The recent wars in Iraq and Afghanistan have produced a large increase in shrapnel injuries among our soldiers overseas.  However, the military is working to combat this trend by training its physicians in a breakthrough surgical technique created by an Ohio radiologist.

Dr. William E. Shiels II of Nationwide Children’s Hospital in Columbus, OH is the creator of a surgical technique known as ultrasound guided foreign body removal, or USFBR. While traditional methods of x-ray imaging are effective in locating metallic shrapnel, it is less adept at identifying wood, plastic, gravel, and other nontraditional materials commonly found in Improvised Explosive Devices (I.E.D.s). USFBR has thus far proven extremely effective in locating both metallic and non-metallic embedded objects. More accurate screening procedures ultimately lead to safer and more effective surgery.

So far, military doctors have relied exclusively on traditional x-ray techniques to identify embedded objects. Because these techniques are less accurate and often do not pick up non-metallic objects, more invasive, open surgery is often required for their removal. Using USFBR, surgeons can easily and accurately locate fragments, leading to less invasive surgery. According to its creators, USFBR “guides minimally invasive removal, often only requiring a .25 inch incision with little or no scarring or cosmetic deformity.”¹

William Shiels, DO is the chief of Nationwide Children’s Department of Radiology, as well as president of Children’s Radiological Institute, Inc. Dr. Shiels initially developed the technique at Nationwide Children’s Hospital, where he and his team of interventional radiologists continued to make improvements. To date, Dr. Shiels and his team have successfully utilized USFBR to remove foreign objects from over 800 patients.

Dr. Shiels and his team are now in the midst of adapting the procedure for use by the military. Along with his team of civilian and military radiologists, Dr. Shiels is currently engaged in training 48 military physicians at four military treatment facilities across the United States. This training initiative is funded in part by a $1 million research grant awarded through the U.S. Army Medical Research and Material Command.

Both the military and Dr. Shiels are optimistic about the potential for USFBR in treating wounded soldiers. Dr. Shiels espoused gratification at the opportunity to provide care for wounded service members, stating: “our hope is that USFBR will become part of the standard of care for war-related foreign body removal.”¹

SOURCES:

1. http://www.newswise.com/articles/nationwide-children-s-hospital-radiologists-train-military-physicians-in-foreign-body-removal-techniques

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The time demands and number of pediatrician positions that are open create a need for more efficient clinical tools to make the best use of their time.  Among several promising paths to efficiency is a program called Clinical Answers. 

Still in development, it is described as a “…synthesized evidence-based summary that supports point-of-care clinical decision-making.”  A survey of eighty-three pediatricians showed results stating that 93% found the program useful or very useful and that it “allowed them to quickly locate critical information (82%).” (1)

A driving factor in the need for efficient pediatrician time management is the pressing demand for pediatricians, nationwide and around the world.  According to the Bureau of Labor Statistics projections in 2010, the need for pediatricians should increase by more than 20% over the next 10 years.  This translates to a need of greater than 30,000 pediatrician jobs, annually.

The need for pediatricians lies in industries that normally employ pediatricians:  hospital and social assistances agencies, followed by private practice. (2)

Such is the need for aid for pediatric oncologists, that computer giant Dell, is donating what is known as computing cloud.  This cloud will “…provide needed computing power to help TGen’s gene sequencing and analysis capacity by 1200 percent….”

According to Dell’s maddaloni president of Dell Public and Large Enterprise, Paul Bell, the “new cloud will help pediatric oncologists develop new ways to eliminate the trial and error in the treatment for pediatric cancer….” (3)

By far, the biggest step forward in assisting the job of pediatricians is the advent of mobile computing devices such as Apple’s iPhone and iPad.  According to Dr. Andrew J. Schuman, practicing pediatrician, the “apps” for use by pediatricians are useful not only for pediatricians, but for pediatricians to recommend to the parents of their patients, who also need informational and technological help in caring for the health of their children.

Pediatricians can call up and hand parents their device to fill out surveys to screen for developmental, emotional, or attention disorders.

Apps for pediatricians cover the subjects of pharmacology, dermatology, pediatric emergency medicine, hospital rounding, news, specifically for pediatricians from sources such as Medscape and the American Association for Pediatrics (AAP).(4)

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The high availability of Family Practice positions is an indication of the looming shortage in the US.  The American Academy of Family Physicians (AAFP) estimates the 139,531 family practice physicians will be needed by 2020 (7). The AAFP’s projection was based on the number of Family Practice Physicians in the workforce and the total number of completed residencies in “allopathic and osteopathic schools” (1).

This number represents roughly 42 family practice physicians per 100,000 people in the United States (7). The AAFP estimates that, in order to reach this ratio, family practice physician residency programs would need to expand by approximately 822 residents per year(7).

The predictions made by the AAFP did, however, have noted difficulties. It was noted that predications based upon historical data may not be foretelling. The main reasoning behind this is unexpected advances in medical technology and factors which might influence physician specialty choice.

The Health Resources and Services Administration (HRSA) noted that any models of future supply and demand, especially in the field of family practice physicians, would incorporate problems that are present in the current health care system.

Sufficient research has concluded that “the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient” (1). On the other hand, it has been concluded that care stability, preventive care, and care coordination, can all accomplish savings and positive health care outcomes.

In contrast, family practice physicians are not able to increase their arsenal of services without sacrificing patient-time, thus decreasing quality. The price of conventional medical services also puts family practice physicians at a disadvantage.

In Boston, Massachusetts, Medicare’s fee for a 25 to 30-minute office visit for an established patient with a complex medical condition is $103.42 (6), in contrast, Medicare’s fee for a diagnostic colonoscopy—a procedural code which accounts for the same period of time—is $449.44 (6).

Numerous findings continue to bring up questions regarding the discretion of a health care system which thinks too little of primary care services. For example,

“Patients of primary care physicians are more likely to receive preventive services, to receive better management of chronic illness than other patients, and to be satisfied with their care” (2).

“States with more primary care physicians per capita have better health outcomes—as measured by total and disease-specific mortality rates and life expectancy—than states with fewer primary care physicians” (3).

“States with a higher generalist-to-population ratio have lower per-beneficiary Medicare expenditures and higher scores on 24 common performance measures than states with fewer generalist physicians and more specialists per capita” (4).

“The hospitalization rates for diagnoses that could be addressed in ambulatory care settings are higher in geographic areas where access to primary care physicians is more limited” (5).

Sources

1. http://www.gao.gov/new.items/d08472t.pdf
2. 25A.B Bindman et al., “Primary Care and Receipt of Preventive Services,” Journal of General Internal Medicine vol. 11, no. 5 (1996); D.G. Safran et al., “Linking Primary Care Performance to Outcomes of Care,” Journal of Family Practice, vol. 47, no. 3 (1998); and A.C. Beal et al., “Closing the Divide: How Medical Homes Promote Equity in Health Care: Results From The Commonwealth Fund 2006 Health Care Quality Survey” (The Commonwealth Fund, June 2007).
3. B. Starfield et al., “Contribution of Primary Care to Health Systems and Health,” Milbank Quarterly, vol. 83, no. 3 (2005).
4. K. Baicker and A. Chandra, “Medicare Spending, the Physician Workforce, and Beneficiaries’ Quality of Care,” Health Affairs web exclusive (2004).
5. M. Parchman et al, “Primary Care Physicians and Avoidable Hospitalizations,” Journal of Family Practice, vol. 39, no. 2 (1994).
6. The fee for this service in Boston, Mass., is represented on the fee schedule as CPT code 45378.
7. http://www.aafp.org/online/en/home/policy/policies/w/workforce.html

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As of 2009, there are over 40,000 active Psychiatrists and over 400,000 clinically trained mental health professionals.  With the lack of Psychiatrists, especially in the Midwest, the population is looking to Counselors, Psychologists, and other mental health professionals to fulfill their psychiatric needs.³

New England, Hawaii, and California are ranked highest in individuals per Physician, indicating there is a more pressing need of Psychiatry jobs in the states between the East and West Coasts.  Psychiatrists in Massachusetts have an average of 3,440 individuals to cover, being the top ranking state.

The drastic difference between New England and the Midwest causes concern for the lack of Psychiatrists in the area.  Idaho ranks last with 18,851 individuals per Psychiatrist, followed by Indiana, Mississippi, Nevada, and Iowa, in ascending order.¹

The number of Psychiatrists has increased by 26% over the past 20 years, but about half of the Psychiatry workforce is of retiring age, making Psychiatry the second-oldest specialty workforce. But this is not of immediate concern due to less stress of the practice and less demand of on-call responsibilities.

Potential Psychiatrist job seekers are looking for Psychiatry job opportunities to provide flexible scheduling and part-time work to create a balanced lifestyle.  Much of what is creating a growth in Psychiatry residency positions are the part-time opportunities that provide comfortable pay. Industry changes are evident in residency positions.

Women now outnumber men in residency training programs; however, international medical graduates have decreased in number. Typically, the international graduates are more likely to treat Medicaid and minority patients, which is an increasingly important concern.  The field does remain stagnant in ethnic and racial minorities, remaining significantly white.³ It should be noted, though, that there is an increase in Asian/Pacific Islander Psychiatrists in California.²

The most significant changes in the workforce, therefore, are in the aging of the workforce, the next generation’s desired lifestyle, the feminization of the field, the growth in residency positions, and the decrease in multicultural Psychiatrist graduates, especially with an aging population under government funded medical assistance.

Sources

1. “Individuals per One Patient Care Physician, Ranking by State and Specialty, 2009.” Iowa Medical Society. 1 February 2011. Retrieved 1 March 2012 from http://www.iowamedical.org/documents/physicianworkforce/2009PhysicianPopulationStateRankingsforSelectedSpecialties.pdf.
2. Lok, Vincent and Susan Chapman. “The Mental Health Workforce in California: Trends in Employment, Education, and Diversity.” Center for the Health Professions, University of California, San Francisco. March 2009. Retrieved 1 March 2012 from http://www.cimh.org/LinkClick.aspx?fileticket=X8qO1WB7zo8%3D&tabid=795
3. Vernon, David J., Edward Salsberg, Clese Erikson, and Darrell G. Kirch. “Planning the Future Mental Health Workforce: With Progress on Coverage, What Role Will Psychiatrists Play?” Academic Psychiatry, Volume 33, Issue 3: 187-192. Retrieved 1 March 2012 from http://ap.psychiatryonline.org/article.aspx?Volume=33&page=187&journalID=17

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Years of education, medical school, and medical residency do not necessarily prepare internal medical physicians for an interview for a highly desired job.  Getting rest, presenting a professional appearance, and organized preparation will assist the successful internal medicine physician, to obtain the job that he or she wants.  That preparation includes researching the targeted practice, anticipating possible interview questions and preparing well thought out answers.

According to Dr. Patrick C. Algire, of the American College of Physicians (ACP), in the online article “Tips for the First Interview”, how the interviewer perceives your professional appearance is a key to gaining that position.  Dr. Algire lists common sense tips to the internal medicine physician candidate that might be taken for granted, but are still necessary.  To make the best impression on an interviewer, do not bring a backpack, avoid too much fragrance or after shave, and wear a clean, pressed suit, and polished shoes.

There are typical interview questions to anticipate, like:  “What are your weaknesses, and how do you overcome them?” “How do you standout from your peers? “Tell me one thing at which you are best?” ”Why did you choose to train in internal medicine?” “What are your strengths? “How do you handle conflict?” Dr. Algire suggests that answers should be sincere and insightful rather than safe, and to avoid trying to guess what the interviewer might agree with.

During the interview, asking poignant insightful questions will not only reveal more about the practice and the job itself, but will reveal a candidate’s excitement and interest in the practice, and the position.  Prepare these questions in advance and bring the list to the interview.

Dr. Algire suggests, “You may wish to gather information about practice philosophy, a typical working day, anticipated responsibilities, medical student and resident teaching, and opportunities for practice growth. You may wish to learn about your expected role in the practice…”  The interview can provide a candidate with key information about the opportunity and the practice.  Information about the practice and the people that work there can make it easier to make a decision if an offer is made.

An interviewee should try to remain focused.  Be respectful and pay attention to the interviewer.  Even though questions and answers may have been anticipated and planned for, listen to the exact wording of the question and answer it as it was phrased.  Avoid discussing salary unless the interviewer brings up the subject.  This is something that can be discussed in subsequent interviews.

For interviews taking place in a new area, it is okay to ask about “housing costs, school systems, cultural activities, and entertainment.”  A short tour might be informative.  Dr. Algire suggests asking to include a spouse when and if a second interview occurs.

Sources

1. Patrick C. Alguire, MD, FACP http://www.acponline.org/residents_fellows/career_counseling/tips.htm
2. http://exams.emedicinelive.net/index.php/usmle/2-residency-interview/52-residency-interviews–real-interview-questions-with-answers

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On almost any given day, Emergency Room (ER) Physicians typically face overcrowding in their waiting rooms. In the early 1990s a decrease in the amount of ER use could be seen. That decline was attributed to the greater enrollment of patients into managed care plans.  Several factors have reversed this trend so that many emergency departments are filled to capacity, increasing the demand for Emergency Medicine Physicians.

The reliance on Primary Care Physicians has decreased.  According to the 1999 National Hospital Ambulatory Medical Care Survey (NHAMCS), a fourteen percent increase has occurred in the amount of ER utilization from the years of 1992 to 1994. This marks a rise from 89.8 million visits to 102.8 million, roughly “38 visits per 100 persons”.

The Center for Studying Health System Change cited three main reasons for increased patient demand in the ER:

1. Less restrictive management practices by managed care organizations (MCOs)
2. Stricter enforcement of the federal Emergency Medical Treatment and Labor Act (EMTALA)
3. Increasing ED use among patients without insurance.

A large percentage of Emergency Room visits are not for true emergencies. Many patients tend to seek care from an ER for symptoms which could have easily been treated in a primary care location. In one study, nurses cataloged 37% of all Emergency Rooms as patients having a non-urgent condition (4). A similar study classified 75% of patients who walked into the Emergency Room as having a non-urgent or treatable condition in a primary care setting (1).

To reduce the number of Emergency Room visits a number of steps are being taken. Specific actions aimed at managing ER use include the following:

•  Access to office appointments – Currently, many primary care practices make it nearly impossible for a patient to receive same day assistance. In order to combat this, many primary care setting are changing their scheduling protocols. Humana has started encouraging primary care providers to provide same-day assistance.
• Triage and telephone services – Many Primary Care Providers have started offering 24/7 phone consultation with medical personnel.
• Patient education – Health care plans have started distributing educational materials to primary care settings in order that patients are instructed in management of diseases.

Demand management strategies can be effective in reducing non-urgent ER visits. “Health plans, delivery systems, and physician practices can employ these strategies to meet the needs of their patient populations”.

Sources:

1. Billings J, Parikh N, Mijanovich T. The Commonwealth Fund, November 2000. Emergency Department Use in New York City: A Substitute for Primary Care? #433. Emergency room Use: The New York Story. #434. (3) Emergency Department Use in New York City: A Survey of Bronx Patients. #435 (4)Summary:Briefing Note: Effective Clinical Practices in Managed Care. November 2000. http://www.cmwf.org/programs/newyork/billings_e mergency_bn_433.asp
2. Brewster L, Rudell L, Lesser C .Emergency Room Diversions: A Symptom of Hospitals Under Stress. Center for Studying Health System Change. Issue Brief No. 38. May 2001.http://www.hschange.org/CONTENT/312/• Coleman E, et al. Reducing emergency visits in older adults with chronic illness: a randomized, controlled trial of group visits. Effective Clinical Practice. March/April 2001;4(2):49-57.http://ecp.acponline.org
3. Grossman LK, Rich LN, Johnson C. Decreasing non-urgent emergency department utilization by Medicaid children. Pediatrics. July 1998;102(1 Pt1):20-4.
4. Young GP, Wagner MB, Kellermann AL, Ellis J, Bouley D. Ambulatory visits to hospital emergency departments: Patterns and reasons for use. JAMA. Aug. 14, 1996;276(6):460-5.

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According to James I. Ausman, M.D., Ph.D., and Ronald P. Pawl, M.D., biological advances and technological innovations will change neurosurgical practices.  Targeted molecular therapies are leading to better therapies in cancer and other treatments.  Technological advances in neuroimaging will lead to better visualization and aid computer assisted surgery, improving neurosurgical outcomes.

Combining all of the recent advances and vast amounts of supplemental education needed for neurosurgeons will create super-specializations and the need for careful collaboration with other medical specializations, sciences, and professions.

Neurosurgeons will need to perform research into areas such as cell implantation, “genetic, behavioral, and immunological phenomena involved to achieve success as did transplant surgeons 25 years ago…” according to Dr. Ausman and Dr. Pawl.  Otherwise, physicians in more cutting edge specialties will lead the way.

James I. Ausman, M.D., Ph.D., and Ronald P. Pawl, M.D., Department of Neurosurgery, University of Illinois at Chicago, Illinois

http://www.medscape.com/viewarticle/433294_2

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The government reform encourages hospitals and physicians to unify through “accountable care organizations” in order to gain additional compensation for better patient care (“Number of Physicians Employed by Hospitalists Snowballing,” Medscape Medical News). An additional incentive the new healthcare policy offers for physician and hospital alliance comes in the form of bundled payments, which may be distributed to both parties for inpatient care.

According to Medscape, “The rise in hospital-employed physicians parallels an increase in the percentage of institutions that use hospitalists, which was at almost 60% in 2010 compared with half that in 2003, according to the just-published 2012 edition of AHA Hospital Statistics.” The American Hospital Association additionally reports that 37.9% of hospitalists working in hospitals were employees in 2010. This is true both of the east coast as well as the west coast.

While healthcare reform is providing extensive opportunities for hospitalist employment, the need for significant cuts in Medicare has resulted in the broad and virtually unrestricted authority of the Independent Payment Advisory Board (IPAB) to restrict provider spending, reports The Hospitalist in an article posted this month. The article explains that IPAB was created under the Affordable Care Act (ACA) in an effort to ensure Medicare provider spending does not exceed the pre-determined caps, a goal Congress has been unable to meet thus far.

Any proposal submitted by IPAB will immediately become law, a huge distinction from the Medicare Payment Advisory Commission (MedPAC), which traditionally counsels Congress on Medicare payments but has minimal to no authority to enforce their suggestions. The only possible checks on IPAB’s considerable autonomy are either Congress drafts an alternative proposal that results in equal cuts in spending, or Congress marshals a three-fifths majority to rule out the proposal. The executive and judiciary branches have no control over IPAB whatsoever; however, members of the board are selected by the President and then must be approved by the Senate.

The Hospitalist article goes on to address the board’s potential effect on the hospitalist profession as a whole and asks the opinion of Judith Feder, a supporter of IPAB and former dean of Georgetown Public Policy Institute. According to Feder, hospitalists will most likely be less affected than other providers, “because the Board’s cost-reduction proposals would likely focus on services where overpayment is the most acute – like imaging and high-cost specialty procedures,” (“IPAB is Medicare’s New Hammer for Spending Accountability,” The Hospitalist). Nevertheless, healthcare specialties have legitimate cause for anxiety when the board assembles this year with $15 million in funding from ACA to start.

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Additionally, we also provide physician services not only in direct support of client facilities and departments, but also in the form of freestanding networks, available to serve the healthcare needs of clients and client beneficiaries.

Sterling Medical fulfills the demands of any healthcare service throughout the U.S. or around the world with high quality and efficiency.

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