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FP/OB Employment Opportunity

Dear Fellowship Director:

I am writing to you regarding a possible opportunity for the fellows who are completing the FP/OB fellowship at your institution.

Our practice, Elgin Family Physicians, is located 45 minutes drive northwest of downtown Chicago in Elgin, Illinois.

We currently have 5 physicians and 2 nurse practitioners, with 2 office locations.  We admit to two hospitals, Sherman Hospital and St Joseph Hospital both located in Elgin.  We round on our own patients and do not use hospitalists.  We also go to several area nursing homes and on occasion make house-calls on selective patients, particularly those on home hospice.

We are a full spectrum practice and 3 of our 5 physician have C-sections privileges.  We have several very supportive OB colleagues for backup and an excellent MFM for consultation and collaboration.  Our primary hospital, Sherman Hospital, has 24/7 in house pediatricians for consultation as well as a full complement of medicine sub-specialists.

Our population is very diverse as is the population of Elgin, both in terms of ethnicity and financial resources.  Sherman Hospital has a very active and strong Family Practice Department and we enjoy the support and respect of the administration. While I recognize it is late in the year, I am writing to you because we would very much like to have another C-section qualified family physician join us.

Please pass along this information to your fellows along with my email.  Thank you for your assistance in this matter.

Sincerely,

Dorothea Poulos, MD

You are well known to Memphis through your long standing commitment and
our previous grad Vanita Gupta MD. You and your colleagues win recognition as
pioneers.

I am copying this to Sara Beth Bush MD who is probably closest to finishing. I am endorsing you as an opportunity where there is no bait and switch so commonly found among recruiters.

Geopolitical challenges ahead include the lack of trainers and sites in which to train. I am suggesting that you give this some thought. You should consider support of the
board certification process in Family medicine Obstetrics with the ABPS.

Through faculty affiliation and planning you probably should have your own fellowship as a pathway to building your operation. You might collaborate with Drs Loafman and Scholcoff at Northwestern.

My caveat on your practice is the lack of point of care ultrasound(NEJM 2011) which has emerged as the quality standard of care for women's healthcare. Sending the women to MFM or the ER will not meet this standard.

wmr

 

ALSO-NRP Required for BC FM OB

At STFM 2013, I presented my historical perspective having been there at the birth of ALSO within AAFP. I also served on the RRC-FM 1994-2000.

In 1989-92, family medicine AAFP formed an Obstetric task force because residencies were not uniformly training to achieve skills in OB. One solution was the standardized course that we now know as ALSO. As with ACLS, these needs were recognized and addressed by practicing physicians because academic institutions could not or would not act. Some of us assumed that residency directors would now have an easy way of inserting these basic OB issues into their curriculum.  

By 2002, a substantial number of residencies remained in silent rebellion against the RRC accreditation standards for obstetrical training. ALSO was not included in the curriculum of many programs, and the RRC never adopted it as a requirement.

One residency director would not sign off on his residency graduate's OB training because he (the residency director) had never had these skills. Subsequently, this residency trained family physician was refused these privileges by the hospital credentials committee. I have other examples. 

Some residency directors who demanded obstetrical training for their residents were fired or resigned. Programs with idealism and resources developed 3+1 programs (One year fellowship following residency). The P4 programs emerged as another solution (tip of the hat to JPS, Oregon, and others). Some 3 year programs with obstetrical training remain true to the founding principles. They are few.

Unfortunately with the demise of adequate OB training in ABMS residencies, hospitals were left with no measure of OB competence for family physicians. The ABFM certificate does not reliably reflect the candidate's ability to deliver a baby.
On the other hand, accountability for this standard remains an open question. Who
owns the right and who has the responsibility to certify?  

As with any monopoly, ABMS attempted to block an emerging competitor. They disparagingly used the term " that renegade board", implying that the ABPS certificate was not valid. But CMS recognition November 2012 has provided evidence to the contrary. Now family physicians have the opportunity to present credentials increasing the probability of serving this important need. 

The PCMH principles do include continuity, access, affordability, accountability...... Are these principles equally important for pregnant women?

Index--Certification Family Medicine Obstetrics, ALSO

STFM 2013 AND 2014

Dear STFM P&H members:

OK.  I actually made it to the STFM Spring meeting in Baltimore with tight connections from Nome through Anch, MSP, & KC (I figured since I wasin the "neighborhood", I should make a showing in Baltimore.)

We had a pretty dismal showing at the luncheon meeting yesterday, but 3 of us had a great time "talking shop", arguing over the variable benefits & curses of the EMR and the PCMH paradigm of "primary care" breathing down all of our necks and
practices, and what this means for traditional "broad-spectrum procedurally-enhanced (Bill R. - that's "surgically-endowed" to you) "cradle-to-grave", "womb-to-tomb", "eye twinkle-to-ice crypt" (for me, that is) Family Medicine. 

There is no STFM Open Group Meeting for Hospital Medicine & Procedural Training at 12:30pm today (not sure why; we have had these at past Spring conferences).

Let me encourage as many of you who are here in Baltimore to come to Family-Centered Maternity Care in Dover C in 15-20 minutes (maybe of us can crash the "Global Health" meeting as well in Kent A/B.

I am just thinking on paper here, but I have a feeling that it is about time for another Phoenix Summit come Superbowl weekend, 2014 ...... interest? ideas? topics of focus for discussion and our next round of publications?

Cheers. pwd

Paul's presence represented us well at STFM 2013. Can we focus on NCFPR 2013 and STFM in San Antonio in 2014?

Now is the time to think about presentations at future meetings. I hope John Gibson and I will reprise our non-OB ultrasound workshop. Regarding the RRC and our three sentinel publications on required curriculum for residencies, the page has turned. RRC FM meets May 23.

Consider the following for 2014. We have always had allies within the STFM Maternity care interest group whose fortunes rise and fall on the existence of hospital privileges for FM and FM OB. The 800 lb gorilla sitting in the corner of this meeting was "point of care ultrasound". These two issues have political traction.

Can we promote an alliance between the 3+1 fellowship programs, the P4 programs, and the rare 3 year only [Dr Coonrod] programs?  Jeremy Fish alluded to this in an earlier post. Can we arrange a reception at the NCFPR AAFP meeting in Kansas City August 1-3?

Less prominent was the federal recognition of ABPS as an equivalent  board
certification.. As you sign your federal and state attestations for retroactive
increases in your primary care reimbursements 2013, there you will find ABPS
alongside ABMS. This is a PCMH issue that is lurking in our common future.

Federal recognition has created new value for Board Certified in Family Medicine Obstetrics by ABPS. We are using this to seek listing in medicaid directories under the "Obstetrics" section. This will promote our visibility among women who depend on Medicaid services. This is a visit-your-legislator issue.

Most Medicaid intermediaries will not recognize family medicine as a provider of delivery services, and most family physicians are restricting their services in this area. Service directories are essential yet very difficult to use for the women who depend on them the most. Our recognition is buried in a directory of numerous primary care providers. Most of these primary care providers will not provide much in the way of women's health care services. Some do not offer Paps smears.

Will non-OB family physicians refer pregnant patients to OB FM instead of referring all pregnancies to OB?

Index--2014 plans for STFM SIG procedures/hospital-- ultrasound, FPOB, PCMH

Procedure Fees

Bill Rodney references “average charges” for procedures (in email below) and lists what appear to be charges at his office.  He is correct,  I did not include  dollar fees 
in our book (Pfenninger and Fowler’s Procedures for Primary Care, 3rd ed) because they are at least a year out of date by the time the book is published.  However, we did include comprehensive procedure codes (CPT’s)  for everything discussed in the text. What I did offer from 1994 through 2011 was The NPI Reimbursement Manual.  This was updated annually and available through NPI and included nearly every code that we would probably use.  It eliminated the obvious (splenectomy, craniotomy, etc…probably should have kept them in for Bill and his group) but had everything Bill listed below and tons more. Skin codes are especially detailed (benign or malignant, size, location, excision vs destruction, biopsy, etc).  CPT codes are fairly consistent over the years. The reimbursement fees are what change regularly.

Anyway, the Manual is about 60 pages and organized by systems (Skin, ENT, GI, etc.).  It includes RVU’s, BCBS, Medicare, and Medicaid payment schedules for both
facility and office locations (they differ significantly) for each CPT code.  The final column I think is most helpful:  average fee charged in the country.  To get this I took three books that purportedly survey the country for fees charged.  (They cost about $250 each.)  The books provide the 20th-90th percentile rates.  I took the 50th percentile fee of each procedural CPT in each book and averaged them to get my 50th percentile charge for the NPI manual.  Common ICD diagnostic codes were included too for each section/page.

The 2011 version has not been updated since there’s been so much turmoil with SGR, sequester cuts, etc. It’s just plain too difficult to know what the fees are/will be for the year!!!  2011 data is still very current and much closer to  appropriate fees than any text published in 2008 or 09.  The Manual  is still available through NPI (www.npinstitute.com).  I still use it in my office several times a week to check the proper code/fee.  But, you all have your EMR’s which probably do everything automatically.  (Someone want to work on an app with me?) 

Of course, with most being employed now, does anyone really care what is being charged?  Hospital clinics charge more and are paid more….compared to the doc in private practice. Go figure.  The cost of running a private practice has gone up 69.7% from 2001 to 2011. Medicare reimbursements have increased only 2% in those 10 years (and most insurance companies followed ‘care rates)!  But, we physicians were supposed to be happy because we didn’t get cut per SGR mandates.  This year we were cut 2% with the sequester so essentially Medicare is paying us the same as 10 years ago.  In Michigan, we’ve had one…yes ONE…increase in Medicaid payments since 1990 with a 10% cut a few years ago.  But, I digress.  I fear Rodney has rubbed off on me.  Yes, the medical world has changed.   

Anyway, if anyone is still interested in what they charge and what the going rates are, The NPI Reimbursement Manual 2011 is excellent, in my humble opinion, and based on the feedback of thousands who took our courses when I was running the show. Since there have been so few reimbursement increases, it is still very close to what current national average charges are.  As things settle down, and if I can figure
out what the government is going to do, we’ll probably update the Manual for 2014.
I’ll need to update it for my own private practice so will make it available to others too. Those who buy 2011 get all the future updates for I think half price. Check with NPI.   And no, it’s not a big money maker for me. What I receive basically covers the clerical fees to put all of the information together…a nightmare. 

Take care, everyone. Hope this helps. Every time I update the information, I am amazed at what I find.

Jack Pfenninger

 

Dear STFM P&H members:

OK.  I actually made it to the STFM Spring meeting in Baltimore with tight connections from Nome through Anch, MSP, & KC (I figured since I was in the "neighborhood", I should make a showing in Baltimore.)  

We had a pretty dismal showing at the luncheon meeting yesterday, but 3 of us had a great time "talking shop", arguing over the variable benefits & curses of the EMR and the PCMH paradigm of "primary care" breathing down all of our necks and practices, and what this means for traditional "broad-spectrum procedurally-enhanced (Bill R. - that's "surgically-endowed" to you) "cradle-to-grave", "womb-to-tomb", "eye twinkle-to-ice crypt" (for me, that is) Family Medicine. 

There is no STFM Open Group Meeting for Hospital Medicine & Procedural Training at 12:30pm today (not sure why; we have had these at past Spring conferences).

Let me encourage as many of you who are here in Baltimore to come to Family-Centered Maternity Care in Dover C in 15-20 minutes (maybe of us can crash the "Global Health" meeting as well in Kent A/B.

I am just thinking on paper here, but I have a feeling that it is about time for another Phoenix Summit come Superbowl weekend, 2014 ......interest? ideas? topics of focus for discussion and our next round of publications?

Cheers.  

pwd

TNE and Office Surgeries

Question: 

Do your perform TNE?

Reply (WMR):

TNE is inherently more uncomfortable than the oral approach. This was another fashionable idea with little evidence to support the claimed benefits. After years of ENT endoscopy experience, physicians did comparisons on convenience samples and realized that TNE could not offer much in the way or replacing a physician who had some training in office sedation/analgesia. This included vocal and topical anesthesia in combination with other agents as needed.

This is why we required sedation/analgesia training as a part of the AAFP courses 1984-2004. Since then we have gone much further up the road and all kinds of options are available to make these procedures very easy on patients without sacrificing safety. 

The experience we gained with sedation/analgesia for GI endoscopy, allowed Medicos to develop a better curriculum on  what is now called levels 1-3 anesthesia.  From there we went on to develop protocols and monitoring equipment for our free range specialty which is now called Surgical Family Medicine Obstetrics. Moderate sedation is actually level 2 . This training is the logical solution for providing twice the service at half the cost(or less).

 

 

Index--GI endosocpy, do your perform TNE?

 

Medicos Para Students

Good Afternoon Dr. Rodney: 

I'm an M1 at UTHSC. A little while back, I attended your presentation "A Training Model for Mission Medicine", and as a Memphian, I can definitely see the importance of medical spanish. Since then, I have been involved with the medical Spanish committee working to get an online curriculum approved. 

Anyways, I recently spoke with a fellow M1 about Medicos, and he mentioned the awesome experience that he has had. All in all, I was hoping to get involved myself!  Please let me know at your earliest convenience if there are any open spots.

Thanks for your time! 

We provide work study programs at 12-15 dollars per hour. Send CV if you are interested, and then we will arrange an interview.

Good afternoon Dr. Rodney:

I am a first year PA student at CBU and was able to hear your presentation to the class last week, thank you.  Your presentation was of particular interest to me as you spoke about providing medical missions abroad and I am very interested in making significant contributions to healthcare in Jamaica (my home country).  I would also like to do a rotation with your practice during my clinical year. 

I was reading about your practice online and the Camellia Foundation and noticed that the website mentioned education support for students. I am writing to ask about the eligibility requirements for this type of support.  As an international student at CBU, I do not qualify for any type of financial assistance or scholarships.  I have also been unable to get any further student loans to pay for my tuition.

Any information that you are able to provide me about any scholarships available through the Foundation will be greatly appreciated. 

Thank you.

Thank you for your interest in a clinical experience at Medicos. Medicos 1999-2013 has been repeatedly rated as an outstanding clinical experience by medical students, residents, and others who work there. Medicos does not accept volunteers. Students apply for the work-study program. When accepted they are paid an hourly rate and the schedules are flexible.

As an application and interview, applicants immerse themselves in the experience for at least 4 hours by arrangement. This is a chance for them to see if the chemistry feels right for their educational goals.  Please submit a CV and your educational goals in the context of your 10 year professional vision.

Medicos is unique in that it does not receive any government or charity support,  Medicos pays taxes and teaches others as a mission. Medicos is more than generic primary care and students must have some predisposition to a future which includes night call and deliveries. Medicos will not accept work-study students unless they agree to work weekends and nights like we do.

Although based in Family Medicine, Medicos represents  a separate specialty--

Surgical Family Medicine Obstetrics with Urgent Care. This is the only logical solution to health care needs in underserved communities and developing countries. American medical schools have become disconnected from the realities of community medicine and mission medicine. The medical schools are part of a hospital industry who profit from fragmented care by subspecialty medicine.

Although family medicine-based systems, such as Contra Costa and Medicos, can provide over twice the service at less than half the cost, it is a challenge to find those training programs. Medicos is a partial antidote to taught helplessness.

Medicos is critical of how students spend more and more time in pursuit of sub-specialization. Residencies and fellowship tracks may last up to ten years without increasing a physician's value to the patients who really need care. Students study more and more to learn about less and less. A commitment to speaking Spanish suggests that the candidate has gone beyond the rhetoric, and is committed to  "walking the walk".

Students with a commitment to "..the road less traveled" are welcome. Due to demand, we have to steward these resources carefully. Your comments and interest are appreciated. 

wmr

 

Index--Orientation info, student application advice, update 13-4-22

 

Nearly 30% of Americans Have High Blood Pressure

http://www.webmd.com/hypertension-high-blood-pressure/news/20130404/nearly-30-percent-of-americans-have-high-blood-pressure-cdc

3 Reasons:

1) Increased use of Generic Medications, significantly less effective than Brand Name (now being proven just by evidence of this article).

2) Insurance Formularies - Insurance companies dictating which meds to use in which patients and not the physicians to determine the best meds.

3)Patients not being to afford the medications whether generic or brand name, ie: no jobs, no insurance.

Falball

Below there is a CDC survey describing perceived HTN prevalence, and 3 possible reasons for it.

As Disraeli  said, "There's lies, damned lies, and then, there's statistics. From MemphisMedicos it looks like this:  

1. Even with Medicaid coverage for the drugs, 25% of our patients do not take their prescription to the drugstore. Barriers of transportation, marital strife, and various degrees of mental disability are profound and prevalent. 

2. An additional 25% of our patients have received fragmented care with inappropriate poly-pharmacy leading to impaired compliance.

3. Our problems have not been solved by prescribing brand names in place of generics.  

4. Apparently Walgreen's will solve this by opening clinics in all of their drugstores. Fragmented care still makes money. 

5. This type of reporting is similar to a speculation built upon a rumor. Is this really a scientific study measuring outcomes? 

6. These surveys are designed to publicize a preconceived notion that the American public needs more health care at any cost. 

7. Eventually the government will run out of other people's money. Health care spending is now at 18% of GDP and climbing.  

8. The good news is that the rate of increase has diminished. I, for one, certainly feel relieved.

 

Index--USA  system, fragmented care, HTN epidemic

Seeking a Place to Join or Start Surg FM OB

Hello Sir,

Sir, I believe the time is now for us to act. You are around and healthy, you are the invaluable resource that Family Physicians & Obstetricians have and cannot afford to be left untapped. Outside Memphis and may be few other cities in the USA,
Family Physicians Obstetricians are having very rough time. With you and with
the existing network of similar minds, especially the physicians in programs
that train fellows in Surgical Obstetrics and the graduates of such program, we
have enough strength to build the necessary political pressure group before it
is too late.

Whenever there is injustice, the best answer is not to run away from it. I my opinion, the best answer is to find diplomatic way of defeating the injustice. It is true that there may be casualties at the end of the day. One of the slogans of the USA is "Freedom is NOT free". ......

I see a big challenge facing Family Physicians across the globe. It is not only in Canada or the USA. I remember vividly that when I spoke with few physicians in Nigeria they were of opinion that FPs had little or nothing to offer in settings where
other subspecialties were available - especially the OB & Gyn. 

I agree with all that you said about finding an opportunityw here residency trained FP's can deliver babies up to and including Cesarean section. Thank you for your previous and continuing support of this important idea.

A group of us have started to implement many of your suggestions. We recommend using the Family Medicine Obstetrics board as our current identity. We are trying to decide where to locate the next project.

We have meetings and presentations planned:

April 6-10 NYC AIUM

May 1-4 STFM Baltimore. ultrasound , reception

June 24-28 ABPS FM OB Puerto Rico. OB trauma, ultrasound, and mission
anesthesia skills.

July 24-26 ALSO with FM OB programs in Chicago

July 30-31 UT OB conference for all 6 current fellows. Great overview with simulation labs planned.

Faculty with similar interests are invited. Sandestin, Fl.

August 1-3 AAFP National Resident meeting Kansas City OB/ER skills for Global Health

August 24-31 mission hospital and proposal for residency training in Cubulco Guatemala

September TBA Memphis Surgery Lab and Ultrasound testing

September 24-28 AAFP annual meeting San Diego

November 8-9 GI endoscopy-AAPCE (Surgical Family Medicine special interest group) Chicago.

TBA Maracaibo Venezuela clinical construction underway for collaboration with University  Medical School and their proposal for residency training in family medicine obstetrics.

TBA Ecuador hospitals in ShellMera, Quito, and Santo Domingo de los Colorados.

Capacity building is the next step. Clinical floor plan design is dependent on the opportunity available. Opportunities vary from community to community. The best opportunities are the ones that are financially sustainable and most likely to be visible for physicians who seek to train for the mission of family medicine obstetrics. In the USA, we are considering Chattanooga, Nashville, North Georgia, Memphis, Texas A&M. We would welcome other suggestions.

We suggest proximity to a residency if possible. The service plan requires call staffing 24/7 365 for OB, hospital privileges for Cesarean etc, and open access Sat/Sun. This means the plan must include funding for more than one physician or an alliance with another group of like minded colleagues. Do you have this in Canada?

Therefore site selection is key. Is Canada the best location? Is there adequate clinical volume?. What is the projected # of deliveries? Are there other options where you could step in immediately doing 10-20 deliveries a month? Currently you have medical licenses in Ga and Tn and Canada. Is this correct?

EMR 2013

A member of the AAFP public relations staff is working with a national news reporter on a story about EHRs. The reporter is working on a tight deadline and needs to speak to a rural physician who has chosen not to implement an EHR at this time because of cost.

The reporter needs to do interviews today, over the weekend, or on Monday (April 1st).  

If you fit this criteria and if you're willing to do an interview that may air on the radio, please contact:  

Amanda Holt |Public Relations Strategist|American Academy of
Family Physicians |Communications Division

Office: (800) 274-2237 |ext. 5223|Cell: (816) 806-3874 |
@AHoltAAFPpr

 Melody Goller

Greetings from Raeford, NC: 

This request is quite timely.  Yesterday I reviewed the final response to expand our Electronic Health Record proposal allowing our team to proceed with Stage III Meaningful Use requirements.  We are currently paying fees based on the total practice revenue collections.  The percentage for the year we pay is 2x greater than the salary for our Practice Administrator and just shy of my Physician salary in a rural based solo North Carolina practice.

We were negotiating a Patient engagement solution which is a major component of the HITECH Act allowing the patient/caregiver to have portal or other direct access to the clinical records as part of a Personal Health Record.  Clearly the concept allows for not only patient empowerment but also accountability which is a important for alternative payment methods in a ACO model. 

Yesterday I received the response from my vendor that they could not provide affordable pricing which would allow us to add this greatly needed component to the current package. The additional rate would exceed our budget in anticipation of the 2% Medicare payment rate.  Our practice is greater than 30% Medicare/Medicaid/Tricare with a 15% Self-pay (typically no pay) population.  I was actually quite floored with disappointment since I really felt like this plan would help our rural impoverished patients finally become more involved in their care.

The practice most recently succeeded in obtaining an special loan allowing our doors to remain open. As stated we need the EHR vendor but I fear we are being priced out of business and may not be able to meet government requirements for all Stages of Meaningful Use especially with the new modifications. 

I would be more than happy to share our experience as this information should be shared to assist others with the challenges of rural practice.  I am available all weekend and can be reached at 910-527-6251 or 843-497-5671.

Thanks,

Karen Smith,  MD,
FAAFP

WMR responds about rural practices failing to afford an EMR:

In an amazing blend of ignorance and apathy, AAFP gave one
of its model practice awards to a physician who could never earn overhead
expenses. She had pilates classes and a yogurt bar on site, but it was all
subsidized. After three years of politically correct promises, she had to sell
the practice to the university where they are accustomed earning no more than 30%
of their expenses.

Medicos been EMR users since 1999, and we receive no external funding. We have been able to survive various broken promises due to the strength of our full scope FP OB model.  

Practice Partner was a good system until they were sold to McKesson who stopped supporting our billing interface software. In 2012, Medicos switched to eMD. We have bitten into the MU apple for level one which required $20k in consultant fees, but relatively painless. Over all it paid for our new EMR. As a solo practice we could not have done it. Level two reporting is more painful and less lucrative.  

Time flow studies document 10 minutes of key-stroking for every note. Let me say that a different way. See 12 patients, spend two hours at the computer.

e-prescribing among poorly compliant patients in an urban area with multiple chain drugstores is not working well. Without a paper Rx backup fewer than 40% of our patients get their meds. Don't forget to print off that visit summary and patient education handout with every visit.

Knowing what I know now, get the bare bones. You need the billing interface or outsource billing. You still need electronic registration. Or only accept Canadian money.

 

Index--EMR issues and boondoggles

Procalcitonin

I commented on the utility of procalcitonin labs ordered in the ER, Marginalizaiton of private family medicine will continue as long as wasteful fragmentation of health care continues to generate profit for hospital ER's and Big Pharma. The whippings will continue until morale improves.

Dr Kumar sent a link describing the continued pressure to have primary care given largely by nurses who will be employees governed by corporate policies.

Recommend you read the following link and prepare:

http://links.mkt2511.com/servlet/MailView?ms=NTI2OTQ0NAS2&r=Mjk5Njk5NDMxMQS2&j=MzE0MDYwNTY5S0&mt=1&rt=0%25%25FORWARD_INFO%25%25

Sincerely,

Ajoy Kumar, MD, FAAFP