PSOTBLOG

Swine Flu Policy

 

 
POLICY-4-30-09

Physicians should be free to exercise their professional judgment on the "swine flu", but Medicos will remain open conducting business as per any flu season scenario. A slightly different opinion from Vanderbilt is attached below.
 
Thank you to Ana Cespedes MD for sharing the information on Vanderbilt's guidelines for the "Swine Flu". They are well written and well intentioned. But, these guidleines create considerable work and expense for the average office.  There is no clear evidence that this flu is anything other than another "flu season".

Medicos will continue to focus on service to the community by remaining open without appointment 7 days a week. Medicos receives no government support and has limited resources for an underserved community.

Medicos' resources are already stretched by hyperregulation of everything ranging from lab to vaccines (required monthly reports on the temperature within the refrigerator 24/7).
 
1.Are the Vanderbilt guidelines attached below or the faxed DHHS guidelines an urgent call to action? Should Medicos implement these guidelines today?
 
2.Who will purchase and transport at 4 degrees the viral transport media? Will the uninsured pay for these tests or should the doctors pay for it? What is the cost of one test?
 
3. Does the average office have the ability to immediately train and then monitor the quality of these complicated recommendations?
 
4. Are there proven benefits of providing anything other than usual conservative care for an upper respiratory viral infection?
 
5.Given the nature of current media reporting on health care issues, isn't it possible that this is more of "numerator news" where a small number of tragic, but naturally occurring, cases are sensationalized for a variety of reasons?
 
POLICY--4-3-09

Physicians should be free to exercise their professional judgment on the "swine flu", but Medicos will remain open conducting business as per any flu season scenario. Those who initiate costs are obligated to pay for them.

 
VANDERBILT GUIDELINES
Currently, our message to staff is "Be prepared, not scared."  In an effort to help you understand the situation, we are sharing how Vanderbilt Medical Center is responding and what you can do to help.

The following actions should be implemented IMMEDIATELY:

ASK any patient presenting with fever and respiratory symptoms (cough, runny nose, congestion, or sore throat) the following:

1)Have you traveled to New York; San Diego or Imperial Counties, California; Guadalupe County, Texas, or Mexico in the 7 days prior to when your symptoms began?

2)Have you had contact with anyone who lives in or has recently traveled to any of these areas in the 7 days preceding illness onset?

If a "YES" response to EITHER question, do the following:

1)Place a regular surgical mask on the patient

2)Put the patient in a private room as soon as possible and keep the door closed

3)Health care workers: Wear an N-95 mask; gowns/gloves; eye protection (NOTE: this is likely to change in the next 24 hours based on CDC guidance).

4)Contact Infection Control and Prevention at  835-1205 IMMEDIATELY

5) Obtain a "flu test" using two swabs: one of the nose AND one of the throat, instill in viral culture media, and send to the lab as per usual practice.  Note on the requisition that there is a concern for swine influenza.

Vanderbilt faculty or staff who have respiratory symptoms and have either recently traveled to an affected area or have had close contact with someone who has had a confirmed case of swine influenza should contact the Occupational Health Clinic at 936-0955 to determine if further evaluation is needed.

FOR CLINICIANS AND CLINICS FACED WITH CALLS FROM PATIENTS:

Patients should be advised not to come to the clinic just because they are concerned about "swine flu."  In addition, usual care for patients is the rule.  Only admit those patients who would otherwise need admission -- do not admit for concern about swine flu; this increases the risk of transmission to others.   Additional guidance for the outpatient clinics on managing patients with swine influenza concerns or suspected illness will be forthcoming.

REMEMBER usual INFECTION CONTROL and PREVENTION PRACTICES:

1)ALWAYS wash your hands (either with soap and water or an alcohol hand rub) BEFORE and AFTER contact with EVERY patient and/or his or her environment

2)ALWAYS wear the required isolation personal protective equipment UPON ENTRY of the room of a patient on isolation precautions, even if you do not plan to physically touch the patient.

3)Follow respiratory hygiene and cough etiquette:

a. Cover your nose/mouth when coughing or sneezing;

b. Use tissues to contain secretions and dispose of them after use;

c. Perform hand washing after having contact with respiratory secretions and contaminated objects/materials.

Please be advised that these issues are evolving and advice may change as new information arises.    Please check the list of swine flu frequently asked questions at http://www.mc.vanderbilt.edu/root/vumc.php?site=infectioncontrol&doc=22025.

With best wishes for your professional success,

FM-EM-OB Issues

I returned from Texas last night, to face a night of call. With the events of a 3 AM 16 yo preterm labor fresh in my mind, I am reminded of the fact that there are two kinds of doctors. There are those who get up in the middle of the night and those who do not.

H. MacMillan Rodney MD 1920-1972.
 
I believe that emergency medicine and family medicine share similar destinies with some, but not all of their members, dedicated to providing health care unrestricted by time of day, age, gender, and organ system. At this point in history these physicians are in the minority and , therefore, idealists. Idealists frequently participate in the process of political reform. One area, as described by Dr Buckler below, is the lobbying for revision of hospital bylaws. I agree, but this will be a city by city, hospital by hospital process.
 
This is similar to the Family Medicine Obstetrics process, and we might borrow from those lessons.
 
The bottom line will be fairplay for qualified physicians seeking employment. there are several approaches for achievement of this outcome. One of them has involved the "legacy FACEP" designation, but there are many without FACEP who also qualify. This machinery established a principle within ACEP. My thanks to the section members.
 
John Peter Smith in Fort Worth Texas is seeking to establish an accredited training program blending family medicine and emergency medicine. The BCEM(one year fellowship following a primary care residency allows the physician to sit for written and oral examinations) approach drew the political wrath of ACEP and ABEM. JPS then applied for stand alone EM residency which apparently was denied.
 
The dual residency EM/FM is now being considered. Drs Haynes, Camargo, and others have approached TCEP and others seeking support for a combined 4 year program. As a former member of the FM RRC for 6-7 years, I have had considerable experience with the dual residency issues. I believe the 4 year program is the best available choice, but the ultimate court will be approval by the RRC's of both of the ABMS boards(ABFM and ABEM).
 
The 5 year residency probably will not be sustainable in the market place. Wilmington Delaware has one, and followup data from graduates will be helpful. These programs probably will not add value for those seeking to address the maldistribution of physicians in the USA and globally. Physicians headed for rural and mission medicine benefit from the combined training of EM-FM, but can readily obtain "earn while you learn" positions in all cities whose market is not dominated by an academic medical center. This has been the most common reality, and how I personally became boarded in EM.
 
The persistent success of the FM-EM fellowships(they are growing and BCEM is growing), demonstrate a market for the 3+1 year track(4 years total). Where might we go from here?
 
PLAN #1 -ABEM/ABFM
Create a written proposal by combining the RRC requirements for EM and FM.
Identify the common elements(ICU, OB, ED, peds, surg, etc)
Check to make sure they can be accomplished in 48 months--If not stop and let's meet
Identify membership of the current RRC's for EM and FM
They cannot go on the record in any way, but.........
Find the objections and count the votes
 
PLAN #2
If the ABEM/ABFM plan cannot be achieved politically, seek permission to proceed with a two tier Emergency medicine training system similar to that of Canada. Basically this will be an extra year of EM  fellowship. It probably should not be linked to BCEM in any way, but would fit within the P4 programs currently available at JPS. Graduates would get a "fellowship year certificate" which then leads back to the issues of hospital recognition per Dr. Buckler below.
 
Since BCEM represents a threat to the current ABMS-AOBMS monopoly on medical credentialing, a fallback position would be to negotiate at the state level for "cease fire" from TCEP. At least there would be an improved training program for addressing the rural and global maldistribution. As time goes on, rational forces might prevail leading to a permanent reconciliation on common ground.
 
Your comments and consideration are appreciated,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural
www.psot.com

Dr. Buckler writes:

I listened with interest to Carlos' excellent presentation of his workforce study, at the ACEP LAC in Washington, DC last week.  I think many ACEP members in attendance learned something new, and that the College is slowly becoming aware of the reality of the EM workforce situation.  It would seem to logically follow that we must now find ways to utilize doctors who are ready, willing and able to work, in spite of being outside the class of the "chosen few".

We should now turn our attention to educating and encouraging hospital medical boards to recind their exclusionary bylaws, if only to make an exception for emergency medicine, a specialty which Carlos' study has clearly shown to be still in its early stages of reaching equality within the House of Medicine.

Hi Bill:
 
Thanks for the thoughtful email. I agree with your ideas and suggested plans.
 
I also would start with Plan #1 (four-year FM/EM). This would result in graduates that were -- one would assume -- acceptable to everyone. However, the change from 5 to 4 years is critical. I don't understand why ABEM wanted complete parity with pediatrics and IM. Peds/EM need to learn about adults and OB ... IM/EM need to learn about children and OB ... while FM already covers children, adults and OB! I think we can make a persuasive argument why peds/EM and IM/EM should stay 5 years and FM/EM should be become 4 years. Evidence that it's difficult to recruit residents into 5-year programs and that the country needs graduates with this combined training will help to move this along. I like your approach below.
 
As you know, Plan #2 will meet with immediate resistance ... and outright hostility. It would be unfortunate if Plan #1 suffered by its association with Plan #2.
 
To be clear, I think it would be fine to have both options but I think that Plan #1 is the better choice for us work on right now -- and in the near future. As people get more informed about realities of the workforce (both in EM and for primary care in general) ... and more and more rural emergency physicians retire ... and more and more money is put into primary care ...  we may see some major changes in attitude, especially by those OUTSIDE the house of medicine. What's impossible now may seem quite obvious in a few years.
 
From everything I hear, President Obama is very likely to sign health care reform by 12/31/09 and that's going to change the political landscape for many of these issues -- including how to best handle the workforce shortages in rural America -- in both primary care & emergency care.
 
Thanks for leading the way. I've admired your work -- both in US and overseas -- for many years.
 
Best wishes,

Carlos A. Camargo, MD, DrPH

Not very experienced in ER.

I'm more in the philosophy of FMOB. While I think that the ER experience can be good for the specialty, I do not know if there is enough power or is too much diversification.

I see a lot of Family Doctors "seeing " the opportunity in Immediate Care. I think that the Medical Home has to include that for our own patients.

My two cents.

Eduardo

  
 Index--fellowships, FM-EM, FM-OB, maldistribution

On the Subject of Emergency Care

The skills of emergency medicine travel well. For over thirty years I went back and forth from emergency medicine to family medicine. I encouraged my faculty and partners to do the same. We were better doctors for it, and our patients were grateful. Gradually hospital and corporate interests became more dominant, and this reduced the degrees of freedom within the practice of medicine. Formerly the emergency department was a responsibility shared by all physicians on staff. Subspecialty backup didn't seem like it was such a problem back then.
 
The advantages of a family medicine-emergency medicine-primary care coalition remain sound at the most fundamental levels of high quality patient care, professional excellence, and financial feasibility. Urgent care is one way to describe these opportunities. When you align with other like-minded refugees from family medicine-primary care, the insurance companies will give you the "primary care bonus' of assigning patients to you. This creates cash flow. Currently this market advantage is not available to ABEM.
 
True, you will have to administrate those patients. You were already saddled with these responsibilities anyway. The "midnight hour" drug seekers, psychos, and unassigned nursing home patients--Are these the patients that make your adrenaline pump work? Now you have the ability to make a professional (and hopefully compassionate) disposition without having the hospital administrator look over your shoulder. Or, you may not be open after 7 PM. You may continue to pull some ED nights as a matter of professional pride.You have the right to make your own choices.
 
The onerous task of hiring your own employees becomes more attractive after you live through some of the employment pool choices of corporate. Who can forget some of those quarterly evaluations describing "retired in situ"? And billing becomes much more interesting when you realize that it's "YOUR MONEY"! But , you MUST audit your check  book each month. Small business remains the  backbone of America, and continues to represent a viable future for those who wish to be managing partners.
 
With best wishes for your professional success,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Medicos para la Familia
Memphis, Nashville, rural

Hi Edd:

Surely we all realize our own mortality in the ED and the majority of us will not end our careers in medicine on our last day of practicing in the ED. I am 52 years old with ten y/o twins. I thought I would retire at age 55. So, that said, I will most likely be practicing well into my 60's or later and it surely will not be in the ED.

I have owned an urgent care center for twenty years. Personally, I believe alternating shifts between the ED and an UC center will extend my ED career and I would encourage members of this Section to work in these centers for their own mental and financial health.

For me, I appreciate any post on this list-serv that may benefit any member of this Section.  While the day is coming when I will no longer be able to keep pace in the ED, I believe the experience of the members of this Section will always be an asset to the College. Personally, I will remain a member of ACEP for as long as a stethoscope hangs from my neck.

John N.

The DepoProvera Question

Wow--total non-response on the DepoProvera question! Let me try again.
 
If you believe family planning is an important service integral to the mission of family medicine, and if you believe that DepoProvera is one of the legitimate choices, have you been victimized by insurances who reimburse less than your costs?
 
Do you believe that current governmental RBRVS schedules recommend reimbursement of approximately $38-39 for an IM injection of medroxyprogesterone acetate 150 mg J10555?
 
Would you like to have a reliable source of purchasing these injections such that you cover the costs of the injection plus make $5-10? Remember, family physicians can and should charge for the injection and the visit.
 
WMR

I did ask the parson who buys the Depo and we pay 59 dollars for each. I just start digging in how we do it and the cost.I know that our Federally funded clinic in town they "see" all the patients who need a shot and charge a visit. Each visit is 104-110 dollars.

Eduardo Scholcoff

QUESTION:

Do you know how to get DepoProvera reimbursed by Medicaid??  In our family medicine residency center, we do not currently keep it in the office as it has apparently been a reimbursement issue.

 Hope things are going well.
 
Anonymous faculty member
 
Reply:

First tell me, have your office managers shared the data describing why they think Depo Provera loses money? Medicos is in the same town caring for medicaid and uninsured patients. MedicosMemphis gave 672 doses last year , and Medicos receives no tax or grant subsidies for its office which is private practice. MedicosNashville gave about 200 doses last year.
 
If I understand you correctly, the university does not allow you to stock DepoProvera for Family Planning services because they have told you that it loses money. How is this possible? Before I give you our data, could I ask if they gave any data from their system? What are the numbers they are using? Are they willing to share this analysis with you?
 
Let me give you some commonly quoted data which is available to those who do not shop for price.
Depo Provera Brand name single dose vial 150mg $82.59
Medroxyprogesterone acetate generic 150mg single dose $58.59
Medicos does not pay these prices. Can you use the internet to locate better prices? Until you personally have the freedom to shop, your clinical operation may not do as well as you would like. Shortsighted and/or misinformed accountants can amputate family medicine's ability to provide services.
 
Let's see if we can solve this problem. What a good price to pay for a multidose vial of medroxyprogesterone acetate?
 
 Ryan, Kelly, Jeremy, Dan-JPS, Dan-Tuscaloosa --do they stock DepoProvera in your family health centers?
Response pattern
Dan-yes
Jeremy UT-no
noresponse--Ryan FQHC, Kelly, JPS,
aafp clinical listserv,
stfm procedures listserv--no x 2.
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural
www.psot.com
[TheProcedural Skills and Office Technology Project]

Index--DepoProvera dilemma, how corporate mismanagement deprives patients of needed services

Support for UT Haiti Trip

Dear Doctor Rodney:

I promised one of my fellow classmates that I would forward this information to you to share at your practice. Some of my classmates are taking a trip to Haiti this summer with Medishare. They are in need of several doctors to accompany them on the trip. I do not know most of the details, but I do know that two trips are planned; the first in June and the second in August.

Whitney Cesari is the M1 student who has volunteered to be in charge of finding the doctors and her contact information is: 404-803-0753
wacesari@gmail.com.

I understand that this is rather last minute, but if you are interested or know any other MD's or DO's that might be interested please contact Whitney or pass on her contact information. They have all been working very hard to raise the money to make this trip possible and without commitments from doctors they will be unable to go.

Thanks so much, and I appreciate your taking the time to read this!
See you in the fall,
Rebecca Overbury, M1
roverbur@utmem.edu

REPLY :

Medicos and the Camellia Foundation support mission trips to developing countries and to the underserved everywhere. Usually these populations are best served by the hybrid we teach; i.e., FAMILY MEDICNE-ER-OB. We are sending a UT student to Argentine this next month. Her trip is carefully planned to allow clinical participation and to have "in country" physicians there to support her.
 
Medicos enthusiastically supports students and others who understand the reasons for this approach. I believe we donated some financial support to another UT student for this trip. I cannot recall the specific clinical focus of the Haiti trip, but we remain interested.
 
To qualify for scholarship[financial and staffing] support, applicants should provide the following information. What are the dates? Where will they go? What is the medical purpose[ophthalmology research, pediatrics, etc]? Who is the Haitian contact? Who will provide the medical licenses for medical practice in Haiti?.
 

Index--International rotation, how to support

Colonoscopy Supression

One of our senior gastroenterology fellows at the NYU Langone Medical Center is currently conducting a national study on colorectal cancer screening practices. Would you please take a few moments out of your busy schedule to help with the research project?

Colorectal Cancer remains a major health care issue. We would appreciate it if you could take THREE MINUTES to complete the attached survey. Your responses are anonymous and will be kept strictly confidential. The OFFICIAL 2008 AGA (American Gastroenterological Association) GUIDELINES are attached at the end of the survey for your reference.

To take this survey, please click on the following URL or type it in your web browser: DELETED

Thank you in advance.

Sincerely,

Malini Sahu, M.D.                                                       
Fellow, Gastroenterology                                             
Division of Gastroenterology                                        
New York University School of Medicine    

WMR replies:
 
It is ironic to see this solicitation for purported "research" by a gastroenterology fellow when gastroenterology has been so aggressive in suppressing training for colonoscopy by physicians in the community. Should we support this? Did anyone else receive this solicitation which I have placed at the bottom?
 
Rodney WM. Flexible sigmoidoscopy and the despecialization of endoscopy: an environmental impact report.  Cancer 1992; 70S(5):1266-1271.
 
For years I tried to convince educators and others that the key to prevention of premature death from colorectal cancer was colonoscopy by physicians at the front lines. Sub-specialists want to have their cake and eat it too. They are not at the front lines, but want a steady stream of referrals for procedures that would be done more effectively in family medicine. These community based physicians are most likely to be trusted by the patient. Without this link noncompliance will remain the norm.
 
Rodney WM.  Flexible sigmoidoscopy: The unkept promise of cancer prevention.  Am Fam Phys 1999; 59:270-273.
 
It was sad to see my own state academy turn its back on this struggle. Basically they refused to address the issue,and joined the attack on those of us who wanted to make it a public health issue. Most would rather be damned by praise, then saved by criticism. Now we have multiple published articles in NEJM, JAMA, and the Annals of Family Medicine reporting, "Colonoscopy: Prime Time for Primary Care?"[JAMA March 4, 2009:921-22]. The tree of family medicine remains lost in the forest of primary care.
 
Carr K, Worthington JM, Rodney WM.  Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice.  J Tenn Med Assoc 1998 (Jan):32-34. This article was attacked in writing by Doug Rex MD from gastroenterology who then petitioned my Dean saying that I should be fired for my misguided work in this area. Doug, thanks for helping me get back to private practice.
 
Most of the FM residencies remain uninterested or too politically weak to struggle for righteousness on this issue.This week a Family Medicine department chair in Tennessee said to me, " If it wasn't required, I wouldn't teach any procedures in family medicine. There is too much other work to do in prevention and chronic care." He'll probably get an award.
 
Rodney WM.  Will virtual reality simulators end the credentialing arms race in gastrointestinal endoscopy or the need for family physician faculty with endoscopic skills? JABFP 1998; 11(6):492-495.
 
Meanwhile, those of us in private practice, do we fill out surveys so gastroenterologists can publish and gain academic recognition which then is used to oppose family medicine colonoscopy?
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural
www.psot.com
[TheProcedural Skills and Office Technology Project]
 
      

Index--Colonoscopy suppression, HOW gastroenterology relates to primary care, state of academic FM

Refocusing On Reform

Background:

ACEP member boarded in family medicine refused privileges for ER job in the Virgin Islands and in Florida. She has worked for years in the ER with a spotless record of service and performance.
 
Sadly, the events of discrimination surrounding the Buckler case suggest continued weakening of fundamental principles within the profession of medicine. No need to belabor the issues of big Pharma and the hospital industry as forces which weaken the integrity of physicians individually and as a group.
 
The concept of meritocracy implies that characteristics such as training, education, experience, and proven ability would be used as objective evidence for the granting of professional privilege. Specialty neutral credentialing is within the Medicare regulations. Political manipulations for control of the health care dollar are so powerful that the average physician and the public feel helpless in fighting against them.
 
Do not despair. All is not yet lost. Speak out! Publish! Run for office! Contribute to the campaign of someone you trust! "If you're not at the table - you're on the menu" - your choice.
 
Here in Tennessee, I am urging all of my colleagues to fight against the bill introduced by the Tennessee Hospital Association which allows them to repeal the corporate practice of medicine act. Briefly it requests authority to employ the RAPE group of physicians[radiologists, anesthesiologists, emergency physicians, and pathologists]. Once signed these physicians are subject to noncompete clauses which basically chain them to their employer. As the last bastions of generalism, family and emergency medicine have common ground in these issues.
 
The hospital independent ER may emerge as a more accessible and more affordable option in the health care rainbow. In this option, many will find freedom from the discrimination which is common. By the way, this is the model for most mission hospitals in developing countries.

With best wishes for your professional success,
 
" Medicos-where 10 percent of the information makes over 90 percent of the difference and where,through Grace, twice the service is provided at less than half of the cost." Constructed and maintained without government grants or charity. A design laboratory for the development of mission hospitals and independent physicians who provide continuing comprehensive health care unrestricted by age, gender, organ system, and location of service. A rural simulation in a city.
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, and international

Office Reimbursement

Dr. Rodney:
 
Do you know how to get depot provera reimbursed by Medicaid??  We do not currently keep it in the office as it has apparently been a reimbursement issue.
 
Hope things are going well.
 
Anonymous faculty member
 
Reply(WMR):

First tell me, have your office managers shared the data describing why they think Depo Provera loses money? Medicos is in the same town caring for medicaid and uninsured patients. Medicos Memphis gave 672 doses last year , and Medicos receives no tax or grant subsidies for its office which is private practice.
 
If I understand you correctly, the university does not allow you to stock DepoProvera for Family Planning services because they have told you that it loses money. How is this possible? Before I give you our data, could I ask if they gave any data from their system? What are the numbers they are using? Are they willing to share this analysis with you?
 
Let me give you some commonly quoted data which is available to those who do not shop for price.

Depo Provera Brand name single dose vial 150mg $82.59
Medroxyprogesterone acetate generic 150mg single dose $58.59

Medicos does not pay these prices. Can you use the internet to locate better prices? Until you personally have the freedom to shop, your clinical operation may not do as well as you would like. Shortsighted and/or misinformed accountants can amputate family medicine's ability to provide services.
 
Abuelo and others on the listserv, let's see if we can solve this problem. What a good price to pay for a multidose vial of medroxyprogesterone acetate?
 
Ryan, Kelly, Jeremy, Dan-JPS, Dan-Tuscaloosa, Millard-Ruth --do they stock DepoProvera in your family health centers?
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Adjunct Professor of Family Medicine
American Board of Family Medicine Obstetrics
Medicos para la Familia
Memphis, Nashville, rural
www.psot.com
[TheProcedural Skills and Office Technology Project]

Another difficult situation is immunizations.  An article was just published from U of Michigan documenting that most insurance companies are basically only paying the cost of the vaccine, plus the administration fee.  Many physicians (including pediatricians) are dropping the service of providing  vaccines.   I have an outside biller who takes 7% of my gross.  For the expensive vaccines, I basically “almost” break even.

The insurance companies can brag to the legislators that they pay for immunizations, when in fact, physicians lose, so they don’t give them, the patients suffer, and insurance companies save money!

Jack Pfenninger

Index-- office reimbursement, Women's Health Care,  corporate policies may impede family medicine services

International Outreach

Dear Emiliano:

As you may know, Medicos will be sponsoring most of my trip to Argentina through The Camellia Foundation.  I will be a representative of the Medicos Family Medicine-OB-ER curriculum.  In this role, I will come prepared to give a series of short powerpoint presentations highlighting the core curriculum in obstetrical emergencies[ALSO], office surgery, CXR, ultrasound, and family planning services such as IUD.  Would it be OK if I arrive a couple days later than I’d originally told you to prepare myself for these talks?  This would be May 20-21.  Also, I was just informed that there may be an opportunity for me to spend the last week or two at a hospital in Buenos Aires with Dr. Scholoff’s family.  Plans are still up in the air.  Please let me know your thoughts on all this.  Thanks for looking into renting an apartment for me.  As long as I’m safe, I happy staying anywhere.  I’m planning to make plane reservations soon.  I know you are very busy. Thank you very much for helping me get this together. I'm very excited!

Leah Conners
 
Leah:

My original idea was to meet with my daughter in Buenos Aires and perhaps with the person who trained me in Argentina. I doubt that we can do a "rotation" because is too late. Cecilia, my daughter, will be in Buenos Aires from 6/14 to 7/28 or so. Will you? Give me times and places. It doesn't matter what I will give you phones and address in Buenos Aires to call if necessary. Also some good restaurants (tambien algunas heladerias)
Emiliano: Dr. Rodney is trying to help develop a "seed" in our country, PLZ help us. If there is a person in the government in San Juan who we (I) can talk in the future, I truly want to start been part of the true Future of Family Medicine !!!

I think that we have to start writing in spanish at least half of our emails. Que les parece?

Eduardo

WMR REPLIES:

Ya me gusta mucho esa idea. Adelante y arriba! La noche pasada vi la pelicula "La ciudiad Perdido" por Andy Garcia y Iris Sartre. Linda y hechicera. La musica de Cube acerca 1955-1965, y la lucha para sobrevivir despues Castro. Quien supo? Ya quizas tendremos una epoca nueva en Cuba.
 
Para construir un program con nada mas de una semilla, tendremos que pensar de metas y objetivos. Es posible la combinacion de Family Medicine-ER-OB en los paises de Latinoamerica? Enn el Proyecto Medicos tuvimos la idea de servicios comunes. Ademas tuvimos la oportunidad de ganar pagos para cada servicio. donde tenemos una oportunidad come eso en Latinoamerica? 
 
Mientras, en un mes Leah viajara al Argentine. Tenemos dos otras presentaciones de diapositivas. Algunas estan transducido. Estan disponibles en el website www.psot.com . Oprima "Espanol". No debemos olvidar, que Leah esta visitando para la primera vez. No tendra que nada mas de ser su mismo, y toda pasara bien.
 
Se Emiliano empezo un website en su programa. El sitio existe todavia hoy. emiliano, diganos cuales estan las temas que debemos presentar. Estoy perdido en la niebla,
 
Bajito y despacito,

 
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
 

Estimado Dr. Mendez:

Saludos, le escribo esta carta para expresar los deseos de establecer un contacto de la clinica "Medicos" en Memphis, Tennessee con usted, el director del programa de medicina familiar de la UCE. Medicos ha fundado programas de entrenamiento en latino america donde hemos donado equipos para prevencion de cancer(colposcopia) y mejorar el cuidado prenatal(ultrasonido). Hemos ensenado estos temas en la universidad por mas de 25 anos y buscamos localizar programas los cuales tengan necesidad de un curriculo. Este es un programa " entrenando a la facultad" el cual ha sido de gran uso para nuestros residentes de medicina familiar.
 
Sin embargo, queremos ver que el curriculo y el equipo sea utilizado si es donado. Existe alguna oficina y un lugar seguro en donde guardar estos equipos? Queremos comenzar con una visita y estamos dispuestos a dar una conferencia en estas tecnicas y otras las cuales ustedes crean que que haya necesidad.
 
Si esto trabaja bien, Medicos financiara un intercambio de sus residentes por los nuestros. Nuestras horas son flexibles. Nuestro interes primordial es enfortecer la medicina familiar para pacientes en america latina.
Att. co

Index--International outreach, Argentine, dominican Rpublic

Seeking Additional Cesarean Experience

QUESTION:
-
Dear Dr. Deutchman-

I am a second year family medicine resident in the University of Wisconsin rural training track in Baraboo, Wisconsin. Our program director is Jim Damos, and he suggested I contact you to see if you could help us with some information.

The other 2nd year residents and I have been trying to get enough experience to perform c-sections independently after graduation. We are looking at jobs in a number of communities in northern Wisconsin and Minnesota that could use this service. To gain experience we have been coming in 24/7 for all of the c-sections in our community (~70-80 total per year). They are performed by a number of general surgeons in town who have been fairly good about letting us perform/assist on these cases (I actually performed 2 c-sections this morning with our favorite general surgeon).

We would like to find a way to increase our surgical experience by performing some sections outside our community. We would also benefit from working with some practitioners who perform a more up to date section (our general surgeons are good but are a little old-school in terms of c-section technique). We have tried to gain access to more training in Madison, but we have been fairly effectively blocked out by the obstetricians and OB training program in town. Do you know of any avenues for obtaining additional training in a concentrated block of time, outside of doing an OB fellowship? We would be willing to travel anywhere. We have a past graduate who went to Illinois to do 30-40 sections in a month, but that training program no longer exists. Because of your interest in training family docs for full-spectrum obstetrical practice, Jim thought you might have some information that could help us out. Thank you very much for you time.

Sincerely,
Chris Frank
U of Wisconsin - Baraboo RTT

REPLY-(WMR):

Dr. Damos wrote one of the most eloquent descriptions of what went wrong with academic family medicine about ten years ago. In addition to his role as a founder of the original ALSO, I have hoped that someday I could meet with him personally. Glad to see that he is still connected with teaching.Most with this interest have been "shot from the saddle", and , as  you mentioned, the programs become rarer with each year.
 
I moved our OB fellowship out of the university about ten years ago, and took it into private practice where it has flourished. The fellowship was a necessity as universities came to offer less and less latitude for family physicians who sought training in things like Cesarean section. Much is this is due to apathy on this issue by current FP academics.There are a few notable exceptions. Because of the predictable regularity of these inquiries we have a pro forma note of explanation. See below.
 
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, rural
www.psot.com

[TheProcedural Skills and Office Technology Project]
 
REPLY:

Great to hear of someone on the road less traveled, and seeking a clinical experience where family  physicians do deliveries including Cesareans. Medicos functions without external support from taxes and grants. Medicos is "private practice" with a training mission[ie, a rural simulation].
 
The main issue is the "lead time".  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. 
 
Only a minority of  private family medicine groups have achieved the ability to maintain volume sufficient for training. Rural programs used to have the strength of being able to allow "old school" professional courtesy[yall come], but they lack the volume. Catch-22.  Urban programs are frequently at the mercy of OB departments within the large hospital. They have no reason to be interested in the training of family physicians.
 
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.
 
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 80 graduates over 18 years suggests that this is an effective model. See www.psot.com under ARFEM fellowship section. In 2008, Medicos averaged 30-40 deliveries a month, and scrubbed another 15-20 sections each month from other family physicians in our Memphis coalition. In 2001-2005 Medicos did less than half this volume.
 
Medicos continues to grow, but,our fellows invested the time and energy to obtain medical licenses and hospital privileges. They have first rights.
More than surgical technique is necessary.  We have evolved a curriculum of topics, discussions, and our own risk management system which requires the discipline of weekly conferences. The Medicos practice is really mission medicine FAMILY MEDICNE-OB-ER. This is heavily dependent on office surgery and full scale OB-Gyn-ER ultrasound by the physician. In summary, family physicians should be encouraged to maintain their idealism, but should consider these barriers as they seek short term surgical and procedural experiences.
 
If you wanted to got trough the licensing and credentialing process, you would be welcome to spend some time with us. You would have to send a CV, a log of previous OB experience, and do an interview. Trying to surmount all of the credentialing hurdles is too much to accomplish in a month or two for almost all states and countries in the post 9/11 world.