1. Stool cultures rarely useful in managing diarrhea. Fam Pract News 2005;35[19]: 33 Arch Pediatr Adolesc 1997;151: 142-5 At last month's meeting of ACEP, a Harvard emergency medicine faculty underscored the fact that these cultures cost almost $900 in his hospital. Medicos case--Ten month old boy with normal growth and development who presented with 2 days of diarrhea and fever to 103 degrees. Physician noted mild dehydration. Exam otherwise unremarkable. WBC in office 8.2k. RX--see patient next day, noted weight, gave diet advice on clear liquids taken frequently in small amounts. When seen the next day, boy was dramatically improved. 2. Tennessee Hospitals Oppose Office-based Surgery Rules. AMA News October 17, 2005;48[39]: 15 The fundamental conflict between hospitals and community based care is heating up with hospitals in Tennessee filing a lawsuit to protect their monopoly on the performance of Level III surgeries which "require general anesthesia up to 6 hours in length". Recoveries longer than 12 hours must be transferred to a hospital. The Tennessee Hospital Association has filed a lawsuit stating that the Board of Medical Examiners has no right to regulate office-based surgeries. The THA is requesting that office surgeries be regulated under a licensing board on which they have substantial influence; i.e., the Board for Licensing Health Care Facilities. If successful, this would allow the hospitals to basically outlaw office surgeries by requiring JCAHO hyper regulation of these clinical activities. This would make them unaffordable for the average group of physicians. Ironically, these regulations were initially written to make it more difficult for physicians in Tennessee to perform IV sedation/analgesia in the office. You need someone with ACLS training, and you have to monitor the patient. The key here is for physicians to maintain the fight for some level of independence in the community. Write your congressman. Wm MacMillan Rodney MD Adjunct Professor of Family Medicine Meharry/Vanderbilt School of Medicine Medicos para la Familia Memphis and Nashville www.psot.com
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What Does It Cost?
Dateline October 2005
Stool culture and sensitivity at Harvard-Approximately $900; Source Harvard ER Professor at
annual ACEP meeting in Washington DC
In Honduras (Valle de Angeles-Dr Funes)
Chest x-ray 2 views $15
Simple office visit $5
Office surgery like laceration repair--$15
Lab for Papinicolaou--$15
One bottle of beer -- $0.55
One gallon of gas-- $3.40
Private Hospital delivery routine vaginal similar to US--$2500 to physician
Public Hospital delivery routine vaginal-- $10-20 if they have it.
Professors of OB-Gyn are paid $18,000 per year
Interns earn $800 per month.
Wm. MacMillan Rodney, MD
Meharry/Vanderbilt Adjunct Professor
Department of Family Medicine
Medicos para la Familia
Placental examinations-When should we request analysis from pathology?
This has recently been given to physicians at one of our hospitals. There seems to be an
unknown charge of about $200-300 for each of these pathology readings. Since most our
patients are uninsured, this seems to take money away from them for no good reason.
Currently I am doing an ALSO course at the medical school in Honduras, and it is clear that
many of our stateside "protocols" are irrelevant even in the teaching hospitals here.
I am reluctant to follow this recommendation for pathologic analysis of the placenta because
I have never seen results change subsequent management. Anyone know of a documented case
(please no second hand reports) where placental exam was important at a trial? Comments
would be appreciated.
"To help avoid medical complications as well as medico-legal considerations, the following
list of indications for placental examinations has been defined by the College of American
Pathologists:"
I. Maternal conditions
A. Diabetes mellitus
B. Hypertension
C. Pre-maturity £ 32 weeks
D. Post-maturity ³ 42 weeks
E. History of reproductive failure
1. Spontaneous abortions
2. Stillbirths
3. Neonatal death
4. Premature births
F. Oligohydramnios
G. Fever
H. Substance abuse
I. Repetitive bleeding
J. Abruptio placenta
II. Fetal and neonatal conditions
A. Stillbirth or perinatal death
B. Multiple births
C. Congenital anomalies
D. Fetal growth retardation
E. Pre-maturity £ 32 weeks
F. Hydrops
G. Meconium
H. Severe depression of CNS (APGAR £ 3 at 5min)
Wm. MacMillan Rodney, MD
Meharry/Vanderbilt Adjunct Professor
Department of Family Medicine
Medicos para la Familia
Memphis and Nashville
I.
D.The Paradox of Primary Care Training as a Negative for Rural Care
QUESTION:
I have been working on a study of the nation's CHC regarding their workforce issues. Related to that work, I am now doing some work for NACHC related to how FP residencies and CHC/MHCs collaborate and train FPs. I want to show some best practices and to identify problems that have occurred with such collaboration. I think most agree that this is an avenue that would help both parties fulfill their missions.
What do you know about CHCs and FP residency training? Do you know of some best practices where things have gone well? Likewise, do you know of some situations where it has not gone well? What are the most important barriers to this type of collaboration? Do you know of any studies or papers on the topic?
Can you post this to the e-mail group and see if we can get a discussion going too?
REPLY:
As a former medical director of a Community Health Center in the 1980's and again in the 1990's, I was able to witness the impact of CHC and FQHC rules on the development of family physicians in training. The impact was negative in one particular aspect, and I'm going to explain why. In summary, there was a general emphasis on generic primary care at the expense of procedural and hospital skills. In particular, cost based reimbursement dis-incentivizes the center for "doing more" such as an ultrasound for example. In Jackson Tennessee an RHC was established as a feeder to the hospital for all lab and other ancillary services. By the way, how can a county hospital performing open heart surgeries, receive funding for an RHC 8 miles away from the hospital in a city of 35,000? Answer: The foxes are guarding the hen house.
I am preparing my thoughts for a presentation at the West Virginia Rural Health Association later this month while simultaneously preparing to recertify in emergency medicine. In my outline I have declared the hypothesis that primary care training is a disincentive to service in a rural community. Similar to Western Europe, most students view the primary care career path as the bottom of the professional food chain. If nothing else they point to the annual salaries widely published by the AMA, Medical Economics, and others. Although family medicine was a generalist specialty, its primary care companions in Pediatrics and Internal medicine never pretended to be. Only Family medicine met the definition of a type of training which could cover a rural area, but FM leadership has lost the high ground with its public. American Medical students are staying away in droves. Fewer than 10% select family medicine as a career. Fewer than 3 % go on to practice the full spectrum of Family Medicine.
Emergency medicine seems to have won the hearts and minds of most American medical students who aspire to be generalists. But these EM generalists will be hospital employees who labor constantly in the glare of medical staff politics and a system which rewards excessive testing at the expense of the American public. The uninsured have suffered greatly in the ER as per the recent overcharging-the-uninsured lawsuits against Yale, Tenet, and others. Emergency medicine is very flashy in the traditional academic health center where they can attain and maintain volumes exceeding 100,000 visits per year. In the American urban environments, emergency medicine is the only true generalist specialty with rare breakthroughs by the occasional maverick FP. The limited generalist (no procedures, no deliveries) model has a very predictable pattern of evolution with most family physicians performing general internal medicine with perhaps 3-5% children. They are closing in on their British GP counterparts, and this is the CHC model.
Meanwhile emergency medicine has attracted many of the brightest American students who seem to enter and leave these programs feeling as though they really could go almost anywhere and acquit themselves honorably in almost any type of medical situation. Most recent family medicine graduates I meet do not understand the infrastructure of delivery services in the community, cannot use ultrasound, and will not even begin to manage a simple fracture. They are especially deficient in understanding the rudiments of collecting money for their services. As recently described in Family Medicine Management, revenue is directly proportional to procedural and diagnostic services provided. A significant minority of family physicians have overcome the procedural helplessness of their training through self motivated strategies such as Selectives or the National Procedures Institute.
How did we as a profession arrive at this point in history? There has been an incredibly blatant manipulation of the medical education curriculum to the point where education outcomes are juxtaposed to the construction of the rural physician skills. Because Deans have become professional fund raisers seeking more money for an endlessly expanding research agenda, they could not afford to lose the political favor and money attached to the generic ideal of a physician generalist (as requested by underserved communities where there are large percentages of uninsured and Medicaid supported patients. These communities constitute over 65% of US geography and over 90% of the world's population.)
I persist in my belief that Family Medicine-ER-OB is the logical foundation for a health care system. But, I am old and my numbers are few. Family Medicine with some OB and a little emergency medicine was too threatening to some, and "too hard" for many of its faculty. Presto change-0 the concept of "generic primary care" was developed. This was a perfect partnership between medical schools and their hospital partners. Family Medicine is the only specialty which required the building of an office outside of the hospital. This does not generate money for the hospital in the way the emergency medicine does. Federal funds for residents are linked to hospital cost reports. Financial incentives are not aligned.
Family Medicine as the poster child for community based generalism was marginalized. It continues to cede territory with many academic family medicine leaders calling for elimination of delivery and other hospital services. The inexorable weakening of family medicine while publicly maintaining an allegiance to "generic primary care" has been a winning combination for the house of academic medicine and the medical industrial complex of hospital services. This has successfully allowed gerrymandering of public funds while totally baffling all who sought accountability. The facts clearly demonstrate hundreds of billions of dollars in support for everything except family medicine and emergency medicine training. Both make money for the hospital, but Family Medicine has gradually been making less and less.
For awhile it seemed that there would accountability for the massive amount of tax support given to the academic centers. Parity of funding for Family Medicine was the goal. However this ideal was short lived, and most truthful academics admit that the ideal medical student is someone deeply committed to sub-specialization and research. This is the antithesis of providing health care in a rural environment which will never support platoons of internists, pediatricians, obstetricians, cardiologists, general surgeons, and orthopedists. Many family physician graduates just can't make it in a small town. The tool chest of generic primary care is too limited to encourage survival in a rural environment. But, the hospitals of rural Tennessee can and do support groups of emergency physicians who are usually organized and owned by entrepreneurial emergency medicine groups with administrative offices hundreds of miles from the rural community served. The recent annual meeting of the American College of Emergency Physicians in Washington DC had exhibit after exhibit of these multi-state groups of emergency medicine physicians who allege that they have become the default "family doctor" to their communities. The hospitals guarantee them over $100 per hour per physician for a variety of reasons, but the fundamental one is financial. The hospitals can and do bill a "room fee" in addition to every physician charge. One rural hospital charges $250 for a PA and lateral chest radiograph. In our offices we receive about $30 from Medicaid. They receive the same from Medicaid, but from the uninsured they collect a major deposit at the door. Any objections to price gouging by an emergency physician will lead to rapid dismissal. Family Medicine has more freedom and a career advantage here.
Having done all of this background research and hypothesis generation, I was surprised to find that the data from ACEP, confirmed by the eagerness of recruiters to locate family physicians, indicate that many of these rural ER physicians are former Family Medicine trainees who seem to proudly feel that they have educated themselves to attain a higher level of clinical expertise with particular mention of acute pediatrics, minor surgery, critical care, and clinical procedures. Emergency medicine has correctly perceived this as a growth opportunity to request more money in support of rural training programs. Even if successful these additional EM graduates will not trickle down to rural areas and, in particular, they will not be part of the FQHC or RHC system.
Trends can be foretold by the significant numbers of over 50 ER physicians making career changes. Those that remain in clinical medicine move away from the night shifts by working in urgent care centers which morphs into some continuity care. It's quite a bit like the British GP, but these former ER docs have many skills available for office surgeries, orthopedic injuries, and interpretation of imaging without referring the income to radiology. On the down side, EM boarded MD's have almost no ability to do women's health care, and they are forbidden by statute from admitting patients to the hospital.
Therefore, this analysis is offered for consideration and comment. My presentation will seek support for a hybrid training programs which combine family and emergency medicine. There has been recent support for this from the AAFP and ACEP, but the agreement appears to place all of the negotiating power into the hands of emergency medicine which has no incentives for the creation of such programs. In particular, there is no incentive for hospitals to add family medicine residency positions when they have so successfully controlled emergency medicine physicians as employees. I predict that the combined programs will be costly and administratively difficult to manage. If so, these combined programs will fail to materialize, but I hope I am wrong.
Wm. MacMillan Rodney, MD
Meharry/Vanderbilt Adjunct Professor
Department of Family Medicine
Medicos para la Familia
Memphis and Nashville
Gestational Diabetes
If you define hyperglycemia as the normal variation seen in gestational diabetics (as opposed to the constant and more severe hyperglycemia of type I diabetics) there is no evidence of toxicity to maternal organs during pregnancy. No studies indicating renal or eye damage. No studies indicating increased disease fro accelerated ASCVD. There are only speculations about the possible downstream effect molecules set in motion by the wind from a butterfly's wings.
Studies indicate that organ damage requires years to begin. Mild hyperglycemic episodes are the rule not the exception. Other problems with the speculative literature include the inability to control for obesity and de-conditioning as these women go on to their middle age. Ask an endocrinologist to give you their opinion about the scientific basis of insulin as recommended by obstetricians.
This theoretical risk of damage from transient hyperglycemia of GDM, creates an extravagant medical care plan based on unreasonably catastrophic expectations. We have managed 10-25 GDM cases every year for the last 20 years. In the early years we occasionally fell victim to enthusiastic young obstetricians specializing in diabetes, but frequently our patients refused to attend their clinics. Oddly enough our results were as good as theirs even though we did not do nearly as much testing and injecting.
When we discovered genuine severe diabetes which was unmasked by the availability of prenatal care, these patients were usually put on insulin by higher risk obstetricians. This was rare. All of our GDM problems have come from macrosomia. No unexpected fetal deaths. No malformations. Therefore we have evolved a management style which keeps the woman in a family centered care system while aggressively managing for risk with NST, AFI, and EFW at about 37-38 weeks. All of these studies are performed in our office by the family physicians who do deliveries.
Finally, I have read the recent study about glucose control during pregnancy as published in the New Engl J Med 2005. The small absolute differences in outcomes from that study, are awaiting replication and external validation.
From John Bucek, MD:
I just posted and noted your response. Is it really Ok to not treat with insulin? Won't the pt have trouble with fluid balance when her sugars are 300 + for weeks?
I don't believe insulin will change neonatal outcomes but hyperglycemia is toxic to mom's organs. Isn't 10 weeks of hyperglycemia worth avoiding?
No insulin. At this point the horse is out of the barn. There are no outcome studies establishing improved outcomes with insulin among gestational diabetics ; i.e. mother did not previously carry dx of diabetes]. Start EFW's at 38 weeks with induction at time EFW >4500 or 40 weeks with good dates. Be prepared for Cesarean or shoulder dystocia. AT 5000 G, we consider elective Cesarean unless she has delivered at least one large baby vaginally.
Reply:
