In one community where I practice, no hospitals offered diagnostic procedures like CT Scans or MRI (Magnetic Resonance Imaging). Thus the current practice is to immediately transfer the patient to a nearby hospital with such capabilities. This, in spite of the fact that medical professionals here can actually perform the needed medical procedure after the CT was done. This practice went on for so long as I can remember and physicians bothered less and less about honing their skills managing ill patients diagnosed with the help of  a CT Scan.

Until one day, one hospital invested in a cat scan. Many physicians suddenly find themselves in a dilemma. That despite, the availability of a ct scan now, many physicians lacked or simply forgot to learn or re-learn how to manage patients that was diagnosed with the help of a CT scan.

The quandary is not about what you don’t know, but about how confident are you in managing those that you now knew because there’s a CT. Should they still refer the patient to another city for treatment despite the fact that the diagnostic technology is available here already? Would you see this as an opportunity for re-learning or would you simply refer the patient and free yourself the hassle of it?

This is just an example of technologies that threaten conventional practice. Many physicians view it as a threat, simply because they lose patients in the process but somehow, there’s this lukewarm acceptance for re-learning of skills. For some, this an opportune moment for seizing the timing for creating value added services (like ICUs and neurosurgery) in the hospital. For patients, this is totally a welcome development and improvement. Lower costs and convenience for both the diagnostic procedure and the value added service cannot be simply ignored. New technology, if indeed necessary, is here to stay.

So are you going to just ignore it and go on with your old practice or re-learn skills to adequately manage the influx of patients as a result of new technologies? Put your comment below.

Copyright secured by Digiprove © 2011 Remo Aguilar

Right. I almost forgot. The medical staff do have “dual” functions.

The medical staff has a dual and overlapping management system- the administrative which involves the activities of a medico-administrative character, and professional, which concerns of the clinical aspects of its functions.

The physician is typically absorbed with the clinical aspects of his profession and rarely bother with administrative functions unless he or she is managing a large group practice or a hospital. Private, solo practice large reduces the physician’s administrative function to bare minimum.

This may not be necessarily true in a practice that involves a tertiary institution.

This realization struck me as I was tasked an administrative position of setting up clinical services for a tertiary level health care facility. While defining clinical functions is not a “breeze”, setting up additional administrative functions for the involved physician is like “walking into a storm”. Again, this is seemingly related to physician’s preference to clinical functions rather than the administrative part. In reality, most physicians shy away from ANY administrative functions at all.  I now understood why physician administrators grow (or lose) gray hairs by the hundreds each day.

The reason?  My personal observation is this: As a physician, we were trained mainly on the clinical aspects of our profession. The few that got some training on the administrative skills probably got stuck in such functions. This compartmentalization of functions seem to enhance productivity on either of such functions but not on both. We were trained to specialize. Even solo, private practice seem to support this observation. The other reason is that physicians are generally slow to adapt to any change. Our comfort zone is just to comfortable to let go suddenly.  Thus, physicians tiptoes and are slow to adapt to administrative changes intended to improved  health care delivery.

This is where I am looking for ways to get viral and enthusiastic response from the medical staff. This dual function of hospital based physicians are intertwined and complementary. Defining such functions is necessary for providing top notch health care service and the smooth operations of the health care institution. I’m not just saying this because I’m now part of a hospital administration. As I’ve said before,  have I recognized administrative functions before in a solo practice, my practice would have been smoother and productive.

In your practice, do you really care about administrative functions at all?

Barely five years into a private medical-surgical practice, some people got interested how I’m “doing” with my “kind” of orthopedic practice.  Orthopedic practice refers to an orthopedic surgeon’s working environment, the plethora of patients or cases he handles, the time, effort and money he or she invests on it as well the returns (monetary or otherwise) he gets from this professional career. This is rather a simplistic definition, one that is based on a business model, but roughly what approximates a “medical-surgical practice” in the real Philippine health care settings. This definition is further muddled by “subtypes” of an orthopedic practice as well as the mix and match attitude by most orthopedic surgeons practicing in this country.

Before I’d shed light on my kind of orthopedics, let me describe what I think is the two extremes in orthopedic practice- the community type, generalist orthopedic practice  and the super specialist tertiary level academic orthopedics.

A community type of orthopedic practice usually caters to patients with general orthopedics (osteomyelitis) and extremity trauma (fractures) problems and usually the first line of orthopedic care in the provinces. These patients are commonly admitted to a non specialist, primary to secondary level, health care institutions found within the surgeon’s community or area of practice. Academic orthopedics on the other hand,  is basically a tertiary, level I trauma care practice that deals with, specialized or complicated orthopedic problems (e.g. arthroplasty or spine cases) that requires super specialist institutions with supporting facilities (ICUs) . Such specialist type of orthopedic practice is usually coupled with training residents in the orthopedic specialty. Some hospitals add admitting and/or administrative privileges to the surgeon.

The contrast between these two types of orthopedic practice is probably  apparent in the  amount of time and effort an orthopedic surgeon “invest” on each cases .  A super specialist academic orthopedics is generally thought to be more time, effort and learning  intensive, compared to a community type of orthopedics.  It is also perceived that specialist care are more lucrative, pay and prestige wise.  Of course there will be exceptions to this observation, as the delineation between “learning” in the country side versus the urban centers is gradually grayed by the advent of fast information and the internet. But for our purposes here, let me just simplify definitions to differentiate between the two.

Why am I differentiating between these two types of practices?  Theoretically speaking, somewhere between these two practices is the middle ground which is for me, the logically desirable type of practice -time, effort and income wise.  Thus, a balanced orthopedic practice (in my opinion) is one that  involves continuous learning and at the same time, offers a “relaxed” environment that caters more to delivering quality orthopedic care in a community setting.

Many surgeons believe such “balanced orthopedic practice” is not easy “find” , difficult to live with, or is unsustainable. The inherent affinity of the orthopedic practice to orthopedic implants and gadgetry as well as to a tertiary level health care institutions is believed to be the primary reason for such negative perception . While many many orthopedic surgeons still conglomerate on urbanized cities and tertiary level care institutions because of  this logistics necessity, a trend towards community type of orthopedic practice is picking up pace because of improved information technology and delivery of much needed orthopedic implants.

One former mentor asked me if I’m happy with this dual type of orthopedic practice. I answered ” yes” although I qualified it immediately by saying “.. with some necessary lifestyle and living adjustments” . Personally, I find it natural that this two sub types of practice  complement each other. A community practice without continuous learning is boring. Likewise, teaching orthopedics without actually doing what you teach is too good to be true. Somewhere between these two “extreme” sphere of practices lies a compromise that I felt, will produce the balancing act.

“But what about lifestyle modifications as you said?” I for one, chose this balancing act, because it fits my lifestyle. Compared to an urban, high volume, city practice, I certainly preferred the relatively relaxed working environment of a community practice. On the other hand, I cannot let go of the many opportunities for learning that these big academic institutions could give. Besides, I love teaching. Teaching could have  been my career if not for the ‘healer” awakening I got in college. Like one mentor said ,  “there’s no better way of learning than to help others learn“.

Well, a community type of practice will rarely make you rich, but I’m pretty sure you’d be able to put food (or a house and a car perhaps along with some other perks) in your family’s table. A simple living will surely come handy in surviving this dual type of orthopedic practice. But it does pay well in the amount and quality of time you spent with your love ones! I guess it all boils down to what fits your lifestyle and your priorities. Mine just happened to be where I wanted to be years before I became a doctor.

So which one do you prefer then, the community type of practice? the academe?or both?

In the few years I have been into practice, giving mobile contact number to a certain set of patients improved doctor-patient interactions and reduced overheads in the clinic.  In several provinces here in the Philippines where landlines are nonexistent,  the advent of mobile phones and SMS technologies provided easier and faster communication between physicians and their patients. Those that live in places away from their physician’s clinic reported a reduction in their  unnecessary clinic visits and ER consults. The perceived overall health care cost reduction (especially with the SMS technology ) is felt not only by patients but also by physicians who find it easier to decongest their very busy clinic schedules.

On the other hand, some doctors has had a bad experience after giving their mobile number to some patients. Abuse of this privilege is related to the patients’ proper education on its use and limitations. Some patients avoid regular clinic visits and rely only on the mobile phone calls or sms messages to communicate with their physicians. Some patients even “shortcuts” and seek immediate attention even if their cases seem to be less emergent than other patients who are physically present in the clinic. The most common complaint among physicians is the total disregard of some patients for the doctor’s private life. It’s not uncommon for physicians to receive non emergent calls or sms messages even on unholy hours.

A reduction in clinic visits (as a result of this mobile phone communication between physicians and patients) necessarily reflect a reduced clinic income if you are based on a service for fee system . Nobody (not even insurance companies) pays the doctor for any of the phone consults that patients incur. It’s all for the sake of better patient management and reduction of health care cost.

But education is very crucial in engaging patients into this type of doctor-patient interaction. Reciprocating respect for the doctor’s or the patient personal private life is of paramount importance in such mode of communication. Put into proper use,  giving  your mobile contact number to patients  reduce the over all health care cost. It’s misuse however,  could end up a fruitful patient-doctor relationship.

So, should  you give your mobile numbers to your patients?Why or why not? Or if you are a patient, would you want your physician ‘s mobile number?Leave your comments here.

SurgExperience, the online surgical grand rounds,  is up already in Scan Man’s Notes. Surgexperience 310 enumerates a plethora of blog post that will definitely raise you brows on issues- from politics of health care to semantics of weird care!