Docnotes

Primary Care jobs?

A Chance to Cut is a Chance to Cure mentions a Medical Economics article about jobs in primary care, and how Internists are (in some markets) in greater demand than family physicians. Hospital systems greater interest in Internists"... is partly a byproduct of employers' current focus on recruiting specialists" according to one of the recruiters quoted in the MedEc article.

Well .. we family physicians can be a bit .. uh .. thin-skinned about this sort of stuff, so please forgive me if I seem a bit negative about the post for a few reasons:

I am disheartened that rather few internists are attracted to primary care. 

I am disheartened that some recruiters and "hospital systems" are drawn to Internists rather than family physicians due to a perception that Internists drive more specialty referrals. Business is business, I suppose. So if the goal of a hospital system is to drive referrals .. and increase utilization of highly reimbursed services (such as surgery), then I suppose these concepts are right on target and we all should nod our heads in agreement.

Yet I wonder if this all misses the point. Why are we providing healthcare? Is the primary goal is to earn money .. and healthcare is the market? (Just like selling cars or baseball hats or computers) .. I sure hope not. As a profession, we do what we do because we want to deliver a valuable service to the world.

Yes - we want/need to be reimbursed - or we couldn't sustain the service. But reimbursement isn't the primary goal.  And if we consider the goals (implied, perhaps) of family physicians - I would suggest that they coincide with the healthcare needs of a community better than most other physicians.

Yet employers of physicians are sadly more interested in the financial picture than the healthcare needs of a community.

• They need to build demand for their service by hiring an Internist rather than a Family Physician. Wow.

Let's change a few words and see how similar that is to:

• "General Motors needed to build demand for their cars by killing off public transportation.

Yeh .. I'm streching the analogy a bit .. but .. you get the point .. is healthcare about "increasing market segment" or about "meeting a community's healthcare needs?" I argue that the two are inherently at odds. Physician supply and recruiting remarkably DOES change healthcare. Yet these "market force" decisions will hurt us far more than they will help us in the long run. We need a system where the skills of physicians trained and recruited will meet the healthcare needs of a community - not the fiscal needs of a hospital or healthcare entitiy.

Epidural analgesia and c-section rates

From BMJ this week:

Epidural analgesia using low concentration infusions of bupivacaine is unlikely to increase the risk of caesarean section but may increase the risk of instrumental vaginal delivery. Although women receiving epidural analgesia had a longer second stage of labour, they had better pain relief.

My partner delivered a baby this week and struggled with 2nd stage so much that she ended up cutting an episiotomy and applying a vacuum and a consequence was a 4th degree tear.  Last month, I cut the 2nd episiotomy of my lifetime and we had to fix a 3rd degree tear (one of only a handful I've been involved with).  Common theme?  Epidural analgesia. 

I struggle with this often.  On one hand .. epidurals are wonderful adjuncts to the care that we can provide to women in labor.  The expoerience can be transformed from a lengthy, horrible experience to uncomfortable and tolerable.  Yes, yes .. I'll never know.  I will never have a baby and so .. my perspective is inherently different from those who have HAD the experience.  My life with back pain has certainly made me more sensitive to my patients with back pain .. and perhaps I would not be so hesitant to embrace universal epidurals if I had really experience the pains of labor.

Yet here we are.  Epidurals can enhance the likelihood of instrumental delivery and therefore complications.  Like most things in medicine .. there is not an easy answer here.  We need to make careful, thoughtful decisions. 

The 12 types of medical students

Discovered today on medlogs: This is very funny (and accurate too!)

Graduation, free e- MDs medication database, evening hours

 

An unusally long day .. but productive .. which is much better than a short unproductive day.

1. The Medical School  graduation was today.  This is the view from the stage .. where I was sitting .. 3rd row.  Can't pick your nose when you are sitting on the stage.  I wore my suit and tie.  Was very well behaved and even got kinda wistful watching these new young physicians stepping into their careers.  The speaker was Joseph Goldstein, who gave a nice short talk on the changing face of medicine today.  His message:  Genes are the future of medicine.  I didn't know as many of the students in this class as I had others.  I'm not one for ceremony or tradition ... but this sort of event is meaningful to me: a recognition of four years of extremely hard work, and the true birthing of a herd of healers/helpers etc. 
   
2. Office hours tonight were uneventful and kinda fun.  We had a first year medical student shadowing me and it was refreshing to see the novelty of family medicine through her eyes.  We had two patients who were here with concerns about possible lyme disease.  the first turned out to be a "textbook" case of pityriasis rosea, and the second was cellulitis of the butt.  We froze some skin tags, treated a UTI (and learned the reason for the term "honeymoon cystitis") and did a few well-child visits, mixed in with a few other new adult patients and a post-partum visit. 
   
   She was struck with how easily I brought up the part of the social hisotry that rhymes with "hex" .. and how easily I asked about same-sex relationships. 
   
   "Just be matter-of-fact" I said.
   
   Nothing is hard to talk about if you are not judgemental about it ... and I don't mean "don't act judgemental"  I really mean .. don't be judgemental. 
   
   This is easier for me with sexuality and other "challenging" topics .. and much harder for me with obesity and smoking and "bad habits" in general.
   
3. Staying here at the office late to take care of the large pile of papers and patient messages.  I got a bit behind on these last week .. and it takes a late night like this to really catch up.
   
4. e-MDs is giving away its medication database.  Hmm  I wonder if NAPCI should try to distribute it ... Multum will also give it away ... but not for commercial use.  The Multum Lexicon Guide, BTW, is a wonderful resource.  A must-read for anyine interested inhealther informatics.
   
   .. back to the charts ...

Medical Weblogs V 2.0 beta

The beta version of the new Medical Weblogs site continues to evolve. I've been adding weblogs and trying to organize things, while Dave fixed the CSS and built a blogroll on the side. I'm working on a form to permit you to add feeds I don't have. I'll open it up for a few days .. so medbloggers will notice it and please do help me get some more blogs in there ...

Medlogs - another upgrade

Here's a sneak peek at the newest iteration of the medlogs medical weblog aggregator. It sorts posts in order. So the most recently updated welbogs are at the top. Maybe this is incentive to keep active! We've also separated things a bit (still working on the categories .. comments and corrections requested) ... so resident blogs are separate from physician blogs which are separate from newsfeeds such as reuters and medscape, etc. Dave has, of course, helped enormously .. as I couldn't have done this myself. Required some re-writing of feedonfeeds , and a bit of php magic. More enhancements on the way .. and a bit of debugging before we move this over to the main medlogs url.

Neckties harbor pathogens

Well .. I don't wear a tie at work.  I did wear one in medical school .. and probably my first few months of residency .. but pretty rarely since.  I just don't like 'em.   Now there is a study that demonstrates that physicians' neckties harbor pathogens.  They don't wash ties as they do the rest of their clothing .. and the ties come into contact with patients frequently .. and physicians' hands too .. (re) contaminating the hands after washing:

 

neckties worn by doctors were eight times more likely to harbor pathogens than were those of hospital workers not normally in contact with patients, according to the results of a new study.

While working at New York Hospital in Queens, lead author Steven Nurkin, a medical student at the American-Technion Program at the Bruce Rappaport Facility of Medicine in Haifa, Israel, noticed that physicians' neckties often come into contact with patients or their bedding.

After examining a patient or conducting procedure, he told Reuters Health, "they would wash their hands, and then adjust their tie," perhaps recontaminating their hands.

So he and his colleagues swabbed 42 neckties worn by physicians who regularly saw patients and 10 neckties worn by security personnel. They then dabbed the swabs onto laboratory plates and identified the microorganisms that grew.

Twenty of the clinicians' neckties carried pathogens, including Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Aspergillus. In contrast, the tie of only one security guard carried a single pathogen, S. aureus.

Nurkin pointed out that neckties are encouraged because they are believed to project an aura of professionalism and increase patients' confidence, but they may not be cleaned as often as other articles of clothing.

Options to reduce the risk of disease transmission, he suggested, include switching to bow-ties or using tie tacks that hold ties to physicians' shirts. Doctors could also decontaminate ties with a "high quality detergent spray that wouldn't ruin the tie" or even use a "necktie condom."

Medlogs upgrade

I've finally updated the back-end that runs medlogs.  It's been re-built entirely .. with some help from Dave.  I had some trouble with the CSS ... and he got things fixed for me. 

Medlogs is now a much better medical weblog and news aggregator.  I'm going to break things up into categories.  Still haven't figured out a good way to get them sorted by date .. which is what I really want. 

Dave has done some great work with coldfusion and LDAP.  Not documented anywhere else .. so if you are a nerd looking for info on how to do coldfusion security with LDAP to Novell or Windows ... Dave's blog will show you how.

My Left Arm for a Gmail Account

Wired News: My Left Arm for a Gmail Account. Lots of talk on the Internet about Gmail accounts. Google's version of webmail provides many features, but the two that have haused the most stir are the privacy issues (google's computers read your e-mail and place targeted text advertisements on the screen next to your message) and the size of the mailbox: 1 gigabyte. I have a gmail account. Lucky me. I won't have to buy one on ebay. Got it from my brother. a) I love the 1 gb of storage. b) I don't care about the privacy issues. I have nothing in my e-mail that google's computers aren't welcome to read. E-mail is inherently insecure anyway. The great features of gmail are the auto-threading, and the ease with which on can "get through" the e-mails. Auto-threading takes all e-mail conversations and groups them together. So if I get a message from mom .. and I reply .. and she replies back .. is all automatically grouped together as one "conversation" instead of three separate e-mails. E-mail processing is also very quick. It's easy to review messages, identify and handle spam, archive, or label a message. All very fast. The user interface is the best I've seen for a web-based e-mail client .. dispacing my previous favorite, oddpost.

Childless couple told to try sex

Childless couple told to try sex A clinic spokesman said: "When we asked them how often they had had sex, they looked blank, and said: "What do you mean?". "We are not talking retarded people here, but a couple who were brought up in a religious environment who were simply unaware, after eight years of marriage, of the physical requirements necessary to procreate."