Family Medicine Notes

Buried in the documents on this page is evidence of enormous changes in store the the American Medical Association.  To some degree, they are (finally?) acknowlegding that the AMA simply does not represent the physicians of this country.  Their members account for only 28% of physicians in this country.  While the AMA claims to repersent us and our patients, it is becoming increasingly obvious that they do not.    

If the business plan is adopted by the AMA House of Delegates, the AMA will transition to an organization or organizations.

By becoming an "Organization of Organizations" there may be no individual members of the AMA at all.  Other medical organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of physicians will send delegates to the AMA meetings, where concensus will presumably be reached on what physicians think is best, and how we should best advocate for our patients and the health of our communities.

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It's Lyme disease time of year again.  Well .. not really.  It's tick bite time of year ... though we have seen lyme disease already ...

Many people are spening time outside .. so lots of people are getting bitten by something.   The CDC is talking about a way to protect mice from ticks. hmm ..

Back here on earth, I've been struggling with what to do about people with real tick bites.  Back in the dark ages, I would provide a handout, reassure the patients that they have only a 2% risk of getting lyme .. and (of course) refuse to treat with antibiotics.

Last year's article on lyme as a great imitator brings up good examples of why we can't be so careless about this diagnosis.  And of course the paper from last year's NEJM on how one dose of doxycycline prevents lyme disease.  Hmm ..

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In the July issue of Psychological Bulletin, an age-old debate is rekindled: shoud children be spanked?  I'll admit that I sit on the "no" side of this fence .. so I am erading this with a bias .. but I do find the discussion quite interesting .. as psychologists -- like parents -- seem not to be able to agree whether this is good or bad.  The author of the study, Elizabeth Thompson Gershoff, finds that

"Parental corporal punishment was associated with all child constructs, including higher levels of immediate compliance and aggression and lower levels of moral internalization and mental health"

What's that mean?  Kids do comply promptly, but are more agressive in general.

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Coding is the process of accounting for what we do .. so that we can get reimbursed for it.  Car mechanics have the flat rate manual that tells them what to charge us.  In medicine, there are similar, but more complicated methods of accounting for what we do.  One of the most complex is coding for obstetric services -- especially when the family physician is not the one who ultimately does the delivery -- as is the case of a c-section done by an obstetric colleague.  We had another such episode this week, and it reminded me that coordination of the billing is important.  Not only do we family physicians need to communicate closely with our obstetrician colleagues closely regarding the care of the patient, but we need to coordinate our billing as well.  AAFP publishes these guidelines ... and there are many others ..

The key is that most insurers expect to pay for the delivery.  So I spend 14 hrs at the hospital and I deliver the baby .. the reimbursement is the same as if  I spend 5 minutes.  Nor like the car mechanics .. but it usually works out OK .. unless my patient needs a c-section.  In this case,  the obstetrician bills for the (operative) delivery and I bill for my time .. or at least I attempt to.  I can also bill for assisting with the c-section .. in which case I can't bill for the time associated with the (attempted) vaginal delivery.

Very complicated stuff .. and certainly nothing that I ever wanted to learn in medical school. 

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Busy week:

• We have the webservice interface to Oncalls.com up and running.  Just in test now .. so I can't post a URL.  But I can say that using Coldfusion MX made it a rather straightofrward process.  It's easier than using Radio or Frontier ... and much easier than it would be with Microsoft's .net platform.  Having this interface running will enable us to rather easily develop interfaces to practice management systems and even hospital information systems.   It's exciting, since OnCalls could now "tell" the practice management system who is working in the office on September 23rd .. making the manual entry of templates unnecessary.  So far, we have only lukewarm interest in this scenario from practice management system vendors ... and it's (unfortunately?) not my nature to be pushy .. so I'm not sure we will ever do this .. but it wouldn't be very hard to do ...
• Discovered the Generic SOAP Client .. a wonderful tool to test webservices.
• Medicine (sorry for the lapse into technology):
• A few interesting articles this month in Journal of Family Practice .. but I can't link to them .. they're behind the login screen. One interesting paper reports that:
• Computer-using patients desire Web-based services to augment their care.
• Practice Web sites should be designed to go beyond information alone and incorporate services such as online appointments.
• Physicians should consider providing “virtual visits” to assist with disease management.
• Indoor Tanning.  While the FTC has a warning about the risks of indoor tanning .. but I don't think this warning goes far enough.  It's rather clear that indoor tanning increases the risk of cancer by as much as 2.5 times.  duh.
• Otitis Media.   OK . so I've blabbed about this before.
• Despite the suggestions of previous authors, who suggested that 50% of AOM is misdiagnosed .. this study suggests that physicians only overdiagnose AOM only 30% of the time.   The author suggests that use of the "NYROP" Guideline .. which I haven't seen .. but I expect that it is similar to the CROP guideline, of which I was the primary architect. 
• Oddly, there remains little research on Acoustic Reflectometry.  There is only one vendor of a tool that my colleagues and I have found wonderfully useful .. and rather few papers on the topic (here's one).  I'm certain that this tool helps keep us from overdiagnosis .. and kids really don't mind.  I find that using the tool has enabled be to struggle less with getting a perfect view of the TM.  If I get reassuring readings on the "ear toy" as the nurses call it .. I'm unlikely to see trouble.   So I often use it first .. then use the otoscope.  Using pneumatic otoscopy only rarely these days ... but had a case of AOM last week that was hard to pick up:  the TM was grey .. (no sign of inflammation) ... the child was s/p tx for AOM about 14 days earlier ... and it wasn't until I tried to move the TM that I saw how retracted it was ... with a better view of the frank pus behind ... oh ... AR was 39 .. so predictive of a very dull ear.  The rationale for AR is rather simple:  sound waves are emitted from the device and bounced off the TM.  The device can do an analysis of the waves bounced back.  An empty coffee can .. when tapped with a pencil .. will convey high pitch sounds.  A dull one .. low.  An empty middle ear will convey high pitch, and a full one ... low.  It works.

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It's been over a week since I posted last.  Will try to get here more often.  Sorry.  Last week was full of patient care (of course) and finishing the application for a grant to help build a digital library of family medicine resources.  While I'vebeen involved in grants before, this was my first experience as the primary author of a grant. 

Today's medical interest:

Saw a 40ish man who runs a lot ... looks like he may have a fibular stres fracture.  How to diagnose this?  Well ... there's a guideline on appropriate work-up of stress fractures, and clearly the recommendation is that after at least one .. but perhaps two negative x-rays ... MRI is the best modaility.  I ordered x-ray #2 yessterday, and tried to set up MRI, but the patient's insurance refuses to let a primary care physician order and MRI.  Wow.  Will refer to ortho.

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