Category Archives: innovation

Trends in Medicine

–Tom Bibey

We’ve been around long enough to see the trends come and go. I’ve seen Aldactone fall in and out of favor three times now as the latest “hip” drug. When I see some young fellow tout the latest study on the merits of the drug as some new thing, I ache from his lack of wisdom.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 Dr. Bibey, who has some gray hair, gives us perspective on the changing knowledge of medicine. We have embraced Evidence Based Medicine (EBM), but the evidence changes. We once encouraged menopausal women to take hormones to protect their hearts, then learned that was not helpful. We encouraged anti-oxidants, then learned that did not make a difference. Talk with your preceptor and explore the other trends that have come and gone as our knowledge and science has grown.

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Modern rural

–Tom Bibey

And yet before you misunderstand, let me reassure. We are modern. We use the same medicines as our city counterparts, and we are only a helicopter flight away from the latest technology, not that it solves all of our problems. We take the same competency tests as our colleagues, and I’ll bet we do just as well or better. (Maybe my old professors did a little better, but they got to write the questions.) We have access to the same information too. My computer is just as fast as the ones over in Raleigh.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Bibey addresses with humor the impression that rural means backward. It is easy to judge the choices another provider made when you aren’t in the trenches with him/her.  In other entries, we’ve examined the innovative efforts to adapt to the quickly changing world of modern medicine that have originated in some rural practices. Examine your setting. Who are the innovators? What are the qualities they have that keep them thinking and moving forward? Is it curiosity? Is it the desire to serve their patients well? Is it the need to keep learning and stay engaged?  

A Modern Country Doc–alphabet soup

Inside the Mind of –Tom Bibey

COLA, CLIA,OSHA, HIPAA, EMTALA. I’ve heard the powers that be are going to start up the NBEMAA (National Bureau for the Elimination of Medical Abbreviations Agency) to question everyone’s integrity for use of nongovernment approved abbreviations. Now if they do, I guess I’m gonna call it a day. The hypocrisy would just be too much.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 Modern medicine is an alphabet soup of acronyms. It can be quite overwhelming to the student. With the turn of the 21st century we’ve added EMR or EHR –electronic health or medical records, HCH or MH—health care home or medical home, but MH can also mean mental health. You may encounter NCQA and JCAHO, both efforts to improve and monitor the quality of care in the US. The ACA, Affordable Care Act, which some folks call Obama care, the national health reform passed during President Obama’s first term and now under attack, also brought us ACOs—accountable care organizations, which are supposed to be different from the HMOs-health management organizations of the 1970s and 1980s. I know that was a run on sentence, but one acronym seems to give birth to others. You can probably add some others to this list. The bottom line is that medical care in the US is complex. All the efforts try to guarantee quality, affordable health care for the patient, but often seem like barriers between the doctor-patient relationship.

A Modern Country Doc–chart jockeys

–Tom Bibey

In the early 1980s, I made almost all my decisions in conjunction with my patient, together with the specialists we deemed appropriate in a given case. It wasn’t but a few years before modern medical “oversight” or “management” began to assert itself. This started first with government programs, soon followed by big business. Docs were forced to learn a new set of skills to overcome these obstacles to the delivery of care.

Early on, it was a benign process. Every once in a while I’d get a call from old Doc Smith who’d ask about a case. I knew him from State Medical Society meetings. Retired, he’d never made all that much when he was in practice, so I understood his need to supplement his income. I’d even taken over some of his patients, so Doc Smith knew me well. He wasn’t going to scoop me on much over the phone. I had the advantage of being the doc who saw the patient, and we both knew he wasn’t in a position to compete with that. Doc had to call every so often. I understood. He’d call and ask a few questions, and I’d tell him in doctor terms about where to go, and we’d laugh.

By the mideighties the minor nuisance grew to a downright disruption of patient care. I remember a fellow I had followed since I started my practice. I inherited him when a local doc retired. The patient was elderly and had multiple medical problems: several heart attacks, a pacemaker revised several times, bad kidneys, bad lungs, but he was a heck of a nice guy.

My first hospital admission for the patient was for an episode of syncope (they call it “falling out” around here) and the situation was complex, so an extensive workup was undertaken. Both carotid arteries had partial blockage, but the surgeon said that the literature showed that only the worst side of a 70 percent blockage warranted intervention. (Here is a country doc tip for you: if a surgeon doesn’t want to operate, I would take that advice very seriously.) I talked it over with the local cardiologist, we ran everything by the big boys at the Medical Center, and everyone agreed to a treatment plan. With some adjustments in medication, we sent the patient home. Surgery, at least at that time, was not indicated. A week later, he had an unanticipated TIA (near ministroke), which thankfully resolved. Due to the change in circumstances, the surgeons changed their minds and proceeded with surgery to correct his right carotid artery blockage.

The patient did well, and he went home satisfied with the outcome. For him, it was the end of that chapter of his story. For me it was the beginning. Six weeks later, I got a letter from one of the Medicare review boys, who determined the first admission to be unnecessary. I knew my patient could get stuck with the tab, so I began to compose a letter of explanation. Before I could complete it, I had a second letter on my desk from a different review bureaucrat (I call them chart jockeys). This jockey determined the second hospital stay was due to a premature discharge from the first admission. I have a fair amount of education, but I was confused. How can one be discharged too early from an unnecessary admission?

I found it a silly demonstration of the lack of medical sophistication on the part of the reviewers, but I did not anticipate the intense effort required to win this battle. However, I lost the war. Years later I noticed reviewer number one had his name on a government medical complex, and I assure you I will labor in obscurity until the end. I’ll consider myself lucky if I just stay out of trouble. I was the doc for my patient until the end, when he died of plain old, very old, age. Every so often we delighted in laughing at the incompetence of those chart jockeys.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. B talks about the chart jockeys. Today they come in many forms. If the clinic is part of a health system, the chart jockey may be the quality review folks who review patient charts for each clinician looking for patients who are lost to follow up or are out of compliance with recommended treatment. They can be helpful. Thanks to electronic health records (EMR or EHR), we can pull up lists of patients based on diagnosis codes (ICD-9, soon to be ICD-10). As a result, I can look at all of my diabetics and know who has been in the clinic in the last 6 months and what their lab values are.  With diabetics we aim to keep their HGBA1C under 8. (Glycosolated hemoglobin-the measure of sugar molecules on a red blood cell gives us an idea of how well a patient’s diabetes is under control over three months, the life of a red blood cell.) Then the nurse and I can figure out which patients we need to contact and ask them to come into the clinic. In the old days, we waited for patients to come to us. Today we make more efforts to reach out to patients, especially patients with chronic health problems. With diabetes we know that certain medications and checks actually keep patients healthier and prevent or delay kidney failure, loss of vision and amputations.

The chart jockeys can be a nuisance when I have to jump through hoops before I can order a treatment or medication–often call a prior authroization, especially if it is what I know I need to do for my patient. On your rotations you will hear lots of clinicians complain about the paperwork or phone calls that accompany this. It is all an effort to avoid unnecessary treatments, identify fraud and to manage cost. Often it consumes time and energy for staff that interferes with caring for patients.

Welcome to Elma–21st century changes in rural practice

–Mitchel Cohen

Hey, you must be our medical student for the day. Short white coat gave it away.
Did you find the office OK? Good, directions aren’t too difficult. There’s only one light in town and I always tell people if you just look for the funeral home and the liquor store we’re just past that. People often drive right past the building though. Most think it is just a one-floor rambler style house. They really have no idea of the history of what’s happened here.

Come down the hall this way; let me show you this picture. This is a drawing
of this office back when it was a hospital. It was built in 1898 by Dr. Blair. There
were two beds for men, two for women, and a surgery/storage area. The nurses
lived in a house attached at this end. Did I mention there was no running water or electricity when he opened his hospital? He put that in ten or twenty years later.

Here’s the mini-library we’ve built and a computer that you’re free to use. We’re still fairly technologically challenged out here. Our IT department consists of whatever we can figure out or con friends and family into helping us with.

Information technology is certainly one of the biggest challenges of being in a small, rural practice. There’s so much potential yet so many barriers. Purchasing, implementing, and maintaining an electronic health record is an expensive proposition. Telemedicine could help bring specialists in for virtual office visits, but again, who can afford to set that up? There’s admittedly some element of technophobia in here. Much of our staff, as wonderful as they are, still are not comfortable with some basic computer functions. There’s a certain conservatism that comes with small-town life, and while this is often a good thing, technophobia is probably not good.

Dr. Cohen addresses the tremendous changes that have occurred in medicine in the last century. As a child of the computer age, you may not fully appreciate the shift the electronic health record brings to patient care, especially for physicians who thought typing was for their secretaries and not for them. The organization of health care into health systems and coops brings resources and economies of scale so that adopting telemedicine and the electronic health record might be a little easier. With that physicians lose some autonomy. The productivity treadmill, which is part of medicine today, removes some of the “fun.”  You may rotate with physicians who have adapted well to the IT age of medicine and others who are moving like dinosaurs.

Dr. Kurt Stange and colleagues have spent a lot of time thinking about how practices adapt and keep up with the rapid changes in medicine today. This 2008 on-line article in the Journal of Family Practice: A survivor’s guide for primary care physicians, examines what works and doesn’t work about practice change. ARTICLE Give it a read, see what you’ve noticed in the setting where you’ve been spending time.

Responding to the need for high quality emergency care in rural America

–Darrell Carter

Another cold blustery January night in northwestern Minnesota, and you hope everyone stays home and your hospital’s emergency department remains quiet. As the night charge nurse on duty, you are responsible for overseeing the care your night staff (one other RN and an LPN) gives to the twelve inpatients in your twenty-two bed Critical Access Hospital (CAH). These twelve patients include a mother and her hours-old newborn and an eighty-two-year-old female who is two days post-op after a hip pinning and who is exhibiting increased confusion and agitation. You hope to let your on-call doctor get some sleep since she was up much of last night delivering the baby in your nursery. The only other practicing physician in your community is gone for a much-deserved five-day break to Cancun.

 All has remained routine until 1:00 a.m. when the squawk from your ambulance paging radio disturbs your charting. The Basic Life Support ambulance is dispatched to a motor-vehicle-crash involving two vehicles and an unknown number of victims. At least two of the patients sound seriously injured. Reluctantly, you shift your role from more mundane tasks to organizing the team for the soon-to-be-busy emergency department.

 In the twenty-first century, seriously ill or injured patients benefit from a growing amount of advanced technology for diagnosis and treatment of their ailments or injuries. Highly trained specialists are now available to help manage a wide variety of complex conditions, and well-trained and highly skilled teams staff emergency departments. Unfortunately, this is true only in the larger population centers of the United States. Rural health care facilities do not have immediate access to this wide variety of specialists and frequently lack the more advanced equipment needed to diagnose or treat the seriously ill or injured patient. Rural providers frequently lack the organized team, knowledge, and skills to rapidly perform the life-saving procedures and treatments needed by the more seriously ill or injured patients. Extensive distances lengthen the time required to transport patients to specialized urban medical centers for life- or organ-saving procedures. It is little wonder that rural trauma victims have a higher mortality rate than their urban counterparts. In 2004 the Minnesota Statewide Trauma System reported that fewer than 30 percent of all motor vehicle crashes occurred in rural areas, but 70 percent of the fatal crashes are rural.

 There are many obstacles to our delivering the highest and most modern emergency and critical care to rural patients. However, the medical legal standards of care and the general public expect similar care to be delivered in both urban and rural communities. Disparity in the availability of advanced emergency care has adverse consequences. In rural areas, these include: higher rates of trauma deaths, increased burnout among providers, difficulty recruiting staff for existing health care facilities, and an increase in medical-legal risks for practitioners due to the inability to rapidly deliver emergency care or obtain easy consultation for some critically ill or injured patients.

 So what is the solution to this developing crisis in rural medicine? Some recommend more helicopters to rapidly transport the rural patients to urban centers. Others promote equipping rural communities with all the latest equipment, as well as hiring skilled specialists to respond to the infrequent events.  But is society willing to finance the cost of such solutions? Others claim living (and vacationing and driving) in the rural parts of our country is simply more dangerous, so if you elect to live in, or even venture into rural areas, then you need to accept the inherent risks.

(Excerpted from A Night in the Life of a Rural Emergency Care Team and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Dr. Darrell Carter and his colleagues responded to this need by starting CALS—comprehensive advanced life support.  http://www.calsprogram.org/

This innovative program combines ACLS, PALS, ALSO and ATLS with a rural focus and a team response approach. In the 21st century, many rural areas are filled with innovative ways to respond to the desire of health care providers and patients to provide and receive high quality care.  What is happening in the community where you are rotating?   Please share some innovations on this blog.