What my children will never see? Things disappearing from the doctor's office

On a recent trip to Austin I flipped through the worn copy of Spirit magazine in the seat back of a Southwest Airlines 737 and saw this nice article about babies -- and specifically what they see and understand very early in life.

I love my two young kids, and although they both aren't as young as they used to be (neither am I), I love to share with them new experiences, sights, and the general joys of life.

I think all parents must feel the same way.  There is just something about seeing the the glint of newness and understanding in the small eyes of a child.  

But today I began to wonder about things our children will never see, particularly related to health care. We have on our own list from when we were growing up, but it's certainly different now.

From polio, mumps, and small pox:  thankfully they are all distant memories.  As a dermatologist I do get to see some of the unusual but still rather rare diseases (measles, for instant) that I heard about in my childhood.

But children today will miss out on many things that are common place in our day to day lives.

Here's my list (feel free to add or subtract in the comment box below):

1) Marcus Welby:  hometown physicians in private practice that take care of families for decades will be a thing of the past.  I've written about my good friend John Keller, MD, a family physician in the small rural town of Fairfield,  Texas before here.  Practicing for over 50 years in one place, he will probably be the last "Marcus Welby" doctor that I know.  And my children will never see that.  Only on re-runs. 

2) Chicken Pox:  childhood vaccination makes this common disorder now very rare.  And, if we're lucky, shingles or herpes zoster will also be a painful encounter our kids will not have to endure.

3) Rectal thermometers:  I'm sure someone will comment that these are still around.  The last time my kids were sick it seemed like someone just shot their head with a laser thermometer -- nurses don't even have to touch the patient any more.  Novel idea.

4) White hats:  speaking of nurses -- what about those white hats?  I mention them occasionally and finally someone in my office told me that she wasn't sure it was politically correct to talk about them anymore.  I'm not sure I understand that, but I've changed my workplace banter after their expressed concern.

5) Prescription pads:  Ok, I know this is maybe a tad progressive.  But in our  paperless office we don't write prescriptions by hand any more.  We send everything electronically using an e-prescribing application.  And, frankly, everyone loves it including my staff, patients, and finally me. I know there are some slow adopters out there, but Medicare and other insurance carriers will drive that train.  Paper prescription pads? They'll be gone.

6) Drug company pens:  Yes, the pharmaceutical company give aways (not just pens: but dummy plastic models of the skin, Post It notes, stethoscope labels, you name it) are all gone.  No longer will kids see a Viagra pen or a Lipitor flashlight.  New pharma rules prohibit these types of "inducements" because some bureaucrat thinks that supplying a pen will induce the doctor to use that pen to write an expensive prescription.  Personally, I think this is stupid.  Maybe doctors shouldn't be taken on golf junkets or expensive dinners...but a pen.  Really.

7) Ties:  Though not mainstream, health care workers are quickly adopting the casual Friday look in the medical office and the hospital room.  Why?  Well those ties were shown to carry germs.  So scrubs and casual shirts are now considered appropriate dress code for health care workers.  

8) The Co-Pay:  Well, it's not gone yet, but more and more insurance products are "high deductible" health plans.  It used to be that patients could pay $20 and get all the health care they could milk out of a 15 minute visit.  Those days are disappearing as the most popular insurance product sold in our home state last year was one with a $3000 deductible.  Patients and physicians are now more cautious in their health care decisions.  That's a good thing.  The bad news is that every care component falls directly to the bottom line.  

Feel free to add or subtract from this list.  Hopefully there will be exciting improvements in our health care delivery system, new drugs to treat disease, and exciting technologies to cure our ailments that replace the items on the list.  

We can always hope.

- Posted using BlogPress from my iPad

Peanut Allergy and Airplanes

DocDano.com explores the actions today by the Department of Transportation which will continue to allow peanuts to be served on airplanes. This follows concerns that peanuts may pose a significant risk to passengers that have a peanut allergy.
What should you do now if you have a peanut allergy and don't want to be caught at 30,000 feet in an emergency situation? This podcast provides you the answer.

The Blurry Line: When non-physicians practice medicine

It used to be that there were well defined roles.

Pharmacists dispensed medications on the order of a physician.

Nurses carried out care and healing as ordered by a physician.

Physical therapists helped patients heal their bodies on the order of a physician.

Physicians practiced medicine.

But that's all changing.  There is a hurrying pace to expand the scope of practice of non-physician providers to include elements of medical practice. The purported reason is the lack of availability of primary care physicians and access to care.

But, honestly, like almost all things in America, it's really not that altruistic.  It's about money of course.

And since it's about money, I've always been curious about the public's willingness to pay for information, time, or care from a non-physician provider at the same rate as if they were paying for a physician.

And when the stakes are high, like with your own health care, it looks like most people would only want the "best."

Now before I start getting hate mail or malicious tweets from the host of non-physician providers out there, I'm sure there are some in that group that practice good nursing, pharmacy, physical therapy, etc.  That's not what this is about.  I'm talking about medicine.

I'm sure if the airlines decide that airplanes have become sophisticated enough that flight attendants can be cross trained first as copilots and eventually as pilots, then the issue will become clear.

Someone once told me that to get hired by Southwest Airlines as a copilot in a 737 that it required 2000 hours in type and experience as pilot-in-command.  This is a hefty requirement but probably why the airline has one of the best records in the industry.

Now if you were to train a flight attendant with a fraction of that time, let's say 200 hours, would you feel as comfortable in seat 6B?  Even if your flight was on-time, everyone was friendly, and you had peanuts and a drink coupon?

But the analogy fits very well with medicine.

Let's take nursing:  its become somewhat politically incorrect to consider nursing any longer as a support role in health care.  There has been considerable growth in the industry in the role of becoming primary care givers.

Many states leave the determination of the scope of practice to the state nurse licensing boards which gives them broad latitude in defining what nurses can and can't do.

Much of this depends on the definition of the "practice of medicine" which has always been understood as the "diagnosis and treatment" of disease.

So nursing boards have morphed a term now to include the title: nurse practitioner, or NP.  These "advanced practice nurses" usually have expanded training, mostly from other advanced practice nurses  and some physicians, in the area of diagnosing and treating basic ailments.

Supposedly.

I say supposedly because there are very few if any statutory limits on these advanced practice nurses.

Think for a minute that it might be one thing for a flight attendant to fire up the plane and taxi out to the runway, but it would be quite another to take off into the fog and rain of a messy evening.

So these APN's go into practice and begin to practice surrogate medicine.

The confusion abounds with patients who don't always know the difference from one provider to the next.  They just know their little girl has an ear infection and needs an antibiotic.

These lines even get blurrier when programs begin to offer "Ph. D." course work in nursing which then entitles the person to be referred to as "Dr. APN." Patients become confused:  just who is a "doctor" any more?

Now most of these non-physician providers are supposed to be either supervised by a physician or they are to practice under specific guidelines drafted and overseen by a physician.

But it is clearly not the same as having a physician see the patient or being immediately available for consultation.

(Think for a minute:  that flight attendant could always radio in for help....if they were to get into trouble...)

Many physicians like using non-physician providers of care because it increases through-put and therefore revenue for the practice.  These environments often deliver superb care in a team environment managing complicated patients.

Physician's assistants are one of the best examples of how the system can work well.  Usually these mid-level providers train directly with physicians, are regularly supervised, and have academic backgrounds that ground them in the basic science of medicine.

This type of preparation and apprenticeship is often lacking in other non-physician provider training programs.

But when advanced practice nurses want to open up a clinic and begin to practice primary care medicine, you really have to wonder if this is a good idea.

It's a slippery slope where most of the time no one gets hurt.

Pharmacists in many states can now give vaccinations and maybe even adjust the dose of someone's insulin to treat their diabetes.

Physical therapists may be able to diagnose a knee strain and begin corrective exercises and rehab.

Advanced practice nurses may be able to diagnose a sore throat in a 3 year old and start antibiotics.

So where does the slope end?  Despite the fact that medicine is becoming even more technical, the number of drugs is expanding at an unbelievable rate, and patients are generally sicker now than in the past (particularly with the economy challenging access to preventative health care services), there is a growing feeling that we need more non-physicians delivering health care.

And because of the purported need for access to primary care, legislatures are changing the statutes and regulations to expand the scope of practice of these non-physicians.

Physicians in the United States on average have completed a four year basic science undergraduate curriculum, four years of medical school, and typically 4 to 5 years of post graduate training in an internship and residency.

Most advanced nurse practitioners complete about 5 to 6 years of training total -- at least of three of which is spent solely in nursing.

So can a legislature obviate the need for medical school just by changing the law?  Of course not, but that is what is happening in many states around the country:  nurses, and other non-physician providers, are seeking independent practice.

This independent practice would remove even cursory physician supervision of their treatment of patients.

If lowering the standards was all that was necessary,  then one solution for the crisis in primary care access would be to shorten the requirements for physicians going to medical school.  I know, that's absurd.

With the technological advances in medicine and particularly surgical procedures and medication treatment -- the course of study cannot be condensed.

But to complete the tale of a story gone wrong, many advanced nurse practitioners never practice primary care. Instead they take up the practice of aesthetic medicine such as treating patients with cosmetic drugs like Botox or lip fillers.

To be fair, all of these non-physician providers in the proper setting offer advantages in our current health care crisis.  Working in a team under the supervision of a physician, health care delivery can be enhanced, access can be improved, and patients can get better service.

There is no better example than that of physician assistants.  This relatively new type of non-physician provider is probably the model that needs to be followed in expanding the scope of practice for medical providers.

Physician assistants usually complete a six year curriculum and even then there is typically a post graduate practicum or   on-the-job training program directly with a physician.  These professionals work hand in hand with physicians in caring for patients, have privileges to write prescriptions and perform some surgical procedures, and can help the physician in coordination of care for the patient.

In most states they are even supervised by the physician licensing board.

But as a rule, they don't have independent practice.  It is the perfect model to expand access of quality care.

Now, I'm usually a self-described progressive, and I'm always open to new ways to educate and treat patients.  But the last thing I want to do is to put patients in harm's way.

We shouldn't allow the access argument to blur the lines of right and wrong so much that we allow the training of our health care providers to be diminished.

If you want to practice in a support role working hand in hand with a physician to provide quality care, I'm all for it, and will work and lobby to make it happen.

If you want to practice medicine independently, then go to medical school.