Rural General Practice

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Conventional wisdom states that we have a shortage of physicians and more is better. A more careful look suggests that the problem is more of a mal distribution of physicians. We suffer a scarcity of primary care physicians. We need more of them in rural communities. Medical educators face both of these problems. The solutions are difficult without better insight into the challenges of both primary care and rural practice. The first problem is lumping pediatrics, internal medicine and family practice into the same category with family practice. Even OB/GYN wants to be considered primary care for women which adds to the confusion. General practice is still general practice. Calling it family practice as a specialty does not make it a specialty and therein lies a problem with identity, prestige and self image. Medical students soon sense this disparity. Thinking of it, however they may, students choose the specialties, and that perpetuates the problem with both distribution of health care and the competence level of those who do choose general practice or family practice. The intellectual filter works against both distribution and competence in rural areas.

Then what is the solution? Sadly, the one that prevails is the formation of a sub prime provider who acts as more of a technician following protocols and algorithms. He or she is glad for the opportunity, and works semi supervised in structured, mostly in public health or native corporation clinics in a team setting. On the surface this sounds good. The problem is in recognizing critical problems that do not fit the protocols and the distance to a center that handles the more difficult case. In reality practicing in any kind of isolation without multi specialty support requires more of a supper physician, rather than a lesser one.

The steps towards motivating the better talented physicians to undertake a rural practice from a clinical viewpoint are several. First, there must be prestige and assured remuneration sufficient to attract the best physicians and their families to live in a rural community. Forgiveness of medical school debt and tuition will not cut it. The only way I see to accomplish these two things is to extend the residency program to four or five years with extensive time spent in the various specialties to the extent of gaining a core competency in each and with extensive clinical experience in each. In addition these young doctors need the basic tools of genomic and proteomic research, biotechnology, computational biology, epidemiology, public health and bioinformatics leading to a PhD. In other words a supper physician. 

Having created a physician for all seasons, the rural practice clinic must match the capabilities of this now highly trained generalist. Here is where government in partnership with the university and the clinician can achieve what the one cannot. The university can focus its considerable computational, statistical, bioengineering, business and law capacities to create a state of the art network of rural clinics in not just a few but all of the underserved areas of the state. The university can additionally provide nursing, student, intern and resident support. The government presumably the state government must provide adequate funding for construction and implementation with the expectation of a payback from Medicaid and Workman's Compensation services more adequately and affordably provided. The physicians would be salaried giving their families an assurance of income and additionally receive a percentage of the fee for service clinic income. 

Such would be a partnership in which each participant contributes and gains more than any one of them acting alone. Underserved communities and all parties benefit.

Diagnosis and the Physician’s Laboratory

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The curriculum renewal committee of the University Of Washington School Of Medicine[1] offers suggestions for curriculum changes that would enhance the numbers of graduates choosing a primary care specialty. Notably the report did not mention the issues of prestige nor the availability and training in the use of diagnostic tools for a primary care setting.

From a clinical viewpoint primary care is more of a science not less of one than the other more limited specialties. The training and clinical tools should match the challenge and they do not. Medical students need both the tools and the training to do serious diagnostic studies. Contrary to the image of a doctor making a snap diagnosis wherein the only problem is the treatment protocol, diagnosis is multifaceted and no simple matter. Multiple conditions, individual patient constitution, and multiple layers of symptoms compound the challenge. Many studies suggest a high percentage of missed and wrong diagnoses, 35.8% in this study.[2] We use to have the autopsy as a final arbitrator of diagnosis but no more. Autopsy has gone out of style; it is not profitable enough. Some medical schools have abandoned the microscope in favor of digital images in training. The microscope, however, remains one of the most essential diagnostic instruments. Today’s microscope should provide polarized light, dark field and fluoroscopy. This is real-time microbiology.

Historically, medical science advanced through the evolution of diagnostic tools and techniques. First, there was the autopsy, then the stethoscope, and the microscope, then statistics, the x-ray machine, ultrasound and more recently bio-molecular science. Today, hospitals excuse the autopsy with reliance on the CT scan. Largely the CT scan replaces the plain old x-ray. This is not progress. Today the stethoscope hangs around the neck unused. Offices send out most lab work, either to a reference lab or to the hospital. It should be obvious that the primary care doctor needs a small clinic version of all of the basic diagnostic tools and some that exist only in research labs. Basic equipment should include ultrasound, microscope, x-ray, and the skills to go with them. Looking to the future, the primary care physician needs to link current clinical research with his or her practice, especially in statistics and genomics. Polymerase Chain Reaction (PCR)[3] should find common use in the clinic; students should have enough undergraduate experience in proteinomics to manage it.

Many frustrations to the practice of good medicine come from outside the profession. These distortions, accepted as the way things are, limit both the role of the physician and his or her ability to diagnose conditions at hand. For instance, EPA limits a physician from conducting many laboratory tests in the doctor’s office, or requires burdensome licensing and exemptions.[4] While well intended to improve quality and control costs, it does the opposite. One fear suggests that physicians do laboratory studies because they produce more revenue. Perhaps some do, but the unintended consequence denies access to simple inexpensive tests. These tests done in real-time, while the patient is present, save time, save money and improve outcome. A trip to the hospital, results in delay and a much more expensive procedure. I cannot imagine a physician doing a gram stain, a peripheral blood smear, stool, a urine sediment, a sedimentation-rate or a culture and sensitivity for the money; although, payment for these services must cover the cost of time and equipment. Some of the tests are time and space sensitive with unstable chemicals and fragile structures, so inaccuracies accrue when the specimen is sent out.

The same argument can apply to office x-ray. The office machine requires the same inspections and calibrations as in the hospital. The machine may be identical. One does not have to use much imagination to see a political undercurrent persuading legislators that everything must be done in the hospital. Unfortunately, hospital profit motivates the lobbying.

In 1998 while on the Board of Directors of the South Peninsula Hospital, I attended a dinner seminar set up by the network of Alaska hospitals including legislators presumably for educational purposes. It had only begun when it became evident that this meeting had the primary agenda of promoting a bill prohibiting office x-ray machines. The program presented undocumented evidence that office x-ray machines were sub substandard and hazardous while hospital machines were new and operated by licensed technicians. Presenters built a case for eliminating office x-ray machines in favor of securing all x-ray business for hospital radiology units. I was sitting at a table next to Senator Murkowski. He turned with a questioning look. I simply compared the cost of flying a patient from a native village to an Anchorage hospital for an x-ray of the chest in order to assess a clinical pneumonia. The unfavorable cost and the poor medical treatment of a time sensitive illness delayed by a trip to the hospital were obvious. The bill did not pass. In today’s environment, a hospital x-ray becomes a CAT scan. The cost is a hundred fold greater and the information only marginally better. The accumulated CT radiation expositor falls into the danger zone.[5] Students should learn the physics of radiology, quantum physics and participate in research for the newer less toxic photonics.

In short, the primary care doctor should be educated as a scientist in the tradition of the great physicians, past and present. He or she needs the tools of science and of diagnosis and be expert in their use. One wonders, just what is the character we strive towards in a primary care physician? Do we want a doc who is indeed a scientist with the humanity of Hippocrates? Or, do we want a Feldsher with an unused stethoscope hanging indolently around the neck?

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[1] http://www.uwmedicine.org/Education/MD-Program/curriculum-renewal/Working-Groups/Documents/Report-Primary-Care-April-2013.pdf
[2] http://archinte.jamanetwork.com/article.aspx?articleid=1656540
[3] http://en.wikipedia.org/wiki/Polymerase_chain_reaction
[4] Clinical Laboratory Improvement Act(CLIA) 1988 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c16.pdf
[5] http://radiology.rsna.org/content/251/1/175.abstract

Microscopy

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Microscopy has gone out of style in medical education. Yet schools struggle to revise curriculums for various philosophical goals one of which is providing more primary care physicians. I cannot imagine practicing medicine without a microscope, much less primary care in a rural community.

The microscope needs to come back to medical school for use at multiple levels: Histology, embryology, microbiology and hematology. If students do not use a microscope in school, they will not use one in practice. In a rural clinic without nearby hospital or laboratory support, the microscope becomes once again the essential frontline diagnostic instrument. Reference labs and small hospital l abs will miss many key findings through delay in processing the specimen, temperature variations in the mail, through automation and, sometimes, unskilled technicians.

OK, the Colter Counter now does the complete blood count (CBC). The price is the same, in fact higher, but the Coulter Counter cannot read the peripheral blood smear. Herein lays a great economic advance for the hospital administrator. The Coulter Counter requires less labor and labor at a non-professional and thus lower cost level. On the contrary, however, critical information may be missing. For instance, a college student with swollen glands, a sore throat and palpable spleen might have Mononucleosis or something worse. The peripheral smear, viewed under the microscope, can identify Mononucleosis and differentiate Mono from Leukemia. The automated Coulter Counter cannot. Today if you suspect Mononucleosis, you might request that the pathologist view a peripheral smear or rely on a blood test for Mononucleosis. The Coulter technician is not skilled in producing peripheral smears and the pathologist is expensive. Furthermore, a blood sample sent through the mail degrades with time temperature and handling.

One look is worth a thousand words. There is just no substitute for a direct look at the little buggers. A gram stain may be the best early identification of an organism causing pneumonia. You can instantly classify the bacteria by morphology and staining characteristics as streptococcus, diplococcus pneumonia, staphylococcus, and various others by direct vision. Various fluoroscopy techniques can improve the accuracy of the identification. Knowing what you are treating greatly improves the selection of antibiotics while you wait for the sensitivity tests to identify the agents and concentrations that will do the job. Unfortunately, laboratory technicians are not very good at reading gram stains. A technician will describe everything in order to make sure of covering all the bases. In other words describing everything fails to distinguish the pathogens from the normal flora of the throat and mouth. This requires judgment and experience -- even some clinical correlation. Sometimes the pathologist is not good at this task either – depending on which one you get. In order to contain costs, most hospitals do not have a PhD microbiologist in the laboratory; they rely on the rotating or even visiting pathologist to fulfill that role.

Recent techniques in electron microscopy and fluorescent microscopy overcome the wavelength limitation of light and visualize structures at a molecular or nanoscale level. When I was in medical school, I envied those with binocular viewing and those with a 35 mm camera attached. Today, look for digital imaging with a view on the computer screen.  We can instantly add images to the patient record.  Multiple substage filters facilitate further convenience. Immuno-fluoroscopy offers instant identification of many pathogens.   

One does not need the current level of technology, however, to make use of microscopy in a doctor’s laboratory.  All that is required is good lenses, well aligned with a selection of objective lenses on a rotating head and a good substage light source. Skill in its use is what counts.

An old but very helpful Laboratory manual by Muriel C. Meyers, a hematology professor at the University of Michigan gives detailed instructions for preparing slides. She also includes other office laboratory procedures not requiring expensive reagents.  Some content may be out of date but other content maybe overlooked by today’s hurried and mechanized procedures. This 129 page manual contains many forgotten incites. Clinical Laboratory Diagnosis and Essentials of Hematology, Bethell and Meyers http://babel.hathitrust.org/cgi/pt?id=mdp.39015009566343;view=1up;seq=116

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Diabetes Screening

Share | The Greeks, Asclepions of Hippocrates's time, screened for diabetes by taste. An alternative method was accomplished by poring the patient's urine on the ground and observing whether or not the urine attracted ants. The taste-test was said to have greater sensitivity while the ante-test offered greater specificity. It might be interesting to compare the sensitivity and specificity of the ante-test and the taste-test with today's fasting blood sugar and one hour glucose challenge test.

Medical Education, medical information

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Educators do not seem much interested in the clinical viewpoint of medical education, so here it is anyway. Medical education equates to the delivery of medical information -- much more than it is possible to teach.  Medical schools should be obligated to provide current medical information from the first year of medical school and throughout the life of the graduating physician --- Current forms of accessing medical information, CME or GME are completely inadequate and obsolete, locked up in copyright, cost and limited by the distribution of the printed text.

Currently there is no real-time source for the total sum of medical knowledge and the leading edge of information growth. Physicians and students alike need such a source that is up-to-date, real time, 24/7. That source should contain it all, terminology and diagnostic criteria as currently understood by the medical school and the specialties.[1] Every medical school should provide total medical terminology, information and current knowledge for every one of their student, residents, graduate and physicians under their employ at no cost by secure 24/7 online access.

Given such a source of current medical information, indexing the relational database could offer an ongoing differential list of diagnostic possibilities for each-and-every sign, symptom and laboratory finding. Despite advances in medical science, missed diagnosis continues to plague the profession. A correct and timely diagnosis seems more likely with instant access to lists of all the possibilities, criteria for diagnosis and brief summary. Statistical analysis of those lists should be ongoing and real-time offering simple probabilities for both single positives and combinations. This statistical process will be essential for assimilating genomic data and applying it to personal medical care.

Information technology offers an unlimited repository of knowledge accessible through a relational database. The computer never forgets. It lends itself to statistical analysis, but it does not think.  Thinking is the job of the student and the physician. That critical clinical thinking and the basic sciences remain the educational challenges of the medical school. Medical information is so vast and so rapidly changing, however, that it has long since grown beyond the capacity of any one physician to learn and forget much less to remember.

Today in the real world the physician is met with time constraints, productivity demands and repetition, all of which discourage discovery and lead to missed diagnosis. Diseases and treatments fall into familiar patterns. A hundred and fifty, or so, conditions fall easily into a recurring pattern of diagnoses. A one-page encounter form can cover the needed ICD codes required for insurance. That recurring pattern, however, erodes away the physicians heard earned clinical acumen. We often overlook rare disease possibilities and there are so many of them with new discoveries all the time. Additionally, increasing numbers of Immigrants bring in problems common to their home country but only now cropping up here in the US.

Physicians keep up to date with expensive seminars and long hours reading expensive journals at home but nonetheless slowly fall behind. The older a physician grows, the greater the clinical judgment but the more he or she forgets. The content shrinks.

Traveling to a conference or accessing journals presents problems of time and money for a rural physician. A limitless source of medical information at the fingertips would help. The generalist must fill the gaps between specialties and cover a broad spectrum of medical challenges. A total medical information system would help met that need. Proprietary systems like Epocrates provide some of the needed medical information. None of the proprietary systems, however, list everything, nor do they have the ability to stay current. Furthermore, marketing and often greed motivate the content; they emphasize drugs and treatment more than diagnosis. Medical schools need to provide an umbilical cord for the student and to the lifetime of the graduate physician regardless of the specialty. We have an obligation in medical education to lead the way and to a pursuit of excellence.

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[1] A word of caution, often overlooked by non-clinical educators, information should be limited to medical students and graduate MDs --- those with the ability, education and dedication to care for patients. Providing that information to various assistants and alternative providers will cut off the supply and even the existence of Primary Care Physicians. Another mandate that should go without saying but today is often ignored; physicians must all freely exchange information techniques and knowledge between one another.

 

Gestational Diabetes Screening, who’s “Best Evidence”

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The National Institutes of Health consensus panel has determined that the one-step screening test for gestational diabetes results in greater numbers of positive outcomes than the traditional two-step method. The one-step requires a 3-hour glucose tolerance test. The traditional method specifies screening with a non-fasting glucose challenge testing at one hour. Only the positives then go on to the 3-hour GTT. The one-step approach results in 15% to 20% positives, whereas the traditional two-step protocol results in only 5% to 6% positives.[1] The panel concluded that the current data do not indicate whether the one-step protocol improves outcome or diagnostic accuracy.

From the data, one might wonder if the non-fasting screen misses significant numbers resulting in fewer diagnoses of gestational diabetes – a matter of sensitivity. Alternatively, the 3-hour test may lack specificity resulting in false positives. Looking further in the literature,[2] O’Shea and O’Connor in Ireland argue in favor of an HbA1c in the second trimester.    The American College of Obstetrics and Gynecology recommends screening by history, risk factors or the non-fasting 50g glucose challenge.[3] The US Preventive Services Task Force argues that there is insufficient evidence for or against anti-natal screening for diabetes. Mayo Clinic states that history and risk factor screening may be sufficient for women under 25.[4]

Obviously, the increasing obesity among young women poses a threat. Hospitals have broadly adopted the one-step approach. One wonders if the hospitals favor the more expensive option with higher numbers of positive results for business reasons. You might conversely ask if the US Preventive Services Task Force leans in the opposite direction for reasons of cost containment.

There is nonetheless a consensus that the definitive test for gestational diabetes is the 3-hour GTT with proven correlation to outcome. Is this not an argument in favor of professional judgment in selecting when to do the GTT rather than elusive best evidence? --- Who's best evidence and who’s viewpoint?

 

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[1] http://tinyurl/c642s5e

[2] www.ncbi.nlm.nih.gov/pubmed/22838107

[3]http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/Screening%20and%20Diagnosis%20of%20Gestational%20Diabetes%20Mellitus.aspx

[4] http://www.mayoclinic.com/health/gestational-diabetes/DS00316/DSECTION=tests-and-diagnosis

The Flexner Report 100 years Later

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858
Thomas P. Duffy