Criminal prosecution arising from medical mishaps: a Japanese perspective

In Japan, the number of physicians being investigated on suspicion of medical malpractice has increased. Specifically, the criminal prosecutions arising from professional negligence resulting in bodily injury or death have also increased. Article 21 of the Japanese Physician's Act compels a doctor to notify the district police when he diagnoses a death to be 'unnatural'. Originally this provision was to increase public safety through crime detection, but one recent criminal case broadened the application of this article to include the death from a mishap during medical treatment. This criminal case made a tremendous impact on physicians, as the convictions and sentences forced physicians to notify the police even when it is not certain the patient died of the malady or of the medical misconduct itself. Besides, we wonder if such obligation of doctors to notify such 'unnatural' death from medical mishap may be against a person's privilege against self-incrimination which is assured by Japanese Constitutional Law (article 38).     

Physician Burnout and Barriers to Care on Professional Applications

Abstract

We surveyed New York physicians to study their perceptions of reporting requirements related to their own mental health care on professional applications, including whether they were experiencing symptoms of burnout. Over half of the responding physicians reported experiencing symptoms of burnout and these physicians were at increased odds of perceiving a barrier to seeking mental health care if they had to report such care on professional applications and renewals for medical licensure, malpractice, and hospital privileges and credentialing compared to physicians not experiencing symptoms of burnout. As state medical boards, hospitals, and insurers seek information to help assess risks posed by physicians, it is essential to strike an appropriate balance between their duty to protect the public and the physician’s right to confidentiality. This balance can be assessed based on the questions that are asked on various professional applications and how information gleaned through physician responses is used. Overly intrusive questions, though well intentioned to protect the public, may run counter to current interpretations of federal law and may inhibit care-seeking among physicians, which is critical to both patient safety and physician health.     

Assessing provider attitudes toward mandated prevention practices

OBJECTIVE: We measured clinicians' level of knowledge and attitudes regarding Department of Defense-mandated clinical preventive services (CPS) delivery and the barriers they believe prevent the delivery of CPS at a large U.S. Air Force referral medical center. METHODS: Our survey listed a range of prescribed specific CPS and solicited reasons why providers believed that they could not be delivered. RESULTS: The overall response rate was 87.4%. Altogether, 91.7% of those responding answered positively when asked if they were aware of specific CPS. Lack of time was the most commonly cited barrier to CPS delivery. Most providers felt that they had the skills necessary to deliver CPS to their patients, yet 84.4% indicated a willingness to receive additional training. CONCLUSIONS: Our findings suggest that these providers are willing to deliver CPS to their patients.     

Perspectives on pre-participation cardiovascular screening in young competitive athletes: U SPORTS

Objectives: To investigate the pre-participation cardiovascular screening (PPS) protocols currently implemented at U SPORTS (the governing body of university sport in Canada) sanctioned schools as well as the attitudes toward PPS as reported by Canadian University medical and athletic personnel.

Methods: A 15-question survey was sent to the U SPORTS athletic directors in both French and English. The survey focused on the current practices of PPS within the respondents’ universities as well as attitudes regarding PPS. Athletic directors distributed the instructions to participate in the voluntary survey at their own discretion to coaches, athletic therapists, physicians, and associated personnel working within U SPORTS-sanctioned schools.

Results: Twenty-three athletic therapists, 12 coaches, 6 physicians, and 5 associated personnel completed the survey (46 in total). Half of the respondents (52%) reported that some form of PPS was conducted at their institution. Eighty percent of respondents agreed with the implementation of mandatory PPS, and 60% reported that they believe their athletes have a neutral attitude toward PPS. Three respondents documented having witnessed an athlete’s sudden cardiac arrest/death.

Conclusion: Members of the athletic care teams at U SPORTS-sanctioned schools display an overall positive attitude toward the implementation of mandatory PPS. Based on concerns raised by survey respondents, PPS procedures would need to be developed in a time- and cost-effective manner if PPS were to be expanded.     

Discretionary medical reporting of potentially unfit drivers: a questionnaire-based survey in Southeast Switzerland

In Switzerland, every physician has the right to report a patient that is potentially unfit to drive to the licensing authority without violating medical confidentiality. Verified information regarding physicians’ attitudes concerning this discretionary reporting and the frequency of such reports are not available. In order to answer these questions, 635 resident physicians were sent a questionnaire. The response rate was 52%. On average, the responding physicians—for all specialties—reported 0.31 patients (SD 0.64, 95% CI 0.24–0.38) in the year before the survey and 1.00 patient (SD 1.74, 95% CI 0.81–1.20) in the past 5 years. Seventy-nine percent of the responding physicians indicated knowing the current legal requirements for driving in Switzerland. In applied logistic regression analysis, only two factors correlate significantly with reporting: male sex (odds ratio 5.4) and the specialty “general medicine” (odds ratio 3.4). Ninety-seven percent of the physicians were against abolishing medical discretionary reporting and 29% were in favor of introducing mandatory reporting. The great majority of the questioned physicians supported the discretionary reporting of drivers that are potentially unfit to drive as currently practiced in Switzerland. The importance and the necessity of a regular traffic medicine-related continuing education for medical professionals are shown by the low number of reports per physician.     

Medical personnel and death

Increased life expectancy and increases in the number of terminally ill patients, the rapid change in healthcare technology and diagnostic protocols and treatment means that we must re-examine medico-social problems and the attitude of healthcare professionals when confronted by death and terminal illnesses. The aim of this paper is to analyse the attitudes of medical personnel towards death and terminal patients. A total of 375 (168 doctors and 207 nurses) were asked about their attitudes toward death and the terminally ill. The sample comprised 165 males and 210 females aged between 20 and 64 years (mean age 34.96, SD 7.83 years). The results showed that 51.0% of the subjects interviewed were afraid of death. Although 59.4% thought that they were personally prepared to treat and help the terminally ill and 75.3% professionally prepared for such a task 42.7% of those interviewed would prefer not to work with the terminally ill.     

The impact of physician training on child maltreatment reporting: a multi-specialty study

BACKGROUND: Past studies have suggested that physicians underreport suspected child maltreatment (CM) cases, possibly because of a lack of knowledge of the subject. OBJECTIVES: To evaluate the amount, format, and content of CM training received in residency (graduate medical education) and continuing medical education (CME), and to compare its relationship to the likelihood of reporting CM. METHODS: A total of 482 U.S. Air Force emergency physicians, family practice physicians, and pediatricians were surveyed regarding the amount/type of CM training received as well as their CM reporting practices. RESULTS: Pediatricians report receiving more CM training during CME than either emergency physicians or family practice physicians, whereas during residency, both pediatricians and emergency physicians received more training than family practice physicians. Two-thirds of the training related solely to physical and sexual abuse, with little attention paid to other forms of CM. Regression analysis indicated that the only factor associated with the likelihood of reporting maltreatment was the amount of CME received. CONCLUSION: CME seems to positively influence physician reporting practices for CM cases, suggesting a need for universal training protocols.     

Einstellungsmuster japanischer Hausärzte gegenüber suizidgefährdeten Patienten

A questionnaire was sent to medical practitioners from various specialities in Okayama City (Japan) which was designed to investigate physicians’ awareness of the problem of suicide and to survey their methods of intervention. About two-thirds of those surveyed did not question patients about their mental condition. When suicidal thoughts were discussed nearly 90% of physicians never or rarely used direct language like “suicide” or “death” and 68% stated that they saw no therapeutic effect in using such terms. Even when physicians had diagnosed suicidal intentions among their patients, they did not prescribe medication themselves but referred them to a psychiatrist. Less than one-third recommended official help centers for suicide prevention to their patients but two-thirds informed the family. We describe some proposals that are considered to be effective in preventing suicides in Japan.     

Medical error reporting should it be mandatory in Scotland?

Healthcare professionals have an ethical and professional responsibility to report medical errors. Doctors in particular are duty bound to consider the best interests of their patients and 'do no harm'. Medical errors are rarely due to individual human error but are often systems based and in many cases are avoidable. Reporting and learning from medical errors improves the safety of patients. It has been over ten years since the reports To Err Is Human and An Organisation with a Memory highlighted the scale of preventable medical errors. These statistics, stimulated worldwide health organisations to prioritise patient safety. Both reports recommended the implementation of a voluntary near-miss reporting system and mandatory reporting of serious adverse incidents that had caused physical or psychological harm or death. Currently in Scotland reporting of all errors is voluntary and there is no sharing of information between Health Boards. Studies have demonstrated failings of the voluntary system and preventable medical errors are still occurring in Scotland. The UK Government in England as of April 2010 has changed the voluntary system of reporting serious adverse events to a mandatory obligation. Failure to report may result in a fine of ￡4000 to the Trust. Patient groups wish the system in Scotland to become mandatory with public disclosure. This would ensure openness, honesty and autonomy for patients. This article reviews the controversial issue of mandatory reporting and whether or not this would improve the safety of patients. In conclusion, Scotland would benefit from mandatory reporting of serious adverse events and voluntary near-miss reporting.     

The JSLM ‘Guidelines for Notification of Unnatural Death’: Comparison with the systems of reporting death in other countries

‘Guidelines for Notification of Unnatural Death’, published by the Japanese Society of Legal Medicine (JSLM) in 1994, has been sometimes criticised by many doctors and lawyers. In various countries, laws specify the type of deaths that should undergo post-mortem examination. The centralized system of reporting death deals with treatment-related deaths. Although the JSLM Guidelines are based on such international norms, the dispute over reporting unnatural deaths in Japan goes against the dominant global trend. One way of solving these issues is to ensure that the police transform their own death investigation apparatus to delink it from criminal investigations. And we need to press for a system that can give the information obtained in investigations back to society, such as to the medical world or other public organisations.     

Traditional Text-Only Versus Multimedia-Enhanced Radiology Reporting: Referring Physicians’ Perceptions of Value

PurposeThe aim of this study was to evaluate referring physicians’ perceptions of multimedia-enhanced radiology reporting (MERR) as an alternative to traditional text-only radiology reporting. MERR supplements text-only reports by embedding user-friendly interactive hyperlinks to key images and graphically plotting target lesion size longitudinally over time.MethodsOf 402 physicians responding to a web-based survey, 200 (50 each medical oncologists, radiation oncologists, neurosurgeons, and pulmonologists) practicing in the United States fulfilled criteria to complete an online survey with questions focusing on satisfaction with current text-only reports and the perceived value of image- and data-enriched reporting.ResultsThe mean respondent age was 46 years, with a mean of 15 years in posttraining clinical practice (85% men; 47% from academic medical centers). Although 80% were satisfied with the format of their current text-only radiology reports, 80% believed that MERR would represent an improvement. The most commonly reported advantages of MERR were “improved understanding of radiology findings by correlating images to text reports” (86%) and “easier access to images while monitoring progression of a disease/condition” (79%). Of the 28% of physicians with concerns about MERR implementation, the most common were that it was “too time intensive” (53%) and “the clinic workflow does not allow itself to view reports in such a fashion” (42%). Physicians indicated a strong increased likelihood of preferentially referring patients to (80%) and recommending peers to (79%) facilities that offer MERR.ConclusionMost specialist referring physicians believe that interactive image- and data-embedded MERR represents an improvement over current text-only radiology reporting. Compared with current report formatting, most would preferentially refer patients and peers to facilities offering more meaningful image- and graphically enriched reporting platforms.     

Think drink, think drugs, think overdoses

The police are frequently called upon to deal with people whose behaviour is disturbing the peace of other citizens. A large proportion of such people will have consumed alcohol, some will have consumed drugs and others will be suffering from mental illness. The role of the FME is to determine whether medical or psychiatric intervention is necessary for that individual. Because of the difficulty in assessing a person's mental state when they are believed to be under the influence of substances, it is commonplace for the person to be reassessed some hours after the initial assessment to enable the effect of any consumed substances to abate. However, if the toxic effects of consumed medication are not appreciated, such a delay in receiving medical care may have serious consequences. We report this case as a reminder to all forensic physicians of the clinical effects and possible grave complications associated with amitriptyline overdose. Doctors who work in custodial medicine should be alert to the possibility of an overdose of a drug with anti-muscarinic effects when confronted with a detained person who is acutely confused with clinical features suggestive of stimulant use.     

Medical practice-related fatalities in forensic autopsy during the past 6 years in the southern half of Osaka city and surrounding areas

To investigate the features of recent unnatural deaths from mishaps and possible negligence related to medical practice, forensic autopsy cases (n=856) during the past 6 years (1996-2001) at our institute were reviewed. Among them, there were 28 cases of medical practice-related fatalities (male/female, n=16/12; range 32-87 years of age). Half of the cases (n=14) were related to possible negligence in nursing and care. These unnatural deaths were reported to the police by physicians in charge (n=14), second physicians and ambulance attendants (n=6), patients' relatives (n=6) and others (n=2). In most cases, there was an event, which was sudden, unexpected and clearly noticeable not only by the medical personnel but also by bystanders. The cases where the deaths were reported to the police by patients' relatives included unexpected deaths during medical treatments following accidental traumas (n=2) and an anesthetic accident. Clinically unexpected deaths should be more critically assessed by the physicians themselves on the basis of the rights, benefit and welfare of the patients.     

Characteristics of women radiologists in the United States.

OBJECTIVE: Although women radiologists are increasingly prevalent, ways in which they differ from other women physicians are poorly described. We compared women radiologists with women physicians in general to see if and how they differed in personal and professional traits. MATERIALS AND METHODS: We analyzed data from the Women Physicians' Health Study, a nationally representative random sample (n = 4501 respondents) of personal and professional characteristics of women physicians in the United States. RESULTS: Radiologists (n = 163; 3.3% [weighted] of respondents) were more likely than were other women physicians to be conservative but were similar to other physicians in age, ethnicity, marital status, and personal health habits. Women radiologists were more likely to be board-certified and hospital-based, were not avid prevention counselors, and worked more hours than did other women physicians. Women radiologists had far higher incomes than other women physicians, but had less career satisfaction and less work control, and were more likely to feel overworked. Radiologists were also more likely than other physicians to report gender-based harassment while in medical school and postgraduate training, and more likely to report sexual harassment while in practice. CONCLUSION: Women radiologists are similar to other women physicians in some personal and professional characteristics but differ in some important and disturbing ways regarding professional experiences and satisfaction.     

Does imaging technology overcome problems of conventional postmortem examination?

We used a mobile computed tomography (CT) unit for postmortem examinations of deceased subjects to see how many mistakes on cause-of-death diagnoses were made in Japan. In 5 of 20 cases, the cause of death determined by CT was different from the diagnosis made by superficial postmortem examination. In one case, the superficial examination suggested no trauma, whereas a subdural hematoma was found on cranial CT images. We concluded that postmortem examinations in Japan were not effective when screening for crimes or accidents. Using a mobile CT scanner in postmortem examination may be a viable method of screening for causes of deaths, although it cannot be used as a substitute for autopsy.     

Subjects' expectations in neuroimaging research

PURPOSE: To explore subjects' attitudes and expectations concerning the detection and management of incidental findings in neuroimaging research. MATERIALS AND METHODS: Healthy control subjects (N = 105) who previously participated in neuroimaging studies in medical and nonmedical settings were surveyed about their expectations and attitudes toward unexpected clinical findings on their research brain scans. We hypothesized that even though the participants consented to a scanning procedure for research purposes alone, they would still expect pathology, if present, to be detected and reported to them. RESULTS: Fifty-four percent of participants reported that they expected research scans to detect abnormalities if they existed. Nearly all subjects (>90%) reported that they would want findings communicated to them, and many (59%) preferred this to be done by a physician affiliated with the research team. The participants responded in similar ways whether they were scanned in medical or nonmedical settings. CONCLUSION: Clarity about procedures for handling incidental findings when obtaining written and verbal informed consent is essential to ensure that the subjects' expectations are consistent with the purpose and scope of the research.     

The effect of reporting speed on plain film reporting errors

AIM: To determine whether reporting plain films at faster rates lead to a deterioration in accuracy. METHODS: Fourteen consultant radiologists were asked to report a total of 90 radiographs in three sets of 30. They reported the first set at the rate they would report normally and the subsequent two sets in two thirds and one half of the original time. The 90 radiographs were the same for each radiologist, however, the order was randomly generated for each. RESULTS: There was no significant difference in overall accuracy for each of the three film sets (p=0.74). Additionally no significant difference in the total number of false-negatives for each film set was detected (p=0.14). However, there was a significant decrease in the number of false-positive reports when the radiologists were asked to report at higher speeds (p=0.003). CONCLUSIONS: When reporting accident and emergency radiographs increasing reporting speed has no overall effect upon accuracy, however, it does lead to less false-positive reports.     

Hospital bed related fatalities: a review

All medico-legal cases of unexpected death during hospitalisation or accommodation in rest or nursing homes, which were investigated at the Department of Forensic Medicine during a 30-year-period, have been reviewed. In the majority of cases, the fatal outcome was bedrail or restraint related, but falls out of bed or from a patient hoist lift can also trigger a death. As expected, the manner of death was mainly accidental. In about 70% of cases, mechanical asphyxia (such as smothering and thoraco-abdominal compression) was substantiated as the mechanism of death. A substantial number of the patients had important medical antecedents, such as cognitive impairment due to cerebro-vascular accidents. In about half of the cases, human negligence was clearly related to the event whereas in only 15% of cases was there a technical mistake. We believe that some sudden and unexpected fatalities, due to physical restraint or other devices (such as a patient hoist lift), are under-reported because of the medico-legal implications. However, reporting such events could induce better precautions and prevent recurrences. Therefore, this study may be important not only for forensic pathologists, but also for a larger group of social workers.