PSOTBLOG

Benchmark Minimum ER Admit Rates+Fake Patients

Reference Rieselbach Re, Kellerman AL. NEJM 2011; 364: 2476-77.

These authors suggest that the lamb bed down with the lion in an equal partnership. "To sustain Community Health Centers, and thereby preserve access to care for medicaid beneficiaries and other low-income patients, while gaining control over growth in costs, we propose community Health Center and Academic Medical Partnerships" June , 30, 2011

The Government, Undercover From: The eWire, 06.29.11 Mystery-shopper project to test PCP availability draws ire of HM practitioners

by Richard Quinn

A quickly-scuttled plan by the Department of Health and Human Services (HHS) to use "mystery shoppers" to test the availability of primary-care physicians (PCPs) would likely never be extended to HM—but the federal tack has certainly touched a nerve with some practitioners. (Ed note: updated June 29, 2011)

"Using surrogate patients or a sneaky way to get the data feels a bit less straightforward," says James Levy, PA-C, vice president of personnel for Traverse City-based Hospitalists of Northern Michigan. "If I were the government, I'm sure it would occur to me to do it that way. Nobody is going to be comfortable with surreptitious observations. That would seem to carry the message that the government doesn’t trust the providers it's reimbursing."

The government proposed using people pretending to be patients, both insured and uninsured, to gauge how long it takes to get PCP appointments. The action was proposed in the April 28 Federal Register. Comments were solicited, but negative feedback prompted HHS to drop the plan in a June 29 announcement.

Levy and David Friar, MD, CEO of Northern Hospitalists, say that the logistics of hospital admission make it near impossible for the government to have anybody pose as something they're not. Still, in an email, Dr. Friar adds that, aside from "philosophical indignation," he would likely not object should HHS try a similar tack with hospitalist groups.

"In essence, every patient that sees a hospitalist is a mystery patient," he writes. "We don't control who comes in, or what their diagnosis is or when they'll arrive. We have little control over any of those things. Since payors are collecting data on every aspect of hospitalists’ performance, and what they aren't, the hospitals we work for are, we have little left to hide."

WMR Writes:

Of course we should give control to USA academic health centers who have done so much to see that the health care system is well balanced with a good supply of generalist physicians providing comprehensive health care unrestricted by gender, age, pregnancy, and location of service. Let's do a simple count to see where these champions of low cost accessible health care have invested the public's tax dollars.

They have created a terribly high cost inaccessible system in which physicians are not allowed to practice a broad scope of services. These academic centers require platoons of internists, laborists, gynecologists, pediatricians, hospitalists, and emergency medicine specialists for every family. Family medicine is not required for accreditation of a medical school.

As they say at Vanderbilt, "You must subspecialize". AT UTenn, recently a dean stated that failure to achieve high test scores would condemn the student to a career in family medicine(Ugh!). Clearly these institutions are the logical choice to design and maintain the nation's system of health care. Why not just write the check for 2.6 trillion dollars today? But, budget more for next year.

Comments:

I'm so tired of all this "politequeria" !!! Bill I'm 100% with you.

Eduardo

 

Index--medical systems 2011 ; healthcare economics

Nurse Practitioners

QUESTION:

Does anyone know the percentage of NPs that practice in rural communities?

I am at the Rural Advisory Committee for HRSA and this came up as part of ACA. Specifically, a demonstration training program for NPs as a way of funneling more into rural medicine. My experience is that most practice in urban or suburban settings. My concern is that this would detract from training FPs for rural settings. How could we measure whether this was a cost effective and appropriate use of resources.  

Sorry, I am limited on time. 
 
REPLY (WMR):

At Vanderbilt, Dean Conway Welch presided for years saying that her nurse practitioner programs made it unnecessary for Vanderbilt to have a family medicine program. Some years ago she noted that few of her NP's were in primary care, and even fewer were staffing rural sites. Some exceptions.
 
In fact, nurse practitioners were attaching themselves to the legions of cardiologists and other surgical subspecialists for which Vanderbilt is so well known. In a brilliant about face, she relabeled her brochures  with the following title more or less " Nurses Practitioners--Come to Vanderbilt and Subspecialize".
 
No one has dared to publish the numerators and denominators suggesting that the empress has no clothes on the original promise of care like that of the family doctor. Sadly, some of data has been gerrymandered or manipulated.

... If you can stand to hear the words you've spoken
    twisted by knaves to make a trap for fools.....
 
In Tennessee, medical schools still count every internist, pediatrician, and OB as "primary care" even though most subspecialize. Nurse practitioners have not solved the health care maldistribution problem in Tennessee. But, urban FQHC's are hiring them as rapidly as they can find them. The tree of family medicine has been lost in this forest of generic primary care.
 
When Tennessee has rural interest day in Nashville, the halls of the legislature are filled with banner after banner describing how Vanderbilt has provided health care for each and every rural county. This is a genuine service and I give them credit for the patients they have helped. Basically the Vanderbilt banners describe people who transferred or voluntarily traveled to Vanderbilt for specialty services. They attach the "nonreimbursed dollars" for each county.
 
Vanderbilt has the ingenuity and resources to gather descriptive statistics and craft them into a skillful public relations campaign. The advertising implication is that Vanderbilt is on the rural scene providing services throughout the state, and that significant amounts are not reimbursed. It is an amazing feat of political finesse.
 
Family Medicine has struggled to find the high ground for legislative attention of this magnitude. It would be nice if schools like Vanderbilt could be convinced to provide leadership in establishing family medicine as the logical captain of a multidisciplinary team providing healthcare services unrestricted by age, gender, pregnancy and location of service, but.....

With best wishes for your professional success,

Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor and Chair
Medicos para la Familia

Procedural Skills and Office Technology
www.psot.com
www.medicosmundial.com

Index--Nurse practitioner data

PSA for John Edwards?

In a message dated 6/14/2011 9:35:31 A.M. Central Daylight Time, xxx writes:

Read the interesting write up on Senator john Edwards.[Charen, Mona. commercialappeal.com June 7,2011 pA7]

Does anybody talk about the Jury who awarded the 6.5 million. The problem is not Edward but the system. You cant prevent these Edwards to gain from loopholes unless you plug them.

Context-- Medicos has evolved policies to minimize use of treatments and tests with a low yield. Unfortunately many of them have been touted in the medical literature. After an initial wave of funded enthusiasm, new data emerges suggesting that the original claims were not totally true. Recently one resident reported that he was strongly urged to order Prostate Specific Antigen(PSA) testing by a faculty member who justified the test on the basis of a recent malpractice award for failure to diagnose prostate cancer.

REPLY--wmr:

As physicians at Medicos practicing surgical Family Medicine Obstetrics, we have freely chosen to take risk. But, every two weeks staff receive a paycheck for providing services to patients. We believe our cause is a noble one, but we could not maintain these services without being paid.

To participate in any revenue collecting business, the individual physician is at risk for thousands of federal and state regulations. Many of them are poorly understood, and some are in conflict with others. Corruption and incompetence place every citizen at risk for litigation and/or punishment.

The jury system which awarded John Edwards with millions of dollars is an unfortunate example of justice gone astray. An American electorate which was manipulated to place John Edwards in the US senate, and then lionized him as a potential Vice President, is disappointing.

Using these awards as a rationale for defensively ordering unnecessary and potentially harmful tests(PSA) represents a professional fall from Grace.

Give up, don't try, stop seeing patients, don't speak out, stop writing, hide in the shadows waiting for someone to save your family.............. or what?

 

Index--PSA, medicine for the uninsured, why private practice

FP Programs With Obstetrical Training

Dr. Rodney:

In a painstaking search of strong family practice programs that offer good quality and quantity obstetrics (which is what I'm interested in), I've come across your name and resources. I'm specifically looking in California, and I've come up with UC Davis FP/OB program, Ventura, Contra Costa, possibly Santa Rosa, and Salinas. I'm also looking for programs in/near NYC (family in both locations). Do you have any suggestions for out there?

Thank you for any leads.

MS4

 
WMR Writes:

The success of this search depends on the ability of the physician to articulate their training goals in the context of their professional destination. The political and economic forces of the US health care system are not aligned to encourage family medicine obstetrics. Most academic environments are not forthright in their approach to students who bring this question.
 
Start here.
 
What will your dream job look like ten years from now? Go beyond the rhetoric of the obvious. Training environments are so artificial, that the learning obstetrics is difficult until you have graduated from residency. This Catch-22 has created a market for fourth year fellowships in Surgical Family Medicine Obstetrics.
 
Programs are easy to understand. Watch what they do, not what they say. To this day I still encounter training where the FP is required to sit with the pit drip for every induction. This is unnecessarily punitive in USA hospitals.  Meharry used this policy to literally eradicate any and all FP interest in deliveries 1985-2002. 
 
The Defining Dozen

There are no more than a dozen defining issues but the first and foremost will be Cesarean section. Find a Chair or Director who has ever done even one Cesarean or trained even one FP OB.
 
If you cannot do your Cesareans, then the second most important thing will be how you fit into a community of physicans who back you up. If Cesareans are not rapidly available, you will not be allowed to do deliveries. See Kirkville, Mo., Nashville, Tn., Anchorage, Al.
 
The third defining issue is the right to use OB-Gyn ultrasound in your own office. Will it be permitted and will you be allowed to bill for it? See #4
 
Four--Will you be a corporate employee or an FQHC staff member? There is a lot of bait and switch in these job offers. They want you in the office, and obstetrics by others will be encouraged. This also applies to office surgery of all kinds. There are exceptions.
 
Lawrence Mass would be worth looking at, but the Cesarean training is done at the fellowship level. Seeking a family medicine group with established obstetrical activity and privileges is the safest choice.
 
Will your future include hospital work?. You would be amazed at how few physicians ask to see the hospital bylaws . They move their families only to find that there is no department of family medicine and that family medicine doctors cannot obtain hospital privileges[including OB].
 
  5. Do you want to see children? Without OB, your pediatrics may be sparse.
 
There is more, but this is a start. Skills, Faith, and career planning transcend training location IF the physician is inoculated against the misinformation given by faculty who have hidden agenda to keep OB out. You have to leapfrog the residency to articulate the conditions under which you hope to establish your professional career.
 
Specific Programs
 
The programs you have listed on the West coast are good choices compared to most programs in the Northeast. There are others in Seattle, Phoenix, Reno, Portland, Chicago, Indianapolis, etc. But everything is in flux. Shop carefully. Lawrence Ma,Boston U, and Brown. FP's have Cesarean privileges at those institutions. One of my fellows moved to Hunterdon NJ specifically for the FP-OB. You should talk to him. Others on the listserv might suggest other programs in the NYC area..
 
I had a fellowship graduate who went to Lutheran General in Brooklyn and they gave her OB privileges to teach in that residency. Many programs need help, and this is a good entry point for acquisition of privileges in a city. Once you have those privileges somewhere, your next application will be easier.
 
The continuing need for FP OB faculty is one reason that fellowships in Surgical Family Medicine Obstetrics continue to prosper. Maybe you are destined to be faculty. But, careful investigation separates out the survivors from the many who are demoralized along the way.. 
 
This is the key.

IF your aspiration includes OB,  do family medicine faculty have Cesarean privileges at the institution? Do they do a substantial amount of the teaching in the residency? One of the Va. programs has a token FP OB, but the other faculty are basically opposed to the entire  idea of FP OB. If the Chair and Residency Director are opposed to FP OB, it is a bad sign.
 

With best wishes for your professional success,

Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor and Chair
Medicos para la Familia

Procedural Skills and Office Technology
www.psot.com
www.medicosmundial.com

Clinical Policy Update -- Your Feedback Requested

An AAFP Request:

An AAFP work group is working on updating the policy (located at: http://www.aafp.org/online/en/home/policy/policies/r/obperinatruralhealthcare.html
and would appreciate your feedback to ensure that your OB delivery needs/issues are met within the policy language.  Please let us know what kinds of changes you would like to see made to the policy to increase its effectiveness.  The policy is also listed below:

Rural Health Care, Obstetrics/Perinatal Care

Recognizing that a deepening crisis currently exists in access to perinatal care in rural areas and that this crisis has the potential of significantly increasing perinatal morbidity and mortality, the AAFP supports actions by governmental and private agencies, as well as by other professional organizations, directed at defining the causes of the crisis and formulating possible solutions.

The AAFP further reaffirms its willingness to participate with other organizations in joint efforts to respond to this crisis by defining ways that family physicians in rural areas can deal with the professional liability crisis and other financing and delivery system issues so they can continue to provide quality obstetrical/perinatal care. (1988) (2006)

WMR Responds:
 
The original AAFP-ACOG guidelines for specialty neutral credentialing in deliveries were never effective. Bruce Bagley, Patrick Harr, and others from ACOG refreshed them in 2006.  We had high hopes for an end to the widespread discrimination against family physicians who wished to receive training in obstetrics. The watershed issue has been credentialing for Cesarean Section. To this day places like Anchorage Alaska hold FP's hostage at the grail of the dreaded Cesarean hysterectomy. Klamath Falls Oregon had the same issue for years. One or two influential obstetricians could literally veto any attempts for family medicine privileges.
 
The rare tragedy of bleeding which require Cesarean Section cannot and should not be used to prevent cesarean training for family physicians in rural and other settings. We were never able to get the residency review committee to put teeth into the requirement that this training be available at every program. Particularly in middle Tennessee this is openly flaunted. The AAFP has never instructed its delegates to the RRC on this issue. They should demand it.
 
Meanwhile, many a young physician embarks on the recuritment trail only to find out that the programs promise much more training than they can provide. The half life of a resident's dream for training in surgical family medicine obstetrics is 18 months. Welcome to the need for independent fellowships in surgical family medicine obstetrics.
 
With best wishes for your professional success,

Wm. MacMillan Rodney MD, FAAFP, FACEP
Clinical Professor and Chair
Medicos para la Familia

Work-study and Spanish Immersion

Dear Inquirer,

Thank you for your interest in a clinical experience at Medicos. Medicos 1999-2011 has been rated as an outstanding clinical experience by medical students and residents. We are grateful for every kind word.

As an application and interview, applicants immerse themselves in the experience for at least 4 hours by arrangement. This is a chance for them to see if the chemistry feels right for their educational goals. Please submit a CV and your educational goals in the context of your 10 year professional vision.

Medicos does not accept volunteers. Students apply for the workstudy program. When accepted they are paid an hourly rate. Flexible hours are available, but, once a student is placed on the schedule, that student is expected to honor that schedule.

Medicos is unique in that it does not receive any government or charity support, Medicos pays taxes and teaches others as a mission. Medicos is more than a generic primary care, and students who have some predisposition to a future which includes night call and deliveries will receive preference points. Medicos will not accept workstudy students unless they agree to work weekends and nights like we do.

Although based in Family Medicine, Medicos represents a separate specialty- Surgical Family Medicine Obstetrics +ER. This is the only logical solution to health care needs in underserved communities and developing countries. American medical schools and residencies have become disconnected from the realities of community medicine and mission medicine.

Although some programs, such as Contra Costa, Fort Worth, Medicos, et al--- can provide over twice the service at less than half the cost, this training is difficult to find..

Due to the restrictions placed on training, many clinical skills are no longer available to medical students.. Sub-specialization is the default. Physicians study more and more to learn about less and less. This further isolates the physician from the reality of providing the broad array of health care services needed in the real world. When physicians have limited skills, career opportunities are restricted. Medicos is a partial antidote to taught helplessness.

A commitment to speaking Spanish suggests that the candidate has gone beyond the rhetoric, and is committed to "walking the walk". Students with a commitment to "…the road less traveled" are welcome. Due to demand, we have to steward these resources carefully.

Your comments and interest are appreciated.

With best wishes for your professional success,

Wm. MacMillan Rodney MD, FAAFP, FACEP

Clinical Professor and Chair

Medicos para la Familia

Index--Orientation info, student rotation application advice

Family Medicine in Latinoamerica

Dr Rodney:

I am interested to know about your involvement in Ecuador.  I have been taking medical teams there the last 6 years.  We work in far south Quito and among the indigenous people there.  I have always wanted to know more about the training of FPs there and would love to know what you're doing there. 

I am headed back to Quito end of July for a couple of weeks.

R. Stewart, MD

Family HealthCare Associates

Shawnee, OK

 

WMR replies:

First, let me insert a disclaimer for all I don't know, and the people I fail to mention. 

Your inquiry  reminds me that we should update an article on la Sociedad Ecuadoriana de Medicina Familiar, the Venezuelan Fundacion de Pedro Iturbe in Venezuela, SOBRAMFA in Brasil. Dr. Iturbe started several programs in Venezuela circa 1982. Julio Ceitlin tried the same in Argentine. Pablo Blasco seems to be the man in Brasil. A tip of the hat to Mark Lepore  and others at Ventura who have tried to carry the Hospitalito project in Guatemala.

Ironically the opportunities for curriculum expansion are probably greater in Latinoamerica than they are in Europe and the USA. In 1982, we took a huge leap forward by establishing a family medicine hospital service at UCLA. Family Medicine faculty daily rounded on Medicine, Pediatrics, OB, and nursery. I don't see much of this in South America, and 50% of USA FP's seem to running away from this. Did FP's jump ship or were they pushed? This would be another discussion for another time.

In 1985 Cal Wilson and others established a family medicine residency program at the Voz Andes missionary hospital in Quito. They also have a rural hospital in Shell Mera which is about 6-7 hours by car from Quito. I think Rita Bedoya MD established a program Lojas which is a telemedicine partner for the annual VozAndes Jornadas Jan-Feb.

We presented ALSO in Quito VozAndes 2003, and it has been given annually by Ecuadorian faculty ever since. In 2006, I tried to start a colposcopy skills program in Quito but failed. In 2009 I installed ultrasound to Shell and in 2010 to North Quito. I was there last week.

David Gaus  MD of Wisconsin has moved mountains to establish a program in Pedro Vicente Maldonado which is 2-3 hours Northwest of Quito by car. Medicos-Memphis will sponsor his faculty for two week immersion courses in Family Medicine OB/Gyn ultrasound. We hope his faculty will be able to participate in our Surgical Family Medicine OB ultrasound workshops September 4-6.

Bob Gobbo seemed to have some success in Domingo de las Colorados, Ecuador. But no one has sustained a break through program for enhanced family medicine yet. By breakthrough program, I mean visible and important to the Deans of the medical schools. Marc Nelson, JPS grad, has sustained GI endoscopy at the Carapungo clinic in Quito. I am trying to help support that effort and the effort of David Gaus as much as possible. Ecuador seems to have the lead here.

 To develop the next generation in Latinoamerica, I believe that family medicine should rebrand itself as "Surgical Family Medicine OB". For lack of an effective urban example, medicina familiar is viewed as a dead end street for 99% of South American medical students. In Colombia , Medicina Familiar seems synonymous with family therapy/behavioral counseling.

Currently there is no board certification available, and there are no faculty privileges in the teaching hospitals. This will change.

Especialidad Medicoquirurgico y Obstetricia;

Medicina Familiar Avanzada

De la maternidad hasta la ancianidad

Comments and corrections would be appreciated.

With best wishes for your professional success

Wm. MacMillan Rodney MD

Private Practice, Medicos para la Familia

Memphis, Nashville, and International

p.s.-We are trying to upgrade the family medicine residency curriculum for programs in Ecuador and Venezuela, by purchasing a video endoscope unit which works well. We would accept a snap on camera for old Olympus scopes but prefer something that is an immersible videoscope. A fancy information management outfit is not necessary.

Index--Latinoamerica , FM Identity in Spanish,

Especialidad Medicoquirurgico y Obstetricia;

Medicina Familiar Avanzada