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Estimated Fetal Weight

 

Question:

Should we do "serial" EFW's and act if we are concerned about LGA >4,000?

I ask because we have always been told, and I have also projected the idea, that ultrasound EFWs near term are inaccurate to the tune of up to 30%

I have usually obtained one EFW at 36 weeks in my GDM patients and then used physical exam to decide when things are getting large.  I should also mention that I’ve caught serious flak (or at least some unkind comments) about my habit of inducing GDM moms at 38-39 weeks if I think the baby is at risk for dystocia.  For a while it was popular to do a FLM and L/S ratio (because our perinatologists didn’t trust FLM testing in GDMs), but I think this has been abandoned after 38 weeks.

As far as using oral meds for our GDM Moms, I do think that the final "standard" in each community is (like it or not), going to be, "whatever the OBs are doing".

Maury

Maury J Greenberg, MD

Clin Associate Professor

Dept of Family Medicine

Stony Brook University

Answer:

Doing serial EFW's may mean doing just one. I do not know what the best frequency is, but I hope that this is a study we can do. As you get to 4000 Grams, there is little reason to wait past 40 weeks. Even with the poor reproduciabily and poor precision of ultrasound, it is currently the best and most reliable tool we have. It is the rare physician who vaguely remembers Leopold's maneuvers. Determinations of fetal weight by using your hands borders on calling Dionne Warwick's psychic hotline.

As a defense witness, I lost a case regarding a noncompliant 300 pound multipara who came to the hospital at 9 cm and, within 30 minutes, delivered a 12 lb baby with shoulder dystocia and subsequent Erb's. Plaintiff successfully convinced the jury, that the physician was negligent for failing detect the EFW with ultrasound prior to delivery. I still show the slide about, "Who wants to deliver this 12 lb baby vaginally?"

At 4000 G, I still have no problem delivering a GDM mother vaginally. I am aware that over 50% of shoulder dystocias occur in normal weight, non-GDM mothers. Risk is part of the territory if one chooses to accept deliveries as part of your practice. But, there is a limit.  At 5000 Grams I have a problem accepting the risk for vaginal delivery, unless tort reform comes soon. Not likely. In between 4000-9,000 G each case is individualized. All women have a right to a second opinion. Over 9000 Grams we consider alien abduction and call the government. HIPPA be damned!

Wm. MacMillan Rodney, MD

Meharry/Vanderbilt Adjunct Professor

Department of Family Medicine

Medicos para la Familia

Memphis and Nashville

Second Degree Burn

 

Arm burn 3.5 weeks after severe circumferential second degree burn involving all of L arm distal to mid humerus. Conservative therapy with Td vaccine, no antibiotics, no silvadene, simple Vaseline gauze on worst part near elbow crease for first 5 days. Rest of wound left open to air. Patient likely to have no scar. There has been gradual ranging of the extremity by the patient without involvement of physical therapy. There will be no loss of function, range, or strength. Appears as though there will be no scar as normal pigment gradually rebuilds over coming months.

Debridement day 4 attached for comparison.

Estimated savings to patient and health care system over $5,000.

Family Medicine-OB or OB/Gyn Experience?

Great to hear of someone on the road less traveled, and seeking a clinical experience where family physicians do deliveries including Cesareans. I am including our most recent one page Medicos overview below. It is possible that Medicos could accept a fellow for a rotation with us. Certainly we have students, residents, and our own fellows, but their experience is 85% office and 4-8 deliveries per week......

INQUIRY:

Hello:

I have recently completed a family medicine residency and am doing an obstetrical surgical fellowship at University Hospitals of Cleveland. I have elective time in January and February and am looking for a place to go where I can increase my obstetrical experience and exposure to family medicine physicians practicing obstetrics and doing c-sections, if possible.

REPLY:

The main issue is the "lead time". For lack of additional long term faculty, Medicos is currently turning away deliveries. We are capping the practice at 30 deliveries a month in Memphis and 12 per month in Nashville. There are no additional openings until March. Medicos has reached the warning track where adding more deliveries cannot be accomplished unless there are longer term commitments from larger numbers of delivery committed physicians. As Medicos adds these physicians, Medicos will expand, and the training opportunities will grow. Remember, Medicos functions without external support from taxes and grants. Medicos is a "private practice" with a training mission (i.e., a rural simulation).

For planning away rotations, residents need to achieve those things most likely to optimize their clinical experience. The lead time ideal is 12 months in real time. But for those building and managing a clinical enterprise, 24 months is better. You must have the horses to pull the high volume OB night call schedule. Then family medicine can start to build.

Only a minority of family medicine groups have achieved this. Even fewer academic family medicine groups have achieved this critical mass. In the academic time mode faculty can withdraw from clinical commitments on 1-6 months notice regardless of what their contract says. Also urban programs are frequently at the mercy of administrative treachery within the large hospital. Rural programs have the strength of being able to allow "old school" professional courtesy (y’all come), but they lack the volume. Catch-22.

This typifies the dilemma for FAMILY MEDICINE-ob training programs. Lead time and a committed critical mass of family physicians is needed to build and sustain delivery services in any community. Unfortunately only urban programs are likely to have the patient volumes readily available for the so called "high volume" experience. These experiences and the "high volume numbers game" tend to be the antithesis of family medicine principles, and this is a dilemma. Exceptions such as Dr LaRavia and the Bogalusa, La. program are noted.

In 1991, as Chair, I abandoned the "high volume hospital/OBSTETRICS" model for our fellowship and successfully transitioned to a FAMILY MEDICINE-ob model which retained the ability to obtain competency in operative deliveries. The data from 70 graduates over 14 years suggests that this is an effective model. See www.psot.com under ARFEM fellowship section.

Also visiting physicians cannot legally touch a patient in the hospital without acquisition of a valid medical license and hospital privileges. The lead time necessary for these administrative tasks is 6-12 months depending on the state. These realities are rarely taught by academic faculty who lack the need to understand life outside the cloisters. In summary, highly idealistic and motivated young physicians should be encouraged to maintain their idealism, but should be taught to understand these issues if they wish to gain access to community-based experiences as requested above.

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com

R gluteal abcess

Here are the photos of the upper outer R gluteal abcess secondary to self administered gym steroids in an 18 year-old male. Failed antibiotics given twice in local ER's prior to self referring to Medicos in Memphis.

Widespread necrosis had resulted, and the initial incision required debridement of substantial skin.

This left a large opening which had been infected for 10-14 days at the original time of incision at Medicos. Management by secondary intention with packing every 2-3 days has been ongoing for two weeks. Note lack of pus and infection despite no antibiotics. Infection resolved within 2 days of incision and drainage. Patient returned to work 2 days after incision and drainage.

But, continues to have transudative drainage secondary to normal process of granulation and cellular repair. Body is attempting to close the long axis of the oval,but at this point we will be improvising with tape to attempt some assist of closure  by natural forces; ie will use principles of steri-strips to achieve approximation of wound edges.

                                                                                                                                                             More to follow. 

                                                                                                

Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine

Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com

Abcess Case and Implications for Training

Original incision was 12 cm long. Patient is white bread , no risk, middle class, just graduated from high school. Review of systems negative for travel, exposure, night sweats. weight loss, appetite loss, n,v, fatigue, cough.

Generally, family medicine residencies are not preparing graduates to deal with wound care problems like these. This is particularly damaging to rural and other underserved communities where these cases are common.

For those who wrote with comments about me being a "surgeon", my appointment in surgery came as a result of my work in rural emergency medicine through the medical specialty of Family Medicine. Like many, I graduated from a mediocre FP residency, but had the good fortune of many terrific opportunities in community practice. These are the skills my faculty try to teach in our FAMILY MEDICINE-ER-OB fellowships.

Noting that photos could only be sent to individuals by request.

Rocco's abcess---Another example of minor surgical cases occurring regularly when services are provided open access to the community. After ten years, I’m still waiting to see the value of routine cultures on these cases.

The White Papers

QUESTION:

What are these "White Papers" and where are they available for family practice?

Jaclyn Randel, MD

Kathy Saradarian <qualityfp@direcway.com> wrote:

I was on my hospital credentialing committee for a number of years. They frowned on numbers but basically referred to "the White Papers" for guidance. Every specialty had their own "requirements" to be considered competent and credentialable for various procedures.

I suggest you refer to those "White Papers" for guidance because a lot of hospitals use them.

Kathy Saradarian, MD

Branchville, NJ

REPLY:

The so-called "white papers", that I know of, were from a for-profit credentialing service in Marblehead Mass. They successfully marketed them nationwide in the mid to late 1990's to hospital administrators who sought convenient and politically pleasing numbers for their medical staff executive committees. These white papers were sub-specialist friendly and used sub-specialist numbers such as a minimum of a cardiology fellowship and 300 documented ECG interpretations before one could interpret ECG"s.

The gastroenterology numbers were equally draconian in the elimination of credentialing for family physicians. The usual "200-300 colonoscopies" and a similar number for EGD's.

Caveat Emptor!

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com

Unfair Insurance Policies Restrict Ability to Serve Patients

"A mind once stretched by a new idea never regains its dimension."

Vasectomy--how to convince our insurers to reimburse FPs?

Didn't expect to get so ticked off reading this particular string...I feel everyone's pain.  Read on if you want a laugh or to share my sad story, and hopefully some of you won't make the stupid mistakes I made (especially any of you military FP's planning to start civilian practices).

I started doing vasectomies as a medical student in the late 1980's and actually it was the lure of procedures like this that made FP so appealing to me, then became a pretty good at it, so that by the time I was a PGY2 Resident I was teaching other resident's and  staff.  Being Air force trained and serving from 1990 to 2002 I was isolated from the civilian woes of reimbursement and malpractice.  At every Air Force Base I served, I became the "Vas" doc and by the time I left the Air Force I had done well over 700 vasectomies.  I very much looked forward to performing vasectomies in private practice and when I started in August 2002 with a fairly large multi-specialty group in Hampton Roads, VA (45 docs, of which 35 are FP's spread out over 8 offices), I requested that my office purchase the necessary instruments (no scalpel set, hyfrecator, etc.) so that my "Vas" doc days could continue.  Like an idiot I did not really look closely at  the malpractice policy that I was given, mainly because my premiums were about 9K and my colleagues in my office who do not perform vasectomies were also around 9K.

Vasectomy patients were SLOW to come (probably should have  advertised... but that's another story) mainly because in my area  there are urologists everywhere and FP's "just don't do vasectomies",  so the word of mouth referrals and networking that I benefited from  in the Air Force was gone.  In the fall of 2003, after only performing about 15 vasectomies for the entire first year of civilian life, my new malpractice premium rose to 17K, while my colleagues only rose to about 11-12K.  My practice administrator (who I call the financial numbers guru) explained my rate was higher because I did vasectomies.  I figured I could handle the extra 5K in premium, so long as my Vasectomy volume picked up.  Another year passed, and in Fall of 2004 (only did 20 vasectomies in previous year with average reimbursement of $450), I was shocked to see my premium jump to 26K!!!!

This just didn't seem right to me....I thought "How could I be  getting so screwed by performing a procedure that I love to do, that  I am highly proficient at doing, and have had NO patients with any  complications,...knock wood?".  By this time, I was successful enough at the other aspects of my practice that I was asked to join the practice as a partner, and I became privy to some of the malpractice rates of the specialists in our group.  Now I got even more inflamed.  The average premium for all the FP's (other than me) was $10-12K, the 2 urologists in our group were $22K & $27K, and the general surgeons (3) were all around $46-52K.  It quickly became clear that I was being considered a "urologist".  What's even more amusing, the average annual income of these 2 urologists is well over $400K, compared to my $120K.  So I called GE Medial protective and asked what the &^%$ was going on, and was informed that, because I perform vasectomies, I am considered a urologist and my malpractice premiums were always configured that way...as a urologist from 2002  to the present.  Apparently, the lower rates I had in 2002-2003 would have been much lower if I did not do vasectomies, but I did not pay any attention to it because the rates were in line with my FP colleagues.  I looked at the numbers and estimated that I would have to perform a minimum of 30 vasectomies annually just to break even, and this was not going to happen in my current practice setting.  So, on November 1st, 2004, I stopped performing vasectomies and my premium was reduced to about $12K.  GE Medical Protective normally charges a $15,000 fee for making such a change (I'm not fully sure I understand why they do this) but I argued strongly that I did not have any clue that I was being considered a urologist from 2002 to 2004, and they "graciously" waved the charge.  So now, as my vas instruments gather dust, my hyfrecator has become the best tool for  SK's, telangiectasias, skin surgery, etc that my colleagues have ever  seen....I reminisce about the days when I was the "Vas" doc, and fume underneath my collar when I have new/established patients present to me requesting a vasectomy and I send them to the 2 urologists in my group!

So what did I learn from all this:

1) Military FP's are ignorant.  We are sheltered from the vicious world of insurance reimbursement, E&M Codes and malpractice.  Any military FP's MUST learn this stuff before they reach the real world.

2) The malpractice system is inherently unfair to FP's.  They don't know what to do with us.  If we do any procedure(s) that a specialist does, we get hit with the specialists MP rate....this is total BS.

3) We must do something proactive that will allow FP's to have  malpractice premiums that not only reflect what we do, but are in-line with our incomes.  An FP that has an annual income of $120-150K should not have to pay 20% of his/her income for MP coverage, when a urologist who makes $400-500K pays only 5% of his income for MP....and does procedures with incredibly higher levels of risk  associated.  Totally makes no sense.

Well, rather than keep venting and fuming....I'll end my rambling.

If there is anyone out there who has a similar plight to mine and has managed to figure out a way to get back to performing vasectomies....let me know.

Kind regards,
Bob

Robert P. Butcher, MD, FAAFP

REPLY:

Step One:

Construct a one page resolution for your local chapter of the AAFP. After obtaining their sponsorship, take it to your local state Congress of Delegates. Once it passes there it can be brought to the national congress in San Francisco or next year in Washing DC for consideration by the national congress.

Step Two:

Think public relations and the need of media for human interest stories. Plug in your creativity and construct a press release. "WOMEN SUFFER NEEDLESS AND EXPENSIVE BTL SURGERY BECASUE OF INSURANCE DISCRIMINATION AGAINST FAMILY PHYSICIAN!!"

Step Three:

Take this to your church.

Step Four:

Consider investing some of your own money in social reform on behalf of your children's future. Place a quarter page ad in the local newspaper. Run it monthly for 4 months.

Step Five:

Write your state and federal legislators. Here's another reason to place patient education materials in your waiting room.

Step Six:

Keep the faith. Non Illegitimi Carborundum!

Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine

Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com

Two less useful procedures- Evidence-based Medicine

Two procedures less useful-evidence based medicine:

1 Developmental Outcomes after Early or Delayed Insertion of Tympanostomy Tubes. Paradise JL, et al. New Engl J Med 20005;353:576-586.

CONCLUSION: Insertion of ear tubes in children with persistent middle ear effusion does not improve developmental outcomes.

2. Effect of timing and method of enteral tube feeding for dysphagic stroke patients: A multicentre randomised controlled trial. Dennis MS, et al. Lancet 2005: 365: 764-772.[Courtesy-Family Practice Newsletter June 15, 2005 p48]

CONCLUSION: Two randomized trials failed to demonstrate improvement in outcomes or death.

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com

Placing IUDs For Medicaid Patients

QUESTION:

The administration for our residency is saying that we lose $400 each time we place an IUD for Medicaid patients and that we should stop doing this (or find a creative way to place IUDs in a more budget neutral way). First of all, does this calculation seem correct to you? If so, do you have any ideas for how we can place IUDs without breaking the bank? (I already unsuccessfully made the argument that an IUD is cheaper than a pregnancy).

REPLY:

Yes, the Camellia Foundation will donate ten FDA approved IUD's for a nominal $20 each if you have the desire to do a fund raiser among residents and faculty on behalf of patients who deserve this service. When you have a log of the ten patients who have received these IUD's, the Foundation will provide another ten.

This way the hospital will not have to buy the IUD's and they cannot lose money. After all, they are simply saying that they do not want to buy anymore of these supplies for your patients.

This is an opportunity to be an FP idealist and a social reformer. Another example of how hospital administrations do not have incentives aligned with community based physicians. This is killing our residencies. Legally and ethically the Camellia Foundation can help you go around them. I will help.

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com

Cesarean Training and Credentialing Standards

QUESTION:

I am currently looking at various OB fellowships and am inquiring about c-section numbers. Approximately how many c-sections would one perform by the end of their fellowship?

REPLY:

The question is, how many Cesarean training experiences will meet the credentialing standards where you are likely to practice. Many hospitals have one or two other important criteria. Approximately 5-10 % of hospitals will not allow credentialing regardless of the number of Cesareans. Generally, our fellowship tries to work with each candidate to determine the hurdles they are likely to face.

The only studies published indicate that most physicians with reasonable aptitude and a commitment to learning can independently operated after 40 Cesareans, but some do it after 20-25. One of our major urban teaching hospitals requires the number of 10 Cesareans documented. Interesting political story there.

My fellowships gave up on the credentialing arms race about fifteen years ago because we needed to balance the fellowship with other skills such as managing the office while you have someone in labor, coding and billing, using off the shelf software to develop and follow risk on a weekly basis (without having the residency secretary do it for you), and on maintaining your primary identity as a family physician who sees the children they deliver. This is almost impossible to do when you are owned by the Department of OB-Gyn.

The outcome we track is the ability to obtain hospital privileges for Cesarean section. Among completers over 95% have obtained the privileges. Locations range from rural to Washington DC/Memphis. see ARFEM fellowship section at www.psot.com

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com

Protecting From Liability Using Special Consent

COMMENT:

Use informed consent stating that it is NOT a diagnostic US, but is to check for twins, placenta previa, dates, amniotic fluid, or whatever else you want to check for - within limitations, of course, as with all procedures.

REPLY:

Thanks to Ric Hahn, Mark Deutchman, and others involved with the Memphis project 1989-1998, we developed and studied the various uses for Ob ultrasound by family physicians in the office and in the hospital. Above, a Texan rural physician is describing the "Quick Look" format. This is a fundamental skill and has been taught in the AAFP Advanced Life Support in Obstetrics [ALSO] course since 1994.

We used these forms in our ultrasound courses dating back to 1989, and they are still used in many courses as well in the offices of those who were among our students. They are available on the Procedural Skills and Office Technology website www.psot.com. Feel free to copy and use them. Click to the link on "Looking for information on costs, charges, and business management?" Then look at the ultrasound section.

Notice that there are 5 ultrasound "products" there. One of them is the quick look ultrasound form and it contains a disclaimer regarding the need or lack of for additional more detailed study/consultation. One obvious example is the woman who has lost her baby and the uterus is empty. Additional ultrasound is not necessary.

During the interval of academic sanity in Memphis, 1989-1998, we performed over 1000 office ultrasounds each year. We never had one complaint or lawsuit. Not even one incident report. In the Medicos para la Familia project, 2000-present, we continue to perform over 1000 office ultrasounds as described on the website. Same story. Yes, our bills are recognized by all third party payers.

Please disregard the obsolete terminology Level I, II, III. There are cases in which the diagnosis is clear, and there are cases in which the examining physician would recommend consultation. In one of our first published studies Rodney WM, Prislin MD, Orientale E, 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.

The consultation frequency was less than 4%. Since then it has decreased down to 1-2%.

Wm MacMillan Rodney MD

Adjunct Professor of Family Medicine

Adjunct Professor Surgery/Emergency Medicine

Meharry/Vanderbilt School of Medicine

Medicos para la Familia

Memphis and Nashville, Tn.

www.psot.com