Medicos—Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia. Wm. MacMillan Rodney MD, FAAFP, FACEP Professor and Chair, Medicos para la Familia Memphis, Nashville, and International Editor, American Journal of Clinical Medicine - PowerPoint PPT Presentation
Medicos—Eliminating Barriers to Medicos—Eliminating Barriers to Family Planning: Hysteroscopic Tubal Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia Occlusion without Anesthesia Wm. MacMillan Rodney MD, FAAFP, FACEP Wm. MacMillan Rodney MD, FAAFP, FACEP Professor and Chair, Medicos para la Familia Professor and Chair, Medicos para la Familia Memphis, Nashville, and International Memphis, Nashville, and International Editor, American Journal of Clinical Medicine Editor, American Journal of Clinical Medicine American Board of Family Medicine Obstetrics American Board of Family Medicine Obstetrics WONCA 2010; Cancun, Mexico; Presenting WONCA 2010; Cancun, Mexico; Presenting The Family Medicine Obstetrics Curriculum and The Family Medicine Obstetrics Curriculum and Data Data Medicos: A New Training Model Successfully Medicos: A New Training Model Successfully Expanding Health Care Services at a Lower Cost. Expanding Health Care Services at a Lower Cost. Eliminating Barriers to Family Planning: Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia Hysteroscopic Tubal Occlusion without Anesthesia
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Medicos—Eliminating Barriers to Family Medicos—Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion Planning: Hysteroscopic Tubal Occlusion
without Anesthesiawithout Anesthesia
Wm. MacMillan Rodney MD, FAAFP, FACEPWm. MacMillan Rodney MD, FAAFP, FACEPProfessor and Chair, Medicos para la FamiliaProfessor and Chair, Medicos para la Familia
Memphis, Nashville, and InternationalMemphis, Nashville, and International
Editor, American Journal of Clinical MedicineEditor, American Journal of Clinical Medicine
American Board of Family Medicine ObstetricsAmerican Board of Family Medicine Obstetrics
WONCA 2010; Cancun, Mexico; PresentingWONCA 2010; Cancun, Mexico; Presenting The Family Medicine Obstetrics Curriculum and DataThe Family Medicine Obstetrics Curriculum and Data
Medicos: A New Training Model Successfully Medicos: A New Training Model Successfully Expanding Health Care Services at a Lower Cost.Expanding Health Care Services at a Lower Cost.
Eliminating Barriers to Family Planning: Hysteroscopic Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without AnesthesiaTubal Occlusion without Anesthesia
Transfer of Technology Transfer of Technology ProjectsProjects
A Mission Hospital Simulation in Tennessee-A Mission Hospital Simulation in Tennessee-MedicosMedicos
Minor Surgery, Urgent Care, and some ER Minor Surgery, Urgent Care, and some ER skills were reengineered for the FP officeskills were reengineered for the FP office
Diagnostic services: ECG, Xrays, ultrasound, Diagnostic services: ECG, Xrays, ultrasound, and lab tests reengineered for the FP officeand lab tests reengineered for the FP office
Cancer Prevention and Early Diagnosis--LabCancer Prevention and Early Diagnosis--LabColposcopy 1984, Electrosurgery and cryosurgery came Colposcopy 1984, Electrosurgery and cryosurgery came with this procedure. Hysteroscopy 1995, 2009with this procedure. Hysteroscopy 1995, 2009
Family Medicine Obstetrics with immediate Family Medicine Obstetrics with immediate access OB-Gyn Ultrasound 1999.access OB-Gyn Ultrasound 1999.
Medicos para la Familia Medicos para la Familia ProjectProject
Was established as a training center in 1999. By Was established as a training center in 1999. By this time University-based Family Medicine had not this time University-based Family Medicine had not maintained its heritage in comprehensive care, and maintained its heritage in comprehensive care, and was an unlikely career choice for medical students was an unlikely career choice for medical students here and abroad.here and abroad.Medicos utilized data from the Transfer of Medicos utilized data from the Transfer of Technology Project 1979-present. See website for Technology Project 1979-present. See website for “Procedural Skills and Office Technology” “Procedural Skills and Office Technology” www.psot.comwww.psot.comRetained hospital privileges for physicians with an Retained hospital privileges for physicians with an emphasis on prenatal care and delivery of babies.emphasis on prenatal care and delivery of babies.Medicos provides data on health care services apart Medicos provides data on health care services apart form the selection bias of university hospitals. form the selection bias of university hospitals. Medicos is built upon family medicine to create Medicos is built upon family medicine to create training more consistent with community needs.training more consistent with community needs.Became self sustaining through reimbursable Became self sustaining through reimbursable services without charitable support. services without charitable support.
Tubal Occlusion Without Tubal Occlusion Without AnesthesiaAnesthesia
Microinserts $700 eachMicroinserts $700 eachRequires 6 week preop with Requires 6 week preop with DepoProvera 150 mg IM DepoProvera 150 mg IM
Medicos--iphone photos Medicos--iphone photos intraoperative for recordintraoperative for record
The protocol for The protocol for Hysteroscopic Sterilization Hysteroscopic Sterilization
by Essureby EssureRemember your heritage as a family Remember your heritage as a family physician.physician.
Hysteroscopic sterilization requires multiple visits Hysteroscopic sterilization requires multiple visits following the sequence of counseling, consent, following the sequence of counseling, consent, DepoProvera, Essure, DepoProvera, HSG, and the DepoProvera, Essure, DepoProvera, HSG, and the possible need for additional procedures.possible need for additional procedures.
Psychosocial barriers may preclude the operation. Psychosocial barriers may preclude the operation. The process of informed consent is complex in the The process of informed consent is complex in the USA.USA.
Mental illness and mental disabilities are more Mental illness and mental disabilities are more common than we thought in Tennessee. Even if they common than we thought in Tennessee. Even if they signed a paper, be prepared ……….signed a paper, be prepared ……….
Be aware of costs to the patient, and plan Be aware of costs to the patient, and plan for followup. for followup.
Hysterosalpingogram[HSG] Hysterosalpingogram[HSG] for Conclusive Proof in USAfor Conclusive Proof in USA
Schedule for 3 Schedule for 3 months postop; months postop; Patient must use Patient must use alternate method alternate method pending confirmation.pending confirmation.
Other countries use Other countries use pelvic xray and or pelvic xray and or ultrasound as proof.ultrasound as proof.
HSG cost in USA varies HSG cost in USA varies $400-1500.$400-1500.
Area of Ongoing Area of Ongoing ResearchResearch
The First 50 Cases Medicos The First 50 Cases Medicos over 12 monthsover 12 months
Total tubal occlusions attemptedTotal tubal occlusions attempted 5050Could not place[gave IUD]Could not place[gave IUD] 11
Initially malpositioned but successfully replacedInitially malpositioned but successfully replaced22
Returned for any kind of followupReturned for any kind of followup 2626Returned pregnant[never followed up]Returned pregnant[never followed up] 11
Received HSG[1 still patent at 3 m]Received HSG[1 still patent at 3 m] 22 22
Paid something[5 pending] Paid something[5 pending] 4242Denied payment for incorrect adminDenied payment for incorrect admin 33
Total paymentsTotal payments $62,806$62,806
Total Cost Devices+EquipmentTotal Cost Devices+Equipment$84,643$84,643
Medicos Obtains postop and Medicos Obtains postop and 3m pelvic radiographs--$30 3m pelvic radiographs--$30
eacheach
Postop confirmation with Postop confirmation with Ultrasound $100; Ecuador Ultrasound $100; Ecuador
$15$15
Unexpected LessonsUnexpected LessonsPhysicians who fail to identify psychosocial Physicians who fail to identify psychosocial problems will live to wish they had spent problems will live to wish they had spent more time with the patient.more time with the patient.
To avoid financial loss , government and To avoid financial loss , government and insurance regulations must be understood insurance regulations must be understood and followed perfectly in the USA.and followed perfectly in the USA.
Physicians must be involved in health care Physicians must be involved in health care economics and the financial stewardship economics and the financial stewardship of their charges and collections.of their charges and collections.
Chance favors the prepared mind.Chance favors the prepared mind.
Fluid Management is Fluid Management is Necessary..No fluid was Necessary..No fluid was
drainingdraining
Family Medicine Obstetrics--Family Medicine Obstetrics--Questions for Future StudyQuestions for Future Study
In our experience many In our experience many women have previously women have previously undetected Gyn and undetected Gyn and psychosocial issues which psychosocial issues which may affect this procedure.may affect this procedure.
Here is a preop ultrasound Here is a preop ultrasound demonstrating a small amount demonstrating a small amount of free fluid in the cul de sac.of free fluid in the cul de sac.
Most of the original research Most of the original research ignored or excluded pre-ignored or excluded pre-existing comorbidities such as existing comorbidities such as pelvic pain, PID, ovarian cysts, pelvic pain, PID, ovarian cysts, etc. etc.
Psychosocial barriers and/or Psychosocial barriers and/or subclinical mental disabilities subclinical mental disabilities prevent HSG followup in over prevent HSG followup in over 50% of cases.50% of cases.
Financing the Mission Financing the Mission Through Expansion of Through Expansion of
ServicesServicesMedicos where 10 percent of the Medicos where 10 percent of the information creates 90% of the difference.information creates 90% of the difference.
References vital to financing the References vital to financing the mission[see mission[see www.psot.com]]
– Rodney WM, Hahn RG. Enhancing the family medicine Rodney WM, Hahn RG. Enhancing the family medicine curriculum in maternity care (OB) and emergency medicine to curriculum in maternity care (OB) and emergency medicine to establish a rural teaching practice. Fam Med Dec 1998; 30:712-establish a rural teaching practice. Fam Med Dec 1998; 30:712-719. 719.
– Rodney WM, Hahn RG. The impact of the limited generalist (no Rodney WM, Hahn RG. The impact of the limited generalist (no OB, no procedures, no hospital) model on primary care training OB, no procedures, no hospital) model on primary care training and practice. J Am Board Fam Pract 2002; May-June 15:191-200.and practice. J Am Board Fam Pract 2002; May-June 15:191-200.
– Rodney WM, Martinez CM, Chiu KW, Garcia RL, Carson G. Prenatal Rodney WM, Martinez CM, Chiu KW, Garcia RL, Carson G. Prenatal patients not delivered: Unplanned events, uncounted services , and patients not delivered: Unplanned events, uncounted services , and risks.[Delivery volumes at one office in Memphis] Am J Clin Medicine risks.[Delivery volumes at one office in Memphis] Am J Clin Medicine Spring 2009; 6[2]: 31-36.Spring 2009; 6[2]: 31-36.
Other health care Other health care credibility as a homecredibility as a home
N=100N=100 Approx $600Approx $600
N=100 Approx $1000N=100 Approx $1000
N=100N=100 Approx $70Approx $70
N=50N=50 Approx $800Approx $800
N=10N=10 Approx $ 950Approx $ 950
N=10 N=10 Approx $300Approx $300
Priceless opportunity to Priceless opportunity to defragment caredefragment care
The First 50 Cases Medicos The First 50 Cases Medicos over 12 monthsover 12 months
Total tubal occlusions attemptedTotal tubal occlusions attempted 5050Could not place[gave IUD]Could not place[gave IUD] 11
Initially malpositioned but successfully replacedInitially malpositioned but successfully replaced22
Returned for any kind of followupReturned for any kind of followup 2626Returned pregnant[never followed up]Returned pregnant[never followed up] 11
Received HSG[1 still patent at 3 m]Received HSG[1 still patent at 3 m] 22 22
Paid somethingPaid something 4242Denied payment for incorrect adminDenied payment for incorrect admin 33
Total paymentsTotal payments $62,806$62,806
Total Cost Devices+EquipmentTotal Cost Devices+Equipment$84,643$84,643
Transfer of Technology Transfer of Technology ProjectsProjects
A Mission Hospital Simulation in Tennessee-A Mission Hospital Simulation in Tennessee-MedicosMedicos
Minor Surgery, Urgent Care, and some ER Minor Surgery, Urgent Care, and some ER skills were reengineered for the officeskills were reengineered for the office
Diagnostic services: ECG, Xrays, ultrasound, Diagnostic services: ECG, Xrays, ultrasound, and lab tests reengineered for the officeand lab tests reengineered for the office
Cancer Prevention and Early DiagnosisCancer Prevention and Early DiagnosisColposcopy 1984, Electrosurgery and cryosurgery Colposcopy 1984, Electrosurgery and cryosurgery came with this procedure. Hysteroscopy 1995, 2009came with this procedure. Hysteroscopy 1995, 2009
Family Medicine Obstetrics with immediate Family Medicine Obstetrics with immediate access OB-Gyn Ultrasound 1999.access OB-Gyn Ultrasound 1999.
Medicos para la FamiliaMedicos para la FamiliaUn Modelo para Medicina Un Modelo para Medicina
FamiliarFamiliarEn las montanas de informacion, hay una En las montanas de informacion, hay una colina de conocimiento. En la colina de colina de conocimiento. En la colina de conocimiento hay granos de sabiduria.conocimiento hay granos de sabiduria.
En el USA 2010, los financieros son En el USA 2010, los financieros son duenos de los hospitales y los hospitales duenos de los hospitales y los hospitales son duenos de las residencias y son duenos de las residencias y entrenemiento.entrenemiento.
A los orgullosos le sigue la destruccion. A A los orgullosos le sigue la destruccion. A las altanerias el fracaso. --Proverbioslas altanerias el fracaso. --Proverbioswww.psot.com [email protected][email protected]
