Monday, January 18, 2010

Toronto ACP meeting to offer mini-courses in minor surgery-what is that about?

I recently received a copy of the advance program for the April 2010 scientific meeting of the American College of Physicians (ACP). On page 38 we find a list of mini-courses in "Clinical Skills in Procedures". These include: skin biopsy and cryosurgery,suturing skills, and my favorite,"toenail removal" about which they state :

"Learn the indications for toenail removal. Using a realistic model and actual surgical instruments ( I guess as opposed to fake instruments),practice a digital block,wedge resection and removal of an ingrown toenail and wound care."

I am puzzled as to the intent of the ACP planners in offering this course. Do they intend that an internist whose post medical school training to my knowledge does not involve the development of surgical skills offer this procedure in his office with only several hours of instruction/practice as his qualifications? Do they believe that one serves his patient well by having an under trained physician perform a surgical procedure?

Should the planners of this course develop a painful ingrown toenail who would seek out for treatment: a general surgeon, an orthopedic foot surgeon, a podiatrist or an internist who took a course at the ACP meeting? I am reminded of this Monty Python skit of a job counseling interview in which the applicant's sole quality for lion taming was a hat that said 'Lion Tamer".

I have written before as has Dr RW (see here and here for his comments and here for mine) on what seems to me to be an identity crisis in internal medicine evidence for which is found in the more recent editions of MKSAP as well as the annual scientific meeting wherein the planners seem to be trying hard to make internists more like family practice physicians. The general internal medicine section of MKSAP had many sections removed from typical or traditional internist's training and areas of expertise such as diagnosis and treatment of corneal abrasions and detailed evaluations of uterine bleeding to name just two. A suturing skills mini-course practicing on pig's feet is part of the "why can't internists be more like family practitioners ?" movement, one that I believe does not enhance internist's patients' care nor the public or self image of internists.


Michael Kirsch, M.D. said...

James, I think that the ACP is trying to assist its members in diversifying their practice and increasing their incomes. Primary physicians (I am a specialist.) are working harder for less, disportionately to other specialties, and their society is trying to get them a few simple office procedures. I don't think this poses an existential threat to IM.

james gaulte said...

Thanks for your comments.The effort may well be well intended but I believe it is not well advised.To take the toe-nail example, there are at least two issues, one practical one ethical. From a practical point of view, how often does an internist's patient present with a painful ingrown toenail requiring removal,
what increase will there be in his malpractice premiums if he adds minor surgical procedures to his policy and what is the cost of surgical supplies etc.From an personal ethical viewpoint I would not attempt a procedure like that when the alternative (referring to someone who really knows what they are doing,say a real surgeon)would clearly serve the patient better.

Michael Kirsch, M.D. said...

Thanks James. Physicians should be able to learn how to do a variety of simple procedures to serve their patients and to enhance their practices. There will always be specialists (like me) who can do the procedure better. Nevertheless, primary physicians should not to limit their skill set by what they know at the conclusion of their training. I realize that there is a balance here and many 'turf issues'. Dermatologists probably don't think family docs should be doing skin biospies.

ray said...

Hi,I do toe nail removals all the time. no problem, my partners learnt them as well, quite easy actually. very convenient for the patient. Also do joint injection, abscess drainage,some of my partners do flex sig, accupucture as well. We are all very good with our procedures since we do them regularly and we have a urgent clinic for our patients. My dad is an retired anesthesiologist who could handle bronchitis, allergies, mionor ailments quite easily without panicking unlike current crop of specialists. What we sorely need is good clinicins!! and a way to reward them for their talent!!!

james gaulte said...

Does the increased revenue from your minor office surgery offset the increased malpractice premiums? I assume it does as you continue the practice.I did not realize how often in an internist practice the opportunity for minor office surgery presents itself.That was not the case in my experience.Still if I need a toe nail removed I plan to see a surgeon.

Michael Kirsch, M.D. said...

James, I follow your reasoning, but I wonder how often the surgeon has removed a toenail! Perhaps, a podiatrist makes sense here.

rcg said...

I think there is a disconnect between the training in IM and the realities of practice. Unless one practices in a relatively remote area, the era of general internists working as consultants is essentially over. The needs of our patients determine why internists need to learn about office procedures, gyn, derm, psych, etc. Rich

james gaulte said...

Maybe we can go further than that and suggest that the notion of an internist as training in the 60s,70s (80s?) produced them are increasing irrelevant and barely economically viable in the world of ER docs,NPs, hospitalists and a well defined and trained supply of FP docs.

rcg said...

Although my practice is nearly all office-based (some weekend rounding), I think training in internal medicine still offers value. It's easier to recognize unusual presentations of common diseases or the odd zebra. It helps with managing patients who don't fit neatly into a category and when receiving the "handoff" from hospital-based physicians.
However, I think a couple years of in-patient work is sufficient and the third year could focus on the non-internal med aspects of practice.
ps I enjoy your blog

Janice Ladden said...

Hi, I am a physical therapist, Dallas, Tx based. Well, since this is the American College of Physicians, I am sure they are aware of the consequences of what they are undertaking. Removing a toenail would not really be that difficult, specially if the internist has some background in other minor surgeries. Otherwise, I would like to think that the ACP will screen those going to take the mini course very well. Anyway, this occurs very frequently in sports injuries and this course would be very helpful in emergency situations.

james gaulte said...

I think the only screening was to see if their credit call was valid.