, a rural apothecary.  He apparently had little in common with Mr. Watson and considered his wages very low. He left Burnop Field after only a year and did his next apprenticeship at Pateley Bridge with Joseph Warburton, also a licensed apothecary. Pateley Bridge was and is a small village in a remote region about 30 miles west of York. Snow lived in the large house that served as both home and surgery to Warburton and his family. Snow viewed Warburton with great respect and friendship, later referring to him as his "old master” (2). He remained with Warburton for 18 months.

 

Formal Medical Education

At the age of 23 Snow began his formal education by enrolling for a year in the Hunterian School of Medicine located on Great Windmill Street in the Soho region of east London (2). During this time Snow rented an inexpensive room at 11 Bateman's Buildings, a narrow alleyway several blocks north of the Hunterian Medical School and just south of Soho Square. In the 19th century Soho could be best described as “dodgy” (5). Respectable families had moved away, and prostitutes, music halls and small theatres had moved in. The Hunterian school was privately run and provided lectures, demonstrations and dissections.  Shortly after Snow completed his year at Hunterian, the school closed.  

In October 1837 at the age of 24, Snow became a registrar at the Westminster Hospital, thereby gaining experience in a hospital setting (2). The hospital was nearly a mile south of his home on Bateman's Buildings, to which he walked most days. The hospital had been reconstructed and enlarged in 1834, and had a good reputation in surgery. After about 18 months, Snow passed his examination to become a Member of the Royal College of Surgeons of England (MRCS), permitting him to practice general medicine. He ranked 7th among the 114 candidates who passed the examination. Snow also passed his Licentiate of the Society of Apothecaries (LSA), ranking 8th on a list of 10, allowing him to prepare and sell drugs and other medicines.  After 12 years of apprenticeship and education he was certified as a general practitioner.

In the mid-1800s, neither the MB nor MD was necessary to practice general medicine. However, Snow's curiosity along with a desire for wealthier, more discerning patients led him to enroll at the newly created University of London Medical School in 1838. While active as a general practitioner, Snow attended the University of London for five years. When he was 30 years old Snow received the Bachelor of Medicine (MB) degree. A year later in December 1844, he obtained the Doctorate of Medicine (or MD), also from the University of London. 

 

Early Practice and Academic Pursuits

Snow continued his general practice in Soho and was now located at a new address about a block south of Soho Square (2). In 1846 he took a position as lecturer in forensic medicine at the Aldersgate School of Medicine, a private medical school in central London.  He remained at the school as Lecturer from 1846 to 1849 when the institution closed for lack of funding. In 1850 he passed the examination to become a Licentiate of the Royal College of Physicians (LRCP) of London.  The LRCP was the most elite of the medical profession.

 

Resuscitation

Beginning in about 1837, Snow joined the Westminster Medical Society. Although not a particularly sociable man, Snow was able to interact with his medical colleagues and to present his scientific theories. Snow regarded membership in this organization as the most influential in his professional growth (2).

In the 1840’s Snow developed an interest in resuscitation. One of the first communications to the Westminster Medical Society described a device for resuscitation of the newborn (6). The instrument was based on the concept of the “pulmotor”. Snow assumed that the stimulus for respiration, including newborns, was hypoxemia. He also speculated that the pulsive action of the blood was in part due to the capillaries, since it seemed unlikely that heart was sufficiently strong to propel the blood through the arteries, capillaries and veins.

 

Anesthesia

Snow’s early practice was not particularly successful, at least in part, because he was not very personable (2). During his time at the University of London, Snow became increasingly interested in anesthetics. He conducted numerous experiments, both on animals and himself and invented an improved ether inhaler (2).  Air and ether were mixed as vapor at one side of the apparatus and drawn over and round the spiral chamber, to be inhaled by the patient through a mouth-tube fitted with cedarwood ball valves. His work attracted the attention of Robert Liston, the best known surgeon of the day. Liston, who performed the first operation in Europe using ether, was impressed with the difference between the result of anesthesia administered by Snow, and that of less cautious anesthetists. Liston put his ether practice almost entirely into Snow’s hands (2). Soon Snow was recognized as the premier anesthetist in London. Although he had practically introduced the use of ether into English surgery, Snow balanced ether against other anaesthetizing agents, particularly chloroform. He administered the later to Queen Victoria during the birth of her last 2 children in 1853 and 1857 (2). Snow published the results of his experience with ether in 1847, including the definition of four anesthesia stages which continue to be recognized in modern times (7).

 

Epidemiology and the Broad Street Pump

By the middle of the 19th century, London along the Thames was a cesspool (Figure 2).

Figure 2. Cartoon of famous English scientist Michael Faraday who wrote a letter to The Times in 1855 complaining of the foul condition of the Thames, which resulted in this cartoon in Punch.

Both human and animal excrement and garbage were placed in cesspits if not thrown directly into the river. However, the cesspits eventually filled and overflowed draining into the river. Disposal of waste in the river was further complicated in that London is close enough to the North Sea that the river level is affected by the tides. Sewage flowed downriver at low tide but twice a day a wall of water would carry it back upstream. Snow’s neighborhood of Soho was especially bad (5). It had become an insanitary place of cow-sheds, slaughterhouses, grease-boiling dens and primitive, decaying sewers.

When cholera first hit England in late 1831, it was thought to be spread by "miasma in the atmosphere” or bad air (2). The cholera outbreaks seemed to occur where the stench was worst, which was often next to water sources. This is hardly surprising since acceptance of the germ theory would wait the discoveries of Pasteur and Koch in the later part of the century (Figure 3).

Figure 3. Timeline for some of seminal infectious disease discoveries of the 19th century. A: 1847-Semmelweis discovers that hand washing decreases the incidence of puerperal fever. B: 1855-Snow publishes On the Mode of Communication of Cholera. C: 1878-Pasteur publishes Microbes Organized, Their Role In Fermentation, Putrefaction and the Contagion. D: 1883-Koch identifies the bacterial cause of cholera.

England had suffered numerous cholera outbreaks during the 19th century. Whenever cholera broke out nothing could be done to contain it. The disease rampaged through the industrial cities, leaving tens of thousands dead in its wake. At the beginning of the 1854 London epidemic Soho suffered only a few, isolated cases. However, on the night of August 31st what Dr Snow later called "the most terrible outbreak of cholera which ever occurred in the kingdom" broke out (8). During the next three days, 127 people living in or around Broad Street died. Within a week, most residents had fled their homes, leaving the shops shuttered, the houses locked and the streets deserted. Only those who could not afford to leave remained there.

By September 10th, the number of fatal attacks had reached 500. Snow’s previous researches had convinced him that cholera, "always commences with disturbances of the functions of the alimentary canal” (2). This led him to conclude that it was spread by sewage-tainted water. Snow had traced a recent outbreak in South London to contaminated water supplied by the Southwark and Vauxhall Water Company (9,10). However, no one believed his theory. The water company pooh-poohed his theories and the authorities were reluctant to believe in a theory of fecal-oral contamination.

From the beginning Snow interviewed the families of the victims. His research led him to a pump on the corner of Broad Street and Cambridge Street, at the epicenter of the epidemic. He mapped the deaths of each of the victims (Figure 4).

Figure 4. Panel A. Snow’s map from his 1855 publication (8). Squares indicate deaths from cholera. The pump is indicated by the red arrow and Snow’s residence on Frith Street by the blue arrow (5). Panel B. Enlargement of the green square from Panel A showing the clustering of the deaths surrounding the Broad Street pump.

Snow would write that “… nearly all the deaths had taken place within a short distance of the pump" (8).  He took a sample of water from the pump, and, on examining it under a microscope, found that it contained "white, flocculent particles” (8). By September 7th, he was convinced that these were the source of infection.

Snow was a prominent physician and considered somewhat an expert on cholera having published several articles on the disease (9,10). He came uninvited to a meeting of the Board of Guardians of St James's Parish, the region serviced by the Broad Street pump on September 7th. In England, the parish is the fundamental tier of local government. Dr. Edwin Lankester, a member of a local group that looked into the causes of the Broad Street outbreak and the first medical officer for the St. James's district, later wrote, "The Board of Guardians met to consult as to what ought to be done. Of that meeting, the late Dr. Snow demanded an audience. He was admitted and gave it as his opinion that the pump in Broad Street, and that pump alone, was the cause of all the pestilence.  He was not believed -- not a member of his own profession, not an individual in the parish believed that Snow was right.  But the pump was closed nevertheless and the plague was stayed” (2). The pump handle was famously removed.

 

Aftermath of the 1854 Cholera Outbreak

By the end of September the outbreak was over leaving 616 residents of Soho dead. However, there were several unexplained deaths from cholera that could not be linked to the Broad Street pump water -- notably, Susannah Eley, a widow living in Hampstead on London’s West End, who had died of cholera on September 2nd, and her niece who had succumbed the following day (8). Neither of these women had been near Soho. Dr Snow traveled to Hampstead to interview the Eley's son. Snow learned that the widow had once lived on Broad Street, and that she had liked the taste of the well-water there so much that she had sent her servant down to Soho every day to bring back a large bottle for her by cart. The last bottle of had been brought to Hampstead on August 31st, at the very start of the epidemic.

Snow’s persistence in obtaining as much data as was possible is a remarkable trait demonstrated by the following incidents (8). Only 5 of the 530 inmates of the Poland Street workhouse, which was just around the corner from the pump, contracted cholera. Snow discovered that few drank the pump water, since the workhouse had its own well. Similarly, among the 70 workers in a brewery on Broad Street there were no fatalities at all. It was discovered that the workers were given a beer allowance and never drank from the well.

Snow’s “Grand Experiment,” compared cholera in the 1854 epidemic in neighborhoods receiving water from two different companies (8). The Lambeth Company delivered water from the upper Thames away from the Broad Street pump and urban pollution. On the other hand, the Southwark and Vauxhall Company relied on inlets in the heart of London, where the contamination of water with sewage was common. Snow showed the harmful effect of contaminated water in two nearly equivalent populations, and he suggested intervention strategies to control the epidemic. His ideas and observations, including innovative disease maps, were published in his book On the Mode of Communication of Cholera (8). Later, beginning in the 1930s, Snow’s work was republished as a classic work in epidemiology, resulting in his lasting recognition (4).

Snow wrote, "The experiment, too, was on the grandest scale. No fewer than three hundred thousand people of both sexes, of every age and occupation, and of every rank and station, from gentlefolks down to the very poor, were divided into two groups without their choice, and, in most cases, without their knowledge; one group being supplied with water containing the sewage of London, and, amongst it, whatever might have come from the cholera patients, the other group having water quite free from such impurity” (8).

Using a classic 2X2 set up, Snow obtained data on the two sets of London households and found that during an 1854 epidemic there were 315 deaths from cholera per 10,000 homes among those supplied by Southwark-Vauxhall but only 37 deaths per 10,000 supplied by Lambeth (2). Snow had gotten his numbers from a less than precise Parliamentary report leading to criticism and Snow’s own admission that the results were not strong enough to establish that cholera was related to water supply.

Still no one believed Snow. A report by the Board of Health a few months later concluded, "We see no reason to adopt this [Snow’s] belief” (2).  The pump handle was replaced. However, about a year after the epidemic Snow’s theories received support from an unexpected source. The Reverend Henry Whitehead, vicar of St Luke's Church, Berwick Street, did his own investigation (2). Although originally a believer in the miasma theory, Snow’s data convinced him that the pump was the source. Furthermore, Whitehead helped Snow to determine the probable cause of the cholera outbreak. Just before the Soho epidemic, a child living at number 40 Broad Street had been taken ill with cholera symptoms. Its diapers had been steeped in water which was subsequently disposed of in a leaking cesspool situated only three feet from the Broad Street well.

Whitehead's findings were published in the architectural journal, The Builder, along with a report on living conditions in Soho (2). "Even in Broad-street it would appear that little has since been done... In St Anne's-Place, and St Anne's-Court, the open cesspools are still to be seen; in the court, so far as we could learn, no change has been made; so that here, in spite of the late numerous deaths, we have all the materials for a fresh epidemic... In some [houses] the water-butts were in deep cellars, close to the undrained cesspool... The overcrowding appears to increase..."  The Builder went on to recommend "the immediate abandonment and clearing away of all cesspools -- not the disguise of them, but their complete removal”.

Nothing was done. The pump handle was replaced. The cesspools were not drained. It was likely “The Great Stink of 1858” that prompted action (11). During the summer warm weather combined with a series of low tides to cause such a stench that Parliament was adjourned for a week. Finally in 1859 the Metropolitan Board of Works, after rejecting many schemes to diminish the Thames’ smell, accepted the proposal of Joseph Bazalgette. The intention of this very expensive scheme was to resolve the epidemic of cholera by eliminating the stench (miasma) which was believed to cause it. Over the next six years the main elements of the London sewerage system were created. As an unintended consequence the water supply ceased to be contaminated and resolved the repeated episodes of cholera epidemics.

 

Later Years and Death

Snow’s health had never been the best.  After receiving his MD from the University of London, Snow had suffered from tuberculosis (2). He recovered by spending a good deal of time in the fresh air away from Soho and the Thames. In 1845 he had an acute attack of renal disease. His physician told him to abandon his strict vegetarian diet and to take wine in small quantities. He improved. 

Likely of greater significance regarding was his self-experimentation with anesthesia (2).  He was the first to carry out experiments on the physiology of anesthesia, and did not spare himself in investigating every possible substance that might be employed as an anesthetic. The pathologic effect of most of these agents was not known in Snow's time. 

A clue to the Snow’s ill health is a photo showing the swelling of the index finger of his right hand (Figure 5).

Figure 5. Close up of Snow’s right hand taken from Figure 1 showing a swollen index finger.

Such swelling of the fingers has been associated with chronic renal failure. Exposure to anesthetic gases is now known to have numerous adverse health effects, including severe renal damage. In Snow's case, his swollen fingers were likely due to extensive self-experimentation over nearly a decade with a variety of anesthetic agents.

On the evening of June 9, 1858, John Snow joined a group of colleagues to discuss a new bi-aural (i.e., two ear pieces) stethoscope and the cause of the first Korotkoff sound when measuring blood pressure (2). The next morning, he suffered a slight stroke while working on, “On Chloroform and other Anesthetics”.  He recovered but a few days later suffered another cerebral accident. His housekeeper found him on the floor. He died a few days later. 

At autopsy, Snow's kidneys were found to be "shrunken, granular and encysted” (2). While there was also scar tissue in the kidney from old bouts of tuberculosis, it seems likely that his kidney problems arose from anesthetic experimentation.

On June 26, 1858, the following short notice of death appeared in The Lancet (Figure 6).

Figure 6. Snow’s death notice in the Lancet.

A humble obituary for so great a physician.

 

Legacy

Snow’s work in so many fields is well documented although he was not always right. Snow’s life is now commemorated in such an English way-a pub near the original site of the Broad Street pump. The pub was renamed for him in 1955 on the centenary of the Snow’s publication of “On the Mode of Communication of Cholera” (Figure 7).

Figure 7. John Snow pub on Broadwick (formerly Broad) Street in modern London.

It is ironic that Snow, who did not drink alcohol or eat meat for most of his life, should be commemorated by a public house where the menu is not vegetarian and the libations are alcoholic.

It is difficult to underestimate the historical importance of Snow’s work. Gro Harlem Brundtland, former Director-General of the World Health Organization has said, "In historic terms the marriage between science and health is a relatively recent event. Not long ago superstition, magic and astrology were the only weapons our ancestors had to fight diseases and epidemics that haunted the world. They were seen as divine punishments or unfavorable influence of the heavenly bodies. We owe that marriage to the creators of modern bacteriology, epidemiology and therapeutics - to scientists such as Louis Pasteur, Robert Koch, John Snow, Alexander Fleming and Paul Erlich - and their discoveries that shaped modern medicine and public health policies. They helped rescue our civilization from the dark ages of the unknown - and the unknown had names such as plagues, cholera or syphilis" (2).

When David Satcher, the former Surgeon General, was faced with a complex public health issue, he would frequently ask, “Where is the handle on this Broad Street pump?” (2).

We celebrate Snow for not “caving in” to popular opinion, even against his more illustrious colleagues, a persistence in getting at the truth of the matter, and the courage to put it in print. Yet, his real excellence, lies in his creativity to look at an event as all his contemporaries did and come up with the novel (and correct) solution and his conviction to that solution when he believed he was right.

References

  1. http://www.ph.ucla.edu/epi/snow.html (accessed 5/7/13).
  2. http://www.ph.ucla.edu/epi/snow.html (accessed 5/7/13).
  3. http://madisonleighrose.wordpress.com/2012/08/27/john-snow-and-the-cholera-myth/ (accessed 5/7/13).
  4. Snow J. Snow on Cholera -- A Reprint of Two Papers by John Snow, M.D. together with A Biographical Memoir by B.W. Richardson, M.D., and an Introduction by Wade Hampton Frost, M.D., Hafner Publishing Company, London, 1965.
  5. Summers J. Soho -- A History of London's Most Colourful Neighborhood, Bloomsbury, London, 1989, pp. 113-117.
  6. Snow J. On asphyxia and on the still-born. London Med Gaz. 1842;1:222-7.
  7. Snow J. On the inhalation of the vapour of ether in surgical operations Br. J. Anaesth. 1953;25: 53-4. [CrossRef]
  8. Snow J. On the Mode of Communication of Cholera. London: John Churchill,  New Burlington Street, England, 1855
  9. Snow J. On the pathology and mode of communication of cholera: part 1. London Medical Gazette. 1849;44:745-52.
  10. Snow J. On the pathology and mode of communication of cholera: part 2. London Medical Gazette. 1849;44:923-29.
  11. http://en.wikipedia.org/wiki/Great_Stink (accessed 5/7/13).

Reference as: Robbins RA, Klotz SA. Profiles in medical courage: John Snow and the courage of conviction. Southwest J Pulm Crit Care. 2013;7(2):87-99. doi: http://dx.doi.org/10.13175/swjpcc063-13 PDF

Thursday
Jun132013

Comparisons between Medicare Mortality, Readmission and Complications

Richard A. Robbins, MD*

Richard D. Gerkin, MD  

 

*Phoenix Pulmonary and Critical Care Research and Education Foundation, Gilbert, AZ

Banner Good Samaritan Medical Center, Phoenix, AZ

 

Abstract

The Center for Medicare and Medicaid Services (CMS) has been a leading advocate of evidence-based medicine. Recently, CMS has begun adjusting payments to hospitals based on hospital readmission rates and “value-based performance” (VBP). Examination of the association of Medicare bonuses and penalties with mortality rates revealed that the hospitals with better mortality rates for heart attacks, heart failure and pneumonia had significantly greater penalties for readmission rates (p<0.0001, all comparisons). A number of specific complications listed in the CMS database were also examined for their correlations with mortality, readmission rates and Medicare bonuses and penalties. These results were inconsistent and suggest that CMS continues to rely on surrogate markers that have little or no correlation with patient-centered outcomes.

Introduction

Implementation of the Affordable Care Act (ACA) emphasized the use of evidence-based measures of care (1). However, the scientific basis for many of these performance measures and their correlation with patient-centered outcomes such as mortality, morbidity, length of stay and readmission rates have been questioned (2-6). Recently, CMS has begun adjusting payments based on readmission rates and “value-based performance” (VBP) (7). Readmission rates and complications are based on claims submitted by hospitals to Medicare (8).

We sought to examine the correlations between mortality, hospital readmission rates, complications and adjustments in Medicare reimbursement. If the system of determining Medicare reimbursements is based on achievement of better patient outcomes, then one hypothesis is that lower readmission rates would be associated with lower mortality.  An additional hypothesis is that complications would be inversely associated with both mortality and readmission rates. 

Methods

Hospital Compare

Data was obtained from the CMS Hospital Compare website from December 2012-January 2013 (8). The data reflects composite data of all hospitals that have submitted claims to CMS. Although a number of measures are listed, we recorded only readmissions, complications and deaths since many of the process of care measures have not been shown to correlate with improved outcomes. Patient satisfaction was not examined since higher patient satisfaction has been shown to correlate with higher admission rates to the hospital, higher overall health care expenditures, and increased mortality (9). In some instances data are presented in Hospital Compare as higher, lower or no different from the National average. In this case, scoring was done 2, 0 and 1 respectively with 0=higher, 2=lower and 1=no different.

Mortality

Mortality was obtained from Hospital Compare and is the 30-day estimates of deaths from any cause within 30 days of a hospital admission for patients hospitalized for heart attack, heart failure, or pneumonia regardless of whether the patient died while still in the hospital or after discharge. The mortality and rates are adjusted for patient characteristics including the patient’s age, gender, past medical history, and other diseases or conditions (comorbidities) the patient had at hospital arrival that are known to increase the patient’s risk of dying.

Readmission Rates

Similarly, the readmission rates are 30-day estimates of readmission for any cause to any acute care hospital within 30 days of discharge. These measures include patients who were initially hospitalized for heart attack, heart failure, and pneumonia. Similar to mortality, the readmission measures rates are adjusted for patient characteristics including the patient’s age, gender, past medical history, and other diseases or conditions (comorbidities) the patient had at hospital arrival that are known to increase the patient’s risk for readmission.

Complications

CMS calculates the rate for each complication by dividing the actual number of self-reported outcomes at each hospital by the number of eligible discharges for that measure at each hospital, multiplied by 1,000. The composite value reported on Hospital Compare is the weighted averages of the component indicators.  The measures of serious complications reported are risk adjusted to account for differences in hospital patients’ characteristics. In addition, the rates reported on Hospital Compare are “smoothed” to reflect the fact that measures for small hospitals are measured less accurately (i.e., are less reliable) than for larger hospitals.

CMS calculates the hospital acquired infection data from the claims hospitals submit to Medicare. The rate for each hospital acquired infection measure is calculated by dividing the number of infections that occur within any given eligible hospital by the number of eligible Medicare discharges, multiplied by 1,000. The hospital acquired infection rates were not risk adjusted by CMS.

In addition to the composite data, individual complications listed in the CMS database were examined (Table 1).

Table 1. Complications examined that are listed in CMS data base.

Objects Accidentally Left in the Body After Surgery

Air Bubble in the Bloodstream

Mismatched Blood Types

Severe Pressure Sores (Bed Sores)

Falls and Injuries

Blood Infection from a Catheter in a Large Vein

Infection from a Urinary Catheter

Signs of Uncontrolled Blood Sugar

 

Medicare Bonuses and Penalties

The CMS data was obtained from Kaiser Health News which had compiled the data into an Excel database (10).

 

Statistical Analysis

Data was reported as mean + standard error of mean (SEM). Outcomes between hospitals rated as better were compared to those of hospitals rated as average or worse using Student’s t-test. The relationship between continuous variables was obtained using the Pearson correlation coefficient. Significance was defined as p<0.05. All p values reported are nominal, with no correction for multiple comparisons.

Results

A large database was compiled for the CMS outcomes and each of the hospital ratings (Appendix 1). There were over 2500 hospitals listed in the database.

Mortality and Readmission Rates

A positive correlation for heart attack, heart failure and pneumonia was found between hospitals with better mortality rates (p<0.001 all comparisons). In other words, hospitals with better mortality rates for heart attack tended to be better mortality performers for heart failure and pneumonia, etc.  Surprisingly, the hospitals with better mortality rates for heart attack, heart failure and pneumonia had higher readmission rates for these diseases (p<0.001, all comparisons).

Examination of the association of Medicare bonuses and penalties with mortality rates revealed that the hospitals with better mortality rates for heart attacks, heart failure and pneumonia received the same compensation for value-based performance as hospitals with average or worse mortality rates (Appendix 2, p>0.05, all comparisons). However, these better hospitals had significantly larger penalties for readmission rates (Figure 1, p<0.0001, all comparisons). 

 

Figure 1.  Medicare bonuses and penalties for readmission rates of hospitals with better, average or worse mortality for myocardial infarction (heart attack, Panel A), heart failure (Panel B), and pneumonia (Panel C).

Because total Medicare penalties are the average of the adjustment for VBP and readmission rates, the reduction in reimbursement was reflected with higher total penalty rates for hospitals with better mortality rates for heart attacks, heart failure and pneumonia (Figure 2 , p<0.001, all comparisons).

Figure 2.  Total Medicare bonuses and penalties for readmission rates of hospitals with better, average or worse mortality for myocardial infarction (heart attack, Panel A), heart failure (Panel B), and pneumonia (Panel C).

Mortality Rates and Complications

The rates of a number of complications are also listed in the CMS database (Table 1). A correlation was performed for each complication compared to the hospitals with better, average or worse death and readmission rates for heart attacks, heart failure and pneumonia (Appendix 3). A positive correlation of hospitals with better mortality rates was only observed for falls and injuries in the hospitals with better death rates from heart failure (p<0.02). However, severe pressure sores also differed in the hospitals with better mortality rates for heart attack and heart failure, but this was a negative correlation (p<0.05 both comparisons). In other words, hospitals that performed better in mortality performed worse in severe pressure sores. Similarly, hospitals with better mortality rates for heart failure had higher rates of blood infection from a catheter in a large vein compared to hospitals with an average mortality rate (p<0.001). None of the remaining complications differed.

Readmission Rates and Complications

A correlation was also performed between complications and hospitals with better, average and worse readmission rates for myocardial infarction, heart failure, and pneumonia (Appendix 4). Infections from a urinary catheter and falls and injuries were more frequent in hospitals with better readmission rates for myocardial infarction, heart failure, and pneumonia compared to hospitals with the worse readmission rates (p<0.02, all comparisons). Hospitals with better readmission rates for heart failure also had higher infections from a urinary catheter compared to hospitals with average readmission rates for heart failure (p<0.001). None of the remaining complications significantly differed 

Discussion

The use of “value-based performance” (VBP) has been touted as having the potential for improving care, reducing complications and saving money. However, we identified a negative correlation between deaths and readmissions, i.e., those hospitals with the better mortality rates were receiving larger financial penalties for readmissions and total compensation. Furthermore, correlations of hospitals with better mortality and readmission rates with complications were inconsistent.

Our data compliments and extends the observations of Krumholz et al. (11). These investigators examined the CMS database from 2005-8 for the correlation between mortality and readmissions. They identified an inverse correlation between mortality and readmission rates with heart failure but not heart attacks or pneumonia. However, with the financial penalties now in place for readmissions, it now seems likely hospital practices may have changed.

CMS compensating hospitals for lower readmission rates is disturbing since higher readmission rates correlated with better mortality. This equates to rewarding hospitals for practices leading to lower readmission rates but increase mortality. The lack of correlation for the other half of the payment adjustment, so called “value-based purchasing” is equally disturbing since if apparently has little correlation with patient outcomes.

Although there is an inverse correlation between mortality and readmissions, this does not prove cause and effect. The causes of the inverse association between readmissions and mortality rates are unclear, but the most obvious would be that readmissions may benefit patient survival. The reason for the lack of correlation between mortality and readmission rates with most complication rates is also unclear. VBP appears to rely heavily on complications that are generally infrequent and in some cases may be inconsequential. Furthermore, many of the complications are for all intents and purposes self-reported by the hospitals to CMS since they are based on claims data. However, the accuracy of these data has been called into question (12,13). Meddings et al. (13) studied urinary tract infections. According to Meddings, the data were “inaccurate” and not were “not valid data sets for comparing hospital acquired catheter-associated urinary tract infection rates for the purpose of public reporting or imposing financial incentives or penalties”. The authors proposed that the nonpayment by Medicare for “reasonably preventable” hospital-acquired complications resulted in this discrepancy. Inaccurate data may lead to the lack of correlation a complication and outcomes on the CMS database.

According to the CMS website the complications were chosen by “wide agreement from CMS, the hospital industry and public sector stakeholders such as The Joint Commission (TJC) , the National Quality Forum (NQF), and the Agency for Healthcare Research and Quality (AHRQ) , and hospital industry leaders” (7). However, some complications such as air bubble in the bloodstream or mismatched blood types are quite rare. Others such as signs of uncontrolled blood sugar are not evidence-based (14). Other complications actually correlated with improved mortality or readmission rates. It seems likely that some of the complications might represent more aggressive treatment or could reflect increased clinical care staffing which has previously been associated with better survival (14,15). 

There are several limitations to our data. First and foremost, the data are derived from CMS Hospital Compare where the data has been self-reported by hospitals. The validity and accuracy of the data has been called into question (12,13). Second, data are missing in multiple instances. For example, data from Maryland were not present. There were multiple instances when the data were “unavailable” or the “number of cases are too small”. Third, in some instances CMS did not report actual data but only higher, lower or no different from the National average. Fourth, much of the data are from surrogate markers, a fact which is puzzling when patient-centered outcomes are available. In addition, some of these surrogate markers have not been shown to correlate with outcomes.

It is unclear if CMS Hospital Compare should be used by patients or healthcare providers when choosing a hospital. At present it would appear that the dizzying array of data reported overrelies on surrogate markers which are possibly inaccurate. Lack of adequate outcomes data and even obfuscating the data by reporting the data as average, below or above average does little to help shareholders interpret the data. The failure to apparently incorporate mortality rates as a component of VBP is another major limitation. The accuracy of the data is also unclear. Until these shortcomings can be improved, we cannot recommend the use of Hospital Compare by patients or providers.

References

  1. Obama B. Securing the future of American health care. N Engl J Med. 2012; 367:1377-81.
  2. Showalter JW, Rafferty CM, Swallow NA, Dasilva KO, Chuang CH. Effect of standardized electronic discharge instructions on post-discharge hospital utilization. J Gen Intern Med. 2011;26(7):718-23.
  3. Heidenreich PA, Hernandez AF, Yancy CW, Liang L, Peterson ED, Fonarow GC. Get With The Guidelines program participation, process of care, and outcome for Medicare patients hospitalized with heart failure. Circ Cardiovasc Qual Outcomes. 2012 ;5(1):37-43.
  4. Hurley J, Garciaorr R, Luedy H, Jivcu C, Wissa E, Jewell J, Whiting T, Gerkin R, Singarajah CU, Robbins RA. Correlation of compliance with central line associated blood stream infection guidelines and outcomes: a review of the evidence. Southwest J Pulm Crit Care. 2012;4:163-73.
  5. Robbins RA, Gerkin R, Singarajah CU. Relationship between the Veterans Healthcare Administration Hospital Performance Measures and Outcomes. Southwest J Pulm Crit Care 2011;3:92-133.
  6. Padrnos L, Bui T, Pattee JJ, Whitmore EJ, Iqbal M, Lee S, Singarajah CU, Robbins RA. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care. 2011;3:40-8.
  7. http://www.medicare.gov/HospitalCompare/Data/linking-quality-to-payment.aspx (accessed 4/8/13).
  8. http://www.medicare.gov/hospitalcompare/ (accessed 4/8/13).
  9. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172:405-11.
  10. http://capsules.kaiserhealthnews.org/wp-content/uploads/2012/12/Value-Based-Purchasing-And-Readmissions-KHN.csv (accessed 4/8/13).
  11. Krumholz HM, Lin Z, Keenan PS, Chen J, Ross JS, Drye EE, Bernheim SM, Wang Y, Bradley EH, Han LF, Normand SL. Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. JAMA. 2013;309(6):587-93. doi: 10.1001/jama.2013.333.
  12. Robbins RA. The emperor has no clothes: the accuracy of hospital performance data. Southwest J Pulm Crit Care. 2012;5:203-5.
  13. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med. 2012;157:305-12.
  14. NICE-SUGAR Study Investigators. Intensive versus conventional insulin therapy in critically ill patients. N Engl J Med. 2009;360:1283-97.
  15. Robbins RA, Gerkin R, Singarajah CU. Correlation between patient outcomes and clinical costs in the va healthcare system. Southwest J Pulm Crit Care. 2012;4:94-100.

Reference as: Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86. PDF

Monday
Mar042013

In Vitro Versus In Vivo Culture Sensitivities: An Unchecked Assumption?

Vinay Prasad, MD*

Nancy Ho, MD

 

*Medical Oncology Branch

National Cancer Institute

National Institutes of Health

Bethesda, Maryland.

vinayak.prasad@nih.gov

 

Department of Medicine

University of Maryland 

 

Case Presentation

A patient presents to urgent care with the symptoms of a urinary tract infection (UTI). The urinalysis is consistent with infection, and the urine culture is sent to lab.  In the interim, a physician prescribes empiric treatment, and sends the patient home. Two days later, the culture is positive for E. coli, resistant to the drug prescribed (Ciprofloxacin, Minimum Inhibitory Concentration (MIC) 64 μg/ml), but attempts to contact the patient (by telephone) are not successful. The patient returns the call two weeks later to say that the infection resolved without sequelae.

Discussion

Many clinicians have the experience of treatment success in the setting of known antibiotic resistance, and, conversely, treatment failure in the setting of known sensitivity. Such anomalies and empiric research described here forces us to revisit assumptions about the relationship between in vivo and in vitro drug responses. 

When it comes to the utility of microbiology cultures, other writers have questioned cost effectiveness and yield (1). Though it is considered a quality measure by some groups in the United States, routine blood cultures seldom change antibiotic choice (3.6%) in patients who present to the emergency room with the clinical and radiographic signs of pneumonia (2)

The objection here is different, but fundamental. Even when culture sensitivities suggest we should change antibiotics, what empirical evidence is there that such changes are warranted? It is by no means a novel doubt. In 1963, at the dawn of in vitro sensitivity techniques, one group questioned their utility to predict clinical outcomes:

“Several objections may be raised…. First, local or host defense mechanisms may act in synergism or antagonism with the antibiotic.  Second, the concentration of antibiotic in tissue fluids, specifically blood, might bear no relation to the concentration at the site of infection…” (3)

And, while substantial pharmacologic progress has been made to ensure proper tissue concentrations, few empirical studies have sought to address the first concern (4). Recent examples suggest the relationship between in vitro and in vivo outcomes may be questionable.

One study of H. pylori tackled this issue (5). Macrolide and metronidazole resistance were determined in lab, and a urea breath test assessed clinical response. Interestingly, treatment with a clarithromycin regiment failed in 77% of persons with clarithromycin-resistant H. pylori compared with 13% of those with clarithromycin-susceptible isolates (relative risk, 6.2 [CI, 1.9 to 37.1]; P < 0.001).  While treatment with metronidazole-based therapy failed in 11% of those with metronidazole-resistant isolates and 38% of those with metronidazole-susceptible isolates (P > 0.25). 

These results suggest that metronidazole susceptibility wholly lacks clinical utility, while clarithromycin sensitivity may be useful. To fully prove the utility of clarithromycin sensitivity testing the authors should show a higher cure rate with a different regiment, and then demonstrate that upfront screening is preferable to empiric treatment and observation.  

Another study suggests that for some organisms and infections— Acanthamoeba keratitis—there exists no relationship at all between in vitro drug sensitivities and the in vivo response (6).

For some conditions, knowing that a causative organism is susceptible in vitro does in fact predict clinical response. For instance, a large study of gram-negative infections treated with cefotaxime found that as the MIC increased, from <4 μg/ml to 64 μg/ml (in vitro), the rate of clinical response fell from 91% to 50% (4). Thus, nearly all patients with susceptible organisms (low MIC) were successfully treated. But, perhaps, what is most interesting about this study is that even resistant organisms were effectively treated in 50% of patients. This finding is supported by work in urinary tract infections, which similarly found a high percentage of clinical response (>80%), even among patients whose causative organisms were resistant to prescribed agents (7).

Basic studies are required for bacteremia, pneumonia, urinary tract infections, endocarditis, and others. To do this work, we should not use our words interchangeably. Treatment failure must refer to an independent clinical outcome and not defined circularly as antibiotic resistance. As of today, faith that in vitro results predict in vivo outcomes remains an unchecked assumption whose treatment implications remain vast and reaching. 

References

  1. Glerant JC, Hellmuth D, Schmit JL, Ducroix JP, Jounieaux V. Utility of blood cultures in community-acquired pneumonia requiring hospitalization: influence of antibiotic treatment before admission. Respir Med. 1999;93:208-12.
  2. Kennedy M, Bates DW, Wright SB, Ruiz R, Wolfe RE, Shapiro NI. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005;46:393-400.
  3. Petersdorf RG, Plorde JJ. The usefulness of in vitro sensitivity tests in antibiotic therapy. Annu Rev Med. 1963;14:41-56.
  4. Doern GV, Brecher SM. The Clinical Predictive Value (or Lack Thereof) of the Results of In Vitro Antimicrobial Susceptibility Tests. J Clin Microbiol. 2011;49:S11-S4.
  5. McMahon BJ, Hennessy TW, Bensler JM, et al. The relationship among previous antimicrobial use, antimicrobial resistance, and treatment outcomes for Helicobacter pylori infections. Ann Intern Med. 2003;139:463-9.
  6. Perez-Santonja JJ, Kilvington S, Hughes R, Tufail A, Matheson M, Dart JK. Persistently culture positive acanthamoeba keratitis: in vivo resistance and in vitro sensitivity. Ophthalmology. 2003;110:1593-600.
  7. Alizadeh Taheri P, Navabi B, Shariat M. Neonatal urinary tract infection: clinical response to empirical therapy versus in vitro susceptibility at Bahrami Children's Hospital- Neonatal Ward: 2001-2010. Acta Med Iran. 2012;50:348-52.

Reference as: Prasad V, Ho N. In vitro versus in vivo culture sensitivities: an unchecked assumption? Southwest J Pulm Crit Care. 2013;6(3):125-7. PDF

Saturday
Jan122013

Profiles in Medical Courage: Thomas Kummet and the Courage to Fight Bureaucracy

“You can’t fight city hall”-Unknown.

Abstract

Thomas Kummet was an oncologist wrongly accused in his mind of delivering substandard care. His fight for correcting what he believed to be a mistake illustrates the difficulty physicians face when challenging the current peer review system. In an attempt to defend his reputation he filed suit which was eventually dismissed by a Federal Court. His frustration over the futility of his fight is illustrative of the difficulties many physicians have faced in fighting a large bureaucracy and an unsympathetic justice system.

Introduction

Thomas Kummet (Figure 1) was an oncologist at the Phoenix Veterans Administration (VA) Medical Center.

Figure 1. Dr. Thomas Kummet

 He had been chief of oncology/hematology for nearly 20 years and was well-respected by his colleagues, staff and students. He was regarded as an excellent clinician. During his 20 years at the VA he no law suits or adverse actions. While attending on general medicine, the deaths of two patients launched a series of events leading Dr. Kummet to eventually file suit against the VA.

Case Presentations

Case 1

A 72 year old male patient was admitted to the surgical critical care (SICU) unit after being found comatose on the surgical ward.  He had undergone surgery for peripheral vascular disease 3 days earlier, but the resident physician failed to order monitoring of his warfarin therapy. At the time of the transfer, his prothrombin time was markedly elevated and a cat scan showed a large intracranial hemorrhage.  The surgery resident stated to the family that the diagnosis was disseminated intravascular coagulation as a complication of the surgery. Shortly after transfer to the SICU the patient expired.  The attending intensivist, a medical internist informed the family of the true cause of the bleeding which led to the patient’s death. The family sued, and received a settlement before trial.

In accordance with hospital policy, the chart was sent to the surgery service for review. The surgery service selected the intensivist as being responsible, who learned of that action only much later, when the state of Arizona began an investigation and placed the intensivist’s name on its public website as a physician guilty of malpractice.

Case 2

JV was a 67-year-old man who was admitted from dialysis clinic to the Internal Medicine Service in August 1999 with a history of non-insulin dependent diabetes mellitus, end stage renal disease with dialysis, hypertension, anemia of chronic disease, and chronic ulcerations of the feet.  He had developed progressive ascites for several weeks, and had been feeling weak and tired. JV was admitted with a systolic blood pressure of 87 mm Hg, a WBC count of 20,000 cells/mm3, and fever. A medical workup was begun to find the source of a possible sepsis syndrome. The vascular surgery service was consulted with regard to a wound on the patient's left arm which had been the result of an attempted placement for a dialysis access which had failed to mature.  The patient was evaluated and found to have a seroma which was subsequently drained without any complications.  During follow up, it was noted that the patient had a gangrenous left foot with non-reconstructible peripheral vascular disease. Subsequently a below the knee guillotine amputation was performed.

However, JV continued to have intermittent hypotension and fever. In addition to broad spectrum antibiotics he was receiving enoxaparin 30 mg daily as DVT prophylaxis.  On the first postoperative day the consulting intensivist recommended a thoracentesis of a left pleural effusion followed by a paracentesis to exclude these as a source of infection. The thoracentesis and paracentesis were performed without incident. Approximately 2 liters of clear ascitic fluid was removed from the right upper quadrant. About 2 hours after the procedure, the patient experienced the acute onset of abdominal pain, a sudden decrease in blood pressure, a rigid abdomen, apnea and a Code Arrest was called.  He was successfully resuscitated.  His hemoglobin was noted to have decreased from 11 to 7.9 gm/dl.

JV was taken emergently to the operating room where a damage control laparotomy was initiated and a massive hemoperitoneum was noted.  This was evacuated and a vessel on the right upper abdominal wall was identified and ligated. During the exploration it was noted that while the cirrhotic liver was unmarked, but the stomach had a 1 cm perforated ulcer in the anterior wall which was bleeding briskly. This was oversewn and then patched with omentum. During the resuscitation, he received seven units of red blood cells, seven units of fresh frozen plasma, and multiple infusions of crystalloids and colloid solutions in an attempt to maintain blood pressure. A Swan-Ganz pulmonary artery catheter was inserted and fluid resuscitation was guided by pulmonary artery catheter indices.  After adequate fluid resuscitation, he remained hypotensive with a low cardiac index and was supported with a combination of vasopressor agents and inotropes including super maximal doses of dobutamine, dopamine, phenylephrine and norepinephrine.  However, he remained hypotensive, and with the family at his bedside and after a detailed discussion, the family elected to cease support.  The patient died shortly afterwards.

Pertinent Laboratory

His creatinine was 3.2 mg/dL and his blood urea nitrogen was 37 mg/dL. Both his pleural fluid and ascitic fluid were exudative. Blood cultures and peritoneal cultures were all negative. His prothrombin time at the time of his paracentesis was slightly elevated at 13.8 seconds (upper limits of normal 13.3) but partial thromboplastin time and platelet count were within normal limits.

Hospital Course and Surgical Review

When the surgical team was contacted regarding the sudden drop in blood pressure and rigid abdomen, they accused the medicine team of “puncturing” the patient’s liver by the paracentesis with the family present. The family then confronted the resident and intern who performed the paracentesis for this “screw up”. Relevant is that this surgical team is the same that had recently been responsible for the events in case one.  

Since the patient expired on the surgical service, the chart in case 2 was again sent to the surgical service to assess attending responsibility. The medical attending at the time of the patient’s initial admission was selected as the responsible physician, again without any knowledge or input from that medical attending.

JV’s family had hired an attorney who hired a nephrologist in private practice from Tarzana, CA to review the case. The physician opined that the paracentesis should not have been performed because of an excess bleeding risk and the patient died as a result of the paracentesis. The physician did not mention the perforated gastric ulcer which was bleeding “briskly” at the time of the operation. A local peer review was conducted and concluded that bleeding was almost certainly from the perforated gastric ulcer and had nothing to do with the paracentesis.

The US Attorney’s Office obtained additional expert opinions from outside the VA who concluded there was no merit to the case and all applicable standards of care were met. Despite these reviews, the US Attorney’s Office settled the case for $250,000. The reason for the decision to settle the case remains unclear.

Local VA Actions

The attending physicians discussed of both cases with the Risk Manager at the Phoenix VA, who dismissed concerns by saying that the hospital needed to maintain its hard-to-recruit-and-retain surgery staff, but that the medical physicians who had been with the hospital for 20 years were less likely to leave.  In addition, the hospital risk manager assured the medical service physicians that the hospital would not report them to the National Practitioner Data Bank, as no one felt they were responsible for malpractice.

New VA regulations were in effect when Case 2 was settled.  Thomas Kummet was the internal medicine attending who was informed by the hospital of the matter for the first time when he was told he had ten days to respond to VA headquarters about the “malpractice” case, and according to the regulations he was entitled to supervised review of the chart and the settlement documents.  However, while he was allowed to see the chart, there were no documents to explain the lawsuit or the rationale for settlement. When the Risk Manager was asked for those documents, it was acknowledged that they would not be provided, no matter what VA regulations stated, as the US Attorney’s office refused to provide them to the hospital. Again Dr. Kummet was assured that the VA did not report physicians to the National Practitioner Data Bank in circumstances where there was no malpractice.

Three VA reviewers found no evidence of malpractice in the management of this patient. However, Dr. Kummet was informed he was being reported to the National Practitioner Data Bank and the State of Arizona as being responsible for a malpractice settlement.

Actions by the State of Arizona Board of Medical Examiners (BOMEX)

After being notified of the NPDB placement, the state BOMEX began their own investigation of Dr. Kummet, after first placing notification on their public website that he and the intensivist in Case 1 were responsible for malpractice.  This prompted patients to begin to ask for details of his “multiple” errors, to be referred to other physicians, and of why he was still allowed to practice. BOMEX asked Dr. Kummet for the medical records, which the local VA refused to provide, claiming Federal law precluded release.  When the state responded that Dr. Kummet’s (only) medical license was therefore at risk, Dr. Kummet hired legal representation.  With that assistance, the hospital sent a copy of the patient’s chart to the BOMEX. 

The state investigation was subsequently completed, no action was taken except to remove the notation on the website that a case was under investigation, and a request by the doctor for the documents of the state’s investigation was denied by BOMEX.

VA Headquarters Actions

The Veterans Administration had come under criticism in the early 2000’s because only 37% of physicians involved in a malpractice settlement were reported to the National Practioner Data Bank (NPDB). The VA initiated a peer review process and began reporting all practioners whose care was judged as substandard to the NPDB. This included some instances of previously settled claims such as Dr. Kummet’s. This new policy was designed to report all physicians because, as it was explained to the local Risk Manager, “it is good for the VA to show that we are tough on physicians.”

After the case was settled, it was referred to John Grippi MD from the Buffalo VA who was heading the VA’s peer review. He referred the case to a non-VA panel consisting of Edmond Gicewicz MD, a retired general surgeon; Norbert Kuberka MD, a retired oncologist; and Gregory Czajka PA, a surgical assistant. The panel concluded that “technical errors in the performance of abdominal paracentesis resulted in significant intra-abdominal hemorrhage”.

Dr. Kummet’s name was submitted to the National Practioner Data Bank, 10 days after he was first informed of the claim settlement and 4 years after the patient’s death.

Legal Action

Dr. Kummet obtained legal counsel and suit was filed in Federal court since the VA is a Federal agency. The suit failed, however, as there is no statutory or case law that required the local institution to follow its own procedures, or to allow physicians due process claims in these matters.

The legal proceedings were unsuccessful at obtaining any documents to support the decision to report to the NPDB, only to be told what was done was legal and in the VA’s best interest. The US Attorney’s office responded to a Freedom of Information Act request by supplying one nearly totally redacted document and claimed everything else was protected attorney work product (Figure 2).

Figure 2. Redacted letter from US Attorney’s Office.

Conclusion

Subsequently, Dr. Kummet left the VA system and is in private practice in Washington State. There are multiple instances where hospitals have retaliated against physicians for financial gain or for reporting substandard care (1). However, this does appear to be applicable in this case. If you, the reader, concludes from the case presentation that Dr. Kummet delivered substandard care, then he was justifiably punished.

On the other hand, if you agree the American Association for the Study of Liver Diseases that a abdominal paracentesis should be performed in patients with new-onset ascites (2) and that the patient’s intraperitoneal hemorrhage resulted from the perforated gastric ulcer rather than the paracentesis, then you likely agree with Dr. Kummet that he was falsely accused by the VA’s peer review system.

Dr. Kummel’s experience illustrates that physicians face a hospital peer review and justice system that fails to grant the basic rights to those accused of professional misconduct that it grants to those accused of criminal behavior. These include the right to a speedy and public trial by an impartial jury; to be informed of the nature and cause of the accusation; to be confronted with the witnesses against him; to have compulsory process for obtaining witnesses in his favor; and to have the assistance of counsel for his defense. Furthermore, the decision to settle the lawsuit that negatively impacted Dr. Kummet were made by attorneys without the background or knowledge to know if substandard care was delivered.

Regardless, Dr. Kummet should be admired for his courage in fighting what he views as unfair accusations by those more concerned with political perceptions than improvement in healthcare and a legal system unconcerned with slandering his reputation.

Richard A. Robbins, MD*

References

  1. Kinney ED. Hospital peer review of physicians: does statutory immunity increase risk of unwarranted professional injury? MSU Journal of Medicine and Law 2009;57:57-89.
  2. Runyon BL. Management of adult patients with ascites due to cirrhosis: An update. Hepatology 2009;49:2087–107.

*Dr. Thomas Kummet assisted in the preparation of this manuscript.

Reference as: Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight burearcracy. Southwest J Pulm Crit Care. 2013;6(1):29-35. PDF

 

 

Friday
Nov022012

Profiles in Medical Courage: The Courage to Serve and Jamie Garcia

“I've seen and met angels wearing the disguise of ordinary people living ordinary lives.”-Tracy Chapman, American singer-songwriter

Abstract

Some of our Profiles in Medical Courage series have dealt with the famous, and several such as Barry Marshall and Archie Cochrane are household names in medical circles. However, some physicians, just as courageous, are not so renowned. Jamie Lynn Garcia was one of those who died earlier this year at the age of 52.  She was a devoted servant of the poor and founder of the Pomona Community Health Center. Her road to becoming a physician was not straight-forward but her life story was an extraordinary one.

Early Life

Jamie was raised in the Westchester section of Los Angeles, just north of the Los Angeles International Airport. She had a rather ordinary middle class upbringing in a Hispanic family where her father was a gardener and her mother a realtor. Her parents were strict Catholics and she attended the Catholic schools. She was a bright student but also had a beautiful singing voice that she was encouraged to develop. "As a child she had severe asthma," but there was a physician who helped her, "a doctor who was inspiring." (1). However, with adolescence her asthma improved but other issues were hard on Jamie. After reading the Bible at age 12, she rejected religion, and after passing a high school proficiency exam, left high school at 16 to become a professional musician.

Rock and Roll Years

Jamie used her voice and her instrumental talent on guitar, bass and keyboards in many of the bands in the Los Angeles during the1980’s while supplementing her income as a realtor (2). These bands followed her eclectic tastes and included country, jazz and pop but the most successful band was the all girl rock band “On the Air”. They had gigs throughout Los Angeles, aired videos on VH1, and garnered the attention of major record labels. However, the band collapsed when the lead singer decided to pursue an education. Several of Jamie’s friends, encouraged Jamie to do the same. Thinking that they might be right, she decided to go to college with no particular goal in mind.

Education

She enrolled at Santa Monica Community College and later transferred to UCLA where she majored in philosophy. During her later years in college she recalled her childhood doctor who treated her asthma. She thought, “I could do that”, and applied to medical school. She attended the University of Washington. There she meant her partner for the next 15 years, Dr. Sue Verrault, a child psychologist. After graduation, Jamie returned to the Los Angeles area for a family practice residency at Pomona Valley Hospital.

As a resident she was moved by what she saw as an enormous need for healthcare of low-income patients, especially those with chronic conditions such as heart disease, diabetes, and asthma. Dr. Jamie, as her patients came to call her, was a compassionate physician, but her faculty noted she spent too much time with patients, especially psychiatric patients. Fearless and confident, she occasionally liberated hospital supplies and took them to the streets to treat the homeless. During her last year in residency, she heard of a homeless man living under a nearby freeway bridge who was in dire need of medical care (2). She crawled under the bridge to find him, and convinced him to come with her back to the hospital. She enrolled him in a treatment program for alcoholics, after which he remained sober.

Pomona Community Health Center

At the time many of the ER’s and clinics were closing in East Los Angeles and she recognized that the inadequacy of the healthcare system to serve the healthcare needs of the poor. While still a resident Jamie partnered with the LA County Department of Public Health to operate the original Pomona Community Health Center, a two-room free clinic serving the homeless, uninsured, and underinsured in east LA County. After completing residency, she continued the clinic with the help of Federal grants (Figure 1).

Figure 1. Dr. Jamie Lynn Garcia (right) with patient at the Pomona Community Health Center.

The next 8 years were difficult. Money was tight but Jamie dreamed of a larger clinic and began the long process of planning the clinic’s expansion. She had no formal training or experience with such a large project, but assembled a board and staff, sketched out each exam room and calculated the cost of materials, planned budgets for doctors, created partnerships to secure a location, and raised over $1.4 million from Federal and other sources.  In 2010 she secured the crucial seed money to build the new clinic and proudly exclaimed on her Facebook page, "We're buildin' a free clinic! We have liftoff!"

Declining Health

Jamie had the fault of many physicians; she often ignored her own health. She had abdominal pain off and on beginning in 2005. When she finally had time to get an abdominal ultrasound in 2008, an ovarian mass was found but it appeared benign and Jamie was too busy to have it investigated. When she got around to a follow-up ultrasound 2 years later, the mass had doubled in size and she was diagnosed with an aggressive form of ovarian cancer. On May 16, 2011, while undergoing chemotherapy she oversaw the groundbreaking ceremony for the new clinic's building on Holt Avenue, in The Village, a "mall" of social services for low income LA residents. She was determined to beat the cancer and complete the new, expanded clinic and live to see it open. "I can't wait to meet the first patient," she told the Inland Valley Daily Bulletin at the groundbreaking (1).

She continued to run the clinic and oversee the construction of the new clinic despite her ongoing chemotherapy. The new clinic opened its doors on July 9, 2012 but three days earlier, Dr. Jamie was admitted to the hospital where she learned she had a large inoperable tumor.  She was advised to prepare for hospice care. On July 27 she died peacefully in her home but had lived to see the clinic open. She was 52.

Legacy

Dr. Garcia received numerous awards (2). She was named Woman of the Year in 2010 by the California State Assembly, a Hospital Hero in 2010 by the National Health Foundation, and her clinic has been recognized by the California State Assembly, National Project Homeless Connect, and the House of Ruth Domestic Violence Shelter. The evening before she died, several doctors from her clinic gathered at Jamie's home and agreed to hang her numerous recognitions on an otherwise-blank wall in the new clinic. "But I don't know, honestly, if there's room for all of them," noted one doctor.

The new 12-room clinic opened its doors on July 9, 2012, and is expected to serve 24,000 uninsured, homeless, and underinsured residents in the Pomona area this year (2). However, her most enduring legacy may be her example in serving the poor. She should be remembered for her enthusiasm, courage and perseverance in making her dream happen. She is representative of the many physicians and other healthcare providers who forgo larger financial awards to serve the poor in relative obscurity. Her life is testimony that "anything is possible" (2).

References

  1. Rodriquez M. Garcia helped those who struggled. Inland Valley Daily Bulletin. August 10, 2012. Available at: http://www.dailybulletin.com/news/ci_21288514/garcia-helped-those-who-struggled (accessed 9-10-12).
  2. Marks R. RIP Jamie Garcia, a health hero in Pomona, 2010 California Woman of the Year. Off Ramp. August 10, 2012. Available at: http://www.scpr.org/blogs/offramp/2012/08/10/9379/rip-jamie-garcia-health-hero-pomona-2010-californi/ (accessed 9-10-12).

Donations in Dr. Garcia's memory can be made to the Pomona Community Health Center: 1450 E Holt Avenue, Pomona, CA 91767.

Reference as: Robbins RA. Profiles in medical courage: the courage to serve and Jamie Garcia. Southwest J Pulm Crit Care 2012;5:231-4. PDF