Broadening the Sphere of Medical Education: Observation and Training in the Private Practice

By Todd E. Schlesinger, MD, FAAD | Dermatology and Laser Center of Charleston

Continuing changes in the healthcare landscape have left medical professionals with gaps in their education.  Healthcare is evolving at a rapid pace, often outpacing the training programs that provide its workforce. One example is in the area of medical economics.  Medical education must be aligned with the practice of medicine that its students will face when the graduate.  Many aspects of the practice of medicine are not taught or given short amounts of time during training. Health information technology (HIT), billing and coding, human resources management, marketing and branding, regulatory and compliance management, legal matters and finance are all important parts of the professional life of a physician.  Surveys show that medical residents feel their training could be improved in these areas.  While advances in technology and compliance promise to offer improved safety and quality of care in the practice of medicine, physicians must be adequately trained, and on the job training may not be enough to provide the knowledge needed. 

Medical education was and is still based somewhat on the apprentice model.  Medical schools, once heavily geared toward the academic and scientific portions of the curriculum have shifted their focus to a more clinical approach.  However, there are some things that cannot be taught in medical school, even residency, or they are learned too late to be useful.  For this reason, I believe it is important for physicians to open their doors to aspiring medical professionals and also those already in training.  One may be surprised how much students and residents can learn from you, even if they are in an observational role.  Additionally, many physicians may find that they too can learn a great deal from their students.  In order for physicians to remain autonomous, rather than another cog in the big machine of healthcare, they have to be knowledgeable about business matters.  Many young physicians today have little confidence in their ability to work either independently or in the physician-owned practice setting. 

In my practice, we have a variety of educational opportunities for different types of students.  Residents from the Medical University of South Carolina (MUSC) rotate through for varying lengths of time to pick up some dermatology skill.  There are physician assistant (PA) students from MUSC that typically come for a month-long rotation where they are engaged full time.  By being in the environment longer, the PA students can gain more in depth experience with respect to the office workflow.  This may ease their transition to the workforce.  College students may consider a summer research rotation where they are exposed to the Research Center and its operations conducting clinical trials.  Hard workers may even complete the rotation with a publishable poster or scientific article.  Last, but not least, there are various other office visitors such as medical students, college students, high school students, cosmetology students, medical assistant students and others who come for a half-day to a day. 

In conclusion, I enjoy working with young medical professionals and pre-professionals, and I believe it to be a duty of all currently practicing physicians.  We can have a hand in helping to shape the future of medical professionals with this type of training.  In addition to caring for my wonderful patients, it is one of the true pleasures of my job and one that I hope to be able to do throughout my professional career. 

The State of Dermatology: An ever-evolving field of medicine.

By Kenneth R. Warrick, MD, FAAD | Dermatology and Laser Center of Charleston

As one of the senior dermatologists in South Carolina, I have witnessed how the field of dermatology has changed over the past third of a century.  Among the major trends are:

• Broadening of the array of treatment modalities such as newer classes of pharmaceuticals and cosmeceuticals, and newer physical modalities as well.Improved electronic means of rapid access to and “crunching” of medical data to enable more evidence-based assessment of our diagnostic techniques and treatments;
• The shift from male to female predominance among new graduate dermatologists;
• The shift towards more cosmetic procedural practice patterns;
•  Freezes on number of dermatology residency slots;
•  Earlier retirement of those dodging reimbursement changes and the switch from paper to electronic medical records, all of which result in markedly fewer traditional medical/surgical dermatologists per capita; and
• Medical school curricula are devoting fewer and fewer hours to teaching dermatology—the subspecialty with the largest number of separately identifiable diseases—further widening the knowledge gap between specialties.

While all of the above factors have had strong impacts on the field, the cost to bring a new drug to market, from test tube to pharmacy, has also skyrocketed.  With ever-increasing economic pressure from governmental and private insurers, decisions of pharmaceutical manufacturers must be closely tied to profitability.  Prohibition of discounts have made many medications unobtainable by patients covered under Medicare, Medicaid, Tricare, and even government employee health insurances.

In some instances the newer classes of pharmaceuticals have been associated with newly described adverse reactions.  Protocols have been developed for dealing with such reactions to enable the continuing use of non-substitutable anti-cancer drugs.

We are seeing an alarming increase in skin cancer cases with reports being published regularly about this climb.  This and the increased cost of pharmaceuticals have stretched both patients’ and insurors’ healthcare expenditure budgets to the max, while dermatologists are working to find the middle ground in providing affordable treatment solutions.

Ask the Doc: Understanding Free Medical Clinics

This week, Dr. Todd Crump, medical director for the Free Medical Clinic in Columbia, answers some frequently asked questions about care received from free medical clinics.

Q: What is a free medical clinic?
A: Specifically at our clinic, we treat poor people with health care needs who would otherwise go without those needs met. When the economy tanked, people lost their jobs, their insurance and their homes. But they didn’t lose their high blood pressure, diabetes and asthma. They must continue to be served and that’s where we step in.

Q: Who qualifies to be seen?
A: We see patients 18 and over who have no insurance, Medicaid or Medicare, and who fall at or below 138 percent of the federal poverty level (about $15,500 in earnings per year for an individual). We require proof of income (pay stubs, tax return) or an unemployment form for verification purposes.

Q: What services are provided?
A: We provide primary care and specialty care across 24 specialties, in addition to preventive care — flu shots, pneumonia vaccinations, mammograms, pap smears, PSA screening, colonoscopies, etc. We also have lab and diagnostic testing thanks to the three major hospital systems in the Midlands. We have limited testing on site — blood sugar, urinalysis, bedside ultrasound. Finally, we provide diabetic supplies along with medications from our in-house pharmacy.

Q: What services are not provided?
A: We do not test for sexually transmitted diseases or offer pregnancy testing or prenatal care. However, we will make referrals to other appropriate agencies. In addition, controlled substances are not prescribed nor dispensed.

Q: Will I be responsible for payment of certain services?
A: We are truly a free clinic. We do not charge patients for visits or for medications dispensed; however we do accept donations from our patients.

There are 41 other free clinics across the state. To learn more, visit: www.scfreeclinics.org.

Read more here: http://www.thestate.com/2013/12/08/3146248/understanding-free-medical-clinics.html#storylink=cpyT

Winning over your audience.

By Deb Sofield, Public Speaking CoachOver the next few months, join Deb Sofield as she goes through her series 15 Rules for the Physician Leader, where she outlines how a physician leader can be successful when speaking, no matter where they are... 

Rule #4. 
Talk about the audience – one mark of effective speaker is that they focus less about themselves and more on those who have come to hear them speak.

Most people want the speaker to know who they are and to have anticipated in some way the needs of those who are sitting in the audience. A speaker who tells stories for self aggrandizement or self congratulations (shocking but true) – will for the most part not impart great wisdom or leave the group with nuggets of truth that can help them in their life.

You, the speaker, have a message or at least the title of your presentation that led that audience to think you had something to offer – now you have to deliver. Talk to them, speak truth to power, and don’t be afraid. You never know when by your truth, knowledge, or wisdom you change them.

Another way you can talk about the audience is to commend them for something good they have done…it will go a long way.

A little twist to this topic is as the presenter you can take charge of the room – from where you stand you can tell if your audience is cold, hot, uncomfortable, or antsy… read and respond to their needs – that shows respect for them and they will appreciate it. I have never had an audience complain that they get too many breaks… to go the bathroom or stretch their legs.

By talking about the audience and caring for them – you will win them over.

Deb's Tip of the Month:

Be careful with Names. Let me share a new rule for the road many of us are incorporating into our speaking. If you can’t say the names of everyone in your audience – don't say any named... people are more sensitive now than ever. So if you, speakers, call one friend over and over by name, the others will wonder why you don’t call them by name. I know it is an odd comment, but I see it from the stage all the time. People want to be known and if you tend to call out the one or two people you know well and not the one you slightly know – you alienate them all.  

Ask the Doc: Diabetes Awareness

In the midst of giving thanks and eating turkey dinners, November is also known as Diabetes Awareness Month. Type 2 diabetes is the most common form of diabetes. Dr. Janice Key, co-chairwoman of the S.C. Medical Association Childhood Obesity Taskforce, answers common questions about type 2 diabetes.

Q: How is type 2 diabetes different from type 1 diabetes?
A: Diabetes mellitus is a disease that causes high blood sugar (glucose) due to a problem with the sugar controlling hormone, insulin. There are two types of diabetes: one in which there is not enough insulin produced by the pancreas (type 1) and one in which there is plenty of insulin but the body is “resistant” to it and is unable to use it normally (type 2).

Q: Who is at risk?
A: Being overweight or obese carries the greatest risk for developing type 2, however, the risk is not the same for all people. If your parents or grandparents have type 2 diabetes, you should be especially careful to keep your weight in a healthy range as you might have a genetic predisposition to obesity-related type 2 diabetes.

Q: What are the consequences?
A: The high blood sugar caused by diabetes coats the lining of blood vessels throughout the body, causing those blood vessels to become clogged, damaging every organ in the body. Over time, this can result in kidney failure (requiring dialysis), poor circulation in the legs (requiring amputation), blindness, stroke and heart attacks.

Q: How do I know if I have type 2 diabetes?
A: Diabetes has such a gradual effect that people usually can’t “feel” it happening. Some symptoms, such as lack of energy and fatigue, are so nonspecific that people don’t think of diabetes. In fact, undiagnosed diabetes can even cause a “silent heart attack”. The only real way to find out if you have diabetes is to get tested.

Q: Can eating healthy and exercising really prevent type 2 diabetes?
A: Yes, the good news is that you can lower your risk of type 2 diabetes by eating a healthy diet and exercising to keep your weight in the healthy range. In fact, sometimes even people who already have type 2 diabetes can get their blood sugars back under control simply by losing weight and exercising. Avoiding sugary, high glycemic foods can help by lowering the high peaks of blood glucose. Getting down to a healthy weight helps by improving insulin resistance. Exercise helps by temporarily reducing insulin resistance. Healthy food and exercise are the best medicine for diabetes.
 
Q: Can children become a type 2 diabetic?
A: Yes, unfortunately more and more children and adolescents are developing type 2 diabetes. As recently as 30 years ago that was not the case. In the 1970s children never had type 2 diabetes (except for the rare child taking high doses of steroid medication). Today, type 2 diabetes is the most common type of diabetes in children. What the difference? Today’s children are overweight and obese. Our children are developing type 2 diabetes simply because they are obese.

Q: What are three foods a diabetic should avoid?
A: People with diabetes should avoid simple carbohydrates and fatty foods. Three examples of specific foods that a person with diabetes should NEVER eat are candy, sugar sweetened drinks (soda, fruit drinks, sports drinks and iced tea) and ice cream. The best approach is to seek personalized advice from your physician, who may also refer you to a registered dietician. The American Diabetes Association has lots of recipes at their website www.diabetes.org.

Q: What foods would you recommend for a diabetic-friendly Thanksgiving feast?
A: Fortunately, many of the best foods on the Thanksgiving table are good for us! Roasted turkey is very healthy, just don’t eat the skin and limit the amount of gravy. Try cranberry relish made with a sugar substitute. Eat all the green beans you want, just not in a fatty, heavy casserole with fried onions on top (you know the one!). And of course, eat fruit for dessert, not pie and ice cream. Enjoy the meal and end the Thanksgiving celebration by getting out for a walk!

Read more here: http://www.thestate.com/2013/11/24/3118223/diabetes-shares-november-with.html#storylink=cpy

Kick smoking habit, especially before surgery

By Drs. Bruce Snyder and Rob Morgan

This was originally published in The Greenville News as a Guest Column on November 16, 2013.

Thursday, Nov. 21, marks the Great American Smokeout, a day the American Cancer Society has designated to encourage smokers to quit smoking, or to develop a plan for doing so. As physicians with over three combined decades of experience caring for patients, many of whom suffer from chronic diseases related to the long-term use of tobacco products, we are the first to acknowledge that it isn’t easy.

The facts about smoking haven’t changed. Nearly 1 in 5 Americans continue to smoke, and tobacco use remains the single largest preventable cause of disease and premature death in the United States (www.cancer.org/healthy/stayawayfromtobacco/greatamericansmokeout/index). The rate of smoking in South Carolina exceeds the national average, and tobacco use costs our state an estimated $5 billion every year in premature deaths, lost workplace productivity, and direct healthcare expenditures (http://www.sctobacco.org/policy/smokingeconomicimpactonsc.aspx).

On the day of the Great American Smokeout, why are an anesthesiologist and a surgeon writing about this topic? The answer is that help is available, and while many readers may not become patients in a hospital setting, we know that surgery and admission to a hospital (whatever the reason may be) represent a “window of opportunity” to kick the habit for many people who have the desire to do so.

First, Medicaid and many insurance companies offer partial or full coverage for tobacco dependence treatment. In South Carolina, Medicaid pays for two medications that are useful in helping patients quit. Patients having surgery and anticipating a hospitalization can be prescribed a nicotine patch during their stay and entered into a treatment program coordinated by members of the hospital staff with expertise in addiction therapy.

Second, as physicians we are the first to admit that a pill or medication isn’t the simple solution to every medical problem. Studies consistently demonstrate that a multi-layered approach to smoking cessation, including counseling or the use of “quitlines,” contributes to a higher success rate than a single intervention alone. Data indicates that only 0.4 percent of smokers in South Carolina use the assistance of a quitline when attempting to kick the habit — ranking us 50th in the nation for seeking such assistance.

What is a quitline and how can you find one? A quitline is a smoking cessation service that is available through a toll-free number. Every state in the country has a dedicated quitline, and by calling 1-800-QUIT-NOW, you will be routed to South Carolina’s quitline where you can gain access to trained coaches who provide information and help for cessation efforts. They can help with development of specific plans, discuss strategies that may work best for different types of people, and best of all, the service is absolutely free.

We know that smoking and surgery are a dangerous combination. Smokers suffer a higher incidence of surgical wound infections post-operatively, they encounter higher risks related to the administration of anesthesia in the operating room environment, and they are more likely to be admitted to the Intensive Care Unit while suffering any number of smoking-related complications after a surgical procedure.

Studies suggest that smoking cessation even within 24 hours of a procedure can begin to reduce some of these risks. And long-term cessation, of course, can have an enormous impact on health, well-being, and longevity.

Today we ask those of you who are taking the time to read this column to take a step. If you are a smoker, consider calling a quitline and beginning the process of kicking the habit for good. If you know someone who smokes, pass along this column or share the phone number listed above. While no one hopes to have surgery or looks forward to a stay in the hospital, know that help is available to quit smoking before you begin such a journey. Our physician colleagues stand ready to help. It’s time to kick the habit.

Ask the Doc: The Myths of Flu Vaccines

Dr. John Ropp, a family medicine physician practicing in Hartsville, answers some of the most common questions about influenza vaccinations.  

Q: Why should I get a flu vaccine?
A: Influenza (the flu) is a serious illness that can lead to hospitalization and even death in severe cases. Although flu seasons do vary in severity, the range of deaths in the U.S. attributed to the flu are from 3,000 to 49,000 annually – mostly in the older population. The flu is a virus and cannot be treated with antibiotics. The vaccine helps protect yourself, and sometimes more importantly, others who you come in contact with during the flu season.

Q: Should my children get a flu vaccine?
A: Yes. Everybody 6 months old and older should be vaccinated annually--- with very few exceptions.

Q: Who shouldn’t get the flu vaccine?
A: Very few. Those who have had a severe allergic reaction to the shot, severe allergic reaction to eggs, moderate to severe present illness, or those with a history of Guillain-Barre Syndrome after receiving a flu shot in the past.

Q: I haven’t gotten my flu vaccine yet. Is it too late?
A: No. Flu season generally occurs between October and late winter, so the ideal time is October. However, since the flu season is long, getting immunized any time during the season is recommended. Flu activity generally peaks in January.

Q: How soon does the vaccine take effect?
A: Two weeks following vaccination.

Q: Is the flu nasal mist better than the vaccine?
A: No. Use of the nasal vaccination is an option for healthy people between the ages of 2 and 49 and who are not pregnant.

Q: What are the most common side effects of the flu vaccine?
A: Common side effects of the nasal spray are mild headache, runny nose, sore throat, and cough that may last a day or two. Side effects of the shot include mild soreness, low grade fever, and some muscle aches.

Q: I heard the flu vaccine can give you the flu. Is this true?
A: No. Neither the nasal spray nor the shot can give you the flu since they have either no virus, inactivate virus, or severely weakened virus formulas. Any real or perceived illness that follows immunization are either mild side effects or another illness that was already beginning.

Q: Which months do you see the most flu cases?
A: The flu season generally lasts from October to late winter/early spring with peak activity in January.

Read more here: http://www.thestate.com/2013/11/10/3088655/flu-shot-questions-answered.html#storylink=cpy