PSOTBLOG

Newborn Won't Stop Crying!

 
The mother is sixteen, and Medicos delivered the baby at term one month ago without complications. They were seen 2-3 days after birth. they were in the office two days ago with the same concern that the baby would not stop crying. The vital signs are normal and the physical examination is noncontributory. The baby has gained a normal amount of weight in the past month.
 
I sensed a reluctance to bill for this visit because the resident correctly assessed that there was no real disease here, and that the parents were very poor. The registration materials reflected a green sheet indicating that the family was going to pay cash for the visit(uninsured patient). Medicos uses pink sheets to signal doctors that the pink sheet patients require navigation of the highly regulated health care insurance industry. Can you believe it--two classes of health care?
 
Where to begin? First, "Grandmother Camellia RN"  suggests that probably the baby is crying because he is hungry. Good thought! Psycho-socially, family physicians should articulate the "teenage mother syndrome" and separately mention special needs for the "uneducated, Spanish only, strange country, socially isolated" new mother. Offering the breast exclusively is immunologically idealistic, but this baby probably needs a "feed on demand" schedule which includes formula after ten minutes on each breast. I apologize for failing to emphasize the feeding issues during our attending session. Medicos attendings need to be vigilant on these newborn issues.
 
The family incorrectly registered as an uninsured patient because they did not understand what their Tenncare card(Medicaid) card meant. The baby received a Tenncare card at the hospital. Apparently there was no translation or structured feedback in the hospital to address this issue. MedicosNash has been asking Dr Dyer to study this situation.
 
Dense misunderstanding of Medicaid rights leads to unnecessary expense for family's with few financial resources. The mother's age was appropriately mentioned by Dr Dyer, but this review is articulating these issues with emphasis and amplification..
 
Secondly there was an understandable reluctance by Dr. Dyer to bill these poor people. BUT, Medicos asks that physicians review the big picture on each patient before focusiing down on the obvious. Primary Care has been driven to the brink of extinction for lack of attention to the ecology of health care financing; ie, charges and collections. Medicos requires that practice management be taught along side traditional disease oriented medicine. This case is a good example.
 
Doctors should immediately tune in to the fact that a Medicos baby delivered by Medicos in one of the Medicos hospitals, has been registered for Medicaid. Medicos has invested financial support to help these patients get registered for medicaid. Our goal was to remove a financial barrier to health care for these children.
 
Therefore, the appearance of a green sheet(indicating uninsured status) on these patients should immediately trigger the "social worker gene" in each of us. Once the Tenncare card is located in the mother's purse, the physician is able to charge a well child and an acute visit to Tenncare. This is much needed revenue(about $105) for support of the mission. Without revenue,  primary care will not prosper.
 
This why the Medicos "system" of attending has been developed. Lay out the encounter form, the green/pink sheet, and the growth chart side by side. All are equally important for each attending session. Don't start teaching until the student has written their opinion of the issues and desired management.
 
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia

Index--Newborn won''t stop crying

Note Review QI

Glad to hear that the pharmacist is helping you prescribe generic meds for Medicos patients. It is Bromfenex which is a combination of brompheniramine and pseudoephedrine. It sounds like a good generic tonic for the pediatric URI's, but we need to spell it correctly and, more importantly, know exactly what is in every combination drug we prescribe.
 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Index--generic list, med4 uninsured

STD Phobia At Medicos

 
In the past ten years Medicos physicians have coined the term "STD phobia" to describe young males with vague symptoms relating to the penis and testicles. All of these patients are young, male, unmarried manual laborers with little education. None of them have been black or caucasian.
 
As I tried to point out, the linear logic of western science does not work well for these patients who are very close to their origins which include the Mayan, Incan and Aztec tribes. Even today these societies routinely support curanderos and shamans who function in a spirit world  similar to the "nocebo" effect which is described in the attached one page book review.WSJ Nov 18, 2008 p D1
 
PLEASE!!! Use the green/pink sheet system which requires listing the ecology issues and the diseases for each patient. Please list symptoms and investigate the possibilities. Do not jump to a diagnosis until you have considered the possibilities. Dysuria can be many things. Fill out the ROs and get a UA first.
 
His vital signs and exam were normal. His UA was negative, and his "ugly" upper lip was notable for a very prominent squamocolumnar junction on the inside of his lip. No sores, ulcers, or inflammation noted. You will occasionaly see these prominent demarcations in the indigenous tribes, and they are different from the other races. But, they are not diseases. The patient is given two powerful antidotes for the "nocebo spell" which had hexed him.
 
First a small piece of white paper which contained his urinalysis results proclaiming his penis to be "healthy", and a small bottle of 400 mg ibuprofen pills to be taken up to three times a day as needed to ward off the return of penile pains. After a sacrifice of $100 to complete the ritual, he came back to the doctors area where he thanked all of us profusely.
 
If society continues its present trend, the cultural gulf that separates well educated physicians and the patients they treat, is likely to grow. You should read what's posted on the wall of the Chiropracter's office in Nashville (He treats asthma--true story). Magical thinking is a powerful influence among over 50% of our patients and among many health care providers.
 
My father left his urology training with a belief that "prostatitis" was a haven for the diagnostically destitute. Please do not refer any prostatitis cases in young men to a urologist without letting me see the patient first. "Young" means anyone under the age of 50.
 

Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural Tn.
www.psot.com

Family Medicine Obsterics Board

COMMENT:

I hope nobody gets sucked into this.  It is a pretend board that has nothing to do with the ACGME.  I believe that this effort has the potential of being used as a weapon against family docs who are well-qualified but don’t play their game.   

rjs
 
REPLY (WMR):

There is much to add regarding the initial angry comment about "getting sucked into" the Family Medicine Obstetrics Board Exam, and the more recent concerns about the cost of the exams. My thanks to Drs Leeman and Avery for their kind words and guidance.
 
Family Physicians should understand that the "guild mentality" of ACGME has been destructive to family physicians seeking delivery privileges and privileges for a wide variety of other modern procedures. Despite lip service to the contrary, the rate limiting step in OB has been privileging which is directly linked to Cesareans. When Cesareans are not available to FP, FP physicians are denied privileges for deliveries.
 
The FP fellowships were good faith and effective educational programs forced into being when residencies were not recognized a a legitimate source of training for Cesareans. FP's could go to Backwash, Tn., but had almost zero chance in any hospital where a board certified OB was available to take their place.
 
Many academic family medicine physicians lack privileges for vaginal delivery, because they don't want them. This was used as prima facie evidence by skeptical OB's in contested hospitals that privileging would require training beyond residency.
 
Catch 22--There was nothing beyond residency for those who wanted to go further in OB. ACGME recognition has never been sought for the simple reason that the house of ACGME would NEVER permit family medicine to fish in the pond of what they consider to be another established medical specialty; ie, OB-Gyn. I was on the RRC for 6 years. We went through this over and over again with regard to emergency medicine.
 
Only the AAPS has the track record and integrity to encourage merit based certification independent from ACGME. This exam will mean Cesarean sections from some who otherwise would have been excluded unfairly.This will mean services for some women who otherwise would not have received them. Praise the Lord for the pluralism of our society. There is indeed more than one road to Rome.
 
In most states, hospital monopolies in Women's health care remain lucrative. These services represent the birth of the family, and the family is the backbone of any society. Advocates for women's health care are a powerful lobby among a wide variety of constituencies. Physicians with a committment to deliveries serve those constituencies when they are permitted to do so
 
Family Medicine literature is tragically misguided and misinformed on the financial realities of private practice OB (and this includes medicaid). In a worst case mix scenario, moderately prudent stewardship yields about $2000 per delivery net collections. In a paper we presented at the AAFP this year, our data demonstrated the wisdom of investing in these services. Malpractice  for OB added about $10,000 per year at maturity in Tennessee and not more than $15 000 in over 70% of the United states. Break even is 7-8 deliveries, and it is less in Tennessee.
 
Associated services include newborn care, EPSDT exams, miscarriage services, ultrasound, and other office surgeries. These add to the bottom line.
 
My point is that this arithmetic is extrememly favorable for the investment of $3500 if it means that you will have the freedom to provide your own Cesarean backup thereby avoiding the de facto exclusion faced by family physicians who go hat-in-hand seeking someone to be there for them 24/7.
 
With best wishes for your professional success, 
 

Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

Bill:

Being one of the FPs who is alone in a 300 bed hospital, and seeing in my case NOT all the OBs but the Board  going against FPs who are excellent trained and they are denying privileges, I agree 100% with you. I was invited to participate in the AAPS effort and I was NOT supported by our own peers.

I'll pay from my CME money if necessary but I think that ALL of us who are doing FULL operative OB in FM has to take it. How to "lobby" for our cause?  Helping the Rodneys the Leemans and many others, in my case until I'm able to take the post.

My two cents.

Eduardo Scholcoff, MD
UIC - Rockford

This board has been proposed to counter ACOG’s attempts to restrict C-S privileging based on specialty, not training or experience.  I am not sure that it is a “pretend board” either and I think we should lobby for its role in certification.  I think it would be wise of us to seek a way to document and demonstrate competence for operative OB skills, and provide a transparent certification process.  Since many OB’s graduate with only about 100 sections skin-to-skin, we should be able to argue that the same number (whatever that is) should be enough to bestow privileges for FM docs with the same experience and training in performing C-sections.    Also, many of our OB colleagues are trained in hierarchical structures that don’t give the resident the responsibility to decide who goes to section (and when) until very late in their training.   I’d love to see a study to show about how many sections it takes your average resident/fellow to get to competence (similar to Bill’s studies on ultrasound training).  That would be icing on the cake.

 Mike Tuggy

Burn Clinic Days 1-14

 

 
Dr Rodney:

Would it be OK if I used your story and pictures in a Derm talk (mostly unknowns, but I thought I'd throw this one in for management issues)?  And if so, any chance you could send me the original story and picture - I seem to have deleted it!

Mary Fairbanks, M.D.
St. Anthony's North
Family Medicine Residency Faculty

WMR:
 
I am honored and pleased that this may have educational value for your work in the Alaska Fairbanks residency. He was a 65 yo auto mechanic speaking only Spanish who came to Medicos as the only place where old school family medicine ]combining ER and OB]is still practiced in three languages every day.  His past medical history was noncontributory and his vital signs were normal. Although pain clouded his neurologic exam, his strength and ROM were normal.  Some observers reported anesthesia to light touch.
 
After 2 weeks of observation and limited wound care, he was declared well. Blisters were never broken and no creams or vaseline was applied. He received a Td shot and no antibiotics.
 
All of my website is submitted for the public domain at no cost. If you strike it rich and want to avoid donations to those who will not support family medicine, donations to the Camellia Foundation are appreciated
 
If you wish we could co-author a case report on this case. More photos are available. Here are couple from the beginning. I have some at 7d also. Day one below showing the "Sabor de Medicos" Mexico, Cuba, Venezuela, Ohio, Tennessee, and Mississippi. The patient is from Mexico.

 
With best wishes for your professional success, 

 
Wm MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville and rural
www.psot.com

Index--ERMedicos-burn clinic cases

Medicos J Club QA/QI: Sugar in the Urine

Dr. Martinez shares two cases from Medicos-Nashville. Neither of the cases below meet currently accepted standards for GDM. Close , but no cigar.
These cases highlight the confusion surrounding the the non-disease of glucose intolerance during pregnancy. Headlines in the Memphis newspaper this morning.--The frequency of diabetes has doubled during the past ten years. They failed to mention that a substantial part of the increase was due to lowering the number at which diabetes was diagnosed.

MEDICOS has chosen to use conservative measures for the diagnosis of "gestational diabetes mellitus".The following cases with abnormal urine glucose tests are interesting but insufficient to require intervention.

How interesting that the 3 h GTT at 35 weeks was normal. Even at this late date, the test probably provides "cover" should the patient develop complications. I can't blame the physician who ordered it, and it is his right to do so. We always see something new at MEDICOS. If it had been abnormal, biweekly NST's and AFI's would have ensued with probable induction at 39 weeks.

Notations regarding "borderline(abnormal)" anything do not serve the patient. In the event that there is an unexpectedly bad outcome, this notation can be used by plaintiff's attorney to imply failure to diagnose. Please do not use this 'borderline" terminology in the notes of Medicos patients. It only serves to raise the red flag of potential liability for all other members of the group.

--wmr
 
CASE #1:  Pt  #38025, Pt is 21yo G1P0 EDC 11/22/08, 1 hr glucola at 25wks was 110.   Fundal height had been appropriate at each visit thus far.
 
seen 10/26 for pnc by Dr. xx at 37wks,  noted to have urine glucose of 250, and urine protein of 30.  She has had glucose in her urine 3 other times during her pregnancy (at 15, 23, and 32 wks), and has had protein trace or 30 in her urine at each visit except for one. and has notation in her chart that she is 'Borderline Glucose Intolerant' and should consider metformin or Glucotrol at next visit.
 
 
CASE #2:  Pt  #39779, Pt is 26 yo G1P0 with EDC 11/23/08.  1hr glucola at 26wks was 127.  Fundal height has been appropriate at each visit.
 
Seen 10/21 by Dr. xx at 35wks gestation.  Was noted to have >1000 glucose in her urine, and also noted to have 500 and 250 glucose in her urine the two previous visits.  Pt was given a 1 hr glucola at her 35wk visit and results were 153.  3hr glucola was performed at 36wks and returned normal (62/136/113/99). 
 
 
DISCUSSION:  Glucosuria when found in a non-pregnant individual can be worrisome and warrants further testing. My understanding is that glucosuria is common in pregnancy, and most of the time, it is ignored. I am not aware of criteria to diagnose glucose intolerance based on findings in the urine, nor of beginning therapy because of this.

The most I have ever done with a patient with recurrent glucose in the urine was to counsel on decreasing refined sugars in her diet, and perhaps serial fingerstick blood sugars...  I suppose doing a HgbA1c would also be possible.  I have never done a glucose challenge on a patient late in pregnancy, and am not sure I would have even considered it.

Your comments would be appreciated.
Conchita
  
 Bill:

I agree with most of the statements. I do try to "protect" our FHC patients from unnecessary tests, which in general carries more unnecessary test, that harms the patient with fear and sadness for a very poor gain.
If one of our patients has glucose in the Urine I do an Accucheck............. that simple. if it is 85........... you are done: glucosuria in the preganacy. Nothing else is necessary. If it is 150 I order a 3 hs GTT. If normal............ stop.

Agree with you that there is nobody "bordeline pregnant" then there is nobody "borderline .................. anything". I do delineate a f/u, discuss it with the patient and I always follow the chart myself later.

In the second patient I would NOT do the 1 hr that is a very unreliable screening test, but I'll order a a 3 hr GTT and and HbA1C.

I'll copy this to my residents then they know that I'm not the only one that thinks about GDM the way I thinks. I'll try to involve them in this dialogue to enrich them and increase the awareness of bad medicine.

Eduardo
Rockford 

My Comment:
 
The lowering of the glucose renal threshold during pregnancy is common, and I have always ignored late in pregnancy if the patient was screened at 28 weeks with glucola.  It does warrant a glucola testing early in the pregnancy if glucosuria is observed, but in the event of a negantive glucola, a repeat glucola at 28 weeks should still should be perfomed.
 
I agree, that over-zealous documentation in the chart is the equivalent of slipping a noose around one's neck while balanced on a tree branch.
 
Greg Laurence

Index--OB, GDM ambiguities