As a Houston, Texas medical malpractice attorney, one of the quality of care issues that I most frequently encounter is the overreliance of healthcare providers on technology, rather than using their own eyes and ears to perform a clinical evaluation of patients.
In October 2017, the Journal of the American Medical Association (JAMA) published a physician’s opinion piece about the dying art of neurologic examination. Neurological examinations are frequently performed by physicians, with orders for follow-up neuro checks by the nursing staff.
In my experience, physicians are becoming increasingly dependent on radiology and lab studies. Some doctors ignore a patient’s troubling signs and symptoms that are right in front of them, in favor of computer-generated lab or radiology reports.
When it comes to neuro checks, many electronic medical records allow nurses to click a box and automatically copy the findings of a previous neuro check. I cannot count how many times where I reviewed medical records that reflect a patient in a clinical decline, but the neuro check documentation is identical time after time, indicating that there is no problem. I cannot help but wonder if, in the circumstances, the nurses were even doing any neuro checks at all.
Physician neurologic examinations
When a patient has symptoms that suggest a neurological problem, the standard of care requires a neurologic examination to use an organized and thorough assessment to determine whether a neurological dysfunction exists. The physician must also identify what part of the neurological system is affected, including motor, sensory, cranial nerves, or a combination of them. Next, the physician should try to identify the precise location of a problem, such as the part of the brain affected. Finally, based on the findings of this thorough neurologic examination, the standard of care requires the doctor to prepare a differential diagnosis list of the possible causes.
To meet the standard of care, doctor must perform additional detailed assessments and testing to rule out different possibilities on the differential diagnosis list, starting with the condition that would be most dangerous to the patient.
The major areas of the physician neurologic exam include mental status testing; cranial nerve function; muscle strength, tone, and bulk; reflexes; coordination; sensory function; and gait (walking).
Experts have begun to realize that the neurological examination is one of the least popular and perhaps most inadequately-performed parts of the complete physical. While it is easy and quick for doctors to order lab or radiology studies, a proper neurological exam takes more time and effort.
The author of the JAMA opinion piece wrote that, “There is no doubt that the art of the neurologic examination is already being lost, as some of these advances come to supplant rather than complement the clinical examination.” He added, “A competent examination helps to confirm the diagnostic impression obtained from the history, to select any investigations that may be useful, and to avoid unnecessary testing.” In other words, good medical care begins with an eyes-on physician examination, which guides further testing and care.
Even documentation of a normal neurologic examination can be extremely helpful in the continued care of the patient. The standard of care requires spine surgeons, for example, to perform and document a detailed neurological exam before going to surgery. These studies provide an important baseline that can be used to assess patients’ progress or decline following the surgery.
Nursing neuro checks and the role of therapists
For hospitalized patients, registered nurses have a significant role in the ongoing neurologic assessment of patients. Physicians will frequently give orders requiring the nursing staff to perform neuro checks at regular intervals and report any changes or unexpected findings. Even absent such orders, though, the standard of care requires nurses to use and organize process to periodically evaluate and document patients’ neurological status.
Post-surgical patients are also frequently treated by physical and occupational therapists. These therapists are specifically tasked with assessing the physical and neurological abilities of patients, and helping them to improve them. When therapists observe signs of potential neurological problems or deficits, the standard of care requires them to notify the nursing staff, as well as the physician who ordered therapy.
Information gaps in neurological care
From the many medical negligence cases that I have handled, I found that there are three significant areas where a change in a patient’s neurological status may go unnoticed or untreated.
First, some physicians are too rushed to perform an initial neurologic examination or follow-up exams. This is a terrible mistake that deprives all healthcare providers of a baseline, which is essential to determine whether a patient is improving, deteriorating, or staying the same.
Second, registered nurses sometimes do not perform proper neuro checks as often as ordered or required by the standard of care. In addition, even when they are performed, there can be a communication delay, in that nurses sometimes wait hours to inform a physician of a change in status, rather than doing so immediately. All of these nursing errors can lead to a dangerous delay in physician diagnosis, intervention, and treatment.
Third, I have found that physical and occupational therapy notes typically contain a wealth of information about a patient’s neurological status. Unfortunately, there is frequently no evidence that these findings are ever communicated to nurses or physicians.
We are here to help
If you or a loved one has been seriously injured as a result of inadequate neurologic examinations by a physician, nurse, or therapist, or from any type of medical negligence, call the experienced lawyers at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.
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Robert Painter is a medical malpractice and wrongful death attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator and focuses his practice on representing patients and families who have been seriously injured as a result of medical negligence.
