PSOTBLOG

POC Ultrasound And BC FM OB

Hello, Dr. Rodney:

I came across your Pointof Care (POC) Ultrasound blog post and thought I might introduce myself. I amthe Program Manager for Innovation with the American Registry for Diagnostic Medical Sonography (ARDMS). I am helping the volunteer Innovation Task Force with the development of POC assessments and/or programs in partnership with other organizations.

One of my responsibilities is to collect articles, research and journal entries relating to POC US practice. I am also trying to collect any curricula that I can. I don’t know that I can provide feedback on your PowerPoint, as I am not a sonography expert, but I would love to see what you have developed if you would be willing to share it.

Thank you for your consideration.

Regards, Liz

Elizabeth Langston, CAE

As a Senior member of AIUM with over 35 years of experience in patient care, teaching, research , and publication--I am pleased to contribute to this important area. We presented at AIUM 2009 and again this year 2012.

I attach several documents for your review. The first one is a generic "Transfer of Technology" position paper. Ultrasound at the bedside by the physician is one of 5-6 areas we have studied over the years. It is God sent for risk management in the office of all physicians caring for pregnancy. Therefore go to the ultrasound area in that document. It is related to other services in Women's Health Care and trauma.

Hahn RG, Ho S, Roi LO, Bugarin-Viera M, Davies TC, Rodney WM. Cost effectiveness of office obstetrical ultrasound in family medicine: Preliminary considerations. J Am Board Fam Pract, 1988; 1:33-38.

27. Hahn R., Ornstein S, Davies TC, Roi L, Rodney WM, Garr D, et al. Obstetric ultrasound training for
family physicians: Results from a multi-site study. J Fam Pract 1988; 26:553-558.

28. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician: Applications in family-centered obstetrics. Postgrad Med, 1988; 83(2):103-107.

29. Rodney WM, Prislin MD, Orientale E, McConnell M, Hahn RG. Family practice obstetrical ultrasound in an urban community health center: Birth outcomes and examination accuracy of the initial 227 cases. J Fam Pract 1990; 30:163-168.

30. Rodney WM, Deutchman ME, Hartman KJ, Hahn RG. Obstetric ultrasound by family physicians. J Fam Pract 1992; 34(2):186-200.

31. Connor PD, Deutchman ME, Hahn RG. Training in obstetric sonography in family medicine residency programs: results of a nationwide survey and suggestions for a teaching strategy. JABFP 1994; 7(2):124-129.

32. Deutchman EM, Connor P, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetrical ultrasound: results, significance, and technique. J Fam Pract 1994; 39:33-37.

33. Dresang LT. Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004; 36: 98-107.

34. Dresang L, Rodney WM, Koch P, Leeman L, Palencio M. ALSO in Ecuador: Teaching the Teachers.
J Am Board Fam Practice 2004;17(4): 276-282. http://www.jabfp.org/cgi/content/full/17/4/276

35. Dresang L, Rodney WM, Rodney KMMR. Prenatal ultrasound: A tale of two cities. J Nat Med Assoc Feb 2006; 98[2]: 161-171

http://www.nmanet.org/JMNA_Journal_Articles/feb-06-jnma/OC167.pdf

We have hypothesized the need for a new family physician incorporating more obstetrics and ultrasound at the bedside. In 2008, the ABPS launched a board certification process in
"Family Medicine Obstetrics". BC FM OB is under the auspices of the American Board of Physician Specialties. This is not ACGME.

This certification symbolizes training which will improve physician skills globally. There will be
an emphasis on developing countries and communities where resources are scarce. Many of these are in the USA.

The second attachment, Rodney Final, describes outcomes of this one year program at one location in Memphis. Note the section on point of care ultrasound training which was formalized in 1992.This was
upgraded in a bilingual community outreach project Y2k-present. Medicos para la Familia Project. Fam Med 2010 ;42: 712-716.

The Medicos para la Familia functions as a small mission hospital in an urban area with many sub-specialists but almost zero point of service care. The Medicos data is attached, but this one office does over 300 ultrasounds a month while simultaneously seeing a full slate of office patients and delivering babies.

My group is proposing a package of these point of care services within a training program based on
three years of family medicine residency and an additional year's fellowship in Family Medicine Obstetrics. We have proposed that his be bilingual--Obstetricia/Ecografia

We will be presenting and demonstrating iPad app supporting the ultrasound piece at the ABPS meeting in Los Angeles June 27-28, this year. structure. Robin use parts of this for the Venezeula presentation.

Wm MacMillan Rodney MD
Surgical Family Medicine Obstetrics
Private Practice Professor and Chair
Medicos para la Familia

Index--Ultrasound, point of care, fellowship , Obstetricia/Ecografia

Point Of Care Ultrasound

I am looking to see if anyone is interested in providing feedback on a PowerPoint I helped develop to teach point-of-care ultrasound to family medicine docs and medical students.

The PowerPoint is the first in a series; it covers sonography physics and instrumentation. It will be followed by PowerPoints on focused aplications of ultrasound.

This is research that we plan to publish. If you get involved, you'll be included as an author. If you can help, please email me and I'll send you the PowerPoint.

Thanks,

Nicholas Cohen, MD, PGY2, Family Medicine Residency Program

Non-ACGME Fellowships in FM-OB are inevitable

wmrodney@aol.com , MD, Clinical Professor is responding to :

Sebastian T. C. Tong, Laura A. Makaroff, Imam M. Xierali, Parwen Parhat, James C. Puffer, Warren P. Newton, and Andrew W. Bazemore

Proportion of Family Physicians Providing Maternity Care Continues to Decline
J Am Board Fam Med 2012 25:270-271; doi:10.3122/jabfm.2012.03.110256

Last night I replied to Tong et al, May 2012 JABFM, stating that the predictable decline in obstetrics by family medicine was the visible tip of a larger iceberg containing various opportunities lost by family medicine leadership in the universities, ABFM, and the RRC.

In response to the question, "Is it ignorance or apathy?" , the usual refrain is "Who knows and who cares?" The majority has voted. But, the limited generalist has a limited future.

Ultrasound was a part of this study--Rodney WM, Hahn RG.

The impact of the limited generalist (no OB, no procedures, no hospital) model on primary care training and practice.

J Am Board Fam Pract 2002; May-June 15:191-200.

Some of this is linked to the regulatory load imposed by ACGME accredited training. Our fellowship has maintained very high quality patient care even though physicians take night call and work the next day. Medicos does not require that our physicians stay in the hospital all night doing labor checks. This is the real world. Medicos has published some data on sleep deprivation using the Medicos curriculum. Ultrasound frequencies are mentioned in the text of this study.

Rodney WM, Hardison D, McKenzie L, Rodney-Arnold KM.
Impact of Deliveries on Office Hours and Sleep Cycle. J Nat Med Association October 2006; 98: 1685-1690.

In most residencies, there is no pathway for family physicians wishing to acquire obstetrical privileges. ABFM certification no longer assures a family physician of the right to deliver babies or even surgically assist on his or her patients. The justification has been that most don't want to do this anyway. Residency trained physicians will work for a lower amount of money in order to receive this training. Ultrasound makes it even better.

Internationally, board certification in Family Medicine Obstetrics has helped to obtain hospital privileges. As usual, rural and frontier hospitals are frequently governed by big city rules. The one year fellowship is the sine qua non of Cesarean privileges in all urban hospitals I know of. Cesarean privileges are an automatic ticket for a variety of other privileges.

Without ultrasound skill at the bedside as part of your OB risk management, you are, as they say here in Tennessee,"..... a one-legged man in a butt kickin contest". Fellowships and residencies MUST teach ultrasound at the bedside by the physician,

No authorship credit sought. Here is some of the published stuff for your bibliography.

Hope it helps and Best Wishes.

DIAGNOSTIC ULTRASOUND AS A SYMBOL OF TECHNOLOGY TRANSFER

26. Hahn RG, Ho S, Roi LO, Bugarin-Viera M, Davies TC, Rodney WM. Cost effectiveness of office obstetrical ultrasound in family medicine: Preliminary considerations. J Am Board Fam Pract, 1988; 1:33-38.

27. Hahn R., Ornstein S, Davies TC, Roi L, Rodney WM, Garr D, et al. Obstetric ultrasound training for family physicians: Results from a multi-site study. J Fam Pract 1988; 26:553-558.

28. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the primary care physician: Applications in family-centered obstetrics. Postgrad Med, 1988; 83(2):103-107.

29. Rodney WM, Prislin MD, Orientale E, McConnell M, Hahn RG. Family practice obstetrical ultrasound in an urban community health center: Birth outcomes and examination accuracy of the initial 227 cases. J Fam Pract 1990; 30:163-168.

30. Rodney WM, Deutchman ME, Hartman KJ, Hahn RG.Obstetric ultrasound by family physicians. J Fam Pract 1992; 34(2):186-200.

31. Connor PD, Deutchman ME, Hahn RG. Training in obstetric sonography in family medicine residency programs: results of a nationwide survey and suggestions for a teaching strategy. JABFP 1994; 7(2):124-129.

32. Deutchman EM, Connor P, Hahn RG, Rodney WM. Maternal gallbladder assessment during obstetrical ultrasound: results, significance, and technique.J Fam Pract 1994; 39:33-37.

33. Dresang LT. Rodney WM, Dees J. Teaching prenatal ultrasound to family medicine residents. Fam Med 2004; 36: 98-107.

34. Dresang L, Rodney WM, Koch P, Leeman L, Palencio M. ALSO in Ecuador: Teaching the Teachers. J Am Board Fam Practice 2004;17(4): 276-282. http://www.jabfp.org/cgi/content/full/17/4/276

35. Dresang L, Rodney WM, Rodney KMMR. Prenatal ultrasound: A tale of two cities. J Nat Med Assoc Feb 2006; 98[2]: 161-171

http://www.nmanet.org/JMNA_Journal_Articles/feb-06-jnma/OC167.pdf

Index--Ultrasound, Obstetricia/Ecografia

Any Doctors Available?

Question:

I have an attorney friend looking to identify a very good geriatrician in the Memphis area. He has family in need of a PCP manager type; patient has multiple doctors but needs a good quarterback for patient’s numerous conditions. Any recommendations?

Reply:

Give me an overview of the patient and I will try to help. Or have them call me at 901.351.3762.
But, I need more information. Let me say a few words about this as a commonly occurring issue.

Your friend has a deserving cause at an unfortunate point in history. The promise of superb
care by multiple highly trained physicians frequently goes beyond the point of diminishing returns.

American physicians are trained to bring patients to the hospital/office where they perform procedures and/or monitor tests. Talking to the family is not valued. Fragmentation of care is known to diminish quality of care. This is part of the reason that USA spends 8,000+ per person per year
on health care. Sadly there are less than 15% general medical doctors remaining in the American Pool.

Our particular practice of Family Medicine Obstetrics cares for the elderly when they are brought here by their family and we conjointly decide on consultation/hospitalization/advance directives. Otherwise, our physicians are triangulated among multiple hospital based physicians who make recommendations that we do not understand. The other physicians do not send us records, and there are no incentives for them to do so. The ACA 2010 will not make this better.

Medicos continues to study the system via various health services research projects. Promises
are made but rarely kept by the insurers. Yesterday we spent 45 minutes on the phone seeking approval for an asthma medicine, Singulaire, only to be told that we would have to certify failure of another drug before Medicaid would approve Singulaire. No good deed, .........

Medicos has continues its retreat from anything requiring its physicians to serve as the secretarial intermediary for the insurance industry. Just as the bible has disappeared from the courtroom, family physicians are being replaced by nurses="primary care providers". Concierge practices are filling this void for those who can afford them.

Coordinating care in a large multi-specialty group is a logical choice, but I've not seen this work as well as you would think.

Call me and I will try to help.

Reply to Wmrodney@aol.com

 

Index--can you recommend a geriatrician?

Conundrum in Training Physicians for the Future

Dr. Bucek wrote:

I think the American business model in medicine and social expectation of how to react to a crisis makes the FM approach somewhat threatening to the status quo. In America needs are identified so
that a market can be created and product sold. Success in medicine is represented by billable episodes. FM is trying to prevent those procedures surgeries and chemo courses from occurring. Our goal is to run the other docs out of business by addressing behaviors and the system that our patients
struggle with. Bad eating and exercise habits are not just a free will issue they are also part of a new societal norm that is good for business.

Cancer and stents and sleep studies and reactive depressions and developmental disabilities are all to a degree preventable. If we prevent them then no one gets paid in the current system.

The end game for “for profit” medicine may be near. The current medical resource rationing involves some people with full service and some people with no service. Especially in training programs we have patients with no way to buy the best care in the world for years. We know secrets about what is wrong with the system.

We are the rain on the parade of a bunch of people trying to squeeze the last profit margin out of a shrinking pool of resources.

In order for FM to adapt to the current pressure of the market we must become partialists and stop looking at the big picture. Big picture problem solving reveals the incoherence of American health care.

Insurance companies are happy with the way the health care system is. Drug and device manufacturers are happy. Cancer specialists are happy. Until last year procedure specialists were happy. As the march to madness continues we in FM clinical care and education are saying ‘we told you so.’ As patient advocates who try to understand the system we are alarmed and confused for 15 years.

Our trainees are reasonable to look at how to control the intrusion of medicine into their lives. Since the reward of gratitude will not be there and the reward of prestige will not be there and since the average indebtedness is $150,000; rational people should try to contain the impact of work on their life, even if it slows their development.

As I have been saying for the last 5 years the only way real change will be adopted is if it occurs after some form crisis or collapse. The best thing that can happen to FM is if the collapse of the for-profit episodic health care system is quick rather than slow.

John Bucek

As usual I agree with Dr Bucek's(and other) comments. This is a clinical topic. My own response has been to construct a rebranded curriculum in " Surgical Family Medicine Obstetrics", and test this product in a variety of markets with varying degrees of regulation. Global health and the Memphis urban projects seem to be promising evidence for prosperity. So far , so good. ref Fam Med 2010; 42: 712-716

Wm MacMillan Rodney MD

Surgical Family Medicine Obstetrics

Private Practice Professor and Chair

Medicos para la Familia

The opportunity for Medicos to support Christian physicians with a heart for service is appreciated. These physicians are dedicated to a medical specialty which has been specifically designed for mission hospitals in communities where resources are limited.

"Surgical Family Medicine Obstetrics" is the logical solution.The current emphasis on subspecialties is financially unsustainable, and proven to be an inferior model. Medicos' mission is to develop training programs and certification in Surg FM OB as a Faith based and evidence based answer.

 

Hospital Medicine and Procedural Training:...

The STFM Group on Hospitalist Medicine and Procedural Training

I am doing a site visit in Guatemala, but new members Roberto Gonzalez MD and his wife Carrie Sanchez MPA will be attending to represent the educational activities of Medicos para la Familia. Please make them feel welcome.

I revisited my notes from the Nashville meeting February 2012, and suggest the following edits for discussion..

Mission Proposal from Nashville 2012 Rodney

Improve patient care in family medicine by improving the curriculum for diagnostic and surgical skills. Support training and privileges for family physicians who provide a full spectrum of patient care. Maintain a clearinghouse for resources, training, and career counseling for these physicians.

Vision Proposal from Nashville 2012 Rodney

The STFM Group on Hospitalist Medicine and Procedural Training will analyze and support training in diagnostic and surgical skills for family physicians such that these physicians can direct and maintain a patien- centered medical home providing high quality health care unrestricted by age, gender, pregnancy, and location of service.

I have lived to regret the terms "procedures, proceduralist, etc". "Procedures" is medical jargon, and it is poorly understood by the public and government. In Latin America a proceduralist is someone
who helps you bribe the appropriate officials. After talking to Jack Pfenninger, I asked ten people to explain what it meant to be a physician who did procedures. I invite you to do the same.

I hope we can evolve and explicitly state, in English and Spanish, what it is that we do.

Mission Proposal from Nashville 2012 Rodney

To improve patient care in family medicine by improving the curriculum for diagnostic and surgical skills. To support training and privileges for family physicians who provide a full spectrum of patient care. Maintain a clearinghouse for resources, training, and career counseling for these
physicians.

Vision Proposal from Nashville 2012 Rodney

The STFM Group on Hospitalist Medicine and Procedural Training will design and support training in diagnostic and surgical skills for family physicians such that these physicians can direct and maintain a patient centered medical home providing high quality health care unrestricted by age, gender, pregnancy, and location of service.

Your consideration and comments are appreciated.

Wm MacMillan Rodney MD
Private Practice Professor and Chair
Medicos para la Familia

Index--Procedures as a word for something else

Brazil MTG Sao Paolo Aug 23-24

Time for coming down here

Obstetrics in Sao Paolo?

Pablo González Blasco. MD, PhD, FACP
Scientific Director
SOBRAMFA - Brazilian Society of Family Medicine

My Blog - Educar no Humanismo

It is time to start building the Memphis Labor Day CME as a national event dedicated to revival among physicians interested in surgical family medicine obstetrics. Here are some preliminary thought for ads describing. Labor in Memphis 2012

September 1 Saturday: Technology Updates--

iPhone colposcopy for the Mission Hospital

iPad Ulltrasound Studies for Documentation and cineloop transfer

Obstetricia/ Ecografia with Medicos patients scheduled for in vivo testing and demonstrations;

View Cesarean technique video as one station among a rotation of skills modules

Evening optional walking tour of Beale street music with --El Vez de Memphis

September 2 Sunday

AM church

PM Demonstrations and lectures --Office anesthesia, office surgery requirements--Competency based testing, view 3rd/4th degree laceration video, Forceps competency based testing See Ob/Gyn survey paper April 2012


September 3 Labor Day------

Best Day for using all six of the Medicos ultrasound machines including the 3d for IUD problems and other unique skills within the fellowship curriculum. There will be test items to asses competence and attendees will be asked to bring ultrasound/delivery/ cesarean logs with them. There will be destination counseling to avoid privileging problems.

Evening Fellowship and Supper---Southern Italian BBQ and Fish Fry with fireworks and firearms at the Pool. children and Families welcome. 1700--2300

 

September 4 Tuesday Surgery Lab

Maybe we should do this 1000-1300 with early out for travel etc.

I would love to teach alongside the SOBRAMFA warriors in Brazil 2012, but we have mandatory ultrasound training Aug 23-25. I will be in Guatemala during STFM, but Dr Gonzalez and his wife, Carrie, will be in Seattle to further discuss this proposal. Please contact them when you are in Seattle. His cell 305 582 8908

Medicos is Faith based, and it is trying to support the following:

Medicina Familiar Quirurgica = Surgical Family Medicine Obstetrics.

There is no straightforward translation equivalency, and some have criticized this as word salad. But, obstetricia/ecografia is well understood in Latin America.

What have we learned? Delivery of the baby by a family physician is the key that unlocks the door to a wide variety of higher quality services at a lower cost. Access is improved. We are seeking an identity built upon the foundation of family medicine.

Obstetricia/Pediatria con Medicina Familiar Avanzada

Centro Diagnostico con radiografia/ecografia/cirugia

How can we collaborate? Could the Camellia Foundation/Medicos could send one of its ambassadors to speak at the Brazil meeting? (Contingent upon their approval)

Carlos Erazo MD speaks Portuguese

Joe Martin MD speaks Portuguese

Alberto Martinez MD

Lee Berkenstock MD

Luis Garcia Lic. is one of our founders of the Medicos project. Luis, Roberto Gonzalez MD, Carrie Gonzalez Sanchez Lic. will be presenting at the Venezuelan Congress in Maracaibo June 19-23.

Others

What has been achieved by the programs in surgical family medicine obstetrics?

There are over 30 programs in the USA and a Board of Family Medicine Obstetrics founded in 2008. We have published, but are trying to address concerns raised by some medical societies. This email is part of it. The references are proposed for documentation of papers we are writing (and could be presented in Brazil-Venezuela)

There are potential collaborations.

1. Ecuador with the Quito Vozandes rural programs in ShellMera

2. Another planned in Santo Domingo de Colorado[Ec] for 2013.

3. The Pedro Iturbe family medicine centers in Maracaibo have constructed surgical suites for their latest family medicine center. They will have a birthing center in the FPC.

4. There is a supportive hospital in Buenos Aires.

5. Others. There are several mission startups in Guatemala, but we need the cities to achieve training volumes and accreditation.

We are constructing a variety of research and position papers.

Family Medicine Obstetrics as the Logical Solution for an Overly Fragmented and Expensive USA Health Care System.

Family Medicine Obstetrics is a logical solution for providing more services at an affordable cost. Training cartels have led to economic monopolies. With the continuing restrictions of an ACGME regulated curriculum, BC FM OB became a geopolitical necessity. Note this disappointing study describing the lack of even basic skills among USA residents.

Murdoch W, Porcerelli J, Markova T, Saghir H, Bridge P. Incoming resident experience and comfort with procedures designated as "basic". Fam Med 2012; 44: 47-51.

Can we form a BC FM OB coalition to improve our Cesarean training videos, and incorporate these video clips into structured CME? Can we and/or should we use of short course CME as a replacement for unnecessarily lengthy and featherbedded residency training.

Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA 2012; 307: 1143-44.

Family medicine USA continues to focus on the word "procedures", but I believe the contested issues are mainly surgical and the anesthesia necessary to perform them. Interpretation of images is the other, and radiology has acknowledged that technology is going to dramatically diminish their ability to maintain a monopoly on these services in an unregulated market.

Can high quality videos can be performed with the iPad? Can this be linked to the iPad ultrasound project? Should we do something for other office surgeries. See the Mike Tuggy book.

Surgical and office anesthesia videos would be helpful for a mission doctor program in surgical family medicine obstetrics. We will be videotaping this glomus tumor surgery on Sunday. The MRI images are remarkable for instruction and understanding.

I have started a position paper entitled "The Defining Dozen Skills for Family Medicine Obstetrics in the 21st Century" , and another entitled "Benefits of the Fellowship Programs in Family Medicine Obstetrics".

Evidence based references.

Newton WP. Family physician scope of practice: What it is and why it matters. 10.3122/jabfm.2011.06.110262 pp633-634. As predicted in 2002, there are few incentives to retain broad based services in family medicine. Dr Newton gets it, but few are interested enough to actually work on it.

Bazemore AW, Petterson S, Johnson N, et al. What services do family physicians provide in a time of primary care transition.

10.3122/jabfm.2011.06.11071 pp 635-6.

Phillips RL, Green LA. Making choices about the scope of family practice. JABFP 2002; 15: 250-254.

Firnhaber J, Kolasa. A pilot study of training family medicine residents in procedural skills at a community health center. Fam Med. 2012; 44: 202-4. During 11 months there were 17 excisions of cysts, 3 lipomas, 6 toenails, 7 shave biopsies, 5 injections for ganglion-carpal tunnel, and 4 vasectomies. Add 30 Cesareans and you would have an average month at Medicos.

Liu H, Waxman DA, Main R, Mattke S. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA 2012; 307: 1178-1184. Guess what, the costs are tripled with no evidence of benefit.

Wunsch H. Weighing the costs and benefits of a sedative. JAMA 2012; 307; 1195-97.

Danzer E, Dumon K, Kolb G, et al. What is the cost associated with the implementation and maintenance of an ACS/APDS-based surgical skills curriculum?

J Surg Ed 2011; 68; 519-533. U Penn will invest $10 million in grant money to build a stim lab. Medicos does not have any grants.

10.1016/j.surg.2011.06.004

Reply to:

Reply to Wmrodney@aol.com

 

Index--Fellowship Curriculum FM OB, references

Surg Fam Med OB-- ATLS, FX Care

Medicos' fellowship year has always been about more than OB, and the ATLS course symbolizes some of the extra skills recommended enthusiastically for our brand of surgical family medicine obstetrics. See attached "Defining Dozen " activities for old school family medicine.
  
The conferences at Medicos cover a wider breadth of topics than some of the other fellowships. Availability of imaging via ultrasound and xrays are key to improved quality through more rapid and accurate diagnosis. But we need to teach them. Like most mission hospitals there is an abundance of clinical material, but the time available for conference and professional development is always too short.
 
Medicos has scheduled these supplementary conferences. Please plan to attend, and other community physicians are invited as well.
        Thursday April 19 M.Schneider MD
        Maternal Fetal Medicine Consultations with the Memphis FP-OB Coalition.
        5:30 PM Buffet Supper Medicos Conference room
 
        Tuesday May 1 T McCall MD
        Family Medicine as the basis for Building a Mission Hospital in Uganda
        Buckley's Box Lunch conference Room Yates Avenue and Poplar East Memphis
         5:30PM-8PM. Buffet Supper provided
 
        Wednesday May 9 or 16 or 23    Christine Mroz MD; Breast Surgeon
        Breast Abcess Cases from Medicos; use of ultrasound and the role of surgery
        5:30  PM Buffet Supper Medicos conference room
 
        Plans for Medicos Labor Day Conferences start now.
 
I will redouble my efforts to get the Medicos Fellowship conferences started no later than 13:30 by closing UPSTAIRS at 12:00 . Upstairs scribes and Dr Carson should be on site to relieve downstairs no later than 12:00. I am asking Daniela and Maureen to arrive at 11:30 downstairs for March 21 and 28.  Our turnover needs to be more rapid. NO elective surgeries should be started after 12:30 with the usual exceptions for walk in trauma and babies.
 
How can we cover this material more effectively? Please have all fractures called to me or send text message with images in real time.  These should always be seen in follow-up in 1-2 days.
 
Your heel fracture case should be presented again in the Elvis Skype room with better x-rays views. The reproduction of x-rays images in the article was not adequate. Please bring the attached electronic version for projection on the teaching screen at the next conference March 21.
 
I am asking that the other physicians review these fracture curriculum cases carefully since it is not taught in the current family medicine curriculum. Physicians should do about 20 of these exercises to fill this void and address the common fractures which present at least once a week at Medicos and in mission  hospitals everywhere.
 
The fellowship assumes that its physicians are preparing for at least some duty in these hospitals. These exercises are based on the principles of performance-based learning and competency based testing.  Physicians need to analyze the images, make a diagnosis, and formulate a management plan.
 
Physicians will view these radiographs and recite the questions. The best answer will be identified and questions will be encouraged.
 
 
 
Wm. MacMillan Rodney MD
Editor, American Journal Clinical Medicine
Board of Family Medicine Obstetrics

Index--Fellowship Medicos 2012, Rebranding Family Medicine Obstetrics

Why Doctors Die Differently

Best thing, among many good things, I have received 2011-12.
Here is the intro--remainder is below

By KEN MURRAY

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. It was diagnosed as pancreatic cancer by one of the best surgeons in the country, who had developed a procedure that could triple a patient's five-year-survival odds—from 5% to 15%—albeit with a poor quality of life.(continued below)

wmr writes--The propaganda of purchased science for the purpose of creating profit through illness and/or supplier induced demand grows more frightening as I age.

Recently our Memphis Academy president offered the following as testimony in Nashville. This is a one page handout hoping that we can continue to communicate with additional details.

1. In Memphis costs for health care have tripled while access and quality remains poor. For 18 years I have been part of a prototype medical practice providing better service at a lower cost, but no one will listen. Why?

2. The hospital emergency room at a minimum cost of $1000 per visit has become the default primary care system. No one has been able to stop the growth of ER visits. Despite claims to the contrary, people are making profit from ER over use and fragmentation of care.

3. Part of this is due to the loss of alternative sources of care. Independent family medicine offices can do a better job than government clinics. But, regulations, academic opposition, and political resistance have driven most of us out of business. The high touch, lower cost family medicine +OB solution has been lost in a gerrymandered system of generic primary care.

4. Medical schools are DNA factories for doctors. These factories are funded and controlled by special interests who lobby for regulations requiring purchase of their products. Medical schools have repeatedly sidestepped all attempts to change their current production pattern; ie, less than 15% of medical students become general community care physicians--superdocs. Academic factories are not accountable in producing an all purpose physician who can care for children, counsel a single parent, manage a simple fracture, deliver a baby, perform simple office surgery, coordinate care unrestricted by age, gender, pregnancy, and location of service, etc

5. Technology has made many diagnostic, xray, and minor surgery services safe in the community health center. Regulations have restricted independent medical practice while simultaneously creating profits through the formation of economic monopolies and training cartels of the academic hospitals.

6. Under the banner of "quality" medical schools and tertiary care hospitals have partnered to create a monopoly on accreditation.

7. Memphis Family Physicians hope you will take a written copy of these comments and the attached bibliography of published studies. There is an opportunity here. Examples and bibliography available.

By KEN MURRAY

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. It was diagnosed as pancreatic cancer by one of the best surgeons in the country, who had developed a procedure that could triple a patient's five-year-survival odds—from 5% to 15%—albeit with a poor quality of life.

 Arthur Giron

What's unusual about doctors is not how much treatment they get compared with most Americans, but how little. Charlie, 68 years old, was uninterested. He went home the next day, closed his practice and never set foot in a hospital again. He focused on spending time with his family. Several months later, he died at home. He got no chemotherapy, radiation or surgical treatment. Medicare didn't spend much on him.

It's not something that we like to talk about, but doctors die, too. What's unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don't want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don't want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

In a 2003 article, Joseph J. Gallo and others looked at what physicians want when it comes to end-of-life decisions. In a survey of 765 doctors, they found that 64% had created an advanced directive—specifying what steps should and should not be taken to save their lives should they become incapacitated. That compares to only about 20% for the general public. (As one might expect, older doctors are more likely than younger doctors to have made "arrangements," as shown in a study by Paula Lester and others.)

Why such a large gap between the decisions of doctors and patients? The case of CPR is instructive. A study by Susan Diem and others of how CPR is portrayed on TV found that it was successful in 75% of the cases and that 67% of the TV patients went home. In reality, a 2010 study of more than 95,000 cases of CPR found that only 8% of patients survived for more than one month. Of these, only about 3% could lead a mostly normal life.
Unlike previous eras, when doctors simply did what they thought was best, our system is now based on what patients choose. Physicians really try to honor their patients' wishes, but when patients ask "What would you do?," we often avoid answering. We don't want to impose our views on the vulnerable.

The result is that more people receive futile "lifesaving" care, and fewer people die at home than did, say, 60 years ago. Nursing professor Karen Kehl, in an article called "Moving Toward Peace: An Analysis of the Concept of a Good Death," ranked the attributes of a graceful death, among them: being comfortable and in control, having a sense of closure, making the most of relationships and having family involved in care. Hospitals today provide few of these qualities.

Written directives can give patients far more control over how their lives end. But while most of us accept that taxes are inescapable, death is a much harder pill to swallow, which keeps the vast majority of Americans from making proper arrangements.
It doesn't have to be that way. Several years ago, at age 60, my older cousin Torch (born at home by the light of a flashlight, or torch) had a seizure. It turned out to be the result of lung cancer that had gone to his brain. We learned that with aggressive treatment, including three to five hospital visits a week for chemotherapy, he would live perhaps four months.Torch was no doctor, but he knew that he wanted a life of quality, not just quantity. Ultimately, he decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months having fun together like we hadn't had in decades. We went to Disneyland, his first time, and we hung out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He had no serious pain, and he remained high-spirited.
One day, he didn't wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

As for me, my doctor has my choices on record. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like so many of my fellow doctors.

—Dr. Murray is retired clinical assistant professor of family medicine at the University of Southern California. Adapted from an article originally published on Zocalo Public Square.

A version of this article appeared Feb. 25, 2012, on page C2 in some U.S. editions of The Wall Street Journal, with the headline: Why Doctors Die Differently.
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Index--Futile Care, End of Life Care

Generic Meds, Meds4uninsured

My University experience 1970-1989, was a blur. I never had any real authority to challenge these things. But as Chair 1989-2004, my regular review of drug sponsored CME was frightening. Drug reps had established positions of authority alongside the professors. Professors were expected to allow the reps "to teach" in return for the financial support of the lunch, conference , etc.
 
The extent of this misinformation went far beyond "salesmanship". Fundamentally, it recommended blind obedience to authority. It was the Golden rule. "He who has the Gold, makes the rules"
 
These drug sponsored talks at the Tennessee meetings, reminded me of the famous 1961 psych experiments where high IQ Yale students were convinced that the pursuit of science justified doing harm to the test subjects.
 
Even as Chair, it was heresy to violate this rule of the "free lunch". I could see that my academic career was coming to an end when......... I was rebuked by faculty for challenging the misinformation presented by an anesthesiologist lecturing us on the renal dangers of naproxen compared to Vioxx. He went so far as to say that naproxen and other standard NSAID's were CONTRAINDICATED IN ALL PATIENTS WITH HYPERTENSION OF ANY KIND.
 
When challenged on this statement, he emphatically repeated as the current recommendation from the scientific literature. In my opinion, the professor's opinion had been purchased by the makers of Vioxx.
 
From 1994-2004, we started a series of clinical laboratories(in the form of medical offices) providing family medicine care geographically separate from the university hospital. Among seven university owned offices, all but one has been closed. Among six privately owned and physician managed offices all are financially stable today.
 
I have spoken about the surgical family medicine obstetrics curriculum as being the foundation of this success. However, there is much more to it than just obstetrics. Renunciation of drug samples and a continuing emphasis on generic meds has also been part of that success. As the medical director in charge of weekly reviews, all bad outcomes crossed my desk for over ten years. I still have oversight for 40,000 visits a year.
 
Using diabetes, htn, headache, msk pain,depression, insomnia, and the many infections associated with a full spectrum of family medicine obstetrics as my basis, I have failed to document significant numbers of therapeutic failures due to generic meds. Among the elderly, polypharmacy and fragmented care seem to be common.
 
I would be interested in accumulating documented numerator events IF there was systematic attestation as to the denominator and the comorbidities which seem absent from antigeneric literature. Even the NNT stats are very weak on the issue of common comorbidities.
 
From the Academic Witness Protection Program
El Vez de Memphis
 

Fascinating on generics

Also need to keep in mind, many just don't work as well, require increase in OV for monitoring, more side effects, increased doses to achieve same results hence again increasing potential for side effects.
 
Anyone else also note that the cost of generics has risen dramatically and I've even had many cases where the formularies / pharmacies and insurance companies have gone back to the "generic is not covered" write for the brand name such-and-such!
 
Look at link:   http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/31463
 
 
Medical News:Generic Drugs' Effect on Health Costs Unclear, GAO Says - in Public Health & Policy, General Professional Issues from MedPage Today
http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/31463

Sent through Doximity, the private network for physicians.

Hmmmm.....seems like I've had this debate with so many of you over the years and had suggested watch out for the consequences.
 
Sincerely,

Falball

Index--generic meds, meds4uninsured

Help For FMOB Targeted For Reduction In Gyn Privileges

Does anyone out there do any of the following procedures:  Hysteroscopy, Essure tubal sterilization, Global endometrial ablation (eg NovaSure, Thermachoice), D&C, Diagnostic laparoscopy, Laparoscopic tubal ligation (interval tubal ligation), Laprascopic salpingoopherectomy (I do these for routine low risk patients so I can be ready/current for ectopics), and TAH?

I have been asked by three of my Ob-Gyn colleagues to voluntarily withdraw the above privileges.  The case being made against me is one of "inadequate training" and nothing based on currency or competency.  I've had no bad outcomes (eg no near sentinel events etc) except for typical M&M associated with practicing within standard of care.  The argument is simply that since I didn't do a Ob-Gyn residency I shouldn't be allowed to perform any of the above procedures - even though I've been privileged and doing them for the last 6 years.

In my opinion, FPs need to be doing office based procedures.  Isn't that what we are - the master of the clinic?!  I can tell you from experience that hysteroscopy is much easier than colonoscopy.  With over 100K hysterectomies being done every year, shouldn't FPs be offering safe, office-based solutions to menorrhagia?  Why shouldn't we be able to handle a missed SAB with an MVA or (only when necessary) a D&C?  They want me to stop doing LEEPs too but I realize that's ridiculous.

As far as the other gyn procedures, please let me know if I'm off my rocker.  I'm willing to take feedback.  The Ob-Gyns I work with say I'm the only FP in America doing TAH.  If that's the case, maybe I should stop?  Do any of you do advanced surgery like appys, choles, hysterectomy, etc.?

I've spoken to my chief of medical staff and he says they do not have a case against me and he supports my credentials and privilege list.  But I'm worried that the pressure against me will progress if I don't do what they want me to do.

I'm so thankful I trained the way I did.  I love practicing with a FP foundation.  I actually think it's superior training because I think patient's benefit from our model - and I really enjoy the biopsychosocialspiritual model.  I'm trying to sort this out because I know some of it is prejudice but what part of their concern ("lack of [what they view as adequate] training") has truth that I should heed?

By the way, the skills have come in very useful in a rural deployed environment.  When the general surgeons in Iraq called me to help with a hysterectomy (after a pregnant women was shot through the fundus), I was able to save her uterus.  And when a different surgeon called me in to assist after he decided to do an oopherectomy for a tubal ectopic, I was able to save the ovary.  (I did have to do one TAH for trauma and a c-section because I didn't feel safe not monitoring a VBAC).

Thanks for you time! 

-michael

Jerry Michael Cline, MD, MPH
LtCol, USAF, MC, FS
Asst Flight CC, Family Medicine Clinic
Director of Women's Health, Family Medicine Residency