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The CMG Voice

Are We Running Out Of Primary Care Doctors?

Posted Monday, July 24, 2017 by Tyler Goldberg-Hoss

Students of healthcare issues think that the national debate over policy and payment issues is ignoring the fact that a crisis is quietly developing in the reduction of primary care physicians (PCP). The American Association of Medical Colleges estimates that the U.S. will face a shortage of 49-100,000 primary care physicians by 2030. This estimate is similar to others, such as the Department of HHS, which projects a shortage of 20,000 PCPs by 2020.

The crisis is multi-factorial. As people live longer, they consume more primary medical care. At the same time, physicians are retiring at a younger age due to, among other things, an increasing regulatory burden. And more young doctors are opting for non-clinical careers.

Some observers think this problem will be alleviated by the increasing use of “physician extenders,” such as Physician Assistants (PAs) and nurses with advanced degrees of expertise. Nurse-practitioners in some states, including Washington, can work in clinics that do not have a physician available, and can do almost everything a doctor does except performing surgeries.

Most doctors who choose to become primary care clinicians obtain their advanced training in “residency” programs, such as those at medical schools. This additional training, in which the doctors rotate through various “services,” such as dermatology, surgery, or rheumatology, provide the wide experience needed to both provide in-office medical are and also to serve as the “gate-keeper” for referrals to specialists.

A problem has been that, as the number of applicants to the National Residency Matching Program has risen in recent years, the number of residency “slots” has increased more slowly. This resulted in federal legislation called the Resident Physician Shortage Reduction Act of 2015, which provides additional funding for medical schools and other medical facilities to increase the number of PCP residency positions.

Other solutions to the PCP shortage have been to rely more on foreign medical school graduates to have access to PCP jobs. This effort has been hampered by sponsorship and immigration and visa complications, which have become more difficult in the Trump presidency.

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Staging skin cancer less exact than you might think

Posted Monday, July 17, 2017 by Tyler Goldberg-Hoss

Many of us have had suspicious lesions sampled and biopsied, looking for malignancies. Those biopsies are analyzed and interpreted by pathologists. If cancer is found, the pathologists often stage the cancer depending on the characteristics of it. Then those findings are sent back to the ordering provider to help direct patient care.

Recently, a study looked into how accurate the pathologists were at diagnosing the skin cancer. The study sent each pathologist a number of slides, then sent them the same slides 8 months later. The pathologists’ interpretations were condensed into five classes, and the results were then analyzed.

The study found that most pathologists issued the same diagnoses in both stages of the study on the extremes: most pathologists were consistent in calling cancers in the first and fifth classes of cancer. However, pathologists interpreting the middle classes of cancer were less accurate.

Researchers analyzing the results of the study estimated that nearly 1 in 5 suspected cases of skin cancer are diagnosed as more advanced than they really are, while a similar number are diagnosed as less advanced than they really are. While fortunately few of the biopsies are invasive cancer, this is disconcerting news to anyone dealing with results from such a test. Perhaps in certain situations, a second opinion may be warranted.

You can find the results of the study here:

Pathologists’ diagnosis of invasive melanoma and melanocytic proliferations: observer accuracy and reproducibility study

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Are Primary Care Decisions Based On Good Evidence?

Posted Thursday, July 13, 2017 by Gene Moen

There has been increasing reliance by physicians on “evidence-based medicine”, or EBM. EBM has been defined as the “conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients.” EBM integrates clinical experience and patient values with the best available research information. Often this information is presented in the form of ranking or grading of various approaches or diagnoses, based on how strongly the studies support those decisions.

A recent study by the University of Georgia’s College of Public Health analyzed 721 topics from an online medical reference for primary care doctors and found that only 18% of the clinical recommendations were based on high-quality EBM. In an online medical reference often used by physicians, areas of care that are supported by EBM are graded A, B, or C, depending on the strength and quality of the evidence supporting the issue.

Some areas of medicine, such as pregnancy, cardiovascular, and psychiatry, had higher levels of EBM reliance, while others, such as hematology and rheumatology, had the lowest. Many primary care doctors relied more on their acquired knowledge of the importance of laboratory markers or symptoms, rather than on studies that take into account such factors as morbidity, mortality, quality of life, or symptom reduction. Overall, only 51% of primary care recommendations to patients were based on well-established EBM.

In light of the ready availability of Internet information about EBM recommendations, it is unfortunate that so many primary care health recommendations do not utilize EBM. This is especially true for primary care visits, which account for 53.2% of all physician office visits.

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AMA Journal calls for change in how hospitals handle and disclose the practice of overlapping surgeries

Posted Monday, July 10, 2017 by Tyler Goldberg-Hoss

Recently I wrote a blog post about how Virginia Mason recently decided to disclose to their patients the practice of overlapping surgeries, including revising their informed consent process to make more clear that the practice occurred and how that might affect the patient.

One area of concern with the new Virginia Mason disclosure was that patients were being told that their surgeon would always been in the operating room for “critical portions” of the surgery, but that term was not defined.

Now the American Medical Association has published an article calling for reforms regarding this practice and disclosing it to surgical patients. It too finds fault in hospitals who allow their surgeons to decide which portions of the surgery were critical. Some surgeons believe that, in certain spine surgeries, there are no “crucial portions”, so the attending surgeon theoretically would never have to be in the OR.

Instead of this practice, the AMA article suggests that a committee within the hospital, and not just the particular surgeon, should define the “critical portion” of a given surgery. Additionally, the article suggests that there should be some method of tracking when a surgeon is physically in an OR.

The article points out that little is known on the subject of whether the common practice of overlapping surgeries actually impacts patient safety. Without that research, it’s impossible to say whether the above steps will have any effect on patient safety. However, at a minimum I hope that greater transparency about the practice will allay public fears.

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Artificial Intelligence is Coming to Healthcare

Posted Thursday, July 6, 2017 by Tyler Goldberg-Hoss

While perusing the Internet the other day I came upon an article at Fortune.com regarding the up and coming sectors of healthcare where Artificial Intelligence (AI) will make the most impact in the near future.

The article highlighted two areas: robot-assisted surgery and “Nursing Assistant Applications”.

Robotic surgeries are nothing new. The da Vinci Surgical System and others like it have been around for years and their use is growing: more and more hospitals are purchasing the $1.4 million dollar machines, and more and more surgeons are being trained in how to use them. These are not just general surgeons anymore, but cardiothoracic surgeons, colorectal surgeons, GI surgeons, gynecologic surgeons, neurosurgeons, orthopedic surgeons and others.

However, my impression of these systems was that they were essentially high prices, highly technical tools for the surgeon to use to do his or her job. A glamorous scalpel, essentially. This new article apparently is theorizing much more than that, including integrating information from pre-operative medical records and “machine learning” to improve surgical outcomes and reduce the length of a patient’s hospitalization.

As a medical negligence attorney focused on patient safety and accountability, I can imagine the complexity of a case involving an AI “robot”, a surgeon, and a surgical error. Who is in charge when the error occurred? Can the “robot” be in charge? Although my sense is that jurors will have an easier time finding fault with a faceless robot, these are complex questions that will need to be addressed to protect all of us from unnecessary medical errors.

The Nursing Assistant Applications appear to include a number of devices that will allow health care providers to monitor vital signs and patient symptoms remotely. These include a number of things already on the market, including apps for your Apple Watch that let a pregnant mother monitor heart rate and contractions and send that information to a health care provider (you can read a recent blog post about that here.

I expect this to continue, as large corporations providing health care will continue to attempt to improve efficiency by reducing the need for patients to actually see their doctor (or ARNP, or PA). After all, why see your doctor when you can hook yourself up at home and wirelessly send that information to him or her (or perhaps a robot with AI)?

The article goes on to list a few other possible areas where AI will be used in health care, including fraud detection and dosage error reduction.

I am certainly not a Luddite: I understand that improvements in technology have had and will continue to have a positive impact on the health of all of us. My worry lies in the unfortunate reality that our healthcare system is in many ways profit driven, and without proper checks and balances, profits will end up being more important than patients.

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