rifunina

Two years ago, James Hawkins, a former online pharmacy viagra CEO, and I wrote Sailing the Seven “Cs” of Hospital Physician Relationships (PSR Publications, 2007). The idea was that hospital CEOs had best patch up physician relationships by acknowledging the importance of CEO competence, convenience for doctors, clarity of communication with doctors, continuity of hospital policies, fair competition between hospitals and doctors, resolution of control issues, and fair distribution of cash.


Hospitals and doctors are at odds on such issues as who controls specialty hospitals and surgical outpatient facilities, patient safety and quality issues, and competition between hospital-owned physicians and independent practices.


The AMA has recognized the need for better relations by saying the organized medical staff should abide by these principles.


• Work with hospital governing bodies to improve patient safety and health care quality.


• Be responsible for credentialing and overseeing clinical quality and patient safety.


• Be involved in hospital strategic planning.


• Communicate with hospital governing body in a timely and effective manner.


• Establish binding bylaws that hospital bylaws or policies don’t undermine.


• Have inherent self-governance rights.


• Create bylaws that are binding and mutually enforceable between the hospital and medical staff.

• Determine how much money it needs to carry out the duties of the hospital governing board and to develop a budget the hospital will fund.



• Elect member representation to attend, speak, and vote at board meetings.


• Have individual members be eligible to be full members of board.


• Develop disclosure and conflict of interest policies for physicians in leadership.


• Address disputes with the hospital board through a well-defined process.

These principles are all fine and good, but a few flies are stuck in the ointment.

• The term “organized medical staff “is an oxymoron. The physician culture treasures independence and often acts independently of hospitals. The medical staff is not basically a coherent entity, since most doctors practice separately from one another.

• The “organized medical staff” is ineffective in overseeing business functions of hospitals. Hospitals know certain specialties – cardiovascular, orthopedic, other surgical and procedure-based groups, and oncology – account for 80% to 90% of revenues. Hospitals therefore tend to do “business” with these specialties, and where possible hire other specialties as employees.

• As Jeff Goldsmith, PhD, president of Health Futures has often observed, the chasm between hospitals and doctors is growing not shrinking. Goldsmith has written,

"As health systems integrated structurally, they disintegrated culturally. The gap between professional and managerial cultures that existed during most of the 1980s and early 1990s widened into a chasm by the late 1990s. Professionals of all stripes – not merely physicians, but nurses, technicians, social workers and others – saw their practices increasingly commoditized and marginalized by the growing corporate ethos in their systems; professionals lost contact, physically and spiritually, with the 'adminisphere' – the tiny handful of people running their systems."

Or as a management hospital operating consultant wrote in an email to me,

Most physicians distrust hospital senior management. A war is going on out there. Physicians feel hospital executives have no experience with the 24/7 responsibility of someone's life and the deep accountability necessary with care. My husband, an internal med doc in a large hospital has said the executive team has consistently failed in just about every endeavor to help. The failure gap widens.


Hospital senior management opposes changing organizational structure and processes to benefit doctors. Operational and financial deficiencies are widespread, and senior teams are engrained in a culture that ignores it and hopes it will go away. None have been willing to build real accountability among them. They are insular, protected, and ineffective in leading operational change.


The culture gap between hospitals and physicians will not be easy to close.

Last week marked a new rotation in the academic viagra schedule, and 2 residents landed in Yellowknife to begin their rural internal cheap cialis rotations. One of them joined me yesterday for clinic. By the end of the morning, he asked if he could ask me a “program” question. “I’m not sure I understand how you utilize subspecialists up here in Yellowknife,” he commented. “Do you call them for advice, or send patients down for consultation?”

I remembered my first few months in rural practice, which included several desperate phone calls back to McGill (where I had trained) for advice. During those days, I was intimidated by the clinic setting and spent hours each day checking notes and online education resources to ensure I was managing patients appropriately. Six years later, life has changed considerably.

“Well,” I replied, “I send patients down when they need a procedure – an MRI, cardiac catheterization, perhaps a MIBI scan. I’m not as strong at rheumatology or outpatient neurology these days, since we have excellent locums who come every 3 months and see patients from all over the north here in Yellowknife. I don’t usually send patients out for an opinion on a cardiology or diabetes patient, since we’re able to offer good service here in the north.”

He thought back over the morning. We had followed up a patient post-ablation for WPW, discussed pharmacologic and other options for SVT with a teenager and her mother, and reprogrammed the pacemaker of a patient from Ulukhaktok, a tiny hamlet on an island in the Arctic Ocean. I had spoken to an Edmonton specialist regarding changes to an outpatient tuberculosis regimen due to drug intolerance, and I was trying to book a pregnant type II diabetic within the next couple of days, to start her on insulin. The tuberculosis and pacemaker cases presented us with some good teaching opportunities, and we also discussed the benefits of continuous glucose monitoring systems in selected diabetic patients.

“I guess I didn’t expect all of this to happen in one place,” commented my resident. “I don’t think that’s what internists do in downtown Calgary, is it?” Having never worked in Calgary, I had no details to give him regarding the outpatient life of internists more familiar to him. “I’m sure that each of them has a practice profile suiting their expertise and meeting a need in their community,” was the best I could do.

I never chose tuberculosis, or pacemakers, or insulin pumps, as part of my job description; in a small community, a specialist’s role develops around local needs and to complement local expertise. Most gastroenterology questions are punted from my desk to a couple of colleagues down the hall, and they reciprocate with nephrology referrals since I work most closely with our dialysis and renal insufficiency programs.

In the afternoon, the resident joined me for stress testing, and we started out with a patient from the small community of Fort Smith. A young man with previous coronary bypass surgery and chronic atrial fibrillation, he clearly needed consistent care to prevent future cardiac events. I listed him for annual stress tests – not because they are necessarily indicated, but because they will guarantee he sees an internist at least annually to review his lipids, diabetes management, ventricular rate control, and cardiac status. “Fort Smith just lost its only permanent physician,” I explained to the resident, “so I can ask the nurses to watch his heart rate, lipids and so on – but I can’t guarantee continuity of physician coverage unless he’s kept in our system.”

The next patient, from Yellowknife, had been unable to find a family physician for months. He had a reassuring stress test but multiple cardiac risk factors. “Our nurse practitioner will follow up his lipids and smoking cessation,” I told the resident; “If anyone can help him stop smoking, it will be an ex-smoker who has plenty of time for phone and clinic follow-up.”

Sometimes it seems that every community in the Northwest Territories has a different model of care, which changes as local medical resources ebb and flow. My resident will soon board another plane for a 1-physician community, where the visiting internist is treated to lunch in exchange for a spontaneous lecture to the local nursing staff on the topic of their choice. He will see patients from the bush and patients from the town, and offer advice and encouragement to the nurses who give most of the medical care to the region’s scattered population.

Perhaps one day my resident (or one of his colleagues) will give himself to a small community, becoming the internist for an otherwise unserved population, learning and growing with local needs and programs. Granted, it is a model he has not seen before; but it is the only life I have known since I was foolhardy enough to accept a 1-way ticket here from Montreal. I do miss the opera, but otherwise I wouldn’t change a thing.

-- Dr. Amy Hendricks

Karuk cialis woman Mavis McCovey and cultural anthropologist John F. Salter will make an appearance at Northtown Books in conjunction with their new book Medicine Trails, Monday, November 2nd at 6:30 pm.

Sometime in 1933 here in Humboldt County, a Karuk medicine woman named Daisy Jones had a vision identifying the tribe's next medicine woman. Later that year, Mavis Smither (McCovey) was born, and in the first twelve years of her life she was groomed by a designated group of medicine women to become a spiritual healer.

Medicine Trails is Mavis McCovey's honest and lively account of the many worlds in which she moves: the Indian and white cultural worlds, and the day-to-day and visionary reality of the medicine woman's world, as well as trips to what she calls "the other side": one of the responsibilities of a medicine woman is to bring back a medicine man's soul if he gets lost on the trails of the world beyond—a task McCovey has been called upon to do.

One of very few first-person accounts of Native American healers, Medicine Trails is invaluable for its insights into the experiences of a modern-day medicine woman. And McCovey is a warm and engaging guide not only to her life, but also her family's history and the history of the Karuk, Yurok, and Hupa peoples of the region.

Mavis McCovey makes no exotic claims about her powers, but describes those functions as seamlessly integrated in Karuk culture. More importantly, she describes a living contemporary culture, enriching the melancholy beauty of our shared world
—Freeman House, from the foreword

Chinese herbal remedy called horny goat weed is a promising alternative to purchase cialis for impotent men, Italian researchers said on Monday. The herb has long held a reputation as a natural aphrodisiac. The lab experiments, which did not look at whether the plant actually increases desire, could lead to new drugs to help men get erections, said Mario Dell'Agli, a researcher at the University of Milan, who led the study. "This could be the natural cialis," he said in a telephone interview. "The novelty is that we have synthesized a new molecule that one day may be able to replace Viagra."




Further tests in animals and humans are needed but the extract from the herb represents a potential new erectile dysfunction treatment with fewer side effects, Dell'Agli said. "The compound icariin is present in the horny goat weed in large amounts and its activity against (the enzyme) is lower compared to Viagra," he said. "But the new molecule we synthesized from icariin is as good as Viagra against (the enzyme)."

Chinese herbal remedy called horny goat weed is a promising alternative to order cialis for impotent men, Italian researchers said on Monday. The herb has long held a reputation as a natural aphrodisiac. The lab experiments, which did not look at whether the plant actually increases desire, could lead to new drugs to help men get erections, said Mario Dell'Agli, a researcher at the University of Milan, who led the study. "This could be the natural cialis," he said in a telephone interview. "The novelty is that we have synthesized a new molecule that one day may be able to replace Viagra."




Further tests in animals and humans are needed but the extract from the herb represents a potential new erectile dysfunction treatment with fewer side effects, Dell'Agli said. "The compound icariin is present in the horny goat weed in large amounts and its activity against (the enzyme) is lower compared to Viagra," he said. "But the new molecule we synthesized from icariin is as good as Viagra against (the enzyme)."