Welcome to Weekly Health Update

“A critical weekly review of important new research findings for health-conscious readers”

PHYSICIAN ERROR

Ah ne’er so dire a Thirst of Glory boast,
Nor in the Critick let the Man be lost!
Good-Nature and Good-Sense must ever join;
To err is human, to forgive divine.

Alexander Pope (1688-1744)

According to the prestigious Institute of Medicine, between 50,000 and 100,000 patient deaths are caused each year in the United States by negligence on the part of doctors, nurses, and other health care providers.  Nearly 1,000,000 patient injuries per year are also attributed to human error in the delivery of health care.

The presumptive causes underlying negligence in patient care are multiple and varied, and continue to be the subject of much debate among patient safety experts.  However, virtually all such experts agree that largely preventable human errors account for the vast majority of patient injuries and deaths associated with negligent patient care.

In the operating room, where I spend much of my time, as a cancer surgeon, we have adopted patient safety “check lists” inspired by the airline industry, and which are designed to reduce the possibility of errors during surgery.  At our institution, the patient’s identity (and the surgical procedure to be performed) is confirmed, twice, by everyone in the operating room before an incision is made.  Towards the end of the surgical procedure, an additional “debriefing” is performed, and the surgeon reviews the procedures that he or she has just performed.  The operating room nurse also confirms that all sponges, needles, and instruments have been accounted for, in an effort to reduce the possibility that any of these foreign bodies will be left within the patient.

One important aspect of physician error is that of errors in diagnosis.  In a newly published clinical study, which appears in the current issue of the journal Pediatrics, 1,362 pediatricians at three major academic medical centers, and 109 affiliated clinics, were invited to anonymously complete an Internet-based survey regarding their self-perceived frequency of diagnostic errors.  These doctors included experienced academic pediatricians, experienced community-based pediatricians, and resident doctors who were training to become pediatricians.  Altogether, 53 percent of the queried pediatricians agreed to complete the anonymous survey. 

More than half (54 percent) of these responding doctors indicated that they made significant diagnostic errors at least one or two times per month.  Not surprisingly, the resident doctors in training acknowledged the highest number of diagnostic errors, with 77 percent of these trainees admitting to at least one or two significant diagnostic errors per month.

Based upon their anonymous responses, nearly half (45 percent) of these 726 pediatricians believed that one or more of their diagnostic errors had harmed patients at least once or twice per year. 

When asked to analyze the underlying causes for their errors, these doctors cited the following explanations:  failure to gather adequate patient history information, inadequate physical examination, inadequate review of the patient’s chart, and inadequate coordination of care and communication among the providers involved (“inadequate teamwork”). 

Specific examples of diagnostic errors cited by these pediatricians included viral illnesses being misdiagnosed as bacterial infections, misdiagnosis of medication side effects, misdiagnosis of psychiatric disorders, and misdiagnosis of appendicitis. 

When asked to offer solutions to common diagnostic errors, these pediatricians most commonly recommended the implementation of electronic health records, as well as closer patient follow-up.

(It is important to note that, in view of the human tendency to “under-report” personal failures, it is very likely that the true incidence of significant diagnostic errors is actually considerably higher than what these pediatricians have self-reported in this study.)

In a perfect world, we physicians would never make the wrong diagnosis, or miss a diagnosis altogether, or miss an adverse reaction to medications or other treatments.  We would never prescribe the wrong medication or perform the wrong operation; and we would never, through acts of either commission or omission, perform anything less than a perfect surgical operation.  Unfortunately, the practice of Medicine, as with all human endeavors, will never become a “zero error” profession.  However, all of us, both patients and physicians (and physicians are patients, as well), certainly would agree that every effort must be made to drive preventable patient care errors down as close to “zero” as is humanly possible. 

While it is unlikely that human error can ever be completely eliminated, in Medicine or in any other profession, the findings of this important study are significant, and point to areas where substantial improvements in the delivery of health care can be achieved by physicians and other health care providers (and, I might add, by patients as well). 

Look for the imminent publication of my new landmark evidence-based book, “A Cancer Prevention Guide for the Human Race,” in August of this year. 

Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author

http://www.youtube.com/watch?v=7-Tdv7XW0qg

I and the staff of Weekly Health Update would like to take this opportunity to thank the more than 100,000 new and returning readers who visit our premier global health information website every month.  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.

Welcome to Weekly Health Update

“A critical weekly review of important new research findings for health-conscious readers”

IRRITABLE BOWEL SYNDROME: CAUSE DISCOVERED?

Irritable bowel syndrome (IBS) is a poorly understood cluster of gastrointestinal (GI) tract symptoms that typically includes varying degrees of abdominal bloating and crampy pain, diarrhea, constipation, and the frequent discharge of mucus-like stools from the rectum.  At any one time, an estimated 10 to 20 percent of all Americans chronically experience one or more of these intestinal symptoms.  In most patients with IBS, these symptoms begin in childhood.  In the United States, and in most other Western countries, IBS is at least 3 times more common in women than in men although, interestingly, in Southeast Asia, men are 2 to 3 times more commonly afflicted with IBS.

Numerous theories about the cause(s) of IBS have been proposed, but none have been definitively proven to cause this common syndrome, thus far.  Because the precise cause(s) of IBS has not yet been determined, there is no specific medical test available to diagnose this condition.  Likewise, there is no specific treatment available for IBS, although fiber supplements and careful attention to dietary “triggers” are often helpful.  Moreover, as IBS is frequently associated with chronic depression and/or anxiety, the use of some types of antidepressant medications has also been associated with an improvement in IBS symptoms.

Among the numerous proposed causes of IBS, an excess of a powerful hormone and neurotransmitter, serotonin, within the GI tract has been the focus of considerable research, lately.  (Serotonin is also commonly known as 5-HT, which is an abbreviated form of serotonin’s chemical name.) 

Serotonin has been shown to have multiple functions within the human body.  Decreased serotonin levels in the brain have been associated with both depression and anxiety, which explains why the most commonly used antidepressant medications, the selective serotonin reuptake inhibitors (SSRIs), are used to treat both chronic depression and anxiety.  (Commonly prescribed SSRIs include Prozac, Paxil, Zoloft, Lexapro and Celexa, among others.)  Because more than 95 percent of the body’s serotonin is found in the GI tract, SSRI drugs also have a profound effect on GI tract function, in addition to their effects on brain serotonin levels.  Indeed, previous observations that certain SSRI antidepressant medications worsen cramping and diarrhea in patients with diarrhea-predominant IBS have at least suggested that serotonin in the GI tract may play an important role in this common form of IBS.

Another serotonin-related disease that is associated with severe abdominal cramping and diarrhea is carcinoid syndrome.  In this relatively rare condition, serotonin-secreting carcinoid tumors of the GI tract cause profuse, watery diarrhea in affected patients after these tumors spread to the liver.

Based upon these apparent clinical links between IBS and serotonin (and for diarrhea-predominant IBS, in particular), additional research into the metabolism of serotonin in the GI tract of IBS sufferers is sorely needed.  Fortunately, a newly published research study, which appears in the current issue of the journal Gastroenterology, sheds further light on the potential link between serotonin and at least some forms of IBS.

In this novel clinical research study, 98 children with chronic GI tract symptoms were evaluated.  Twelve of these children presented with chronic symptoms suggestive of IBS.  Endoscopic GI tract biopsies were performed on these 12 children, and the results of these biopsies were compared with similar biopsies performed on other age-matched children who were undergoing endoscopy for reasons other than IBS symptoms.

When compared with the biopsy results on the “control” children without IBS symptoms, the children with IBS symptoms were found to have significantly elevated levels of serotonin (5-HT) in the mucosal cells lining their GI tract.  At the same time, the children with IBS symptoms were also found to have lower levels of a protein that is responsible for removing serotonin from the GI tract (serotonin transporter protein, or SERT) when compared to the children without IBS symptoms.  Therefore, these two findings, in children with chronic IBS symptoms, further and strongly suggest that an excess of serotonin in the gut may be associated with classic IBS symptoms.

In view of the varying degrees of diarrhea and constipation (and other IBS-associated symptoms) observed among individual patients considered to have IBS, it is highly likely that this syndrome has more than just one cause.  However, the biopsy-proven excess of serotonin in the GI tracts of the 12 children in this study with chronic IBS symptoms is a powerful indication that the abnormal regulation and metabolism of GI tract serotonin likely plays an important (if not causative) role in many, if not most, cases of this chronic and very common GI affliction.  The data from this powerful little clinical study also supports the continued development and clinical testing of serotonin/5-HT blocking (antagonist) agents in patients with diarrhea-predominant IBS.

For additional information on IBS, please see my previous column on this topic:

Irritable Bowel Syndrome (IBS), Diet & Fiber

To learn more about the critical role of diet in the prevention of cancer, look for the publication of my new landmark book, “A Cancer Prevention Guide for the Human Race,” in the summer of this year. 

Disclaimer: As always, my advice to readers is to seek the advice of your physician before making any significant changes in medications, diet, or level of physical activity

Dr. Wascher is an oncologic surgeon, a professor of surgery, a cancer researcher, an oncology consultant, and a widely published author

http://www.youtube.com/watch?v=7-Tdv7XW0qg

I and the staff of Weekly Health Update would like to take this opportunity to thank the more than 100,000 new and returning readers who visit our premier global health information website every month.  As always, we enjoy receiving your stimulating feedback and questions, and I will continue to try and personally answer as many of your inquiries as I possibly can.