Wm. MacMillan Rodney MD, FAAFP, FACEP Professor and Chair, Medicos para la Familia

1. Medicos—Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia • Wm. MacMillan Rodney MD, FAAFP, FACEP • Professor and Chair, Medicos para la Familia • Memphis, Nashville, and International • Editor, American Journal of Clinical Medicine • American Board of Family Medicine Obstetrics • WONCA 2010; Cancun, Mexico; Presenting • The Family Medicine Obstetrics Curriculum and Data • Medicos: A New Training Model Successfully Expanding Health Care Services at a Lower Cost. • Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia

2. Transfer of Technology ProjectsA Mission Hospital Simulation in Tennessee-Medicos • Minor Surgery, Urgent Care, and some ER skills were reengineered for the FP office • Diagnostic services: ECG, Xrays, ultrasound, and lab tests reengineered for the FP office • Cancer Prevention and Early Diagnosis--Lab • Colposcopy 1984, Electrosurgery and cryosurgery came with this procedure. Hysteroscopy 1995, 2009 • GI Colonoscopy/ EGD/ENT endoscopy 1981 onward • Family Medicine Obstetrics with immediate access OB-Gyn Ultrasound 1999.

4. Medicos para la Familia Project • Was established as a training center in 1999. By this time University-based Family Medicine had not maintained its heritage in comprehensive care, and was an unlikely career choice for medical students here and abroad. • Medicos utilized data from the Transfer of Technology Project 1979-present. See website for “Procedural Skills and Office Technology” www.psot.com • Retained hospital privileges for physicians with an emphasis on prenatal care and delivery of babies. • Medicos provides data on health care services apart form the selection bias of university hospitals. Medicos is built upon family medicine to create training more consistent with community needs. • Became self sustaining through reimbursable services without charitable support.

5. Colpo, Cryo, Ultrasound ServicesMedicos para la Familia-Memphis

6. Family Planning Options—Psychosocial Considerations • Condoms, abstinence—Better than nothing • Birth Control Pills—requires compliance • IUD’s[Mirena cost in USA over $350] • Nuva Ring[rare], Norplant extinct • Diaphragm [rare] • Tubal Ligations—need OR time • Fallopian Tube Occlusion by Hysteroscopic insertion of 4cm microinserts

7. Medicos Office Equipment 2009Hysteroscope Cost $12 000+

9. Tubal Occlusion Without Anesthesia Microinserts $700 each Requires 6 week preop with DepoProvera 150 mg IM

10. Medicos--iphone photos intraoperative for record

11. The protocol for Hysteroscopic Sterilization by Essure • Remember your heritage as a family physician. • Hysteroscopic sterilization requires multiple visits following the sequence of counseling, consent, DepoProvera, Essure, DepoProvera, HSG, and the possible need for additional procedures. • Psychosocial barriers may preclude the operation. The process of informed consent is complex in the USA. • Mental illness and mental disabilities are more common than we thought in Tennessee. Even if they signed a paper, be prepared ………. • Be aware of costs to the patient, and plan for followup.

12. Hysterosalpingogram[HSG] for Conclusive Proof in USA • Schedule for 3 months postop; Patient must use alternate method pending confirmation. • Other countries use pelvic xray and or ultrasound as proof. • HSG cost in USA varies $400-1500. • Area of Ongoing Research

13. The First 50 Cases Medicos over 12 months • Total tubal occlusions attempted 50 • Could not place[gave IUD] 1 • Initially malpositioned but successfully replaced 2 • Returned for any kind of followup 26 • Returned pregnant[never followed up] 1 • Received HSG[1 still patent at 3 m] 22 • Paid something[5 pending] 42 • Denied payment for incorrect admin 3 • Total payments $62,806 • Total Cost Devices+Equipment $84,643

14. Medicos Obtains postop and 3m pelvic radiographs--$30 each

15. Postop confirmation with Ultrasound $100; Ecuador $15

16. Unexpected Lessons • Physicians who fail to identify psychosocial problems will live to wish they had spent more time with the patient. • To avoid financial loss , government and insurance regulations must be understood and followed perfectly in the USA. • Physicians must be involved in health care economics and the financial stewardship of their charges and collections. • Chance favors the prepared mind.

17. Fluid Management is Necessary..No fluid was draining

18. Family Medicine Obstetrics--Questions for Future Study • In our experience many women have previously undetected Gyn and psychosocial issues which may affect this procedure. • Here is a preop ultrasound demonstrating a small amount of free fluid in the cul de sac. • Most of the original research ignored or excluded pre-existing comorbidities such as pelvic pain, PID, ovarian cysts, etc. • Psychosocial barriers and/or subclinical mental disabilities prevent HSG followup in over 50% of cases.

19. Financing the Mission Through Expansion of Services • Medicos where 10 percent of the information creates 90% of the difference. • References vital to financing the mission[see www.psot.com] • Rodney WM, Hahn RG. Enhancing the family medicine curriculum in maternity care (OB) and emergency medicine to establish a rural teaching practice. Fam Med Dec 1998; 30:712-719. • Rodney WM, Hahn RG. The impact of the limited generalist (no OB, no procedures, no hospital) model on primary care training and practice. J Am Board FamPract 2002; May-June 15:191-200. • Rodney WM, Martinez CM, Chiu KW, Garcia RL, Carson G. Prenatal patients not delivered: Unplanned events, uncounted services , and risks.[Delivery volumes at one office in Memphis] Am J Clin Medicine Spring 2009; 6[2]: 31-36.

20. Untabulated Indirect Revenue • Office visits for Family Planning prior to Essure • Medroxyprogesterone injections • Pregnancy tests • Well woman visit-Paps • Pelvic ultrasound • Pelvic Xrays • Other health care credibility as a home • N=100 Approx $600 • N=100 Approx $1000 • N=100 Approx $70 • N=50 Approx $800 • N=10 Approx $ 950 • N=10 Approx $300 • Priceless opportunity to defragment care

21. The First 50 Cases Medicos over 12 months • Total tubal occlusions attempted 50 • Could not place[gave IUD] 1 • Initially malpositioned but successfully replaced 2 • Returned for any kind of followup 26 • Returned pregnant[never followed up] 1 • Received HSG[1 still patent at 3 m] 22 • Paid something 42 • Denied payment for incorrect admin 3 • Total payments $62,806 • Total Cost Devices+Equipment $84,643

22. Transfer of Technology ProjectsA Mission Hospital Simulation in Tennessee-Medicos • Minor Surgery, Urgent Care, and some ER skills were reengineered for the office • Diagnostic services: ECG, Xrays, ultrasound, and lab tests reengineered for the office • Cancer Prevention and Early Diagnosis • Colposcopy 1984, Electrosurgery and cryosurgery came with this procedure. Hysteroscopy 1995, 2009 • GI Colonoscopy/ EGD/ENT endoscopy 1981 onward • Family Medicine Obstetrics with immediate access OB-Gyn Ultrasound 1999.

23. Medicos para la FamiliaUn ModeloparaMedicina Familiar • En lasmontanas de informacion, hay unacolina de conocimiento. En la colina de conocimiento hay granos de sabiduria. • En el USA 2010, los financieros son duenos de los hospitales y los hospitales son duenos de lasresidencias y entrenemiento. • A los orgullosos le sigue la destruccion. A lasaltanerias el fracaso. --Proverbios • www.psot.com wmrodney@aol.com

24. Medicos—The Defining Dozen • Finance your personal and professional needs • Build a team -sustain staff , equipment, computers-emr • Primary Care-outpatient Med Peds, Paps, Family Planning, Dispense meds • Emergency Care ACLS, PALS, NRP, ALSO, CALS • Open Access 7d/week • Hospital Privileges • Prenatal and Obstetrics • 24/7, 365 • Office x-rays • Office Ortho, Fractures • Office lab • Waived[strep, preg, UA, glucose, HgbA1c • CBC=CLIA • Office ultrasound • Office surgery • Trauma, lacerationS • Biopsies, aesthetics • Gyn, colpo, hysteroscopy • IV sedation/analgesia • The Transfer of Technology will continue