PSOTBLOG

Career Advice: EM vs FM Options

Dr. Rodney:

I have been involved in Emergency Medicine since 1995.

With you being involved with ACEP, I was curious if you could shed light on a rumor I've heard? Since graduates of a family medicine residency can have up to one year counted toward a second Emergency Medicine Residency, is there a move to have 2 year emergency fellowships created or recognized that would be equal to a residency in Emergency Medicine? I have asked both ACEP and AAFP but neither have been able to really answer this question. I ask because I wish to complete a fellowship in Wilderness Medicine which I must complete an Emergency Medicine Residency first. Such a move, I believe, could be equal to a 5 year combined EM/FM residency or a 3 year FM follows by a 2 year EM residency, which both are already recognized.

Thank you for your help and I look forward to meeting up and any other advice you can give.

Lawrence

Reply(WMR):
 
Your career vision of FM/EM/ wilderness medicine is not clear to me. What will be the market value of these EM fellowships, wilderness medicine, and/or a combined EM/FM residency?  With FM boards and a few merit badges you can get a job doing all the EM you want. This true all over the world unless you apply to Vanderbilt, but who wants to go there? Why not just complete the residency, see something of the real world, and then decide? Going from one adolescent experience to another seems futile.
 
In 2009, I wrote the following.
www.psot.com
Index--procedure training, residency choice.
Re: "Procedure Heavy FM programs"
sent to listserv without the student's name on it.
 
Although both EM and FM are the last of the "true generalist" specialties,  corporate employment versus self determination will be watershed issues in career choice. Technology enhanced independence may level the playing field or tilt it in favor of the physician (or not). I have been board-certified and practiced in both specialties. Physicians need to decide if corporate employment is better than what they could do  independently. Unfortunately residencies are extremely corporate and the forces of indoctrination are strong.
 
There is soooo much to say about this, but, in a nutshell, there is little future for the private practice of emergency medicine. You will be a shift worker with very limited opportunity to follow the clinical course of your patients, and you will be a corporate employee. This will limit your professional development, but it can be a good job.
 
ER choosers usually are building a castle of "free time", and using that to develop other business or family interests. They view, the office as a "ball and chain", and a financial negative. During the honeymoon period the EM pay is better than FM. Family physicians can choose this future also, but they have other choices as well. FM choosers may be primary care 9-5 M-F. Pay is commensurate with the simplicity of the task.
 
But, the FM door is open to what we call the ownership or shareholder track. These doctors have an ability to shape their patient load, schedule, equipment purchased, etc, Onsite doctors who understand their own business can do incredible things. Medicos is traveling the world doing Surgical Family Medicine Obstetrics +ER. Why not?
 
Paradoxically, the potential accumulation of capital assets and patient continuity(human assets) is better in FM. Many patients are worth knowing. Seeing kids grow up while treating their mothers is amazing. Most FM residents lack the clinical infrastructure to see much of this. Other than your chronic disease internal medicine patients, how many acute care or pediatric patients do you actually see in continuity? Unfortunately many FM residencies have ceded these patients to the ER which is one reason students have that attraction. EM residents generally don't value family dynamics, and have little interest in cultivating these skills.
 
At Medicos we sought an antidote to learned futility. Medicos functions like an ER without the nights and without the nursing home patients. We have focused on young families, workers injuries, and women's healthcare. WE have prepared ourselves for the reality of a small mission hospital, and we happily deliver a babies in the middle of the night.That is our professional joy, and this joy is a Blessing.
 
EM boarded physicians cannot "elect" to enroll as primary care physicians for assignment of patients in the current medicaid and medicare systems(currently over 60% of the population in Memphis). FM physicians can perform Cesarean sections, but EM physicians see themselves as more "surgically inclined".  What's wrong with this picture?  EM will not strive to follow patients out of the hospital, but feel that they have a major impact on the community.
 
Starting an ER costs millions of dollars, and it is an accreditaton nightmare. Medicos with endoscopy, xray, ultrasound, and a surgery suite cost $300,000 to build and run at a loss for 18 months. We did it without an attorney.
 
The control of ultrasound imaging is an interesting example. Ultrasound is the current state of the art for many common clinical problems. It is minimally invasive and is reimbursable. Seventy percent of FM has voluntarily relinquished this skill because the regressive FM programs operationally create a MedPeds curriculum with only token participation in the defining dozen procedural areas.
 
Ninety percent of EM is politically constrained from using ultrasound because hospital bylaws award the franchise to radiology. Surgical skills eventually atrophy because treatment of fractures, for example, are automatically referred under all cases.
 
The big gateway to surgical and ultrasound skill is pregnancy care. Find a program strong in this, and you will find an FM programs where your path to surgical and emergency skill is not obstructed. Programs with active fellowship programs in OB and/or EM are likely to have potential for enriched surgical training. But there good programs without fellowships as well. More to follow.

With best wishes for your professional success,
Wm. MacMillan Rodney MD, FAAFP, FACEP
Professor of Family Medicine
Board of Family Medicine Obstetrics
 
Hi Dr. Rodney:

I'm a 4th year medical student at stuck between EM and FM. If I do FM I want to go to a procedure heavy program. That's the only way I would want to do FM. 
 
Dr. Rodney:

I wish to work in both FM and EM fields as well as work in a wilderness environment. One answer to your question is provided in my original message, you must complete an EM residency to do a Wilderness Fellowship, a second answer is in your response that without the residency training I can be limited where I can work.

I can become board certified both through the second residency or through a fellowship/experience but the length of time is the same yet the residency opens more doors currently. I'm sure my adolescent experiences might seem futile to some but this is something I've been considering for 17 years and how the system is currently set up, it is the best option that I know of.

L. LeBlond

Resident for EM/FM/Wilderness Med continues...

I wish to work in both FM and EM fields as well as work in a wilderness environment. One answer to your question is provided in my original message, you must complete an EM residency to do a Wilderness Fellowship, a second answer is in your response that without the residency training I can be limited where I can work.

I can become board certified both through the second residency or through a fellowship/experience but the length of time is the same yet the residency opens more doors currently. I'm sure my adolescent experiences might seem futile to some but this is something I've been considering for 17 years and how the system is currently set up, it is the best option that I know of. 
 
REPLY(WMR):

Thank you for the clarifying your thoughts. No personal slight was intended, but an extended period of dependence is a professional risk. Your potential restrictions are difficult to quantitate, but anything is possible. A pessimist is someone prematurely disappointed in the future.

With best wishes for your professional success,

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

The most frustrating aspect of my career path has been from established physicians, including program directors. If I talk to EM docs, they tell me I need to go FM to best fulfill my desires. If I talk to FM docs, they tell me EM is the way to go. I only ran into one FM program director that seemed to know what I was trying to accomplish and that was because a friend had done it (he was one of the many program directors that seemed to say anything to get you to rank their program including saying they were ranking me or that the interview was a formality because I was already in, things I found out from others that had been told them).

The fastest way to become board certified in any group after completing a FM residency takes two years (1 year of fellowship followed by 1 year of working or 2 years of EM residency). If I don't get the residency and am able to start the EM fellowship, I can still do a lot of what I want but I will have to do some adjusting.

L LeBlond

 

 
www,psot.com
www.medicosmundial.com
Index--Career advice, EM vs FM options

 

RE: OB/C-section privileges question

While laparoscopic approach to ruptured ectopic requires extensive training, doing exploratory laparotomy approach is not much harder than C/S at all. 
 
I have personally never performed a single C-Hyst in my life.  However, while consulted by FP OB fellows in Memphis, we avoided C-Hyst a few times by B-Lynch, O'Leary's Stitch, and vigorously correcting accompanying DIC.   Bakri balloon, sand bags are also useful in dealing with PPH.  Those approaches for PPH are relatively easy to learn for FP fellows.  My point here is: If we can avoid C-Hyst, we can minimize disatisfaction of patients and potential lawsuits.
 
I have also done a few TAH with OB fellows here.  I am extremely satisfied by the surgical skills those fellows demonstrated: some are much better than average OB residents.However, without GYN or surgery backup, in emergency situation, supercervical hysterectomy is safer and easier than the whole TAH.
 
Bo Charles Li, MD, FACOG
Memphis, TN
 
I need to publicly thank Dr. Li who has been nominated for our "consutant hall of Fame"award. Dr. Li has been a wonderful teacher and deserves credit for the success of our fellows.

WMR

CME 2011

The Labor2011 Surgical Family Medicine Obstetrics Conference was the most ambitious of the Medicos teaching projects, and it happened at a time when administrative support was thin. I am exhausted, but thankful for the prayers and guidance. Next Year I think we should make this happen two weeks after the UT US course.
 
Medicos successfully built an ultrasound experience separate from, but synergistic with, the UT STF presentation. This was designed in 1992 as a discipleship course. It was a good feeling to see our former students, faculty, and fellows leading the St F faculty development ultrasound course 20 years later. 2012 August 23-25.
 
2011 allowed the Camellia foundation and Medicos to go a step further, and continue His work. Among ten model patients Labor2011 had 3 abdominal exercises, three gyn cases, 3 OB cases, and the twin gyn case simulator with knobology on an unknown machine. The Esaote Bio-sound advanced knobology by Carl Barton was real step forward.
 
Three August 2011 Medicos fellows have received 36 hours of structured ultrasound experience, and performed at least 50 ultrasound examinations in their first 6 weeks. In addition Labor2011 provided an ultrasound textbook, and references.
 
There were several tests with feedback given ([Thanks Ike). Medicos-mundial is preparing to certify, as ultrasound assistants, the residency prep group. This process helped validate several of our testing instruments. Thank you.
 
Labor2011 was a prototype, and next year we must build in more admin support.
Should we consider submitting a manuscript describing this as an educational innovation for presentation at STFM and AAFP 2012? It will have possibilities as we suggest curriculum for projects in Ecuador, Venezuela, Guatemala, and Nigeria.
 
I especially want to thank Coleman Arnold, Manoj Mazumder, and Ravi Singh for their previous and continuing contributions to this project. Dr. Arnold flew in from Chattanooga.
 
Suggestions for next year are appreciated. Thus far we have---pre-ship the articles and assigned readings. Build in time for a longitudinal curriculum using the Wednesday conferences. Reviewed the EM ultrasound disc. Faculty 2012--Ike, Singh, Arnold, JRMR, Manoj, Gonzalez, Jairo ?
With best wishes for your professional success

Wm. MacMillan Rodney MD
Private Practice, Clinical Professor and Chair
Medicos para la Familia
Memphis, Nashville, and International

Index--CME 2011, Surgical Family Medicine Obstetrics

Equipo Mylabfive reparado sr. nr. 01120

Estoy de acuerdo con sus recomendaciones. Por favor, siga con todo. Su informacion esta agradecida. El numero serial me ayuda. Como sabe, estamos estudiando el proceso de construir un curiculum para Medicos en Ecuador, Guatemala, y Africa. Estamos desenando una especialista medicoquirurgica--Obstetricia con Medicina Familiar Avanzada. Destrezas de ecografia son esenciales.
 
Cada ecografo se necesitara su campeon en cada ubicacion. Cada medico tendra entender la necesidad de apagar la maquina corectamente cada vez. Sus observaciones seran muy importantes para todos. 
Gracias y Bendiciones.

WMR

 
Hola Dr. Wmrodney:

Gracias por sus mensaje, le debo una explicación por la demora en entregar su equipo reparado, lamentablemente un error en fábrica nos despacharon la tarjeta equivocada en consecuencia hicimos el reclamo y debiamos  esperar que me remitan la correcta más los procesos de desaduanización, etc.., luego durante el mes de agosto fábrica entró en el periodo de vacaciones por lo que la tarjeta correcta la recibí recién a principio en septiembre, lamento mucho esta demora que sale de nuestro control y que no es normal estos retrasos por equivocaciones en fábrica, en todo caso el equipo ha sido ya reparado y esta actualizado con el último software que agrega mas prestaciones y esta en condiciones de funcionamiento.

Estoy preocupado, porque ambos equipos presentan daños similares y estos se dañaron en "Shell", lamentablemente las condiciones eléctricas en el oriente ecuatoriano no son buenas y podría ser la causa que los equipos se hayan dañado en el mismo lugar... en consecuencia le recomiendo instalar un juego de baterías internas de respaldo a ambos equipos le cotizará pronto y hay que importarlas de ESAOTE, estas baterías mantendrán al equipo alimentado por ellas y no dependiente de la red eléctrica proveyendo un respaldo de 2 horas en caso de cortes de la electricidad , además de esto le recomiendo que los equipos se conecten siempre a través de un UPS con respaldo de 20 minutos y capacidad 600 VA, le podemos proveer los UPS que recomendamos para evitar estos problemas y no son costosos cada uno cuesta $ 120,00 más IVA, esto ayudara y protegerá a los equipos en condiciones malas de suministro de electricidad con variaciones de la red de suministro eléctrico.
El equipo que lo recibimos el sábado lo estamos revisando ya que ha perdido información en el disco duro por eso no arranca y muestra el comportamiento, hemos pedido el software a fábrica, esperamos realizar este proceso para llegar al diagnóstico final de avería.

Con relación al pago pendiente le informare en cuanto este acreditado en mi cuenta.

saludos y gracias por confiar en nuestra organización

Jaime Arizaga
ENELIN
 
HOLA DR. WMRODNEY:

EL NUMERO DE SERIE DEL EQUIPO MYLABFIVE RECIBIDO EL SÁBADO 3. SEPT. 2011 PARA  REPARACIÓN ES: SR.NR. 01956

CON RELACION A SUS PROYECTOS CON MUCHO GUSTO PODEMOS AYUDARLOS SOBRE TODO EN EL MANEJO DE LOS EQUIPOS PARA QUE LOS USUARIOS PUEDAN SACARLE PROVECHO A LA MAQUINA Y TENER UN DIAGNOSTICO SEGURO, CON EL DR. ERAZO CONVERSAMOS DE ESTE TEMA Y LE SUGERI QUE PUEDEN HACER UN ESTUDIO COMPARATIVO DE LA PRECISIÓN DIAGNOSTICA EMPLEANDO UNA MAQUINA DE ULTRASONIDO Y EL DIAGNOSTICO SIN EL¡¡  CLARAMENTE HAY UNA GRAN CONFIDENCIA DIAGNOSTICA Y MEJORA MUCHO EL MANEJO DEL PACIENTE....CON GUSTO ESTAMOS PARA APOYARLOS, DE ACUERDO CON USTED SI EN CADA LUGAR TIENEN UN ECOGRAFISTA SERIA FANTASTICO

LA FORMA DE APAGAR LA MAQUINA TAMBIEN ES IMPORTANTE, ESTO LO INDIQUE AL DR. ERAZO CUANDO ENTREGAMOS EL EQUIPO REPARADO SR. NR. 01120  Y ES TAN SENCILLO COMO APAGAR UN PC.

SALUDOS
JAIME ARIZAGA

 
Index--ultrasound equipment, international issues

Flu Vaccines and the Vaccine Police

WMR WRITES:

Dr. S comments about "targeting males" as vaccine scofflaws support those that propose removing hospital privileges from those physicians who cannot provide proof of flu vaccine. This was passed by several Memphis hospitals in 2010. How many freedoms are you willing to trade for saving one life somewhere?

The vaccine police are alive and prospering in Tennessee. But why stop there?

There are so many opportunities for additional life saving regulation. Public Health officials should demand a BMI card for the right to eat fast food.

"Sorry we cannot serve you, your BMI is over 40".

WMR
 
Dr. Rodney:

Although I agree that H1N1 was a hysteria, there are plenty of articles and studies showing the benefit of influenza vaccine. It’s not just death from flu, it’s also CHF and MI. I don’t know that I buy into the wide spread vaccination of everyone, that seems like overkill, but then you have time out of work saved, time out of school, other indicators. Don’t forget, the last 2 years flu season has been incredibly mild and the pandemic H1N1 turned out to be a nothing flu virus. How many adults and adolescents are we vaccinating against pertussis to prevent a couple of infants from dying. But, it’s infants, right? Seems worth it.

Found this article that demonstrates the benefits:

Benefits of Influenza Vaccination for Low-, Intermediate-, and High-Risk Senior Citizens

Kristin L. Nichol, MD, MPH; J. Wuorenma, RN, BSN; T. von Sternberg, MD
Arch Intern Med. 1998;158:1769-1776.
Background Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease. Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group.
Objective To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens.
Methods All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts. Subjects were grouped according to risk status: high risk (having heart or lung disease), intermediate risk (having diabetes, renal disease, stroke and/or dementia, or rheumatologic disease), and low risk. Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics.
Results There were more than 20000 subjects in each of the 6 cohorts who provided 147,551 person-periods of observation. The pooled vaccination rate was 60%. There were 101619 person-periods of observation for low-risk subjects, 15482 for intermediate-risk, and 30450 for high-risk subjects. Vaccination over the 6 seasons was associated with an overall reduction of 39% for pneumonia hospitalizations (P<.001), a 32% decrease in hospitalizations for all respiratory conditions (P<.001), and a 27% decrease in hospitalizations for congestive heart failure (P<.001). Immunization was also associated with a 50% reduction in all-cause mortality (P<.001). Within the risk subgroups, vaccine effectiveness was 29%, 32%, and 49% for high-, intermediate-, and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza (for high and low risk, P.002; for intermediate risk, P =.11). Effectiveness was 19%, 39%, and 33% (for each, P .008), respectively, for reducing hospitalizations for all respiratory conditions and 49%, 64%, and 55% for reducing deaths from all causes (for each, P<.001). Vaccination was also associated with direct medical care cost savings of $73 per individual vaccinated for all subjects combined (P=.002). Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup (range of cost savings of $171 per individual vaccinated for high risk to $7 for low risk), although within the subgroups these findings did not reach statistical significance (for each, P.05).
Conclusions This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination. All individuals 65 years or older should be immunized with this vaccine.

Another graph:

 

I’m not sure what happened in 1999. And I expected to see a rise in 2004 when we had the vaccine shortage. With widespread immunization there has been a decline in rates. How much is worth it? I don’t know. Based on this, looks like we should be vaccinating males or targeting males anyway. So $25 to prevent a few deaths, a few more hospitalizations, a lot of time out of work and out of school. I know, I would rather not spend a week sick with the flu if I can help it as it is really unpleasant to have.

Kathy Saradarian, MD

Dr Kimber writes:

The problem with this study is that it is an observational study. People who did and did not get vaccinated in the 3 risk groups self selected, and therefore were likely very different in many ways (measured &/or measurable and unmeasured &/or unmeasurable). These differences are the likely cause of most, if not all the differences in outcomes between the two groups, not the fact of having had influenza vaccination. This effect has been shown time and time again when the outcomes of RTCs did not show the purported benefits of therapies that seemed to be beneficial on the basis of these kinds of observational studies (not matter how well the authors tried to statistically adjust for confounding factors). The illusory benefits of post menopausal estrogens is an example that most immediately comes to mind.

The problem with the traditional approach to flu vaccination has been that those targeted (sick, elderly, and sick elderly) were least likely to mount an effective immune response to vaccination. The new strategy is an attempt to protect them by herd immunity in the community, by my understanding of the scientific rationale. That it fits with the economic interests of the public health-academic medical-vaccine industrial complex kind of clouds the picture.

The pertussis situation just returns us to the status quo ante prior to 1970s, as it is long known that pertussis immunity wanes, and absent a well vaccinated adult population and preponderance of breast feeding, the most vulnerable cannot be fully protected by vaccinating them, and yes there is a huge payoff in terms of years of life gained in that case.

As I think about it, moving vaccination from the (now almost completely socialized) health care system into the market place, is not a bad idea. Let people be educated or mis-educated, and let them make their own decision and spend their own money on flu shot.

Roger Kimber

 I agree, Dr. Rodney.

One of the unintended effects of the H1N1 hysteria was a clarification of the true burden of influenza. As you know for much of 2009 and 2010 patients who died after ILI (influenza-like illness) and patients admitted to ICU with ILI had virus specific typing of their viral illness. In many months the majority of ILI is not in fact influenza. The months where the ILI peaks incudes RSV, rhinovirus, picornavirus and so on. Also some of the influenza that was typeable did not match the antigen chosen for the year. I received the weekly NJ state department of health stats with all the state wide ICU admissions and deaths related to ILI and the weekly scatter plot of ILI and what percentage is influenza A, influenza B and untypeabe influenza.

The number of deaths in patients with lab confirmed influenza in NJ for year 2009-2010 : twenty four
The number of deaths in patients with lab confirmed influenza in NJ for year 2010-2011 : eight

We have heard the hype number 36,000 annual deaths for decades now. Instead of more detail and more testing bolstering that number we have the opposite. The last two seasons where there was an unprecedented effort to document as many cases of influenza as possible the case /fatality rate in NJ was 570 / 8. That means 570 positive samples for patients with ILI and 8 deaths among those patients. If you use the same rate for the positive sample number nationwide you get about 800 deaths. (54,226 influenza positive samples in the USA last flu season of the 250,000 total samples done by the CDC/WHO influenza surveillance system).

Are we to believe that 35,000+ influenza deaths are missed by the CDC? More likely there are around 1,000 influenza related deaths per year in the USA and several thousand other deaths after non influenza viral illnesses. I think if you use 1,000 annual US flu deaths (eight in NJ) you can make a better estimate of how much risk there is for your patients.

John L. Bucek, MD,
Somerset Medical Center

Paid off legislators using purchased science have inflated these miniscule statistical benefits for the purpose of profit. Why play? I know everybody has an anecdote,but do you really believe that you are saving lives with all of this? NNT?

wmr

I received my first shipment of flu vaccine Friday, Walgreens has had it (or at least the big roadside sign has been up) for six weeks already. Used to be we could fall back on the CDC recommendation to delay the vaccine till closer to flu season, but they have migrated to a policy of "Give it as soon as you've got it".

I'm considering just no longer ordering any, or only ordering enough to make sure my gravids get it. The medical industrial complex trumps the cottage industry of family medicine once again.

Arthur Freeland
Kirksville, Missouri

It’s a battle for us. Every pharmacy I call I have to listen to the message for 5 minutes about how they are offering flu vaccine. I am going to have to change my answering machine to include the message. I also by my vaccine from VaccineShoppe and they offer a free service where I just have to provide them with an Excel list of phone numbers and record a 30 second message to my patients to come in for their flu shot. So I am moving forward on that. It’s either stop doing it or advertise it to my own patients as much or more than the pharmacies.

I have even started reminding my patients this summer that I will get the vaccine and I have ordered it for them. Trying to guilt them a little if they go elsewhere for the vaccine.

Remember the pharmacies don’t have anything but the traditional vaccine. I am ordering doses of hi-dose for my oldest and sickest and I am trialing a few of the intradermal although it doesn’t sound better to me.

Kathy Saradarian, MD

 Kathy S, sounds like you have the right approach.  We have been giving them out for 2 weeks already, offering them to all that come in and all that will take them. Bill Vaccine and Bill the Administration Fee

Falball

Safeway sign: “10% off groceries purchased same day as flu shot”.

Earl J. Carstensen, MD, MHS

It's the same complaints and issues for the last 10 years. That's just the way it is. I'd say move on. We've all been upset and disturbed by this for years. It hasn't changed.

The AAFP hasn't come out and lobbied for us on this. It's ok to make me in CT have to have a Physician or an RN administer the vaccine. Can't allow or have my MAs even draw vaccines up, much less give them. That's stepping on the RNs turf and toes. So had to spend more money hiring a nurse for vaccines, even though MAs are experienced and trained for it. So my extra time doing them ourselves (the physicians) and paying extra $$$$ / hour for a nurse, didn't matter much to the AAFP ears and years ago. It isn't going to matter now. This is the way it is. Live with it. Move on.

Earl:

Tried that years ago. Took vitals, Asked about egg allergies. Billed 99211. Every insurance company denied payment. Had to write it all off.  Have to do more than that.

Kathy Saradarian, MD

We give them out for a routine office visit. No one just comes in for Flu Vaccines any more

Falball

Even if there are acceptable studies showing a reduction of influenza burden in an immunized population, the benefit is always overstated by docs and public health officials.  Many of the groups like pregnant patients and young children are not studied so requiring them to get the shot is just unscientific.   Thankfully there has been no major safety disasters with influenza vaccine since the swine flu vaccine in the 1970s.

However there was a recent significant safety issue with the H1N1 shot marketed in Europe. Dozens of children in England and Australia and Sweden got the condition narcolepsy from their 2010 H1N1 vaccine.   These countries will no longer give the vaccine to under 6 year olds as a result. If that level of side effect is possible then I want much better info on the NNT and NNH. Even if available these stats are not very helpful with influenza because the vaccine and the virus changes each year.

John Bucek

I agree with the general tenor of Dr. Rodney’s remarks. I was required to either get a varicella titer or varicella vaccine, even though I can remember having chicken pox as a child, and I was born in 1950!! (I took the shot to avoid the risk of having a false negative serology result,and have to get two procedures.

That said, I get my flu shot every year. Documented decreased sick time lost (Target employee RCT study a couple decades ago), and I get enough viral respiratory illnesses in the course of my work, and I would not like to be part of a chain of contagion. 

Roger Kimber
 

Index--Vaccine Police, flu vaccine

OB/C-Section Privileges Question: Further Comments

I would echo with Dr Rodney, that bringing up all the “possible” problems that might occur for those of us doing full scope FM and OB should NOT be a source of dismay and discouragement.  Basic surgical skills, diagnostic acumen and decision making can be applied to all the possibilities mentioned without the need for specialty surgical consultation IMMEDIATELY available.  We DO need to make sure our training programs and OB fellowships give robust exposure to a wide spectrum of surgical procedures so in those remote locations, we can handle these issues and more… I would think most if not all rural hospitals that CAN do C-Sections also have general surgical backup for these kinds of problems as well. If they don’t, then I would work on getting the credentials myself.

John Gibson, MD

 
Great question. Surgical backup is almost impossible in rural Alabama. We have involved our fellows in performing hysterectomies and surgical management of ectopic pregnancies for the obvious reasons. We have published a technique for cesarean hysterectomy that FM/OBs could do in the AJCM. So many techniques for managing PPH have become available that cesarean hystectomies are far less common today. Of interest, many graduating OB/GYN residents have never seen a cesarean hysterectomy, much less perfomed one.

Daniel Avery, MD
Tuscaloosa, AL

While laparoscopic approach to ruptured ectopic requires extensive training, doing exploratory laparotomy approach is not much harder than C/S at all.   
 
I have personally never performed a single C-Hyst in my life.  However, while consulted by FP OB fellows in Memphis, we avoided C-Hyst a few times by B-Lynch, O'Leary's Stitch, and vigorously correcting accompanying DIC.   Bakri balloon, sand bags are also useful in dealing with PPH.  Those approaches for PPH are relatively easy to learn for FP fellows.  My point here is: If we can avoid C-Hyst, we can minimize disatisfaction of patients and potential lawsuits.
 
I have also done a few TAH with OB fellows here.  I am extremely satisfied by the surgical skills those fellows demonstrated: some are much better than average OB residents.   However, without GYN or surgery backup, in emergency situation, supercervical hysterectomy is safer and easier than the whole TAH.
 
Bo Charles Li, MD, FACOG
Memphis, TN
 
I'll Echo Bill and Dan. When GI is doing scopes do they have Surgery back up in house in case of perforation? When Cardio does an angio they have in house back up in house in case of need of CABG or laceration of an artery?

I can go on and on......

What I do think is very important is to know how to handle the emergency with O'learys or Mgmt of the ectopic emergency for 45 minutes with fluids, blood, and others.

My 2 cents.

Eduardo Scholcoff, MD, FAAFP

OB/C-Section Privileges Question

Question:
 
A Cesarean trained family physician, asks about having additional surgical backup as a prerequisite for accepting responsibility for surgical OB night call. He cites the need for someone to manage ectopics, ruptured cysts, and bleeding fibroids.   
 
WMR Replies:

This is a variation on the C hyst dilemma, but double coverage of this type is nearly impossible for most rural, frontier, and mission hospitals.
Is there data describing the epidemiology of these events?

Is the event frequency 1 per 1,000, 10,000, 100,000 female patients 15-44 per year?
Needs assessment is the foundation of curriculum planning.
 
Early and frequent office ultrasound at the point of serivce has totally changed the game with the majority of our ectopic pregnancies(which are rare to begin with) now being managed nonsurgically(methotrexate).

If desirable, why not just learn to remove an ectopic surgically? It's only a few clamps and a few more sutures. 
 
As to the ruptured cysts, this is a pain and observation issue with chemical peritonitis or life threatening hemorrhage being rare to the point of invisibility. Bleeding fibroids as a cause for urgent surgical intervention? Everybody has an anecdote, but what are the data to justify all of this extra commotion and double coverage?
 
During 12 years of gathering data for the Medicos Project which now stands at overe  500,000 office vists and over 5,000 deliveries--We have not seen any need for these last two skills as prerequisites to allowing  Cesarean section trained family physicians to take night call.
 
As Dr Mary used to say, "Age is a wonderful teacher, but a lousy beautician"
aka "Risk and fecal debris occur spontaneously".

----wmr
 
PREVIOUS EMAIL INQUIRY AND RESPONSE:

Good morning everyone:
 
I know this is a colonoscopy list but I know many of you still do operative OB.
 
I recently finished my OB fellowship in Seattle at Swedish First Hill. It was a great experience. I want to thank many of you who helped me in deciding where to go and what programs to look at.
 
I am now working as faculty in a residency program in Canton, Michigan. We are working on getting our OB numbers up but in the meantime I wanted to continue to operate by moonlighting here. I have C/S privileges and the OB department has been very helpful.
 
The problem with moonlighting on OB is that occasionally you have a ruptured ectopic, ruptured cyst or bleeding fibroid which I am not credentialed to do.
 
Do any of you have something worked out with your hospital so that when you are on call covering OB there is a "second call" gyn who can come in on the rare event one of these cases presents itself? Do any of you have ideas about how I can approach this when asking to moonlight and this comes up?
 
Thank you for your help.

I have worked in two communities and in both instances I made certain that I did have coverage for those circumstances before signing a contract.  Yes, I am employed as are the obstetricians, which really helps with leverage. I also moonlight as a hospitalist there and bring a lot of patients to the hospital... which again, helps a lot with leverage.  In other words, I think it is key to have the hospital supporting your 'type of practice' and to gain their support, you need to bring something in return.

xxxxx MD

 

Index--Surgical OB, privileges, fellowship curriculum needs