Physicians Practice Medicine Research Articles

Abstract 15864: Genetic Findings of Cardiac Sarcoidosis in a Case of Apical Variant Hypertrophic Cardiomyopathy With Recurrent Ventricular Tachyarrhythmias

Background: Genetic sequencing is changing the way physicians practice medicine. Hypertrophic cardiomyopathy (HCM) is one of the most common inheritable cardiac diseases. Sarcoidosis is a multisystem disease involving granulomatous infiltration of the lungs, heart, and other organs thought to be caused by a dysregulated immune system, influenced by genetic factors. Here, we present a case where an individual initially diagnosed with HCM was experiencing frequent episodes of ventricular tachycardia (VT). Further workup, including advanced imaging along with whole genome screening (WGS), revealed an unlikely diagnosis of concurrent cardiac sarcoidosis (CS). Clinical History: A 62-year-old man had ventricular fibrillation with workup notable for an ECG with deeply inverted T-waves, normal coronary angiography, and an echocardiogram and MRI showing apical HCM. An ICD was placed. Six years later, he had VT requiring a shock and was started on sotalol. He has now developed recurrent exercise-induced VT. While VT is seen HCM, the increasing frequency prompted further evaluation. A CT coronary angiogram showed normal coronaries and mediastinal lymphadenopathy. Lymph node biopsy revealed noncaseating granulomas and a PET/CT revealed hypermetabolic basal myocardium meeting HRS criteria for CS. Given minimal apical FDG uptake and a low likelihood that he had CS for 9 years without significant fibrosis, he likely has both HCM and CS. Using WGS, four genetic variants previously described in CS and HCM were identified confirming this diagnosis, HLA-DRB1, HLA-DQA1, ALPK3, and TTN. Discussion: HLA-DRB1 and HLA-DQA1 are both major histocompatibility complexes associated with CS. ALPK3 encodes alpha kinase 3 while TTN encodes titin. Truncating variants of ALPK3 are associated with HCM while pathogenic TTN variants have been described to cause HCM, DCM, and ARVC. This case reflects the potential of WGS in aiding clinicians in confirming an unlikely diagnosis.

Healthcare Enforcement Laws and Federal Healthcare Employment Laws: What Would Physicians be Prudent to Learn?

It is incumbent upon physicians to become knowledgeable regarding healthcare enforcement and employment laws. Federal regulatory policies directly impact how physicians practice medicine, and transgression of these laws can lead to loss of license, exclusion from CMS payments, fines, and civil and criminal penalties. Contravention of federal employment laws can result in similar devastating penalties. This article aims to equip the reader with a preliminary understanding of these complex laws. The interested reader will need to take a deeper dive into the weeds of healthcare enforcement and employment law.

Promoting Culture Change Within Organizations.

Promoting Culture Change Within Organizations.

Rural Physician Shortages and Policy Intervention

Although fourteen percent of the U.S. population lives in rural areas, only ten percent of primary care physicians practice medicine there; populations in areas with physician shortages have measurably worse health outcomes. We analyze the effects of incentive programs intended to eliminate physician shortages. Using a differences-in-differences approach, we estimate that student loan forgiveness programs cause an increase of three physicians per rural county. We then estimate a model of physician location decisions and find that physicians are unresponsive to differences in compensation and prefer to live in their home state. Consequently, current programs are too small to eliminate shortages.

Point-of-Care Ultrasound in Internal Medicine

Over the past few decades a variety of technological advances have dramatically change the manner in which physicians practice medicine. Both clinically and administratively the practice of medicine is in evolution – for example; stents instead of surgery and digital health records instead of paper charts. For internal medicine physicians one of the biggest transformations with respect to how we will practice medicine is just on the horizon. The routine use of point-of-care ultrasound (PoCUS) will become an essential skill for the practicing internist. The application for PoCUS in the field of internal medicine is immense – accurately assessing the JVP in critically ill patients, performing arterial and venipunctures, diagnosing pericardial tamponade or determining the likelihood of a pulmonary embolus, or the diagnostic and therapeutic removal of body fluids, to name a few.While some of our colleagues have adopted this technology as an adjunct to the clinical examination or as an aid to conducting bedside procedures most have not adopted this as a routine skill set. Some of the barriers include insufficient training and a lack of readily accessible equipment in all clinical settings. But this will change, and the use of PoCUS will eventually become a required skill of all practicing internists.In the current issue of CJGIM Lewis et al have conducted a needs assessment of PoCUS in answering either a clinical question or in guiding a procedure. As the Royal College of Physicians and Surgeons does not yet require all internal medicine residency programs to provide a formal PoCUS curriculum, the objective of their study was to conduct a systematic needs assessment for the introduction of a PoCUS curriculum to an internal medicine program. The results showed that some internal medicine residents were already using PoCUS yet they had never been formal trained in the skill. One is left to wonder what a similar survey would find if conducted amongst practicing internists.While each residency programs will inevitably develop a PoCUS curriculum for their trainees, it will remain a continuing education challenge for internists already in practice. The importance of this skill cannot be under estimated and it will require the leadership in the internal medicine community to ensure that they create the opportunity for all internists to master the use of PoCUS.

Protecting the airway and the physician: Aspects of litigation arising from tracheotomy.

In recent decades, medical malpractice costs have increased and have led to a change in the way physicians practice medicine. Tracheotomies are cases in which complications have a high risk of morbidity and mortality and the potential for litigation. The Westlaw legal database was used to gather data on 43 jury verdicts and settlements from 1987 to 2013. Various factors included outcome, defendant specialty, and the reason for litigation. Median settlements were $500,000 and median verdict awards were $2,000,000. Postoperative negligence was alleged most often (81%) followed by intraoperative negligence (27.9%) and permanent injury (18.6%). Otolaryngologists were named as defendants most often (25.6%), with nurses named second most often. Pediatric cases had significantly higher awards and were more often named in favor of the plaintiff. An awareness of tracheotomy malpractice litigation has the potential to both help physicians avoid future litigation and improve patient safety.

The ethics and economics of pharmaceutical pricing.

The cost of drugs is a major and rapidly rising component of health-care expenditures. We survey recent literature on the ethics and economics of skyrocketing pharmaceutical prices and find that advances in economic research have increased the sharpness and focus of the ethically based calls to increase access by modifying patent protection and reducing prices. In some cases, research supports ethical arguments for broader access. Other research suggests that efforts to broaden access result in unintended consequences for innovation and the medical needs of patients. Both ethicists and economists need to be more cognizant of the real clinical settings in which physicians practice medicine with real patients. Greater cross-disciplinary interaction among economists, ethicists, and physicians can help reduce the disjunction between innovation and access and improve access and patient care. This dialogue will impact private industry and may spur new multistakeholder paradigms for drug discovery, development, and pricing.

Should General Surgery Residents be Taught Laparoscopic Pyloromyotomies? An Ethical Perspective

The authors examine the ethical implications of teaching general surgery residents laparoscopic pyloromyotomy. Using the authors' previously presented ethical framework, and examining survey data of pediatric surgeons in the United States and Canada, a rigorous ethical argument is constructed to examine the question: should general surgery residents be taught laparoscopic pyloromyotomies? A survey was constructed that contained 24 multiple-choice questions. The survey included questions pertaining to surgeon demographics, if pyloromyotomy was taught to general surgery and pediatric surgery residents, and management of complications encountered during pyloromyotomy. A total of 889 members of the American Pediatric Surgical Association and Canadian Association of Paediatric Surgeons were asked to participate. The response rate was 45% (401/889). The data were analyzed within the ethical model to address the question of whether general surgery residents should be taught laparoscopic pyloromyotomies. From an ethical perspective, appealing to the ethical model of a physician as a fiduciary, the answer is no. We previously proposed an ethical model based on 2 fundamental ethical principles: the ethical concept of the physician as a fiduciary and the contractarian model of ethics. The fiduciary physician practices medicine competently with the patient’s best interests in mind. The role of a fiduciary professional imposes ethical standards on all physicians, at the core of which is the virtue of integrity, which requires the physician to practice medicine to standards of intellectual and moral excellence. The American College of Surgeons recognizes the need for current and future surgeons to understand professionalism, which is one of the 6 core competencies specified by the Accreditation Council for Graduate Medical Education. Contracts are models of negotiation and ethically permissible compromise. Negotiated assent or consent is the core concept of contractarian bioethics. Nonnegotiable goods are goals for residency training that should never be sacrificed or negotiated away. Fiduciary responsibility to the patient, regardless of level of training, should never be compromised, because doing so violates the professional virtue of integrity. The education of the resident is paramount to afford him or her the opportunity to provide competent care without supervision to future patients. Such professional competence is the intellectual and clinical foundation of fiduciary responsibility, making achievement of educational goals during residency training another nonnegotiable good.

Medicine as Practice: Notes on Keeping the Mind of a Beginner Despite Becoming an Expert

Isn’t it interesting that, in the vernaculars of both physicians and Buddhists, the activity that each one, respectively, takes part in is called ‘‘a practice?’’ A physician practices medicine; a Buddhist practices meditation. One crucial part of ‘‘a practice’’ is the challenge of advancing one’s understanding while retaining a sense of openness and uncertainty. I would posit that the best kind of growth entails the balance between these seemingly dichotomous modes of thinking and being. Through continual repetition of the building of awareness, those of us just beginning our way in medicine can protect our vocation from the risks of our own hubris as we undergo our own development from neophyte to expert. Medicine and Buddhism both require a balancing of advancement with receptivity while slowly building understanding. One errs, notes the mistake, and then, ideally, reformats methodology to avoid similar errors in the future. Accumulation of knowledge in this way over the course of a career needs to be balanced with an openness to possibility that often dissipates with the quotidian of day-to-day, accrued experience. At a certain point in any form of practice, one is faced with the dangers of narrowing: cynicism can arise as one gains knowledge and a sense that one thinks that she understands the boundaries of things. The famous teacher of Zen in the United States, Shunryo Suzuki, was quoted saying, So the most difficult thing is always to keep your beginner’s mind… Even though you read much Zen literature, you must read each sentence with a fresh mind. You should not say, ‘‘I know what Zen is,’’ or ‘‘I have attained enlightenment.’’ This is also the real secret of the arts: always be a beginner. Be very very careful about this point. If you start to practice [Zen], you will begin to appreciate your beginner’s mind. It is the secret of Zen practice. (Suzuki 1973) What Suzuki calls ‘‘beginner’s mind’’ is as useful a methodology in medicine as it is in Zen Buddhist practice. Think of the special qualities of beginners. They attend to what is

Disponibilidad de médicos y especialistas en Chile

The availability and planning of Human Resources are important issues in many countries, as it is a key factor to cope with the critical challenges of Health Care Systems. In Chile, the Ministry of Health has undertaken several studies in order to improve knowledge about the medical workforce both in public and private sectors. The aim of this paper is to update and systematize the existing data on physicians and specialists availability in Chile. Several information sources were crossed to obtain new and more precise figures about this topic. According to the Internal Revenue System, 29.996 physicians practice medicine in the country, 43% of them hired in public services, part or full time. There is a high concentration of professionals in the central regions of Chile. Being the overall density of physicians of one per 559 inhabitants, the figures in the central region is one per 471 and one per more than 800 in the South and North. Between 2004 and 2008, the public sector increased its physician workforce by more than 80% in primary health care and more than 20% in the secondary and tertiary levels. This paper presents a method for a more rigorous identification of the categories of general practitioner and specialist respectively, and the results obtained from the databases used.

Availability of physicians and specialists in Chile

The availability and planning of Human Resources are important issues in many countries, as it is a key factor to cope with the critical challenges of Health Care Systems. In Chile, the Ministry of Health has undertaken several studies in order to improve knowledge about the medical workforce both in public and private sectors. The aim of this paper is to update and systematize the existing data on physicians and specialists availability in Chile. Several information sources were crossed to obtain new and more precise figures about this topic. According to the Internal Revenue System, 29.996 physicians practice medicine in the country, 43% of them hired in public services, part or full time. There is a high concentration of professionals in the central regions of Chile. Being the overall density of physicians of one per 559 inhabitants, the figures in the central region is one per 471 and one per more than 800 in the South and North. Between 2004 and 2008, the public sector increased its physician workforce by more than 80% in primary health care and more than 20% in the secondary and tertiary levels. This paper presents a method for a more rigorous identification of the categories of general practitioner and specialist respectively, and the results obtained from the databases used.

Judge Says Prescribing Data Can't Be Marketing Fodder

Back to table of contents Previous article Next article Legal NewsFull AccessJudge Says Prescribing Data Can't Be Marketing FodderRich DalyRich DalySearch for more papers by this authorPublished Online:5 Jun 2009https://doi.org/10.1176/pn.44.11.0003A federal judge has upheld a Vermont law that bars the release of physicians' prescribing information to drug companies, which then use the information for marketing purposes.U.S. District Court Judge Garvan Murtha in April rejected a suit by“ data-mining” companies challenging the state law that bars access to prescribing records without consent of the prescribing physician.As part of the data-mining process, third-party companies purchase prescribing information from pharmacy chains and the companies that manage drug benefits for employers and then sell it to drug companies. Drug companies pair physicians' professional information obtained from the AMA's database of member and nonmember physicians with physician-specific prescribing data to tailor sales pitches to individual clinicians.In his decision in IMS v. Sorrel, Murtha also upheld the law's creation of an evidence-based education program for physician prescribers and creation of a consumer-fraud cause of action for advertisements printed, distributed, or sold in Vermont that violate federal law.The ruling was based in part on the input of the Vermont Medical Society, which said that the use of prescribing data to market to clinicians intrudes on the way physicians practice medicine and creates the “possibility that representatives could exert too much influence on prescription patterns.”Lawmakers crafting the measure cited evidence indicating that the use of prescriber profiles increased the cost of health care by fueling the marketing of only the most expensive brand-name medications.“As the court found, this evidence adequately demonstrates that prescription data privacy regulations promote substantial state interests in cutting prescription drug costs and promoting evidence-based prescribing,” said Sean Flynn of the Program on Information Justice and Intellectual Property, which filed an amicus brief in support of the state law on behalf of the Vermont Medical Society, AARP, and other patient-privacy advocates.The judge agreed with evidence that lawmakers cited in crafting the legislation indicating that data-driven marketing resulted in the prescription of newer medicines, which ran counter to evidence-based prescribing guidelines. He cited several specific examples of brand-name drugs that were widely prescribed over generic alternatives and were eventually pulled from the market after potentially lethal side effects were discovered.The impact on health care costs in Vermont resulting from marketing based on data mining was cited by state legislators who backed the measure. Bill supporters noted that drug makers had been spending an estimated $10 million annually on prescriber-focused marketing in Vermont.“This law certainly seems to return more control to physicians and gives them more awareness about what can or cannot happen to their patterns of prescribing,” said Jonathan Weker, M.D., secretary of the Vermont Psychiatric Association.Murtha's decision was based in part on his conclusion that a substantial state interest existed in restricting such commercial activity. Legislators had delayed the law's start date until July so that the courts could rule on its constitutionality.The case was consolidated with another lawsuit filed by the Pharmaceutical Research and Manufacturers of America (PhRMA), which sought to block part of the law requiring drug companies to pay a fee to support an“ evidence-based education” program for clinicians. The judge rejected PhRMA's argument that the provision unconstitutionally forced drug makers to fund a government-controlled message in which they had no input.Three of the data-mining companies that challenged the Vermont law said in a written statement that the ruling would cost patients in Vermont more money by restricting the companies' ability to access prescribing data, and the companies raised the possibility of appealing Murtha's ruling.The decision followed a federal appeals court ruling in November 2008 in the case IMS v. Ayotte, which upheld a New Hampshire law to restrict data mining (Psychiatric News, December 19, 2008). A similar Maine law, however, was overturned by a federal court in December 2007.The ruling inIMS v. Sorrellis posted at<www.prescriptionproject.org/tools/solutions_resources/files/0040.pdf>.▪ ISSUES NewArchived

“The Cure Is in Hand”? The Brave New World of Handheld Computers in Medicine

According to a 2001 market report, titled “The Cure Is in Hand,” handheld computers, or personal digital assistants (PDAs), will “dramatically change the way that physicians practice medicine.” Such enthusiasm has resulted in an extraordinarily rapid diffusion of PDAs into a wide range of clinical settings. One report states that 47% of internists use PDAs once a day with rates of daily usage reaching 70% for resident physicians. Another study found clinical usage as high as 85% in teaching hospitals. The rapidly expanding employment of PDAs, however, has been uneven. Some clinicians have explored the devices’ benefits more thoroughly than their colleagues. Similarly, a number of potentially valuable uses of the handheld computer have been ignored or remain insufficiently developed by the medical community and the health delivery system at large.

Surfing The Web: Practicing Medicine in a Technological Age: Using Smartphones in Clinical Practice

Mobile technology has the potential to revolutionize how physicians practice medicine. From having access to the latest medical research at the point of care to being able to communicate at a moment's notice with physicians and colleagues around the world, we are practicing medicine in a technological age. During recent years, many physicians have been simultaneously using a pager, cellular telephone, and personal digital assistant (PDA) to keep in communication with the hospital and to access medical information or calendar functions. Many physicians have begun replacing multiple devices with a "smartphone," which functions as a cellular telephone, pager, and PDA. The goal of this article is to provide an overview of the currently available platforms that make up the smartphone devices and the available medical software. Each platform has its unique advantages and disadvantages, and available software will vary by device and is in constant flux.

Looking Forward: The End of Autonomy

Forecasting how medicine will be practiced 50 years from now presents a challenge. While advances in technology will have a major impact, new cultural outlooks on physician professionalism and autonomy will have an even greater significance in daily practice. The current healthcare system is in crisis. As members of a profession with responsibilities to both individual patients and society, all physicians have a duty to help solve the critical issues plaguing the healthcare system today. Solutions will require some major changes in the way physicians practice medicine. The most important--and the most difficult--change will be relinquishing our long-held belief in the premise of physician autonomy. As recognized in the Institute of Medicine's (IOM) Quality Chasm report, medicine today requires "more to know, more to do, more to manage, more to watch, and more people involved than ever before." Looking forward, these complexities will only intensify. To create the high-quality healthcare system of the future, the profession must discard its view of the physician as an independent, self-governing craftsman and adopt practices that are consistent with the principles of evidence-based medicine, continuous quality improvement (CQI), and transparency.

Medical Student, Medicine Resident, and Attending Physician Knowledge of the Medicare Prescription Drug Modernization and Improvement Act of 2003

Background: The Medicare Prescription Drug Modernization and Improvement Act of 2003 (MMA) will undoubtedly influence health care delivery and affect how physicians practice medicine in the United States. Purpose: To evaluate the extent to which medical students, medicine residents, and physicians are informed about key provisions of the MMA. Methods: Eighty-four attending physicians, 104 medicine residents, and 115 fourth-year medical students at the University of Pennsylvania were surveyed over a 2-week period in February–March 2004. The brief survey instrument consisted of 10 multiple-choice questions: 9 questions assessing how well-informed respondents were about the MMA and 1 question assessing their knowledge of general current events. Results: Most respondents (77.8%) either “strongly disagreed” or “disagreed” that they were adequately informed about the MMA. While more than half of all respondents correctly answered the two questions about drug importation from Canada and general current events, a majority did not provide the correct answer to each of the other questions. No significant differences appeared by training. Conclusions: Attending physicians, medicine residents, and medical students at the University of Pennsylvania were generally ill informed about the MMA. Physician ignorance about important health care legislation continues to be a significant problem. More effective means of educating and informing medical students and physicians at all levels of training about important health policy changes may be warranted.

From Capitation To Fee-For-Service In Cincinnati: A Physician Group Responds To A Changing Marketplace

The experience of Group Health Associates, a multispecialty practice physician group in Cincinnati, Ohio, offers an important case study of how payment incentives and market realities can change the way physicians practice medicine. After nearly thirty years as a capitation-based medical group, these physicians recently switched completely to fee-for-service reimbursement-not willingly, but in response to an evolving marketplace. Their new business strategy seeks to create a case for being paid for performance and treating the chronically ill.

Personal view: passing the buck and taking a free ride – a game‐theoretical approach to evasive management strategies in gastroenterology

'Free-riding' physicians enjoy the status, prestige and income of their profession without fully contributing to its overall mission. By shifting the costs of potential medical complications and difficult patient encounters to other physicians, they reap the benefits of their profession without carrying its full weight. To describe this phenomenon in terms of decision analysis and characterize the parameters affecting its occurrence. The interaction between two physicians is modeled as a non-zero-sum game. Two strategies of either contributing to patient management or taking a free ride are available to both physicians. The four possible outcomes are arranged in a two-by-two game matrix. Physicians practice medicine because their personal benefit exceeds their cost. High cost to the physician results in a high probability of taking a free ride and copping out from potentially risky management. Increasing the benefit decreases the probability of free riding. As the number of possible encounters with other physicians increases, the probability of free riding increases and the probability for effective management by each individual physician decreases. If individual gastroenterologists felt less threatened by administrative repercussions and medico-legal consequences of untoward events, each one of them would contribute more to effective patient management.

Assessing the health of future physicians: an opportunity for preventive education.

Research shows that physicians who model prevention are more likely to encourage preventive behaviors in their patients. Therefore, understanding the health of medical students ought to provide insight into the development of health promotion programs that influence the way these future physicians practice medicine. A university-based General Clinical Research Center (GCRC) provides a venue well suited to the health assessment and education of medical students. This research explores the utility of a GCRC in a program measuring the prevalence of clinical risk factors and related health behaviors in first-year medical students. A 6-year cross-sectional study of first-year medical students measured clinical and behavioral variables associated with metabolic syndrome. Statistical testing was used to determine the prevalence of risk factors and the influence of gender in these variables. This group of medical students displayed better health indicators than did the general young adult population; however a small proportion of medical students exhibited early risk factors for chronic disease. There were significant gender differences in mean values for clinical risk factors, with males displaying higher cardiovascular risk overall. Males and females demonstrated significant differences in dietary intake and exercise programs. A GCRC can be used to provide a health assessment of medical students. Moreover, some students may benefit from health promotion programs incorporated into medical school curricula. This study provides a foundation for further research on the health of future physicians and the development of health promotion programs for this population. It also begins to explore the use of a GCRC as a teaching resource for medical students.

Physician Liability and Managed Care: A Philosophical Perspective

Despite the emergence of managed health care and the resulting dramatic change in the role of the third-party payer in the physician-patient relationship, the liability standards applied to physicians largely have remained unchanged. This has created a tension between physicians' legal and ethical obligations, and the requirements imposed on the physician by managed health care. Specifically, the issue confronts the physician in the context of malpractice liability. Managed Care Organizations impose a significant amount of control over the way physicians practice medicine, often forcing physicians to ration care. Notwithstanding any beneficial cost savings that might result, this approach subjects the physician to the risk of malpractice liability. Current malpractice law enhances this risk, because courts frequently speak of physicians having a duty to resist the pressures of managed care. This presents a significant policy problem, not just for physicians and their patients, but for society at large, as the current legal framework does not further, but in fact undermines, society's overall goal of containing health care costs. Professor Fine examines the policy problem through a philosophical lens, and maintains that the law's failure to account for the change to a managed care model and the resulting change in the way the physician practices medicine has created a situation that is fundamentally unfair to physicians. More importantly, it is argued that the continued adherence to outdated principles of liability is deficient from a utilitarian perspective, as the current framework hinders society's overall goal of lowering health care costs. Finally, Professor Fine evaluates proposed solutions to this problem, and concludes that the best approach is one that relies on the medical profession to take the initiative and institute reforms in the way medicine is practiced so that considerations of cost can be responsibly and effectively incorporated into treatment decisions. This would make the standard of care more reflective of the current state of health care, and better promote the goal of cost containment.