PSOTBLOG

Screening and Medicine Debate - Where to Start, Where t...

Unfortunately science has been purchased for purpose of profit. Universities have emphasized indoctrination in place of education. The medical profession has been infiltrated with special interests parasitically requesting larger allotments of public money for their particular "product". Below I will go item by item offering  my observations as I morphed from university admin to private practice physician 1999-2012.
 
Scams-- Most not all--PSA, FSH, LH, Ca 125, age 40 mammograms, all H pylori lab testing. eosinophilic esophagitis, Calcium scores. Fibronectin, cervidil in place of misprostol, Pap smears under age 21. annual Pap smears, HPV subtyping,urine cultures, MRSA cultures, rectal exams, the cough test for hernias, bimanual pelvic exam, genetics testing in average risk pregnancies, CT scan lung CA screen, testicular self exam, nongeneric meds most of the time, more.
 
The vaccine industry has gone wild doubling the number of needed vaccines. All young men with sex on their mind, don't forget your Gardasil injections. Newly recommended by scientists with stock in the company.
 
Really useful--  office xrays for persistent cough, dyspnea, and pediatric age 1 week-age 4 pneumonia. In addition to standard adult medicine,Medicos doubled its volume in an overdoctored urban area by marketing Medicos as freestanding Diagnostic center/ER with special services for women and their children. Our OB practice and open 7 days a week really turned the tide for us. Our Pediatrics segment is 30-35%.
 
My CBC, UA,  and ECG machines are really important. Spirometry is helpful. Pulse ox and Peak flow are wonderful but Medicaid will not pay for them, Still, I wouldn't have an office without them.
 
Ultrasound is our stethoscope for the pelvis and abdomen. Must have. EGD in the office is the pathway to diagnosis and management for all dyspepsia
Office anesthesia including ketamine-- a really big deal. Must have. Colonoscopy screening is over done but case finding is important. Need IV sedation analgesia in the office to make this work. Once you have the office anesthesia a whole new world of needed office surgery is avialable: Bartholin's, perirectal abcess, fracture reduction etc. Diabetes and preg test in the office at point of care, yes yes yes. Lipid profiles overdone.
 
 
Will acquire if I get back into geriatrics--echocardiogram STD testing--we just treat most of the time, but we use them.
 
Wm MacMillan Rodney MD
Senior Editor
American Journal Clinical Medicine

Falball writes:

Other no votes     Microglobulin ,CA125

Treadmill Stress Tests--never that helpful. Last resident we taught finally gave it up. And he does almost everything else.
Carotid Ultrasounds--no           

Peripheral Neuropathy Testing-no

Index--Office tools most likely to be helpful

OB Didactic Curriculum For FM Residents

Dear Dr. Rodney:

I am a residency faculty in the Indiana University Family Medicine Residency.  I completed my family residency and OB fellowship training at IUFMR.  Currently, I am a fellow of the MSU primary care faculty development fellowship program and I am working on a project to rework our OB didactic curriculum for our residents.

As part of the MSU fellowship requirement, I am required to plan a curriculum, have an expert reviewer of the project and also to teach a pilot unit.  I have heard about your contributions and passion in promoting OB in family medicine and has extensive experience in education of residents and fellows from Dr. Kelly Arnold who was in our program the year before.  Also, when we were setting up our OB fellowship, we have found interesting data from your prior research efforts on OB fellowships, ultrasounds in family medicine residents, etc.

With your expertise in the field, I would like to have the opportunity to ask for your agreement to act as an expert reviewer of the curriculum.  I would like to set up a phone appointment with you to further discuss the request. I am available the following times:
1/18  430pm
1/19  1-4pm
1/20  1-4pm
1/23  1-430pm
1/24  1-430pm

The content for review will include a curriculum manual and  teaching materials, sample test questions for the pilot unit and a review form for you to complete.  I anticipate that it will take around 2 hours of your time and it should be ready to be sent to you electronically (or shipped to you if you prefer) in mid February. 

Thank you and looking forward to hear from you soon.

Regards,

Bonnie Wong MBBS
Assistant Professor in Clinical Family Medicine
Indiana University School of Medicine

WMR Replies:

I am honored. We really need to talk in person. Send me a CV, and the approval process for installation of this curriculum at IU. The rumor was that IU FM had been encouraged to downscale its ambitions in the OB fellowship. The  existence of a family medicine obstetrics fellowship year affects the design of such a  curriculum.
 
Political reality is a major determinant in the family medicine obstetrics curriculum. Some of this should be filed for discussion in Ecuador.

 
Cesarean section is the 3rd tier for family medicine. This is partly described in the fellowship overviews attached. The ultrasound curriculum is essential and we have some curriculum materials and an ipad app which need to be seen in person.
 
Let me offer you a scholarship grant including cost of a trip to Memphis such that you can see and taste the Memphis curriculum first hand. We are 24/7-365, so the ideal time would be fly Friday, spend Saturday hospital and office, home that night or Sunday am  There are many choices depending on fights, and your schedule.
 
You should consider the distinctions described in our recently published 3 tier system of family medicine obstetrics[Fam Med 2011; 43: 631-7] and some information about the  board certification in surgical family medicine obstetrics.
 
Index--fellowship OB, curriculum

Medicos Interview Background

Some background on Medicos' curriculum for interview visits:

Medicos was designed to train physicians for medical missions in developing countries where there is no medical insurance.
 
There is no geriatric medicine unless the family accompanies the grandmother or grandfather at the time of the visit. A family member usually witnesses all office surgeries up to and  including hernia repair.
 
Medicos discharges patients who are repeatedly concompliant or who insist on fragmented care (ER abuse-doctor shopping). Prescriptions are not refilled by phone with rare exceptions. Medicos will not prescribe chronic lortabs or benzos. Medicos will not ever prescribe ADHD meds for adults.
 
Medicos generally discourages HPV subtyping, herpes cultures, and other costly interventions which add little to the management of the patient.  Medicos avoids almost all  nongeneric medications. Doctors are required to tabulate the cost of each visit prior to discharge of the patient.
 
Most medical management approaches are identical, but in some areas Medicos is different. Xrays, ECG's, and ultrasounds are rarely overread except by targeted consultation. Integration of psychiatric issues is a daily occurrence. Addressing the emotional needs of mothers and families is always a factor in the Medicos visit.
 
Even though Medicos has attracted many English speaking patients, Spanish is spoken every day most of the time.
 
Medicos does not employ any full time OB faculty, because Medicos believes that family medicine needs to govern its own house while collaborating with OB specialists for consultation as needed. OB specialists do participate in the program.
 
This fellowship focus is slightly different than the current American FM residency training system. These idiosyncrasies merit investigation during the interview.
 
We share a common interest in maintaining delivery services within the medical specialty of Family Medicine. With regard to Medicos'FAMILY MEDICINE-OBSTETRICS fellowship, the central goal is the ability to perform a Cesarean section. Most applicants are residency trained and "soon to sit for their boards" family physicians.  To enter the fellowship they are required to obtain a Tennessee Medical license  and hospital privileges including normal deliveries. Medical malpractice insurance is provided. Over 60% of graduates practice rurally, but some have gone on to positions of leadership in training programs and hospitals.

For 20 years fellows have come with the expectation that the benchmark of success will be the ability to respond to an obstetrical emergency by performing a Cesarean section. The range for the past 80 fellows has been 70-240 Cesarean sections with some of them being assists. For the past four years all fellows have performed over 120 sections and most did over 200. Our goal is 50. Medicos  teaches a surgery lab twice a year, and there is a weekly high risk OB clinic. Over ninety percent of graduating fellows 1992-2010 have obtained Cesarean privileges. [Rodney WM, et al. Fam Med Nov 2010; 42: 712-716]

 
With best wishes for your professional success

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

Index--fellowship brief disclaimer

efds

Circumcision

Comment:

What is wrong with you supposed human beings with subjecting another human being to the totally needless circumcision procedure?  You are absolutely sick individuals when you converse as if there were no one being tortured by your actions.  You all need healthy doses of psychiatric care. Your actions are not far removed from those of the demented physicians who tortured in the Nazi death camps.

Waspman

WMR Replies:

Medicos does not encourage circumcisions. We do so at the insistence of the family. Please let me know who you are and what happened. WE agree that there should be fewer circumcisions if any. How do we convince the American public?

I sincerely appreciate and respect your kind reply.   Your posted site language is, however, very pro-circumcision appearing. I would hope that, on site, you would allow your thoughts that there should be fewer circumcisions if any to show through your messages.  How do we convince the American public?  One case at a time, but you must start that process and be vocal. Circumcision rates have dropped considerably in the USA and that momentum continues.  You could add to that momentum by making non-offending statements as to your true feelings.   
 
As to who I am, I am a male in Maine who has lived both ways (i.e.) intact and circumcised and, believe me, will do everything in my power to keep ignorant individuals from inflicting the cruel circumcision procedure on innocent young children.   They are maimed for life and, no matter how one may try to justify circumcising, the innocent victim’s life is permanently and negatively changed.  No one has a right to inflict that on a child.   In any event, thank you for communicating. 
 
Waspman

Medical Mission Team to Osun State, Nigeria

Yellow fever vaccine is not needed.
I sent IKe the itinerary to pick the exact same flights.
 
This is a summary review of what I have packed so far. WE are bring three-four excess bags from Memphis. One will include the ultrasound machine and transducers. The second bag will include the fetal monitor. In the third bag I may bring an electrosurgery unit with the tools. I am bring an extra pack of surgical equipment and all of the sutures. 
 
I have not purchased any surgical drapes, but will bring some various drapes if we really have to. I am using some shoe covers and hand scrubs for padding around the heavy equipment I will bring a complete of surgery instruments including one bladder blade.
 
We preshipped the colpsocope, one vacuum. one forceps, and the pelvic model to demonstrate. The crate contains two of the latest Pfennninger Procedural textbooks which we can present as a token of our esteem. Plus these books represent the extensive curriculum in surgical family medicine obstetrics. You should have the info to obtain this crate from customs in Lagos.
 
We will also bring the small pulse oximeter and portable otoscope as potential gifts to the programs if it is established. Or Dr Adebisis may keep them in his house there for future use. I have sterile gloves and did obtain a box of 6 1/2 as requested by anesthesia.  I have box of 25 G spinal needles, and several spinal anesthesia trays.
 
WE have power point presentations, but MUST have a VGA or HDMI connector to link our laptops a projector for our presentations? ipad requires an HDMI cable I think.

Tuesday--Ultrasound basics; ovaries, interesting cases to demonstrate the unique power of early and accurate diagnosis by a family physician OB. Ihope to bring an ipad2 to demonstrate the ipad program we have designed. I really would like  to do live demonstrations on patients who we would pay to be models (if necessary)
   
Wednesday--NST and EFM in Obstetrics. Ike had some really good slides in green about the power of the fellowship which he was going to present in Phoenix. He should bring them and use part of them. Our newly published review on this topic is attached. We should have it printed and distributed.
   
Thursday--as with previous two days we need a classroom and some idea of who will be attending. We have handouts which will need copying for distribution during the class so some idea of the attendance would be helpful. We will be using website learning to demonstrate our Procedural skills and Office Technology links(www.psot.com) for the ECG.

 We have ALSO discs for the vacuum and forceps presentation. Hopefully the mode l will be ready for demonstration. A labor demonstration would be nice if we could find a slow crowning primip, I would demo.
 
We have purchased no drugs yet and need to have your comments so far.
 
 
Wm MacMillan Rodney MD
Surgical Family Medicine Obstetrics
Clinical Professor and Chair
Medicos para la Familia