ACP Internist

Thursday, September 2, 2010

QD: News Every Day--Home-grown medical students more likely to stay nearby after graduation

Nearly a third of medical graduates at the University of North Dakota continue in primary care, down from nearly half just two years ago. This is the university that leads the nation for the percentage of students (about 20%) choosing family medicine.

North Dakota overall will be short about 160 physicians by 2025, and the need is now affecting urban areas as well as rural ones, said Joshua Wynne, FACP, dean of the university's School of Medicine and Health Sciences.

Keeping medical students interested in practicing primary care in rural America depends upon whom medical schools choose to admit. For example, one-fourth of the University of North Dakota's student population hails from small towns, and 80% are in-state.

More and more medical schools are looking at locally grown talent to fill their residencies, believing that these students are more likely to stay after graduation. Bruce Pitts, FACP, president of Sanford Clinic Fargo in North Dakota, tells local news source Inforum that he uses "trap lines" to cull physicians who grew up locally, or have a spouse or friend who did. Once he finds a recruit, he then expands the network a little further.

These programs also use more familiar means, such as loan forgiveness for service in areas of medical shortage, such as the RuralMed Scholarship at the University of North Dakota.

In Kansas, the University of Kansas School of Medicine-Wichita accomplishes similar recruiting and retention efforts via its Scholars in Rural Health program, which identifies promising potential medical students raised in small towns. During their undergraduate freshman and sophomore years, they shadow a rural doctor at least 40 hours each semester as well as during the summer months between their junior and senior years, and complete reports and projects. With good grades, the students are guaranteed acceptance into med school.

Garold O. Minns, FACP, professor and program director in the department of internal medicine at the medical school, said, "We are concerned about where we are today because we are just barely meeting the needs for rural Kansas. The pipeline of doctors is not as full as we would like it to be for the future."

And, programs in Maine, Arizona and New York have tried similar methods to great success by dangling half-tuition scholarships and condensed study programs to students interested in staying close to home. For the most part, students are interested, even if they haven't seen the opportunities.

Said Robert G. Bing-You, FACP, at the Maine Medical Center, "We want to show the students they can have a very productive career in a community or rural site."

Labels: medical education, primary care shortage, QD, rural medicine

Cruel shoes

GlassHospital is on vacation this week, writing to you from vibrant Toronto. Toronto is home to the Bata Shoe Museum, well worth a visit if you're ever here on a Thursday night when admission is free. In addition to a display featuring shoes of Elton John and Shaquille O'Neal (among others), there is a nice historical series featuring shoes from the ages that seem very strange to someone from the 21st century.

Well, at least to me.

My family was intrigued by the tiny shoes that Han Chinese women wore during generations of the practice of footbinding. Beside those doll-like appendages, I haven't been able to get over the chopines, foot high platform shoes worn by upper class women in Renaissance Italy.

All of this reminded me of a story about feet that shows some of the craziness of our technologically-driven health care system.

A thirtysomething friend of mine, let's call her Sally, started running last year in an effort to get in better shape.

As often happens in these scenarios, Sally developed some foot pain. So she went to a "foot" doctor (I'm not sure whether she meant a podiatrist or an orthopedic surgeon specializing in feet).

Reasonably enough, the doctor ordered an X-ray of her foot. The official reading showed no fracture, but there was a "questionable" finding on the edge of one of the midfoot bones such that the doctor couldn't rule out some more insidious process. A stress fracture, perhaps? Those can be awful, and take a long time to heal.

So, again in reasonable fashion, the doctor ordered a CT scan of Sally's foot. This is the logical next step if a plain old X-ray is abnormal. Heck, a lot of the time, even when an X-ray is normal, we still order the CT scan looking for something that we can't see on the X-ray.

And though I said this was a reasonable choice, if you really think about it, was it so reasonable?

I mean, did Sally really need a $1,000 test to see what was causing her foot pain? If you're Sally, you sure might think so. You want to know what the heck's wrong. You want to know why you're having pain when you run. You want to keep running. After all, as a primary care doctor, I love it when a patient tells me that they're serious about exercise. Aside from not smoking, that's the best thing I can hear from a patient.

But Sally hadn't traumatized her foot. She hadn't dropped a bowling ball on it. She probably had an overuse syndrome. A repetitive stress injury. A running "tweak."

The X-ray showed that, for heaven's sake. We knew there was no broken bone. No smoking gun. [I told you, we hate smoking.]

So a week after sitting for the CT, Sally still didn't know the result of her scan. She called the doctor's office to no avail. She was put off by the staff, even told by a nurse she'd have to come in for an appointment to discuss the results with the doctor.

By this point, she's worried. "Is there something terrible that he's waiting to tell me?" she wondered. "Do I have foot cancer?"

Sally adjusts her schedule, dutifully shows up for the appointment, to hear the doctor tell her that her CT is normal. Did she really have to wait a week and have an office visit to find this out? That is one shoddy patient experience in my book.

Nevertheless, she reasonably asks the foot doctor what she should do about her pain.

Physical therapy? Low impact exercise (use an elliptical trainer, perhaps, or bicycling)?

She doesn't get much of a concrete answer.

She decides to buy some new shoes.

She goes to a local shoe store that caters to runners. Let's call it Fast Feet.

There, they measure her feet. No charge. Lo and behold, her feet have grown 1/2 a size.

Sally was running with shoes that were too small! That was the source of her pain. No CT was needed. In fact, probably even an X-ray was unnecessary.

Now, this story shows how when a patient comes to see a doctor, we often go right to diagnostics. We want to get you an answer, after all. We're not shoe salesmen, for heaven's sake. We don't even have those thingie-dingies that measure feet. [Do foot doctors?]

Next time someone comes in complaining of foot pain, I'm going to ask them when the last time they had their feet measured.

[Author's note: re: the title of this post, google Steve Martin and read about his books.]

This post originally appeared at GlassHospital. John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.

Labels: ergonomics, exercise, GlassHospital, health care delivery, health information technology, humor, John H. Schumann

Practicing primary care: A lesson in treading water

As a primary care physician, I am becoming painfully aware of how hard it is to be good --I mean really good--at what we do today. I would prefer to believe that it has always been so, yet I do not believe that our predecessors in the medical profession found it nearly as difficult to excel in their time as we do now.

With all of the technological and medical advances, you might ask how I could believe this to be true. Too, you might consider it pessimistic or even crazy to suggest that physicians 20, 30 or 100 years ago found it easier to practice medicine well in their time.

You could counter with numerous or obvious examples such as antibiotics, pharmaceuticals, robotic surgical procedures, or even our wondrous ability to peer inside the human body without cutting it open. You also would be correct to point out that the technological advancements of the 20th century opened the way for the medical profession to become a real science thus giving me and my colleagues the chance and knowledge to make a real difference in our patients' lives today.

Yet, none can benefit from knowledge they and their doctors lack, so time studying science is a requirement for physicians wishing to properly wield all of this lifesaving technology. Unfortunately, this time is currently needed to learn ICD-9 and CPT codes (with ICD-10 and 10,000 new codes coming soon) or to scour the HHS ruling just released defining "meaningful use" in the practice of medicine.

It would be hard for many to believe that some larger organizations are required by OSHA to actually have their physicians spend time filling out yearly paperwork reminding them to wash their hands or pointing out that needles are sharp and might transmit HIV. This seems to me the equivalent of making an employer remind an electrician not to stick his wet finger in the socket.

Fifteen years ago, my first office was next door to a hospital where I was granted privileges to perform a multitude of invasive procedures including intubations, bone marrow biopsies, and the placement of central lines. An average day would start and end with hospital rounds, with office appointments sandwiched between, and, if I was lucky, a medical conference at lunch time would provide both food and education.

Today, many internal medicine residents choose to either become a hospitalist or to practice only outpatient primary care medicine. And statistics show that patients have better outcomes and shorter hospital stays under the care of a hospitalist than a general "old-fashioned" internist, a trend that points out the challenge today's primary care doctor has in keeping up in his field while not spreading himself too thin.

Furthermore, the inordinate and incessantly growing amount of time spent on cutting or avoiding the red-tape spun by innumerable government rules and regulations monopolizes our time and makes it difficult to find the time or energy to pursue further medical education.

I believe that some of these restraints preventing us from practicing medicine to our true potential are unique to the primary care doctor and this is, precisely, why many can describe us as "endangered." It is all most of us can do just to keep our heads above water each day- leaving little time for study and less for research. The Hippocratic Oath I took included the promise to protect the noble traditions of the medical profession, a promise, in my estimation, that is growing harder to keep with each successive Congress.

Until next time, I remain yours in primary care,
Steve Simmons, M.D.

This post by Steve Simmons, MD, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

Labels: physician shortage, primary care, primary care shortage, work-life balance, Workplace issues

QD: News Every Day--Risk-reducing surgeries may spare lives following breast cancer

New evidence supports risk-reducing mastectomy and salpingo-oophorectomy for women with the BRCA1 and BRCA2 genetic mutations, according to newly published research.

Researchers wrote in the Journal of the American Medical Association that no breast cancers were diagnosed in a cohort of 247 women with risk-reducing mastectomy, compared to 98 women among 1,372 breast cancer patients without it.

Furthermore, women who underwent salpingo-oophorectomy had a lower risk of ovarian cancer, including those with prior breast cancer (6% vs 1%, respectively; hazard ratio [HR], 0.14; 95% confidence interval [CI], 0.04-0.59) and those without prior breast cancer (6% vs 2%; HR, 0.28 [95% CI, 0.12-0.69]).

An editorialist told Reuters that 10%-20% of breast and ovarian cancers are due to BRCA1 or BRCA2 mutations, so prophylactic surgery can save many patients. And, she added, it falls on primary care physicians, gynecologists and the patients themselves to be aware that genetic tests are available.

The editorial from JAMA continued, "From the time BRCA1 and BRCA2 were identified and testing for them became an option, not all primary care physicians have been convinced of the benefits of hereditary risk assessment. However, risk-reducing surgery has been proved effective--and this evidence has emerged because of the willingness to adopt testing, identify women at risk, and study interventions in this specific population."

The issue is becoming more important, as the survival rate of breast cancer overall has risen to more than 80%, as ACP Internist examined in May 2009. Patient need to be checked not only for cancers, but then for the host of ailments that might get lost to follow-up as this population ages.

How do physicians decide which patients would most benefit from which new prevention and treatment strategies? ACP Internist next reported in June 2009 how detection and prevention are changing in the face of new tests and treatments.

Labels: breast cancer, cancer, genetics, genomics, patient communication, women's health

To medical students considering primary care

Dear Student:

Thank you for your consideration of my profession for your career. I am a primary care physician and have practiced for the past 16 years in a privately owned practice. (At some point I intend to stop practicing and start doing the real thing. It amazes me at how many patients let me practice on them.)

Anyhow, I thought I'd give you some advice as you go through what is perhaps your biggest decision regarding your career. Like me, you probably once thought that choosing to become a doctor was the biggest decision, but within medicine there are many options, giving a very wide range of career choices. It is the final choice that is, well, final. What are you going to do with your life? "Being a doctor" covers so much range, that it really has little meaning. Dr. Oz is a doctor, and he has a very different life from mine (for one, he's not the target of Oprah's contempt like I am, but that's a whole other story).

Here are the things to consider when thinking about primary care:

1. Do you like talking to people who are not like you?

Primary care doctors (PCPs) spend time with humans, normal humans. This is both good and bad, as you see all sides of people, the good, bad, crazy, annoying, funny, and vulnerable sides. If you see mental challenge as the main reason to do something, and would simply put up with the human interaction in primary care, don't do it. The single most important thing I have with my patients that most non-PCP's don't have is a relationship. I see people over their lifetime, and that gives me a unique perspective.

2. Do you prefer variety over predictability?

Every room I walk into is different--often vastly different--from the last. I could be walking in on a crisis or a stable recheck. The person could be elated or crying. They could be 90 years, or two days old. They could have something wrong with any system, and it could range from mild to life-threatening. I'd go nuts doing the same thing every day, be it looking just at skin or just dealing with the kidney. But some folks do better with routine and a lack of surprise; they don't want their days to be unpredictable.

3. Do you need to be in control?

Primary care is not about control. Those primary care doctors who try to maintain control of their patients are both unsuccessful and unhappy. Relationships are not always predictable, and much of what PCPs do depends heavily on the patient's "cooperation." I put the word in quotes, because the word implies that the doctor's agenda is more important, an implication that I reject strongly. PCPs are part of "team patient." Our job is to help them, not direct them. We give them our expertise and they make the final choice. Surgeons, on the other hand, don't consult the patient when operating; they don't depend on patient compliance as they cut a person open.

4. Are you a people-pleaser?

The flip side to #3 is that a PCP must always practice good medicine, even if it makes people mad. You have to learn to say "no" to people who seek drugs, who want an antibiotic, to drug reps who want you to prescribe their products, and to insurance companies that want you to work for free. We are not co-dependents. We don't base what we do on the reaction we get from patients. Often we are the only ones with the opportunity to tell them the hard truth about lifestyle choices or about their future health. I deal daily with the consequences of people-pleasing PCPs, who addict their patients to drugs, who create antibiotic resistance, or who give in to drug reps and give expensive prescriptions where cheaper ones are better. Please don't choose primary care if you are a people-pleaser.

5. How important is social status?

PCP's have an interesting paradox in their social status. In the eyes of the public, we are the ones who earn less money and so must have gotten worse grades than the cardiologists and dermatologists. In the eyes of those same specialists, however, good primary care doctors have a very large amount of respect. We are actually the ones who run the medical show, using specialists when we think it is needed. We need to know 90% of all specialties, and also know when we are in the 10% we don't know for each of them. I often get "I could never do your job" from my colleagues. So if outward social status matters (like what kind of car you drive or how big a house you own), then don't choose primary care. I am not saying that PCPs don't have a good income (98% of my patients would like my income), just that my outward status is not nearly that of the surgeon who operates only on left ring-fingers.

6. Do you like puzzles?

The term "gatekeeper" got applied to primary care via our friends in the HMOs, and that term has haunted our profession since. Good primary care is not simply triaging people and sending them to those who can offer real care. Some PCPs do that, but they are both lazy and unambitious. I do whatever I can to keep people from the specialists and out of the hospital. I need to know when to send them, but I also need to know what to do before I send them. This endears me to my consultants, as I am sending only patients who needtheir expertise. I know orthopedists will give an anti-inflammatory and probably order physical therapy for shoulder problems, so I do this before I refer the patient. 80% of my patients avoid orthopedists this way, and the ortho docs know my consults are not usually fluff.

But the real challenge of primary care is the fact that I am usually the first to see a problem. Specialists get sifted problems. I have already thought the situation through and so they get the leftovers. I don't usually send people to specialists for a diagnosis, I send them for a specialized treatment for the problem I have diagnosed or strongly suspect. I am the quarterback, the manager, the lead singer, the director of the symphony orchestra.

7. How patient are you?

I have to confess that I was not a beacon of patience when I started practice. That being said, I have learned that one of the most powerful tools in medicine is waiting. We get to see the big picture. We see people over months, years, and decades, and watch the progression or deterioration of conditions. I find this most satisfying. People who were suicidal ten years ago are now cracking jokes and are productive citizens. One of the biggest mistakes a PCP can do is to value intervention over waiting. We are caretakers of the big picture. Surgeons do their job in a few hours, radiologists in a few minutes, and oncologists in a few months or years. But PCPs do their job over the lifetime of the patient. To me, that's a plus, not a minus.

8. Are you compassionate?

Again, this is something that has developed over time for me, but the seed of it was there early in training. Primary care is about "care" in all of the definitions of the word. We care for people because we care. It does matter to us that people are hurting. There is a degree to which primary care is a calling or ministry, not just a job. There will always be a necessary detachment we have from our patients (for our own sanity), but a PCP who is simply punching the clock is both sad and dangerous. You need to be able to listen and see things from people's perspective. You are their doctor, and they are your patients. The possession is emotional, it is one of caring. People judge PCP's on how much they like them and how well they feel listened to.

There is much more to say (read the rest of my blog, as well as other primary care blogs such as Kevin MD, Musings of a Dinosaur, Jill of All Trades, and DB's Medical Rants for a more complete picture. Sorry to those I left off; there are many other good ones). Any specialist would tell you that a very good PCP is incredibly valuable. I love my job, as do many of my colleagues. I want more PCPs, but I only want you in my field if you'd raise the average. We need good PCPs.

Come join the fun.

This post appeared at Musings of a Distractible Mind. Rob Lamberts, ACP Member, writes the blog and is on Twitter. His podcast, House Call Doctor, is available online and on iTunes). He is board certified in Internal Medicine and Pediatrics and was an early adopter of electronic medical records.

Labels: careers, primary care, primary care shortage, Rob Lamberts

QD: News Every Day--Patients prefer doctors, deserve to know who's treating them

Patients in the emergency room would rather wait for a doctor than be treated by a nurse practitioner or physician assistant, a survey found. Patients would even rather see a resident.

Researchers administered surveys to a random sample of patients in three emergency departments and another survey to emergency department residents and physician assistants. They reported results in the American Journal of Bioethics Almost 80% of patients preferred to wait for the doctor.

Even for a cold, only 57% would want a nurse practitioner and 53% a physician assistant. Patients deserve to know who is treating them, the bioethicists said, and what level of training each type of provider has. Some nonphysicians may not properly identify themselves when busy, and patients may not understand the differences even when they do. (American Journal of Bioethics, American Medical News)

Labels: ethics, hospital medicine, QD, residency

QD: News Every Day--Charitable hospitals to act like for-profits to stay open

More than one-fifth of hospitals are government-owned, but states and counties are out of cash to keep them open. So, charitable hospitals are being sold to for-profit groups or facing closures. Rising costs and more uninsured patients run smack into falling Medicare and Medicaid reimbursement. When bonds come due, there's little chance of states and counties paying them back. And the facilities are often standalones, and they can't fall back on corporate backing. This year, 53 hospitals have been sold in 25 arrangements. While the deals often stipulate that care for the poor continues, so one is certain exactly how or even whether such services will continue.

That said, other charitable hospitals are making big profits. What are they doing differently? First, they're competing for patients, so they're increasing room sizes, offering amenities and even investing in high-end procedures such as robotic surgery. They continue to offer community care, but they're acting more like for-profit institutions to cover their charitable missions. But this conflicts with an old-fashioned view of what charitable care is supposed to be.

Stepping into the breach is the Centers for Medicare and Medicaid Services, which is offering one solution, by increasing reimbursement for inpatient services in rural areas. The agency is expanding a pilot program by increasing reimbursement for inpatient services. Facilities are eligible if they offer care to rural areas in the 20 states with the lowest population densities, have fewer than 51 beds, provide emergency-care services and are not a critical-access hospital. (Wall Street Journal, Washington Post, Modern Healthcare)

Labels: health care cost, hospital medicine, Medicaid, medicare, QD, reimbursement

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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

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Thursday, September 2, 2010

QD: News Every Day--Home-grown medical students more likely to stay nearby after graduation

Cruel shoes

Wednesday, September 1, 2010

Practicing primary care: A lesson in treading water

QD: News Every Day--Risk-reducing surgeries may spare lives following breast cancer

Tuesday, August 31, 2010

To medical students considering primary care

QD: News Every Day--Patients prefer doctors, deserve to know who's treating them

Monday, August 30, 2010

QD: News Every Day--Charitable hospitals to act like for-profits to stay open

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