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Budget Cuts And Their Potential Complications For Family Medicine

Every day in the news, you hear about the United States federal budget and the potential political complications if something is done or if nothing is done. And every day in the news you hear about possible cuts in Medicare. What you don’t know is that some cuts in Medicare can significantly impact the training of future Family Physicians. What do I mean by this? Well, did you know that residency programs are paid Medicare funds (called Graduate Medical Education funds) going to hospitals? Check out this great article about how residency programs are funded.

So, let’s play this out with its potential complications for Family Medicine. If GME funds are cut as they are proposed, then many hospitals with only one residency program (usually a Family Medicine program), may be forced to close the program – thereby decreasing the number of Family Physicians being trained. In those hospitals with multispecialty programs (like large university hospitals), cuts in GME funding would force hospitals to cut their Family Medicine residency slots in favor of more specialty residency slots, which are more lucrative for hospitals. Again, this would decrease the number of Family Physicians being trained.

With GME funding being cut, there are two other disturbing possibilities that may happen. First, residency programs may need to actively seek out financial support from pharma to just keep the program open. Or, some Family Medicine residents may need to pay tuition to complete their training. If not, then those Family Medicine Programs would close as well.

Now, I’m not a part of a residency program. I’m a practicing physician in a community office and a community hospital. How will GME cuts affect me? Well, with less Family Residents being trained, recruiting efforts for our practice just got a lot more difficult – especially since the more veteran physicians will likely retire earlier with the proposed Medicare cuts for physician payment. In addition, with the lack of Family Physician workforce, practices like mine may be forced to look toward midlevel providers to pick up the slack. Now, don’t get me wrong, there is nothing wrong with midlevel providers. It’s just that it would be nice to be able to choose between a Family Physician and a midlevel provider when the time is right for our practice.

What can be done? Great question. The first step is to educate our Family Physician friends and colleagues of this potential tragic situation. I admit that I didn’t know much about this until some good friends alerted me of the situation. The next step is to contact Congress to let your federal legislator know about our concern and our need to #SaveGME. You may have noticed on twitter the hashtag #SaveGME. This is our way to raise awareness about this legislative issue and the future of Family Medicine. I encourage you not only to spread the word, but also to contact Congress via the AAFP Speak Out website. This is the easiest way to locate and to contact your specific legislator. Another way is to use this link for the House and to use this link for the Senate.

Here are the key points that we need to convey to the legislators about #SaveGME:

  1. There needs to be an “unlinking” of GME funding from hospitals. GME funds need to go to the primary care residency program directly
  2. GME funding for Family Medicine and other primary care training only
  3. Do not fund (already profitable) procedural specialty residency programs

Finally, I would like to tip my hat to my Family Physician colleagues who have written blog posts on this issue. Please drop by the blogs below and leave a comment. We’re also having our friends on twitter help spread the word about #SaveGME. Feel free to join us with your tweets and retweets. In addition, Dr. Pat Jonas will be talking about this issue on his podcast on Tuesday night. And, there may be a twitter chat from #FamMedChat that could be taking place on Thursday night as well. We’re trying to spread the word on this issue throughout the social media universe. Please help us do that! The future of Family Medicine could be at stake here. Let Your Voice Be Heard and Make A Difference Today!

Kevin Bernstein from the Future of Family Medicine Blog: GME Funding For Family Medicine Residencies Must Be Preserved Now!

Mark Ryan from the Live In Underserved Medicine Blog: Another Reason To Preserve Medicare Funding: We Need More Doctors

Ben Miller from the Collaborative Care Blog: His #SaveGME Post

Pat Jonas from the Dr Synonymous Blog: Family Physician Training – Save GME Funding For Primary Care

Jennifer Middleton from the Singing Pen of Doctor Jen Blog: Why Does GME Matter?

*This blog post was originally published at Family Medicine Rocks Blog - Mike Sevilla, MD*

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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