PSOTBLOG

Derm Mystery: Male Nipple

A healthy 43 yo male tile worker came to office today saying that this lesion started as a pimple 4-5 m ago. He was born in Mexico Guajuatenejo which is urban. He moved to USA over ten years ago.The color is a little more vivid than is represented in this photo.
 
His review of systems is negative and he has not applied any medicine to this lesion. It looks like a granuloma eaten away, but we have no path. He has a small red streak running east west one inch above the nipple and on the medial side. It resembles the streak of visceral cutaneous migrans.See photo above.

His CBC is normal and his chest xray has no acute disease. We applied a PPD because both hilar areas appeared large and his parenchymal markings are too prominent.
 
A few weeks later he developed a group of four lesions on his R flank. They appear crusted over without any associated redness, drainage, or warmth. They measure 1-2 cm and the group is in an area of 5x5 cm. We will biopsy if he returns and if he can afford the path($400).
 
I am stumped. Your comments are appreciated.

What Is Up With Actos And Bladder CA?

Quality FP Writes:

I would like a blog that posts all the “new news” in the medical field like this. Like what did Dr. Oz say today or “the Doctors” if they are still around.

Apparently there is some evidence of a significant increase in bladder cancer on patients taking Actos, dose related.  Which is why the reps are now quietly saying, “you probably don’t want to go above 30 mg as increasing to 45 mg didn’t reduce sugars much more”.  Or at least mine were before I had heard the news.  It’s just that bladder CA is pretty uncommon so it’s still not that frequent but from 1-2% baseline to 3-4% on Actos. FDA is saying benefits outweigh the risks. 

Now I see malpractice lawyers advertising for patients taking Actos and having bladder cancer.  My patients are asking about this.  Did I miss the boat?  Where was that announcement?  What evidence is it founded on?

WMR Replies:

It's been so long, since I've heard "RepSpeak". A wave of nostalgia swept over me for a nanosecond. Neverthless, Memphians remain proud of pioneering innovations in medical excess, public education, and "Jackpot Justice". These seem to have widely adopted.

Index-- Profit Driven Love Affair Continues

Accreditation for FM OB Fellowship

Greetings:

I am a current fellow at USC/CHMC Family Medicine OB Fellowship. Our fellowship program has been around for a few years then lost funding for six years but is now re-funded and going again. We have 3 fellows this year and will have 4 fellows next year. How can we go about having the fellowship recognized by your organization so graduating fellows such as myself can apply for diplomat status upon completion?

Fellowship website: http://keck.usc.edu/en/Education/Academic_Department_and_Divisions/Department_of_Family_Medicine/Education_and_Training/USC_Obstetric_Fellowship_at_California_Hospital.aspx

Regards,

Dr. Khan

WMR Replies:

 
In 2010 I met with your newly reconstituted fellowship faculty in LA, and encouraged contact with our Board. I'm sure life is busy, but they have not expressed any interest yet. Thank you for raising this issue again.
 
This certification produces a tangible assert for those who follow through with it. Just this week I had contact with someone who was turned away from Cesarean privileges for lack of a "fellowship certificate", even though he had completed 145 Cesareans. Cesarean skills are the rate limiting step for quality delivery care in may critical access hospitals and in mission hospitals throughout the world.
 
This certificate has special impact for those with any plans to work internationally. We will be in Los Angeles June 26-30, and would like to sponsor a Supper to discuss this issue for the programs of Southern California.
 
In the meantime, If you could send me an overview of your current curriculum, I would like to take a look at it. I hope your faculty will see the important ground to be gained through an affiliation. Attached is our data on outcome of the fellowship in Surgical Family Medicine obstetrics. Download RodneyFinal fammed 2010 42 p712 

Let me reaffirm my willingness to help your group with this.

With best wishes for your professional success,

 
Wm. MacMillan Rodney MD
Editor, American Journal Clinical Medicine
Board of Family Medicine Obstetrics
 

Chaperone-Medical Assistant Policy Version Revisited

Sir:

This is what I read today. http://www.pulitzer.org/archives/6414

Manjo Mazumder

The story below deals with a NYC gastrenterologist who was charged with sodomizing a woman during an unchaperoned colonoscopy. From the facts available, it appears that he unjustly loses his medical license and more. I assume his wife continues to be a physician.
 
Unfortunately training as a limited specialist, increases your risk of failure to diagnose mental illness. The doctor who operates without understanding the family and social history is riding for a fall.
 
I am impressed with Manoj's recall and records regarding my emails. Bad things can happen to good people and no chaperone can prevent an evil woman from filing a lawsuit in a country where the process of law is defective. You can live free tolerating calculated risk, or you can crawl through life hoping that nobody ever notices you.
 
Dr. Mary MacMIllan used to say, "Without courage, you can practice no other virtue".
 
On a cultural note, The Endoscopic Elvis Award went to Tom  Kintinar MD, president of the American Association of Primary Car Endsocopy[AAPCE] tonight in Memphis. Tom Kintinar is riding with the King.
 
With best wishes for joyous Thanksgiving--

WMR

 

The Original Post:

It is not a legal standard and it is not Medicos policy that all Paps smears, pelvic exams, or transvaginal ultrasounds require a female chaperone. Some have requested a chaperone to do an abdominal ultrasound on a female patient. This is an inappropriate use of  resources, and delays care for other patients who are waiting. Chaperones should be used selectively for procedures which require an extra set of hands, and/or for women with psychiatric/chronic pain issues. 
 
Colposcopies, endometrial biopsies, D&C, Bartholin cyst,--These are examples of gyn procedures which require an extra set of hands. Doing them without an assistant is ill advised and may lead to a low quality result.
 
A bimanual pelvic examination is NOT required, and recent studies suggest that there is nothing to be gained when ultrasound is available. Rectovaginal exams have been abandoned. Suspected pelvic pathology requires ultrasound. Medicos believes that transvaginal ultrasound can and should replace the bimanual pelvic examination when such an examination is indicated.
 
If the physician does not have time to review the chart and update the problem list prior to a pelvic exam or office surgery, STOP. GET THIS INFORMATION BEFORE YOU START. Every year Medicos operates on someone who has a postop complication fueled by previously unknown mental issues.
 
Male physicians may have anxiety about the risk of being alone in a room with a female patient, but there have been no cases reported or suits filed in my 35 years of practice. If someone can produce a documented case, Medicos will pay a $100 finders fee if you can find a case.
 
The big exception is the patient with mental pathology. Family physicians should have advanced skills in the recognition and management of mental pathology. But fragmented care and out of date problems lists are persistent problems. It is Medicos policy that physicians review problem lists, current medications, and previous notes prior to a pelvic exam or office surgery. OB patients have similar requirements. This week Medicos had two notable cases which will require review.
 
Female physicians should feel comfortable with a male assistant for pelvic exams and gyn surgeries. The main issue is to have a second pair of hands for equipment and specimens. Some in the clinic have delayed pelvic exams pending the availability of a female chaperone. Some staff feel that the doctors have "always" required a female assistant for a pelvic exam. This is not true, and Medicos has clarified this policy every two years.
 
Assistants are not legally required for Paps smears and transvaginal ultrasound exams. Physicians with concerns about lurking psychosexual risk, have a right to have an assistant for protection of a witness, but the gender of the assistant is not the major issue.
 
When female assistants are mandated for every pelvic and transvaginal ultrasound, it unnecessarily delays care and adds no benefit.  I hope that Medicos physicians will develop the clinical judgment to maintain quality while adapting to the realities of the pelvic exam in the 21st century. 
 
With best wishes for a Merry Christmas and a Joyous New Year,
 
Wm. MacMillan Rodney MD, FAAFP, FACEP
Chair, Academic Affairs
Medicos para la Familia
Nashville, Memphis and International

Procedural Skills and Office Technology
www.psot.com

 
Index--Policy Paps smear chaperones, medical assistant, gyn surgery, pre operative clearance in the office
Index--chaperone policy

The Worst Evil?

Seeing that poor woman with the Implanon yesterday, reallly brought this dilemma into focus for me.  As you may or may not know, Implanon requires training and "certification" for  its use. This requires an investment of the physician's time.
 
Those who implanted the device in this woman, may not have effectively educated her of the hormonal side effects. Someone probably gave her the information, handouts, etc. Every day Medicos sees patients carrying 10 pages of printed information following their ER or clinic visit. These papers document that  patient education materials were distributed, but the reality is that the patients know little of the contents. A month later, they know even less.
 
In the case of the Implanon woman we saw this week, she was unaware that someone with surgical skills would be required to remove the device when its 3 year life was over. She was unwilling to leave it in as she viewed it as a foreign object. Even simple surgical extractions seem to be beyond the abilities of the generic primary care provider. This patient could not remember the name of the "provider" who inserted her device almost 3 years ago.
 
 Later that night I witnessed the Mirena campaign on television.[See below] When I see these glossy million dollar advertisements on network TV, I think about the Cialis dual bath tub spots. I remember the Avandia and Vioxx and Neurontin and Zyprexa misrepresentations. Mirena prosecuted  physicians who imported low cost equally effective generic IUD's on behalf of uninsured women.
 
Medicos deeply admires the mission and passion of the One Step Ahead Foundation in providing family planning for uninsured women.. On the other hand, my experience with the Mirena and Implanon marketing campaigns suggests that Medicos will continue to refer those women with special needs for these products. Comments are appreciated.
 
With best wishes for professional success,

WMR

While I agree that we can often do a better job with patient education, especially in providing patient-centered contraceptive counseling, I have to correct one of your points, at least as it applies to my locale...The many docs in Rhode Island (all OBs, to my knowledge) who were inserting cheaper IUDs  acquired abroad were billing insurers AND self-pay patients the full price for Mirena. The Dept of health, not Mirena manufacturer, came after them for fraud.  The insurers and the patients weren't too happy either.

-Melissa

 

Someone sent me this last Spring...
 
God knows there's a lot of competition for that category, but selling drugs to vulnerable people at bankrupting prices who've put their faith in you to help them has to rank at or at least near the top.

Here's an ex-pharmaceutical rep explaining how the business works and what its true goals are.

Hint: The goal is not to make you better.

Video: http://www.brasschecktv.com/page/1065.html

Index--Contraception, IUD, Family Planning

Cesarean Op Reports

For the first time, the Memphis FM OB coaltiion of private practices had simultaneous concurrent Cesareans at Baptist and St Francis hospitals two days in a row. We are fortunate to have prepared for this through an expansion of the program which is the only one in the country operating totally on private funding. A special thanks to all of you who have supported this program. This fellowship is unique in encouraging that some of the program be completed internationally IF the posting includes privileges in obstetrics. Drs.Gonzalez, Encinas, Mazumder, and Soliman will be accepting postings in 2012. Contingent on her approval, Medicos is negotiating a posting in Ecuador for Dr Dooley.
 
Dr. Self has completed the first phase of his hospital/clinica in Guatemala, and the schematics are available for those with this interest. Our compliments to Dr Self for realizing his vision of service to the indigenous people of Guatemala.
 
Medicos continues its study of surgical family medicine obstetrics in an over-doctored USA metropolitan area. Thanks to Drs Self and Dooley for providiing timely progress reports on delivery activity for the 3 month period Aug 1- Oct 31. These data reflect a surgical harvest of 85 Cesareans for the quarter. These data do not reflect the activity of the UT St Francis fellowship which is separate. Therefore the city wide number is larger, and we estimate that city-wide there are over 2000 Family Medicine based deliveries in Memphis every year.
 
Medicos always struggles with the credentialiing transition each Summer. All hospital applications must be carefully screened prior to submission. Any gap or glitch can cause a delay of months. As a group, can we meet for planning of the Methodist OB privileging proposal.
 
Your previous and continuing support is appreciated,
Hagase tu Voluntad

WMR--Medicos

Index--Cesarean training, International outreach