PSOTBLOG

Medicos QA/QI

Thank you for participating in our teaching efforts. As you know there is a review of all consults and/or interesting cases in order to maintain a mutually beneficial educational environment. I continue to ask that all junior physicians, residents, and students keep copies of their pink and green sheets, for review at the end of each rotation.  These are audited to make sure that students and residents have a list of issues documenting their understanding of the "big picture".
 
1.Male with frenulum tear on penis. These lacerations can be repaired by Lamin, Conchita, Chiu, Millard Collins, Julian Fields or anyone who does circumcision. The patient was seen in followup today at my request. The bleeding had stopped and he did not go to the urology appointment. Medicos has a highly developed office surgery curriculum in support of cases like these. Call me anytime 901-351-3762 if there are questions on these cases.
 
One recently departed physician repeatedly came back to Medicos to borrow office surgery equipment which was not available at his new job at the Waverly Belmont FQHC clinic. Residents hired into these settings eventually relinquish all of their procedural skills. These settings gradually "dumb down" family medicine due to their inability to maintain diagnostic and surgical services such as ultrasound, x-rays, and surgical equipment. Only Medicos has successfully supported these services. If you encounter a nonemergent case for office surgery or a difficult ultrasound, and I would appreciate a call. Medicos will be building its procedural curriculum in Nashville by having office surgery day every week. We are looking for cases.
 
2. Medicos emphasizes antibiotic injections for children with strep throat and otitis media. Research has repeatedly demonstrated that patients do not fill the prescriptions and/or do not take the pills as directed in at least 50% of cases. This is made worse by language barriers. Medicos has a "point of service" document which highlights  the "Medicos guidelines" for uninsured and Tenncare patients with barriers to care. Please make sure, you review this. It will improve your experience at Medicos and help our patients.
 
3. Otitis externa should NOT be treated initially with cortisporin-neomycin-polymixin. Please stock white vinegar
(3% acetic acid) in 10-20 cc bottles. This is the curative and cheap approach for 90% of these cases. AND it does not breed resistant bacteria. It is also good for gradual dissolution of cerumen. RX bid without cotton inserts or Qtip use. See Medicos guidelines attached below.
 
4. All repeat Cesarean sections must be referred to me or Conchita without exception. We will arrange appropriate consults with the objective of having Medicos particpate in the Cesarean as a service to the patient and her new baby.
 
5. Dr Rodney would like to review the Paps smear log at the next meeting.
 
With best wishes for your professional success, 
 

Index--Medicos clinical newsletter; Meds4Uninsured; Curriculum updates
 

HCA and Medicos

I have to confess that the moment remains bittersweet.Yes, Medicos was instrumental in providing testimony unfavorable to HCA at the CON hearings of Feb 25, 2009 in Nashville. Medicos physicians exposed the the corporate manipulation of services by HCA in their hometown. Unfortunately the testimony which they orchestrated gives further evidence to the effectiveness of their corporate juggernaut. I believe this juggernaut will, unless redirected, have a negative influence on the survival of the medical profession as we know it.
 
Isaacs et al NEJM 2-12-2009 p655, " The Independent Physician--Going, Going..." and NEJM  Franz Ingelfinger 1990 who predicted the negative influence of what he described as the "medical industrial complex". Geyman JABFP 2003
 
As private practice family physicians who feel morally committed to the care of uninsured and underserved women we have grown accustomed to our minority status. We have been marginalized and discredited as irrelevant to the coverage needs described by Genesys OB and Dr Hamburger yesterday. HCA has made it very difficult for us to obtain hospital privileges and they have formed a complex series of interlocking relationships which allow discrimination under the banner "high quality care".
 
Yesterday, commission members correctly perceived these administrators were less than forthright. Many examples. Even the kindly gray haired neonatologist could not bring herself to clearly answer the question of profit driven inconvenience for transport of newborns to Centennial one hour away versus MTMC ten minutes away. The discouragement and deflection of Family Medicine's opportunity to apply for privileges was redirected to the legal fact that "HCA Southern Hills never received the application and we have no record of it". A classic case of blaming the rape victim for inciting the offense.
 
But, family physicians correctly question whether they should assume the personal risk in publicly challenging the workd's largest for-profit hospital system in the town of their corporate headquarters. On the bright side, no new enemies were created. These people at HCA have made it difficult for fair play from the beginning. Simultaneously they have proclaimed their intentions to be above reproach. The main HCA executive testified to the effect that he had known all of the board members "too long" to ever attempt to mislead them on any issue of health care for the public. Then there was the ad hominen attack on California nurses interfering with Tennessee business. Wow! Deja vu Enron et al.
 
To be fair, the right hand of these large corporations frequently doesn't know what the left hand is doing, and there are some kind people in the HCA system. Nobody seems to grasp the big picture and the ecological damage done by all too fallible corporate chains of command.
 
But, plausible deniability does not excuse the fact that there is a widespread dysfunction and bias in this system. Many of these hospital helath care systems have been silently doing damage to health care among uninsured and underserved women while publicly proclaiming "we are the best". The fruits of subspecialism need to be balanced with the unique 24/7 365 committment offered by facilties such as Medicos para la Familia. The technological miracles for the tiny babies has overrun the needs of 98% of the women who have uncomplicated deliveries.
 
Hopefully the Family Medicine-OB cause and abilities will be recognized as desirable by other hospitals in the Nashville area who will then grant us privileges. We are going to have a talk with Dr. Shaw at Baptist, and we will approach MTMC. HCA may label us as the enemy, but we repeat our request that they talk to us and find the common ground. Medicos' focus remains on a prosperous and righteous future for those students and other physicians who wish to join us on the "...road less traveled" providing health care to least well off members of our society.
 

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

HCA OWNED AND OPERATED BY OUR COLLEAGUE / REPRESENTATIVE BILL FRIST AND HIS FAMILY.  MONEY BUYS ALL.  OBAMA STATED RECENTLY THAT HE WOULD HELP LOWER COST BY ENCOURAGING COMPETITION BETWEEN INSURANCE COMPANIES - YOU KNOW WHO IS THE LOSER ON THAT ONE.  THEY ALSO THINK THE EMR AND ELECTRONIC PRESCRIPTIONS ARE GOING TO SAVE THE WORLD.  WHERE DO THEY GET THAT IDEA ???  THE CEO OF ALLSCRIPTS IS ONE OF OBAMA'S ADVISERS.  THEY REALLY WANT A SYSTEM WHERE THEY CAN MONITOR THE GOOD OLE DOC AND MAKE SURE HE IS DOING EXACTLY WHAT THEY WANT - AND THEY WANT US TO DO ALL THE WORK SO THAT WE CAN BE MONITORED !!  THEREFORE, ANOTHER 10 LAYERS OF RED TAPE WILL BE CREATED AND THOUSANDS OF MORE IDIOTS DELVING INTO THE MEDICAL PIE MAKING US CRAZY BUT A NUMBER OF OUTSIDE ENTITIES WILL MAKE A FORTUNE.  THE PHYSICIAN WILL BE TOSSED A BONE OF SOMETHING LIKE 1-2% MEDICARE BONUS.  WOW, INSTEAD OF $74 FOR A LEVEL 4 VISIT WE GET $75.48.  YOU DON'T SEE AMERICANS SWIMMING TO CUBA NOW DO YOU.  BOTTOM LINE IS THAT THEY WANT TO CREATE A "MEDICAL HOME" AND UNFORTUNATELY OUR REPRESENTATIVE ORGANIZATIONS HAVE NOT BEEN ABLE TO SHOW THEM THAT WE HAVE PROVIDED THAT SERVICE ALL ALONG.
 
PERRY C. ROTHROCK III, M.D.

Sorry my ignorance but I do not know what is HCA or CON.
I'd love to help. I suffer similar problems every day.
Let's keep up with our work, try to enjoy what is good for our patients and make long term plans in how to change this environment.
My 2 cents.

Eduardo

Bill:

The neonatologist you refer to below is Susan Campbell.  She works with Sami Ismail.  I know them both fairly well.

Today, The Tennessen quotes Norm Hamburger, the senior partner at Genesis now, along with Al Fox and Gina Hamrang.  There are several misleading statements recorded in the article that are rather concerning.  In one, he states that Genesis went from 7 members to 3 after others retired due to disabilities.  In fact, only Marissa Ogle retired because of disability (Carpal Tunnel) and is now selling Arbonne.  Steven Ross retired because of other health problems, and both Cynthia Wesley and Kathryn Mills left because of internal disagreements.  Wesley opened Lotus Women's Care just down the hall but left the area after a couple of years, and Mills is now a laborist at MTMC.

I mention this because it supports Bill's statement below that the HCA axis has been "less than forthright" in their public statements, and even in their revelations to board members "which they have known too long to mislead".  I believe it also supports his claim that locally, HCA is biased against Family Medicine doing anything other than ambulatory care.  Though Genesis is not under HCA employ, they play the HCA game well, and are one of the groups HCA used to destroy Cedar Medical Group's Family Medical approach to "do it all" months after we opened our doors after being recruited to do the same by HCA in 2002 (opened 4Q 2003).  Having served on the Board of Trustees and the MEC at StoneCrest and being the first Chair of OB/GYN and Peds at the hospital, I came to realize quickly that thought they say they hold themselves to a higher standard, they use a great deal of deceit, manipulation, and intimidation to advance their objectives.  On the other hand, I must say my involvement at the corporate level on HCA's Executive Perinatal Services Committee was very satisfying as all on the committee exhibited outstanding decorum and professionalism, and also seemed to be unbiased towards Family Medicine.

I know their game well.  Their playbook is straight out of the hallowed halls of the Horty Springer law firm.  They manipulate physicians, hold them captive, and destroy them should they raise a finger in question by using their own Medical Staff Bylaws written by Horty Springer and the hospital, and passed by the MEC and the Board.  Several local physicians have recently called me in fear as they are being compelled to vote in certain ways on committees - including peer review.  If they fail to vote as instructed, they risk laying themselves on the chopping block.  Though there is a great deal of talk out there about preventing these types of things from happening, no one is really interested in standing up for the individual physician - including AAPS - because it is risky, expensive, and time consuming.  It can also be career ending.  I agree with Bill, American medicine is in serious danger and is almost irrecoverable.  The AMA, TMA, AAFP, etc are playing dead, and AAPS is of no real help.

That said, I agree there are many good people at HCA, and I believe HCA has a very good operational business model as is evidenced by their incredible success.  However, the culture that is bred is one of deceit, fear, and intimidation and is one that feigns quality while chasing revenue at the patient's expense.

I found it interesting interesting that Neil Heatherly, the CEO at StoneCrest, announced his resignation yesterday.  There is no one in place to immediately replace him, and there has been no announcement as to where he is headed.  I am not sure that it has anything to do with this, but who knows?

Omar

Index--Privileges reform

Student Seeks Spanish Year Pt.2

William:
 
Thanks for talking us up !  
 
As you know,  we have worked hard to create a program that meets the needs of both Latin Americans and US health care personel.
 
We are unique in that we have become a major training center for AHA and for ALSO in Mexico.   San Miguel is now a UNESCO World heritage site.  The cost of operation in San Miguel is more expensive than elsewhere, but we find that the cultural enrichment is is worth it.
 
We are actually working with the ALSO network in Guatemala and Ecuador to develop local MedSpanish sites there and to have the students bring them some ALSO training equipment.
 
In any case,  If someone wants to spend an extended period of time with us, it is our practice to charge two months regular tuition and then the cost is to cover the cost of the Spanish tutors. In addition to the Medical Spanish experience, we hare glad to have students  help out with training around the country ( http://pacemd.org/calendario.html )
 
This summer , we have a 6 week long Pre Clinical program whereby the student actually becomes Eligible for a NREMT Cenrtified First Resonder certification and then spends the remainder of their time as a third rider with the Red Cross ambulances, while learning general and medical Spanish.

Another point worth mentioning.  Because our programs are highly individuallized , we are able to take absolute beginners and generally progress rapidly with them.
 
We are interested in working out strategic relationships, leveraging our successess and experiences with organizations that can further our mission and develop our excellent training sites.   Please review our review and share this link http://www.squidoo.com/PACE-MedSpanish
 
¡ Nos Vemos !
 
Haywood Hall, MD FACEP

Hola,
 
There no country that should not be entered with caution and situational awareness. And the expectations on both sides and at different levels need to be considered. Drugs and politics have a complicated history in Latin America  (and South East Asia, and with our present wars).  We have not always been on the right side (Noriega was our friend when we needed him to help with the Sandanistas). Most people in the world seem to have a better memory on these things and that is just some of the baggage our budding medical providers carrry.
 
I dont know much about Bolivia, but the issues are probably more political than personal.  That is to say, the LAST thing that the Cubans and Venezuelans want is an injured US medical student on their heads.  I have been to Cuba (legally) and found the people to be extremely curious and friendly.   On the other hand, there are neighborhoods in any urban US setting where  the risk is SERIOUS.
 
It is different being a (efferent) student of a language and a culture in a a general or a clinical setting.
 
It is also a completely different thing to be an afferent monolingual episodic service provider on a mission.  It provokes completly different responses from locals at different levels.
 
And even more so if it is part of community based training such as  the Advanced Life Support for Obstetrics program in Chiapas.
 
 
On actual Spanish training, it is my significant experience that we can get 90% to at least do a history and physical in 3 to 4 weeks in Spanish.  Communicating informed consent , however, is a big thorn (even in English).It probably takes 90% of people 4-6 months to get more generally fluent.It is important to note that any reasonable attempt to communicate results in a better therapeutic relationship, even if you still need an interpreter.
 
Here is something on you tube about the program we run.
 
http://www.youtube.com/watch?v=4pHUMZKCjyY
 
 
Saludos,
 
Haywood

I agree with Dr. Rodney to enter countries like Cuba, Venezula and Boliva with caution. I am going to Bolivia in March, but with the knowledge that things may change at the last minute and I will be unable to go and am only going for a short time to a needy area to provide services with contacts I know and trust from there. If one is going for a longer period of time or with the goal  to learn spanish, other countries in general are better and and having reliable contacts in important!  Yes, the Ambassador and the Peace Corps were kicked out/left over conflict with the president re: cocaine production.
 
I would say from personal experience that while in a year you could be very fluent you probably don't need that much time. I have spent 2 2-weeks stints in the Dominican Republic, 1 month long stint there, and 2 weeks in Bolivia over a 5 year period and have taken Rosetta stone and while I am far from fluent can see most patients by myself without a translator in the office/hospital and can travel comfortably in country, be sociable, etc. Small immersion times also work well over longer time period and can get you the fluency you need/desire without requiring more time in school.
 
Just my input, Michele

More Obstetrical Experience

INQUIRY:

Dear Dr. Rodney,

I have a third year resident looking to get more OB experience.  Do you have any one month electives for OB for April 2009?  We would supply his malpractice

insurance.  He is going to join our faculty and perform deliveries with us (there are just two of us currently doing it now)  He is extremely smart, very

conscientious and hard working.  He is taking the ALSO course in March. Please let me know if you have any openings or any suggestions. 

Thank you for your time,

  From 2005-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 (wmr):

For those trying to build OB, I highly recommend it. Financially it built our department. I admire your efforts to build from within, but you must have the

FM faculty to cheerfully take OB night call schedule.  Few academic family medicine groups have achieved this FM-OB infrastructure, and if it was already in

place you would have no problem training your own. 
 
The main issue for rotations in another state is the "lead time" necessary for licensing anb hospital privileges. Medicos functions without external support

from taxes and grants. Medicos is "private practice" with a training mission(ie, a rural simulation in a city). Your offer to provide malpractice insurance

is noble, but a Tennessee hospital probably will not recognize policies from another state.
 
Physicians cannot legally touch a patient in a hospital without acquisition of a valid medical license and hospital privileges. A "training license" will not

suffice.The lead time necessary for these administrative tasks is 6-12 months depending on the state. Ironically tax supported universities have become

equally provincial.
 
If you find a place where these obstacles do not exist, let me know. I had to obtain Arkansas medical licenses for my physicians to do some rural work in

that state. Getting a Texas license can require a year or never for an IMG. I do know that someone recently had a successful rotation in Alaska, but the

volume may be less that you expect. John Cullen has a post on this topic.
 
This typifies the dilemma for FAMILY MEDICINE-ob training. Lead time and a committed critical mass of family physicians is needed to build and sustain

delivery services in any community. Unfortunately urban programs are more likely to have patient volumes 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. This is a dilemma.
 
Please read my recent blog on the need for a numerical definitiion of 'more obstetrical experience". Is the resident seeking one more delivery? Ten more? One

hundred more? If only we could design a way for more "emergencies" to occur.
 
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 added the ability to obtain competency in operative deliveries. We did other helpful things such as mandatory ALSO and a rigorous ultraound curriculum.

The data from 77 graduates over 17 years suggests that this is a better model.
 
 In summary, family physicians should understand these licensing and administrative issues if they wish to gain access to community-based experiences as

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

The 4 weeks after 3/30 can be a good time to help him. Illinois problem is that he needs to get a license to be able to do something here.
Then he can contact me and our coordinator Brett Ruiz (815 972-1030) email is in the CC.
Started at 3/30 and finishing 4/26;

Eduardo Scholcoff, MD
University of IL at Rockford.

Index--Rotation-training requests (an oldy but a goody)
 

Ultrasound Coding

Question:
 
Do you know if using the high risk code gets you more than the one US with medicaid? We are using that code often here, and I don't believe it is specific enough to get paid.  I can't seem to track the info though:) 

Thanks. 

Kim

REPLY (WMR):

The answer is YES, and this is a good area in which we should share resources. I have just finished a very tedious review of this topic using the 2007 and 2008 data from our EMR. Medicos has increasingly emphasized practice management in its fellowship curriculum, and this area of high risk coding was one of the major QI changes in 2008 at Memphis. Medicos cannot avoid high risk and, we must manage it well. Why not get paid for it?
 
We have not been coding it correctly, and part of this is due to the bad advice we received from hospital coders.
 
According to the data of 2008, Medicos now has system that works better. But, it is a 20 minute presentation to describe the core content, the present situation, and propose continued improvement.This is part of our email journal club process and will lead to changes in the format of the encounter form as well as individual retraining.

SUMMARY 2008[n= 371 deliveries most of which were not "high risk"]
            Use of V23.89 high risk led to successful reimbursement on 337 visits for      $15, 712
            This allowed reimbursement for 184 NonStress Tests 59025                       $  5,974
                                                          116 limited Ob US    76815       $  7, 466
                                                          19 BPP               76818       $   1,328
Additional revenue for improved monitoring of GDM, PIH, and other cases
                                                                                           $ 30, 480
 
                                                           
I believe that most situations requiring an NST merit a limited US 76815, so I suspect that we are still not capturing a significant amount of revenue for the services we provide. This is the classic dilemma for the busy physician. I'd like to propose that we develop a research proposal in this area.
 
In separate conversations,  Drs Givens. Harraway Smith, and all of us combining Family Medicine-OB have indicated the desirability of a combined regular meeting. Since resources are chronically scarce, could I take this opportuniity to volunteer a lunch or supper conference?
 
It would be nice to share resources for a monthly educational conference on other items which we naturally share. Medicos has finally developed its staged curriculum on colposcopy basics, ultrasound OB, ultrasound Gyn-ovaries and ectopics, moderate sedation in the office, basics of office fractures, and others. As you have observed, moderate sedation with analgesia is the  key to office D&C.                 
 
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor of Family Medicine

Index--ultrasound coding, fellowship business currciulum

Students Seek Spanish Year

A medical student writes about taking a year off for a Spanish immersion experience. His letter is appended at the bottom. For years I have seen students set off for these experiences without investigating the amount of actual structure and feedback they will receive. My own daughter went for a month in Cuba which was advertised for "Spanish fluent" medical personnel only. Many of the students who went lacked of Spanish. Why? Because these are  not true educators. They make their profits by having the Americans pay dollars(almost always up front non refundable), and the educational instruction is only a shell for the recruitment of students who then have little recourse to complain.
 
In addition to the risk of coming in and out of Cuba, Cubans I trust are amazed at the under-reporting of human rights violations by American media. Students do not realize the extent of oppression which still exists there. Raul Castro's reforms allowed people to buy cell phones and computers for the first time in Fall 2008. Access to the internet is still restricted in Cuba as of 2009. You are ill advised to enter these countries(Cuba, Venezuela, Bolivia) at this time.
 
Michel Walsh is returning to Bolivia this March. She may have something to say, but wasn't the American Ambassador to Bolivia ordered out of the country?
 
Reliable language schools are well known in San Miguel Allende, Mexico and Guatemala which are USA friendly countries with no political risk and access to the internet. There are  family medicine programs in Ecuador, la Republica Dominicana and in Argentine. We have good contacts in these places.
 
Medicos and the Camellia Foundation have an interest in sponsoring or collaborating with medical students on these endeavors. But let us send you for a week to interview with Brad Quist in Ecuador, or talk to Patrick Moran MD when he comes to town Feb 13. He is going to Nicaragua to explore the beginning of a training program there. More to follow.
 
Dr. Rodney:

I'm sure you appreciate the fact that every American physician should be prepared to treat Spanish speaking patients, especially since demand is only growing. As much as I enjoyed my experience at Medicos I felt that my ability to contribute was compromised by my dependence on the English language. For these reasons I am seriously looking at taking a year away from UT to have a medical experience abroad in a Spanish speaking country. Of course I realize as a third year medical student without language proficiency means I have very little to offer the international community/would be employers so I am trying to be realistic with my expectations.
 
Right now I am making inquiries about joining international medical students who enroll in a Spanish language immersion semester in the Cuban medical school system. Cuba is particularly interesting not only because of its focus on international medicine but because much like Medicos they present a model of healthcare which provides for many with minimal resources at a fraction of the cost. I am not sure what is realistic yet but if you have any suggestions and/or advice I am all ears. Any rewarding medical experience research included-although clinic based) in a Spanish speaking country would be appealing to me. Please tell me what you think when you have the time. Thank you and thanks again for making our CIAO guest speaker series an annual success.
Sincerely,

Houston Bonnyman

William:

Thanks for talking us up !  
 
As you know, we have worked hard to create a program that meets the needs of both Latin Americans and US health care personel.
 
We are unique in that we have become a major training center for AHA and for ALSO in Mexico. San Miguel is now a UNESCO World heritage site. The cost of operation in San Miguel  is more expensive than elsewhere, but we find that the cultural enrichment is is worth it.
 
We are actually working with the ALSO network in Guatemala and Ecuador to develop local MedSpanish sites there and to have the students bring them some ALSO training equipment.
 
In any case,  If someone wants to spend an extended period of time with us, it is our practice to charge two months regular tuition and then the cost is to cover the cost of the Spanish tutors. In addition to the Medical Spanish experience, we hare glad to have students  help out with training around the country ( http://pacemd.org/calendario.html )
 
This summer , we have a 6 week long Pre Clinical program whereby the student actually becomes Eligible for a NREMT Cenrtified First Resonder certification and then spends the remainder of their time as a third rider with the Red Cross ambulances, while learning general and medical Spanish.

Another point worth mentioning.  Because our programs are highly individuallized , we are able to take absolute beginners and generally progress rapidly with them.
 
We are interested in working out strategic relationships, leveraging our successess and experiences with organizations that can further our mission and develop our excellent training sites.   Please review our review and share this link http://www.squidoo.com/PACE-MedSpanish
 
¡ Nos Vemos !
 
Haywood Hall, MD FACEP

Index--Spanish Lang Develolpment