By Stacey Butterfield
In regard to a recent article on hand-carried ultrasounds (ACP Observer, May 2007), I would like to stress the importance of physician ultrasound certification and make a case for physicians' performing the ultrasounds in low-volume clinics or the ER.
In the region that I work and in most of the underserved regions of the U.S., clinics cannot afford to have a technician just for the purpose of performing occasional ultrasounds. Having an inexperienced technician can also result in missed reads.
Just recently, a patient was sent to me for a cardiac ultrasound, despite having a negative liver ultrasound done in another facility the same day. When I was doing a subcostal view of her heart, I saw two target lesions in the patient's liver. Most rural areas don't have onsite radiologists and thus depend on technicians.
Ultrasound is a dynamic modality, with hand-eye coordination learned through experience and repeated scanning. Real-time interpretation is the best way to get it right. If you do the study you could almost see it in your mind as a "three-dimensional real time." If you are in the ER evaluating the patient you could do the ultrasound while you see the patient and get your own "stat reading." Also, having experience in ultrasound reading allows safer U.S. guidance procedures in the ER, improving quality of care. Most radiologists read a static picture taken by a technician because they do not have time to do the scanning themselves. Reading a static picture could mean loss of information not saved by the technician.
A standardized, Internet-based test should be developed and made available to board certified internists or surgeons, especially the ones who have done these procedures for years without radiologist oversight. For new doctors coming out of residency, a short residency program for six months could be added in order to be certified for ultrasound reading. It would go a long way to improving quality of care and reducing wait times and patient costs in rural areas.
Sergio E. Abriola, ACP Member
Santa Rosa, N.M.
I thought the ACP article on hand-held ultrasound captured both the promise and the challenges presented by the technology. The article noted the support some of the physicians have received from SonoSite. I would also like it noted that Johns Hopkins has received research support and the loan of machines from SonoSite.
David B. Hellmann, MACP
A dressing down
Stacey Butterfield's article, "An evidence-based approach to getting dressed," (ACP Observer, April 2007) is not quite what it should be since she is highly selective in the "evidence" she chose to write about and she bases her study on a very incomplete survey of the field. She does not consider the evidence that doctors' clothing may be contaminated and serve as a contributing factor to American's obscenely high nosocomial infection rate and death rate.
We must constantly remind ourselves that more Americans die of these infections than of breast cancer, and almost all of these infections are transmitted person-to-person. While we may implicate the sick person in the next bed as the most likely culprit, the doctor wearing a fluid-stained formerly white coat, an infested necktie, and a mostly useless contaminated stethoscope—more garment than diagnostic tool—is a serious potential menace.
Ms. Butterfield cites a New York Times article on this subject that appeared some months ago professing disgust and shock at the clothing young women doctors wear to work—exposing far too much cleavage and thigh. That article reached the pinnacle of silliness in the age of the nosocomial infection. No one ever died of MRSA or C. difficile diarrhea by staring at cleavage or thigh. The modestly covered-up doctor in a filthy coat with a filthy tie and a filthy stethoscope is a real or potential culprit in the increasingly dangerous world of the modern hospital.
Alvin Newman, FACP
Locums can work
I read with interest the letter submitted by Byravan Viswanathan, FACP (ACP Observer, May 2007) and empathize with his dilemma. Physicians have become slaves to the middlemen, but we have allowed it as individuals and as a profession. The insurance companies, large corporations and the locum tenens companies would have us all "work for them." We can either become victims or we can find new paths.
My husband is a physician assistant and I am a nephrologist and internist. We chose to pursue career locum tenens privately 11 years ago and would not turn back. My first experience was with locum tenens agencies in 1988.
We find that by doing long-term locum tenens jobs as independents we can pick and choose our jobs, arrange our own travel and take our home on the road. We work four to six months at each job and can take off equivalent lengths of time. We rarely use agencies.
We are able to establish strong patient rapport, contrary to Dr. Viswanathan's experiences. Whether this is a result of the type of patients we see in nephrology, the length of the jobs, or personality variances is difficult to determine. We do not accept short jobs unless it is with a group or hospital with which we already have a strong alliance and know the patient population and staff.
We feel very strongly that the climate of healthcare is changing to favor the locum tenens life for all the reasons that Dr. Viswanathan stated and more that are in our book. Unfortunately health care workers oftentimes feel that they need someone else to do the paperwork, footwork, etc. We feel that healthcare professionals have the intelligence and wherewithal to make their own decisions and get back to enjoying the practice of medicine. Whether retired, new into medicine or simply wanting to take back control of your life, career locum tenens can be a very viable option.
Dorothy K. Nemec, ACP Member
Punta Gorda, Fla.
Editorial note: Dr. Nemec and her husband are the authors of Finding Private Locums, and run MDPA Locums Inc. (www.mdpalocums.com), a for-profit independent locum tenens corporation.
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