Saturday, April 23, 2005

The slow advancement of ambulatory medical practice

Medical Notes: TOC

Eons ago, when I created the personal notes I'm linking to above, I was a real physician (GP basically, usually called an FP nowadays). Now I work in healthcare IT, but I continue to do the CME (continuing medical education) required to retain my licensure -- though I wouldn't see real patients without some supervised retraining. It's been more than 10 years since I was a country doc.

I've just completed two days of the Minnesota Academy of Family Practice's CME program.As I reflect on my notes, it's easiest for me to compare what I read to what I practiced in 1994 (I've done lots of CME since then, but it's in day to day practice that book learning becomes knowledge). I'm struck by one remarkable observation -- things haven't changed all that much.

I'm not talking about out-of-date docs practicing the medicine of their residency days. The faculty are state-of-the-art academics, including many subspecialists, all introducing the latest best practices. It is however true that a course like this only samples a few subjects. We didn't cover HIV management for example -- an area in which there's been great change. Like oncology, most HIV management is really a specialists domain. Where FPs care for cancer and HIV patients, we are usually working someone else's plan.

Some of the more remarkable changes in the past 10 years, are, in fact, retreats. We used to know how to manage the menopause (ERT), now we really don't. (Testosterone is popular now for female sexual dysfunction -- tell me that won't come to grief.) We used to try hard to identify reversible dementia -- no-one talks much about that any more. Alzheimer's is part of aging -- we are all touched by it in some measure, there are no effective preventive interventions, no good treatments (yet), just good management approaches. PSA used to be wonderful, now it seemed to a bit gauche.

The major breakthrough, compared to 1994, was in the management of erectile dysfunction. That's a pleasure to hear about (I'm not being ironic, it's great to be able to do something about this age-old problem), but there wasn't much else in the same league. Type II diabetes management is finally catching up to what many of us suspected 10 years ago (insulin is a double-edged sword), but the changes are not revolutionary. The preventive cardiologist and endocrinologist want everyone on statins, but there's still some nervousness in the audience about effects on neuronal membranes. Sure -- Lipitor for the diabetic or the patient with known heart disease -- but do want ever American male with a waist over 40" on high dose Lipitor?

Given my lack of practice and my aging brain, I suspect that 1994 JF with 1994 knowledge would do better on today's exams than I could. Yes, stroke management is somewhat changed and the old antibiotics don't work so well (be afraid -- they don't have easy replacements), but much of day to day healthcare seems to be changing more slowly than most people imagine. One big change was the source of much complaining -- noone likes their medical record computer system very much.

No comments: