Docnotes

Not Enough Generalists?

SoloDoc writes a nice entry on family medicine .. and the problems we're having recruiting students to go into our specialty:

One of the solutions has got to be increasing the reimbursement rate for primary care physicians so that they can make a decent living without working themselves to the bone. If medical students see happy family doctors, they will want to become a happy family doctor, too.

At our local Medical Mecca, we graduate 130 students every year.  Back in the old days - 7 or 8 years ago, we would routinely see 20% of the class go into family medicine.  This year, it may be less than 5%

Of course, this is exacly the opposite of the trend that should be ocurring, if we consider the healthcare needs of the United States (or the world, for that matter).  But the pressures that generalists feel are real, and the solution is unclear.

Hospitalists - a good idea?

When we got the letter from the hospital - offering the new hospitalist service to us .. we told 'em we would give it a try.  So for the past few weeks, if an adult patient of ours comes to the ED, we are supposed to get a call from the ED physician.  S/he will describe the situation, and we will have a choice of whether to admit the patient ourselves, or allow the hospitalist to care for the patient.  They assured us that there would be excellent care and good communication.  So we said we would give it a try.

It makes sense.  We usually have only one or two patients in the hospital.  Just driving there and back takes more time than seeing the patients, so it's a lot of time .. and one could argue that the patients may get better care and/or service from someone who is always in the hospital. 

But ..

Two nights ago, the husband of a patient called because his wife was in the hospital.  She was admitted "with a kidney infection" and now urology said that it wasn't .. and neurosurgery said it wasn't a herniated disc .. but no one had been "in charge" of the visit (from the family's perspective) .. and they were frustrated and angry.

"uhhhh"  says me.  I didn't even know she was in the hospital.  They never called me.  Just admitted her to the hospitalist service. 

So ... like any geek-physician, I logged on to the hospital's computer system and saw that her WBC on admission was 6.5 .. and there were scant RBC (no wbc) on a cath urine specimen from admission.  Renal ultrasound was negative, and an MRI of the l/s spine showed mild herniation at L4/5 .. with no nerve root impingement.

Then I visited her in the hospital yesterday morning.  The admission H & P was dictated and very thorough.  From there, the four day admission read like a team of blind men were treating an elephant.  A different hospitalist saw her every day and ordered new tests and new specialist consultations.  She was confused and angry and the bottom line is that this poor woman had back pain.  Frustrating and painful .. but something that probably should have been managed outside of the hospital from the beginning. 

I nudged the very nice physician's assistant who was seeing her yesterday (for the first time) for the hospitalist service to discharge her asap .. and I would see her in the office in a few days.  I sat with her for five minutes and listened ... something no one had done in four days .. and she felt much better ... eager to go home.

Maybe this hospitalist thing isn't gonna work ...

[No Title]

Posted to Family-L recently:

 NWAHEC - Herbs&Dietary Supplements is a very well done online curriculum on herbs and dietary supplements.

The program includes:

Baseline assessment of participant's knowledge, attitudes and clinical communication practices with regard to herbs and dietary supplements.

Answers on this assessment are for curriculum evaluation only. The answers on this questionnaire do not affect educational credit.

The curriculum. 40 1-page, self-instructional modules on commonly used herbs and supplements (sample module). Access to evidence-based information from reliable Internet sites from academic centers and the US government (links and resources). Access to a moderated Listserv (discussion group) with your colleagues who are interested in herbs and supplements. The Listserv will have a maximum of two postings per week. There will NOT be any advertising in these postings, and participants may choose to un-enroll in the ListServ. Post-course assessment and evaluation. Participants must get 70% correct on 10 knowledge questions to obtain continuing education credit.

Goin to the ER

From "A Chance to Cut is a Chance to Cure"  This note about sending patients to the ER.

In primary care .. it's not so clear as in general surgery.

Yesterday I met a patient at the office (yep -- Saturday afternoon) who called with "doc I feel just rotten." It would not have been appropraite to send him to the ER ... and some may have had him take some tylenol and come to the office Monday AM. ..

when I saw him, I was glad that I did what I did.

Temperature was 103. Exam revealed cellulitis of the right leg ("well, my leg did hurt some") and a blood sugar of 156.

(no known medical problems, by-the-way)

So now you know the diagnosis.

While I doubt anyone would argue that this would have been an abuse of an ER .. I think that most would agree that cellulitis and a new diagnosis of type 2 diabetes is more appropriately managed in the primary physician's office -- where follow-up can be arranged (he's doing much better today) and continuity is maintained.

How to bill?

99215

99050 (rarely paid .. but we'll ask the insurer for it anyway)

90788

J0696

J0696

682.7

250.90

A Primer on Summer Safety

From FDA.GOV: A Primer on Summer Safety.

Is Medical Arrogance Striking Again?

Russ points to this article in the Reno Gazette Journal: "Patients claim fibers sprout from lesions and parasites crawl under their skin. Most doctors tell them it's all in their heads" The topic brings up a problem in medicine that we (oddly) find hard to acknowledge: we don't know everyting. I do have a few patients similar to the folks descibed in the article .. and I have a hard time knowing WHAT the problem is. Saying "I don't know" is often the best method. My problems escalate when a patient brings to me a hypothesis from another healthcare provider which is as reflexive and condescending as "it's in your head." Consider Dr Harvey's statement in the Gazette article I link to above: �Without understanding the skin lesions fully, I�m treating patients with antibiotics and having clinical success. Something appears to have happened to their skin immunity.� He's making a treatment decision in the absence of any rationale. Am I an arrogant physician because I wouldn't treat a problem with antibiotics unless I knew there was a clear rationale for that treatment? Dr Weil's talk at STFM yesterday touched on this a bit. He acknowledged that much of the "alternative medicine" that people are embracing is in fact garbage. We need to be thoughtful and evidence-based as we practice integrative medicine .. just as we do for "traditional" medicine. Yet there will be integrative methods without much evidence, just as there are traditional allopathic methods without much evidence. He suggests that the requirement for evidence of efficacy be dictated by the level of risk in any treatment.

STFM, Medlogs, etc

Like many, I've responded to the change of movabletype from a shareware product to a commercial one. As a colleage suggested to me ... people gotta eat. I will not move to wordpress. Upgraded to MT 3.0 without too much trouble. It does seem more stable - though I lost my HTMLAREA WYSIWYG editing which I liked very much .. so will have to figure out how to reainstall that to MT3. The tempaltes have changed a bit so it may take some work to figure this out. This morning's keynote speaker at the STFM conference was Andrew Weil. He gave a compelling talk on integrated medicine and I find myself agreeing with much of what he has to say. He appropriately described the obvious links between family medicine and integrative medicine - as we do see patients as the sum of a whole - rather than as a disease or diagnosis. The key is that we need to work the training of integrative medicine into our medical schools and residencies. He told a compelling tale of Dr Laurence Craven (descibed in this pdf .. and some other places: In the 1950s, a California physician named Lawrence Craven made a keen observation. For several years, Craven had been prescribing Aspergum, a chewable form of aspirin, as a pain reliever for patients who had undergone tonsillectomies. Craven noticed that these patients experienced an unusually high occurrence of bleeding problems. In a bold leap, Craven theorized that this apparent “side-effect” of Aspergum might have beneficial applications. Within the arteries supplying the heart, Craven reasoned, an increased bleeding tendency might prevent the formation of the clots believed to cause heart attacks. Though his hunch would prove prophetic, Craven’s data were far from conclusive, and he became little more than a footnote in the aspirin story. Craven’s reports on aspirin were uncontrolled clinical observations, which only reached relatively obscure regional medical periodicals. His data were not published in the prestigious journals of the established research community, where they might have sent other scientists scurrying onto the aspirin trail. Craven was a family doctor, not a trained researcher, and his studies did not employ the rigorous scientific methods necessary to test his intriguing hypothesis. For example, he eventually had thousands of patients chronically taking aspirin, but assembled no control group of patients not taking aspirin against which their cardiovascular disease rates could be compared. Craven also betrayed the sort of unbridled enthusiasm for his hypothesis that can sometimes serve to discredit even the most plausible theory. In one report, Craven said that he placed 8,000 patients on regular doses of aspirin and not one suffered a heart attack or stroke. This track record appeared too good to be true. There was a smattering of other reports from scientists who also theorized that aspirin might have beneficial effects on cardiovascular disease, but the exact biochemical basis for such an effect remained unclear. Weil's point is that one fo our problems in medicine today is that physicians often consider the SOURCE of information before we consider the informationitself. Craven, a General Practitioner, was not considered to be authoritative - so it too the cardiologists another 30 years to "discover" the compelling benefits of aspirin in the prevention of cardiovascular disease. My session on Medical Weblogs went well on Friday .. I'll post an update about that if I have a few minutes later today .. otherwise we'll get to that tonight .. ;-)

Pneumonia Severity Index Calculator

AHRQ Pneumonia Severity Index Calculator is a useful tool .. available in web, Palm OS and PocketPC versions.

Physician Fears

Ny Times: Doctors, Too, Have Fears; They Just Go Underground

This is an article about "Medical Student Syndrome" and how it recedes after medical students magically become physicians.

It's an accurate depiction of what happens to students, but the author misses the point in her portrait of physicians. 

AAFP Monograph - Aging

The AAFP sends out mongraphs every few months.  I often glance at them and then pile them up in my study so taht I can r"ead them later"  .. (so that I can throw them away the next time I tidy up).

They're all on line ... so today's copy: Aging and Health Issues: The Family Physician's Role is going right into the recycling.  It looks interesting .... and ther are several useful screening tools:

• Folstein MMSE
• Michigan Alcoholism Screening Test - Geriatric Version (MAST-G)
• ADL self-maintenance scale
• Instrumental Activities of Daily Living Scale (IADLS)

Now I'll never lose it ...  and the office stays clean!