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In my previous post, I sited a research project that found the average amount of journal reading in 2000 for a practicing internist was around 4 hours per month. This is not an awful lot of reading, given that there are 17,000,000 articles currently available in MedLine. Our field is especially prone to information overload, given the breadth of patients and illnesses we come in contact with. When I graduated from medical school, I did as I was told others did, browsed the medical literature, pulled out articles and put then in a “journal file”, and felt guilty about not doing enough to “keep up”. No wonder the average physicians’ medical knowledge base was directly related to when he or she graduated from residency.

Fast forward 20 years. The Internet was invented by Mr Gore and the personal computer by Mr Gates. Mark Ebell outlines how physicians should use the medical literature. He points out theat the most useful information is relevent, valid and takes little time to access. Computer accessable information is more useful that textbooks (many of which are outdated prior to hitting the shelf). Many physicians now use decision rules to help sort out complex clinical situations. These rules are typically evidence based and often have been validated in “real world” situations. Examples of such rules include the Framingham Cardiac Risk Assessment and the Wells Criteria for suspected pulmonary embolism. Services are now available which aggregate literature and offer clinical “answers to questions” that have been developed using a standardized process. Up-to-date is one such service popular with our residents. If a single journal article is used, it is important to look for those journals that have started to include an assessment of the evidence which supports the recommendations. Then there is searching the 17, 000,000 articles to find the needle in the haystack. What used to be time consuming and complex is now available to anyone on PubMed or Google Scholar.

In short, where previously 15 to 20 clinical questions went unanswered in a typical day, now access to clinical information at the point of service has never been easier. The most important thing is that it’s only going to get easier.

Live a simple and a temperate life, that you may give all your powers to your profession. Medicine is a jealous mistress; she will be satisfied with no less. 


One of my internal medicine attendings, Dr George Burch,  relayed this aphorism to us while we were in our first pre-clinical year at Tulane. The power of the medical education process is illustrated in the fact that I can still see myself in that auditorium watching this (seemingly very old) man offer this and the advice on how to counteract the siren call of medicine…”get a good book and sit under a tree and read.” 

Although we’d like to believe otherwise, Osler was correct. Being a doctor still entails a lot of study prior to completing training. Although the hours that are required in training for direct patient care are limited to 80 in a week, there is no limit to the amount of study time learners must put in to learn their craft. As a program director, I have tools that I use to assess student’s and resident’s medical knowledge and their ability to synthesize it into patient care. There is no substitute for study and preparation. 

Once out of training, physicians must maintain their clinical skills. They did so traditionally through meeting attendance, journal reading, and informally through conversations in the doctors’ lounge. Now things are more formalized with continuing education credits being offered for using the right tools to look up information regarding patient care, as well as our Board requiring us to take specialized instruction to maintain certification. 

All of this takes time. Internal Medicine specialists, when polled, reported spending about 3.3 hours per week on reading. The part of the evidence based practice incorporated into the new model of care in Family Medicine will require data input and physician and staff education. At this time, none of these efforts result in money into the physicians pocket (back to the mistress…) 

Why put up with it? Aside from the fact that it pays pretty well, I find that it really is an interesting way to spend a day. I get to work with people who occasionally want to be healthier. I get to learn about stuff in the news (and occasionally be in the news). Every now and again though, I pick up a good non-medical book and think about Dr Burch. 





I have to give a presentation to the residents on “Clinical Decision Making” and this caused me to reflect on  “How Doctors Think” (Jerome Groopman’s book) and, more importantly to me, “How Should Primary Care Doctors Think?”. In an interview on NPR, Dr Groopman follows the story of a patient who lived with severe nausea, cramps, and weight loss ( mis-diagnosed  as anorexia for 15 years when in fact she suffered from a gluten intolerance) and who has seen approximately 30 physicians, none of whom are very helpful. The patient is saved when a physician (self-referred) sits down with her, elicits her entire story, then does the appropriate diagnostic test.

Dr Groopman feels that we in medicine are letting our patients down . He bemoans the fact that our training has become less apprentice like where we learn at the feet of the great clinicians. He suggests that the use of clinical algorithms  has led us to place patients in clinical “boxes” which benefit insurance companies, and pharmaceutical companies, but not patients. He feels (and I agree to an extent) that the solution isn’t following evidence based algorithms but lies in listening to the patients narrative. Where he and I differ is that where he thinks we need to focus more on critical clinical thinking in medical education and less on algorithms, I feel we need to teach folks when to rethink and how to put systems in place which limit the consequences of poor clinical thinking. The patient whose case he uses seems to me to have been let down by a system which encourages sloppy thinking, includes limited quality assurance, and rewards procedural efficiency.

First, the advantage primary care physicians have is that of time. We have done a poor job of teaching physicians how to utilize time as an aspect of disease management. In a separate interview, Dr Goopman identifies “anchoring” (when physicians latch onto a piece of information and do not change despite evidence to the contrary) as a problem which leads to missed diagnoses. If a patient such as this one is mislabeled as having a certain illness, multiple visits should offer the clinician a clue something else might need investigation. For example, abdominal cramps and intense nausea are not the diagnostic criteria for anorexia (see below) and in this patients care should have led to further investigation

Criteria for anorexia

  • Body weight < 85% of expected weight
  • Intense fear of gaining weight
  • Undue emphasis on body shape or weight
  • Amenorrhea (in girls and in women after menarche) for three consecutive months

    Secondly, in Advanced Primary Care involving the use of a high end electronic health record, algorithms can be used not to limit thinking but to confirm diagnostic labels. For example, if a diagnosis of diabetes is added to a patient’s medical record, the diagnositic criteria could be placed in front of the clinician to get confirmation that this is what was really meant and avoid mis-labeling. From a quality assurance standpoint, a diagnosis should be confirmed and the management should then be optimized based on accepted guidelines. Guidelines should be used to guide testing and therapy, not to limit thinking.

    Thirdly, we have lost critical thinking in all of medicine but it has been especially missed among subspecialists. Dr Groopman suggests that primary care docs, with only 12 minutes per visit, merely get a sketchy complaint from the patient and then route them to the appropriate “subspecialist”. In truth, the 12 minutes is a very loose average. The average primary care doc sees approximately 25 patients in an 8 hour day, resulting in approximately 20 useable minutes per patient. An ear infection takes approximately 3 minutes. We can (and do) use this extra 17 minutes to listen to and work with complex patients over the better part of an hour. What we (and patients) would benefit from in the way of subspecialty care are physicians who will listen to the patient’s story again, and work with us to help make a correct diagnosis and determine the appropriate treatment rather than calculating how to extract money from the patient’s insurance via invansive procedures. I was taught at Tulane by George Burch, C. Thorpe Ray, and others who prided themselves on being the good kind of consultant. What I try to encourage my learners to do is to find those types of consultants and latch onto them so that their patients will get complete care.


    In our (soon-to-be-paperless-but-not-soon-enough) office, we have boxes where messages from patients, abnormal labs, and such are placed by the staff for action by the provider. Because it is not possible for everyone to know where everyone else is at any given time, we have taken to placing paper over the cubby-holes notifying the staff that we will be out until a certain day. If one is going someplace fun, a picture or something else fun is placed on the message as well. As Chairman, my cubby is covered more that most and this past week I used my “Out Reforming Healthcare” message for 3 of the 5 days.

    On Tuesday I traveled to Birmingham to meet with the folks from the Patient Centered Primary Care Collaborative and hear Paul Grundy speak to primary care physician leadership as well as Alabama business leadership. His message is always strong and consistent and it is getting more focused.  As a physician who is involved in direct patient care as well as population based care for IBM employees, he is encouraging all employers to stop paying for garbage (his words). From a recent interview:

    “40% of the care that’s delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it’s $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.”

    He sees transformational change coming and being lead by an empowered primary care workforce. Denmark is being looked at as a model with the number of hospitals reduced by 80%, for example.

    On Wednesday I traveled to Montgomery to preside over the Alabama Rural Health Association board of directors meeting. As I have detailed previously, Alabama has an impending crisis regarding the healthcare workforce in rural Alabama. Although this meeting will not make a difference as a stand-alone activity, it is refreshing to get people in a room who are able to agree on a problem, potential solutions, and set in place a strategic planning activity focused in addressing the shortage. In that meeting we committed to focusing resources on FaceBook to recruit young folks interested in rural Alabama (search on FaceBook to find the page yourself), creating a strategic plan to better direct our resources, and finalizing issue briefs on the manpower crisis in rural Alabama health care prior to January 2010. We also committed to doing rather than talking.

    Lastly, we went to New Orleans on Thursday to recruit Tulane students into our Family Medicine Residency program. The refreshing thing about this trip (aside from the soft shell crab) was that we spent a lovely evening with students who clearly entered medicine for the “right reasons” and they were committed to Family Medicine. We had a very pleasant visit and hopefully will see them in Mobile during the interview process.

    In summary, like Paul Grundy I believe transformational change is coming. I believe it can happen in rural Alabama. The attitude of the students on Thursday confirmed my optimism. It was, however, a long week…

    Neonatal mortalityOne of the things that I have been able to do as an academic “Family Doc” is to continue to participate in the deliver of babies. The word obstetrics is from the Latin obstare which means “to stand by”. That is what I did last night, stand by for a complicated laboring patient who ended up having a sunrise (5:30 am) delivery. By my calculations I have either delivered or supervised the delivery by Family Medicine residents of over 1000 babies. I am struck by how deliveries at “teaching hospitals” have changed since I was a student at Charity Hospital in New Orleans. Medicaid required states to pay for prenatal care beginning in the mid 1990’s. Given a “public option”, many people are happy to use SOBRA Medicaid to pay for their pregnancy care (although in fairness, they don’t have any out-of-pocket expense) and many companies are content to have at least some of their maternity care covered via”the public option” when their employees can’t afford the high deductible insurance.

    The stigma attached to being on “public assistance” for maternity care is gone. Many hospitals in Mobile are more than happy to take maternity Medicaid. We have had to compete for these patients and so we deliver babies at a very a nice facility (USA Children’s and Women’s Hospital) with birthing rooms, televisions, and lots of stuff that looks nice and makes patients want to come back. This is in contrast to my memories of Charity, with its open bay wards, communal laboring patients, and lack of involvement (in my memory) of the teaching faculty in the daily management of the patients.

    Neonatal mortality has been reduced in the United States from 4/100 births in 1940 to 0.6/100 today. This correlates with the inclusion of maternity care in insurance policies and the growth of Medicaid as a viable payor for maternity care providers. Unfortunately, even for pregnancy care, access is not universal.  There are still great disparities in outcomes that are associated with the race of the mother in this country, almost certainly due to differences in access to healthcare. Mortality and morbidity correlates with state of origin. In Alabama  the current rate is 1.1/100 births, probably reflective of access and underlying conditions. 

    Although changes in infant mortality can be attributed to other things as well as access to the health care system, it is clear that improvements in maternity care correlate with the reduction of the use of cash for childbirth and the development of this  public/private partnership, however dysfunctional it may be. When I was in medical school in 1985, prenatal care and a comfortable well attended delivery were clearly luxuries.I have attended this healthcare system during the transformation.  What we need to be discussing is which components of the care work and how to deliver them more efficiently. Instead, we have Senator Kyl who wishes not to pay for anyone else’s childbirth, no matter what.   Why are we as a country even having this discussion?

    Frank deGruy, the Chairman of Family Medicine at the University of Colorado, came to Mobile as a visiting professor last week. Prior to his arrival, he sent me some of his reflections on the healthcare system as it is now and where his vision is on where it should (will?) go which I have posted here. The references in .pdf are only available to folks within the USA system but can be obtained through most libraries. Very interesting reading.

    I spent the weekend working on an inventory of health workforce development activites in Alabama and was struck by some very clear needs that we have to deal with as a state if we are going to provide adequate healthcare to Alabamians, regardless of what happens in DC
    1) It is incredibly important to develop a health careers infrastructure at the K-12 level on a state wide basis. Many counties are only likely to have physicians return if they were born or spent a significant amount of time in that county. In most of these programs, the children who are trained may take advantage of the opportunity to leave so the programs have to train above need and replacement to take that into account. IN Alabama, we currently have less than 100 students engaged in programs such as this annually.
    2) Once rural students and students interested in caring for the underserved are enrolled in medical school, there needs to be predictable funding for the medical school infrastructure at UAB, USA, and possibly AMEC to offer instruction and support in rural and underserved medicine. The current funding strategies in medical education are neither sufficient nor predictable enough to in its current iteration accomplish this.
    3) We do not have adequate Family Medicine residencies in Alabama to replace physicians who are retiring, much less address the shortage. These positions should be increased independently of other health manpower activities as residencies predictably place graduates near the program “hub”.
    4) Community recruitment and retention efforts and payment reform will need to be accomplished as well to retain these docs in Alabama and not lose them to neighboring states. If there is insufficient reasons for physicians to move to or stay in an area, they will move away
    Norman Rockwell Doctor and Doll 1942

    Norman Rockwell Doctor and Doll 1942

    One of the reasons I have a vested interest in the reform effort is that without it, I fear that we in America will head into the uncharted waters of a healthcare system without primary care as outlined in a recent USA Today article as well as other venues. The roots of the shortage are in a 20 year deselection of primary care by US Medical Students. Of the 16,300 US Medical School graduates in 2007, only 1351 (8.2%) went into Family Medicine. In 2009, this number was 1040. Of the residents who entered Internal Medicine (2726) only 2% (50) stated they had an interest in primary care.

    Josiah Macey Foundation in conjunction with the Robert Graham Center looked into “What influences Student Choice of Specialty” earlier this year.They found that students’ choices of primary care or specialty careers are influenced by student related factors, curriculum factors, income differences, and institutional factors. 

    Student Related Factors

    Students who grow up in rural areas, plan to choose family medicine at matriculation to medical school, and are male, have historically been more likely to practice rural primary care. The majority role that women now play in the Pediatrician workforce may be one of the explanations for why Pediatricians have nearly stopped going to rural and small towns.Similarly, students who grow up in urban underserved areas are more likely to practice in inner cities.Being born in a rural county increases the odds of practice in a rural area by 2.4 times and nearly doubles the odds of choosing Family Medicine. It is therefore not surprising that the significant declines of acceptance of rural-born students to medical school overlaps so well with the declines in student interest in choosing primary care, rural practice, and care for underserved populations. Under-represented minority physicians and women are more likely to care for underserved populations. Personal values, spirituality, and mentoring also increase students’ likelihood of choosing service careers. Intention to serve underserved (rural) populations more than tripled the liklihood that a graduate would practice in a rural or underserved area. Students with no or low debt (less than $50,000) and those with high debt (more than $150,000) had higher odds of not choosing primary care, while those educated in public institutions with debt between $100,000 and $150,000 had the highest odds of choosing primary care. National Health Service Corps (NHSC) alumni provide vital health care in their sponsoring communities and have a high likelihood of continuing to care for underserved populations even after their commitments have ended, although they are less likely to remain in underserved practice than physicians who initially care for underserved populations without NHSC financial support. Pathman also demonstrated that state-sponsored scholarship and loan repayment programs support a substantial work force of physicians in underserved communities throughout the country and that physicians who benefit from statebased financial incentives are more likely than other generalist physicians to practice in needy areas and care for uninsured and Medicaid.

    Curriculum Factors

    Longitudinal, comprehensive medical school and residency educational programs with the explicit goals of preparation of students and physicians for underserved practice have demonstrated clear success. Training in primary care, community health electives, and highly rating one’s primary care elective all significantly increased the relative risk of working in a geographic Health Professions Shortage Area. Rural community medicine electives and experiencing a family medicine clerkship both significantly increased the relative risk of practicing in a Medically Underserved Area. Family medicine residents who train in Community Health Centers are also more likely to later care for underserved populations. implementation of a required clinical clerkship in family medicine increases the proportion of medical students who choose Family Medicine careers. Longer clerkships in Family Medicine appear to be more effective. Students report that mentors and training experiences are also important in their specialty intentions.Mentoring and training experiences are very important. Medical students often receive negative messages from mentors about primary care and these messages may be influenced by the academic culture and income disparities.

    Income Difference

    Ebell demonstrated a tight correlation between specialty income at graduation and choice of residency specialty.They found that the income gap is a significant and substantial factor in students’ eventual practice location and specialty Institutional Influences

    Instuitutional Culture

    Medical schools’ institutional culture seems to correlate with career choice. For example, medical schools located in rural areas graduate substantially more rural physicians,and training away from urban centers is believed to be a core component of preparation for eventual rural practice. Schools that graduate a greater proportion of primary care physicians are more likely to: 1) have community hospital teaching sites, rather than academic medical centers have explicit primary care missions; 3) have been founded since 1960; and, 4) have Family Medicine departments.There seems to be an inverse relationship between the amount of institutional NIH funding and the proportion of primary care graduates, Unfortunately, the culture of academic medicine, as a whole, has a negative disposition toward primary care.

    Unfortunately, the problems are often easier to identify than the solutions. Over the next several weeks I hope to share some things that are working to increase the number of primary care doctors in our country.

    HertzlerI outlined for the new residents how we got to the place we are today (in my opinion). Over the next couple of posts, I will try to put into words what was in the Powerpoint.

    My history began with the story of Arthur Hertzler. Dr Hertzler (pictured above) He was known as  the “Horse and Buggy Doctor”.He attended Southwest Kansas College and then Northwestern University Medical School. Since the average country physicians was not as well educated, Dr Hertzler’s private practice in Halstead, Mo would have been unusual in its own right. The fact that he maintained this practice and taught pathology, histology, surgery and gynecology at the University Medical College in Kansas City and University of Kansas School of Medicine was amazing. his fame, though, was from his book, the Horse and Buggy Doctor, written in 1938 about his practice. In it was a personal account of his experiences and it was an instant best seller. It offers a discription of the quintessential “country doctor”.

    Darly Ward Darley was not a family physician, but was also innfluential in the speciaties founding. He had his A. B. and M.D. from University of Colorado and after a period of private practice in Denver he went on to become president of the AAMC in 1952 and president of the University of Colorado in 1953. In 1949 he wrote “The place and training of the General Practitioner”.  In it, he says “This doctor-a physicianin the fullest sense of the word-should be interested in and qualified to function as a healthCounsellor and a health coordinator for a given individual from birth to death. Personal preventive medicine, as well as community health, should claim a great deal of his effort. Ability to function effectively in the prevention, early diagnosis and treatment of emotionally and personality determined illnesses should be of the first importance. General diagnostic ability predicates that he will recognize his limitations and know when specialist consultation or referral is indicated. The need for proficiency in the therapeutics of the common medical conditions should be apparent. His need for surgical ability other than diagnostic will depend upon the locale of his practice and his proximity to surgical consultants and facilities.” In essence, he discribed the need for and the training of the prototypical family physician.

    In 1965, the Millis commission further discribed the need for generalist training and outlined the barriers to care. As a result of these and other great men and women, the American Board of Family Practice was founded in 1969 with 15 pilot training programs. The training was notable in its ininclusion of behavioral sciences and its requirement for recertification.

    In upcoming posts I will describe the formation of USA Family Medicine, and the path to health reform and the role that our programs have played.

    As healthcare reform moves into the sausage factory phase, I remain convinced that healthcare reform is imperative for the health of Alabamians almost more so than most Americans and that Alabamians are the least likely to appreciate the urgency and the effort.

    I don’t know how many of our citizens are aware that government pays for 45% of healthcare costs (through Medicare, Medicaid and other programs). If they were, they would perhaps appreciate that President Obama rightly feels that we as taxpayers should be getting value for our tax dollar. That is why his principles (outlined at focus on universal coverage, coverage portability, prevention of illness, and reduction in medical errors and waste.

     Our Senator, appearing on Fox News Sunday, bemoaned the efforts of the Democrats to dismantle the “the best healthcare system the worls has ever know”. I wonder if he is aware that the average age of primary care physicians in Alabama (overwhelmingly the type of physician practicing in rural areas) is 50, and some counties have fewer than 3 physicians for the entire county. Eight counties have no hospital at all.

    Delays in care are common throughout our state. Trauma deaths, the best predictor of care availability, are twice as high in rural Alabama than in the US as a whole. Obstetrical care is unavailable in 33 of the 55 rural counties. Life expectancy in rural Alabama is 3 years below that of the United States overall, a difference that can be directly attributed to lack of access to health care. See the Alabama Department of Public Health website for further details on the state of medical care in rural Alabama.

    On the hope side, we graduated 4 new Family Physicians at the Admiral Semmes last night. Unlike previous years, where the graduates were going to practice Emergency Medicine or Urgent Care, this year the graduates were entering the practice of Family Medicine. In addition, we had 6 “Interns” complete their first year of training, at least one of whom will practice in rural Alabama. Maybe the glass is half full.Residents