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Which Procedures Add
Value: A Paradigm Shift 1971-2011
Wm. MacMillan Rodney, M.D.
TECHNOLOGY TRANSFER
PROJECT
In the
A
“generalist physician” predictably provides comprehensive health care unrestricted
by age, gender, organ system, and location of service. The term “primary care” was coined in the
late 1980’s, and generic primary care does not follow this operational
definition. To survive, family medicine will need to do more than primary care.
Traditional
physicians cared for children, delivered babies, managed simple fractures,
attended the hospital, made occasional house calls, managed an office, and when
all else failed, comforted the dying.
They went from the nursery to the nursing home, without taking the
patient to the poorhouse along the way.
As “General Practice” disappeared from the academic environment, there
was a corresponding decline in the quantity and quality of the general medical
curriculum. Breadth of care in diagnostic and therapeutic skills continued to
shrink while technology-assisted procedures grew in various medical and
surgical subspecialties.
Since
1983, a group of educators, supported by the
By developing continuity of
care in the office, in the hospital, and with many procedural services,
patients and physicians are better served.
A bibliography is presented in the accompanying attachment.1
Wm.
MacMillan Rodney, M.D., FAAFP, FACEP
Meharry/Vanderbilt
Professor and Chair 2000-2004
Professor
and Chair, UT-Memphis 1989-1998
Residency
Director UCLA 1979-84
1.
Originally presented 1986 at the
Society of Teachers of Family Medicine Regional Meeting in
TECHNOLOGY
TRANSFERS
AN ENVIRONMENTAL IMPACT REPORT ON MEDICAL PRACTICE
Wm. MacMillan Rodney, M.D., FAAFP, FACEP
July 1989-present
I. ASSUMPTIONS
A. In health care, accurate and early diagnosis is of public
value.
B. Dissemination of diagnostic and therapeutic skill to a
broader base of physicians is desirable, if the costs are acceptable. This improves access.
C. Training resources are limited, costs are significant, and
tax support for medical education has been deflected away from the training of
generalist physicians.
D. Technology is quietly transforming the biomedical model and
the psychosocial model. A new paradigm
is evolving.
II. PREDICTIONS
A. Offices will continue to evolve into health centers which
offer preventive care, team care, patient education, counseling, resource
management, procedures and sickness care.
B. New diagnostic and therapeutic skills will gradually blend
the technical power of the hospital into the high touch environment of the
office (community health center).
C. For example, the power of diagnostic imaging will return to
the office. Defragmentation of health
care will enhance continuity and patient satisfaction.
D. Digitized images, computerization, and other advances will
create electronic information management systems linking offices into efficient
primary care research networks. Outcomes
will be measured, analyzed, and published.
E. Health care quality will improve, legal liability will
decrease, and health care costs will not increase. Access to health care will be improved.
F. Parallel health care systems will persist and compete. Without painful reconfiguration, parallel
systems of medical education will persist and compete.
G. The absolute numbers of general physicians will grow
slowly. Generic “primary care” will
compete with procedurally enhanced generalists for training resources. Comprehensive care physicians (much needed in
rural and underserved communities) will constitute less than 10% of practicing
physicians until a sustained crisis precipitates change or until economic and
technologic events shape evolutionary change.
QUOTE TO
REMEMBER
"Everyone is in favor of progress, it’s the changes
that they don't like."
Anonymous.
III. BACKGROUND DATA AND
EXAMPLES
A. Megatrends noted.
1. These and many other techniques take the physician to the
bedside of the patient. These skills
will enhance the profession's number one tool--THE BOND OF TRUST AND MUTUAL RESPECT IN THE
DOCTOR-PATIENT RELATIONSHIP.
2. Other bedside techniques will advance and also create change
for the better. Time and space prohibit
a complete list.
B. Primary care endoscopy arrived in the 1980's. Listed below are specific examples. Each procedural skill is followed by the
years in which the first and subsequent studies were published.
1. Procedural skills established and
accepted in Family Practice
a) Flexible Sigmoidoscopy 1982-1989; replaced by colonosocopy
b) Endoscopic Biopsy 1984-1989, A nonissue by 2000
c) ENT Endoscopy 1988-1991; never became popular
2. Procedures established, but still
contested
a) Colonoscopy 1986, 1988, 1992, 1996, 1998,2005
b) Esophagogastroduodenoscopy
1979, 1990, 1992, 1994, 1997, 2005
c) Polypectomy 1991-1996, bundled into colonoscopy
d) Endoscopic Hemostasis 1991-1993, bundled into EGD
3. Videoendoscopy transforms the nature of care by blending
distinct technologies. Interspecialty
boundaries are transformed. 1985, 1986, 1987
C. Women’s Health Care Emerges as an area
requiring special skills.
1. Colposcopy training in Family Practice residencies follows a
dissemination curve similar to that of flexible sigmoidoscopy. 1987, 1990, 1994
2. Ultrasound improves access to maternal and fetal health care
in a community health center. Training
pathway for obstetricians and OB-capable family physicians is created. 1988-1992,
1995, 2001,2004-6.
3.
A structured course in obstetrical emergencies (ALSO) is adopted by the
4.
Cesarean section skills (operative obstetrics). 1995, 1996, 2002, 2004,
2006
D. Enhancing family medicine curriculum in maternity (
“Study the past, diagnose the present,
foretell the future, practice these acts.
As to disease, make a habit of two things: to cure, or first above all,
do no harm." Hippocrates 460-377
B.C.
IV. REFERENCES
A.
ENDOSCOPY AND INFORMATION
MANAGEMENT
1. Rodney WM, Felmar E.
Why flexible sigmoidoscopy instead of rigid
sigmoidoscopy.
J Fam Pract, 1984; 19:471-476.
2. Rodney WM, Beaber RJ, Johnson RA, Quan M. Physician compliance with colorectal cancer
screening (1978-1983): The impact of
flexible sigmoidoscopy.
J Fam Pract, 1985; 20:265-269.
3. Rodney WM, Ounanian LL, Werblun MN. Second-generation video
sigmoidoscopy. Am Fam Phys, 1985;
31:127-132.
4. Corey GA, Hocutt JE, Rodney WM: Prototype study of nasolaryngoscopy
outcomes
in family practice. Fam Med 1988; 20:262-265.
5. Rodney WM. Procedural skills in flexible sigmoidoscopy and
colonoscopy for the family physician.
Primary Care - Gastrointestinal Disease, WB Saunders,
6. Rodney WM, Hocutt JE, Coleman WH, Weber JR, Swedberg JA, et
al. Esophagogastroduodenoscopy by family physicians: A national multisite study
of 717 procedures. J Am Bd Fam Pract
1990; 3:73-79.
7. Rodney WM. Flexible sigmoidoscopy and the despecialization
of endoscopy: an environmental impact report.
Cancer 1992; 70S(5):1266-1271.
8. Rodney WM, Dabov G, Orientale E, Reeves WP. Sedation associated with a more complete
colonoscopy. J Fam Pract 1993;
36(4):394-400.
9. Rodney WM, Weber JR, Swedberg JA, Gelb DM, Coleman WH,
Hocutt JE, Huston T.
Esophagogastroduodenoscopy by family physicians Phase II: a national
multisite study of
2,500 procedures. Fam Pract Res J
1993; 13(2):121-131.
10. Conwell CF, Lyell R, Rodney WM. Prevalence of Helicobacter pylori in family
practice patients with refractory dyspepsia: a
comparison of tests available in the
office. J Fam
Pract 1995; 41(3):245-249.
11. Hopper W., Kyker KA, Rodney WM. Colonoscopy by a family physicians: a 9-
year experience of 1048 procedures. J Fam Pract 1996; 43(6):561-566.
12. Pierzchajlo RPJ, Ackermann RJ, Vogel RL. Colonoscopy performed
by a family physician: a case series of 751 procedures. J Fam Pract May 1997;
44(5):473-479.
13. Pierzchajlo RPJ, Ackermann RJ, Vogel RL.
Esophagogastroduodenoscopy performed by a family physician: a case series of
793 procedures. J Fam Pract Jan 1998; 46(1):41-46.
14. Carr K,
15.
Rodney WM. Flexible
sigmoidoscopy: The unkept promise of cancer prevention. Am Fam Phys 1999; 59:270-273.
16.
Rodney WM. Will virtual reality
simulators end the credentialing arms race in
gastrointestinal endoscopy or the need for family
physician faculty with endoscopic
skills? JABFP 1998;
11(6):492-495.
17. Rodney
WM, Richter R. Virtual colonoscopy: Can we screen for cancer of the colon? ……...Curr
Surg. 2003;60(2):130-134.
18. Newman RJ, Nichols DB, Cummings DM.
Outpatient colonoscopy by rural family
…..physicians, Ann Fam Med
2005; 3: 122-125.
19. Wilkins T, Gillies RZ.
Office based unsedated ultrathin esophagoscopy in a primary care setting. Ann
Fam …..Med 2005; 3: 126-130.
20. Hahn RG, et al. Use of the thin
colonoscope. J Am Bd Fam Medicine 2007
B. RURAL AND UNDERSERVED--WOMEN'S HEALTH
CARE CERVICAL CANCER SCREENING/COLPOSCOPY
21. Felmar E, Cottam C, Payton CE, Rodney WM. Colposcopy: It can be part of your practice. Primary Care and Cancer, 1987; 7(4):13-20.
22. Rodney WM, Felmar E, Richards E, Morrison J, Cousin L.
Colposcopy and cervical cryotherapy: Feasible additions to the primary care
physician's office. Postgrad Med, 1987;
81(8):79-86.
23. Rodney WM, Clement K, Euans D, Huff M, Hutchins C, McCall JW. Colposcopy in family practice: pilot studies of pain prophylaxis and patient volume. Fam Pract Res J 1992; 12:91-98.
24. Rodney WM. Onsite
colposcopy services in a community health center. J Am Bd Fam Pract 1998; 11:80. (letter)
C. DIAGNOSTIC
ULTRASOUND AS A SYMBOL OF TECHNOLOGY TRANSFER
25. Hahn RG, Ho S, Roi LO, Bugarin-Viera M, Davies TC, Rodney WM.
Cost effectiveness of office obstetrical ultrasound in family medicine:
Preliminary considerations. J Am Board
Fam Pract, 1988; 1:33-38.
26. Hahn R., Ornstein S, Davies TC, Roi L, Rodney WM, Garr D, et
al. Obstetric ultrasound training for family physicians: Results from a
multi-site study. J Fam Pract 1988;
26:553-558.
27. Morgan WC, Rodney WM, Garr DA, Hahn RG. Ultrasound for the
primary care physician: Applications in
family-centered obstetrics. Postgrad
Med, 1988; 83(2):103-107.
28. Rodney WM, Prislin MD, Orientale E, McConnell M, Hahn RG.
Family practice obstetrical ultrasound in an urban community health center:
Birth outcomes and examination accuracy of the initial 227 cases. J Fam Pract 1990; 30:163-168.
29. Rodney WM, Deutchman ME, Hartman KJ, Hahn RG. Obstetric ultrasound by family
physicians. J Fam Pract 1992;
34(2):186-200.
30. Connor PD, Deutchman ME, Hahn RG. Training in obstetric sonography in family
medicine residency programs: results of a nationwide survey and suggestions for
a teaching strategy. JABFP 1994;
7(2):124-129.
31. Deutchman EM, Connor P, Hahn RG, Rodney WM. Maternal gallbladder assessment during
obstetrical ultrasound: results, significance, and technique. J Fam Pract 1994;
39:33-37.
32. Dresang LT. Rodney WM, Dees J. Teaching prenatal ultrasound to
family medicine residents. Fam Med 2004; 36: 98-107.
33. Dresang L, Rodney WM, Koch P, Leeman L,
Palencio M. ALSO in
34. Dresang L, Rodney WM, Rodney KMMR.
Prenatal ultrasound: A tale of two cities.
J Nat Med Assoc Feb 2006; 98[2]: 161-171
http://www.nmanet.org/JMNA_Journal_Articles/feb-06-jnma/OC167.pdf
D. THE IMPACT OF EDUCATIONAL SYSTEMS ON THE
PRACTICE ENVIRONMENT
35. Rodney WM, Beaber RJ: Maximizing patient care services to improve
funding in a family medicine residency. J Med Ed 1984; 59:567-572.
36. RodneyWM, Zeffer K, Burnett H.. Patient
“drop-outs” in a family practice residency:
System-dependent versus physician-dependent factors. Fam Pract Research J 1985;
4: 226-233.
37. Rodney WM, Richards E, Morrison JD, Ounanian LL. Constraints on the performance of minor surgery by family
physicians: Study of a "mock"
skin biopsy procedure. Family Practice-An International Journal, 1987; 4:36-40.
38. Larimore WL,
39. Larimore WL, Sapolsky BS.
Maternity care in family medicine: economics and malpractice. J Fam Pract 1995; 40(2):153-160.
40. Harper MB, Mayeaux EJ, Pope JB, Goel R. Procedural training in family practice
residencies: current status and impact on resident recruitment. JABFP 1995; 8(3):189-194.
41. Deutchman ME, Sills D, Connor PD. Perinatal outcomes: a comparison between
family physicians and obstetricians.
JABFP 1995; 8(6):440-447.
42. Rodney WM, Hahn RG, [Crown LA-forced to disclaim authorship],
Martin J. Enhancing the family medicine
curriculum in maternity care (
43. Rodney WM, Hahn RG.
The impact of the limited generalist (no
J Am Board
Fam Pract 2002; May-June 15:191-200.
44. Rodney WM, Deutchman ME, Hahn RG.
Advanced Procedures in Family Medicine: The Cutting Edge or the Lunatic
Fringe? J Fam Pract 2004; 53:209-212.
45. Rodney WM, Hardison D, McKenzie L, Rodney-Arnold KM.
Impact of Deliveries on Office Hours and Sleep Cycle. J Nat Med
Association October 2006; 98: 1685-1690.
E. OPERATIVE
OB-GYN
46. Deutchman M, Connor P, Gobbo R,
FitzSimmons R.
Outcomes of cesarean sections performed by family physicians and
the training they received: a 15-year retrospective study. J Am Bd Fam Pract 1995; 8(2):81-90.
47. Heider A, Neely B, Bell L. Cesarean delivery results in a
family medicine residency using a
specific training model. Fam Med 2006;38: 103-109.
V. MISCELLANEOUS RESOURCES
A. Website:
www.AAFP.ORG
Phone: 1-800-274-2237
1. Task Force on Obstetrics, 1989-1995
Concise
bibliography describing the scientific basis for prenatal, perinatal, and
postpartum care by family physicians.
2. Commission on Scope and Quality of Practice
(overview of policies from AMA, JCAHO, HCFA, and other health care agencies).
3. AAFP Task Force on Procedural Skills, 1993-1995.
Miscellaneous
data and policy.
B. Procedural Skills and Office Technology Bulletin at
PSOT.com, Advanced Family Medicine Specialists, Association for Rural and
Emergency Medicine; www.psot.com
C.
Wm. MacMillan Rodney, M.D. Check the internet (www.psot.com), fax
901-754-8119,
or e-mail Wmrodney@aol.com.
VI. NEEDED DEFINITIONS AND UNANSWERED
QUESTIONS
What is a general practitioner? What is a family physician?
What is a primary care
physician? What is a generalist?
What are the educational implications if these terms
are used interchangeably?
Reference: Halvorsen JG. J Am Bd Fam Pract 1999; 12:173-177.
Should
society train a better generalist or is this best left to nurse practitioners
and physician assistants? See
Barondess and Greimeder JAMA 2000:284:
2873-4.
Grumbach, K. Specialists,
technology, and newborns-Too much of a good thing. New Engl J Med 2002; 346:1574-5
Fisher ES. Medical Care—Is More Always Better? New
Engl J Med 2003;349:1665-67.
VII. DISCUSSION
A. Without faith and courage, you will practice
no other virtue—Andrew Jackson
B. The medical specialty that cannot provide
its own training, certification, and privileges has been reproductively
sterilized.
Your
consideration and comments are always appreciated,
Wm.
MacMillan Rodney MD
Clinical
Professor of Family Medicine
www.psot.com
Workshp/transfer.tech.2.19.08