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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

Medco oversees drugbenefit plans for more than 60 million Americans arthritis in lower back and hips 100 mg diclofenac with amex, including 6 arthritis of fingers diclofenac 50mg low price. Reuters interviewed Kasey Thompson arthritis medication methotrexate side effects buy 100mg diclofenac free shipping, director of the Center on Patient Safety at the American Society of Health System Pharmacists arthritis diet what foods to avoid order diclofenac with amex, who noted: “There are serious and systemic problems with poor continuity of care in the United States. The average intake of medications was five per resident; the authors noted that many of these drugs were given without a documented diagnosis justifying their use. Seniors are given the choice of either highcost patented drugs or lowcost generic drugs. Drug companies attempt to keep the most expensive drugs on the shelves and suppress access to generic drugs, despite facing stiff fines of hundreds of millions of dollars levied by the federal government. One study evaluated pain management in a group of 13, 625 cancer patients, aged 65 and over, living in nursing homes. While almost 30% of the patients reported pain, more than 25% received no pain relief medication, 16% received a mild analgesic drug, 32% received a moderate analgesic drug, and 26% received adequate painrelieving morphine. The authors concluded that older patients and minority patients were more likely to have their pain untreated. Carcinogenic drugs (hormone replacement therapy, * immunosuppressive and prescription drugs). Surgery and unnecessary surgery (cesarean section, radical mastectomy, preventive mastectomy, radical hysterectomy, prostatectomy, cholecystectomies, cosmetic surgery, arthroscopy, etc. Health care is based on the free market system with no fixed budget or limitations on expansion. The federal government does no central planning, though it is the major purchaser of health care for older people and some poor people. Americans are less satisfied with their health care system than people in other developed countries. Huge public and private investments in medical research and pharmaceutical development drive this “technological arms race. Any efforts to restrain technological developments in health care are opposed by policymakers concerned about negative impacts on medicaltechnology industries. The high cost of defensive medicine, with an escalation in services solely to avoid malpractice litigation. The availability and use of new medical technologies have contributed the most to increased health care spending, argue many analysts. The reasons government attempts to control health care costs have failed include: 1. Market incentive and profitmotive involvement in the financing and organization of health care, including private insurers, hospital systems, physicians, and the drug and medicaldevice industries. In addition to R&D, the medical industry spent 24% of total sales on promoting their products and 15% of total sales on development. If health care spending is perceived as a problem, a highly profitable drug industry exacerbates the problem. Many argue that reductions in the preapproval testing of drugs open the possibility of significant undiscovered toxicities. Assessing risks and costs, as well as benefits, has been central to the exercise of good medical judgment for decades. Examples of Lack of Proper Management of HealthCare Treatments for Coronary Artery Disease 1. Both procedures increase in number every year as the patient population grows older and sicker. Rates of use are higher in white patients and private insurance patients, and vary greatly by geographic region, suggesting that use of these procedures is based on nonclinical factors. They reviewed 1, 300 procedures and found 2% were inappropriate, 90% were appropriate, and 7% were uncertain. The New York numbers are in question because New York State limits the number of surgery centers, and the percapita supply of cardiac surgeons in New York is about onehalf of the national average. A definitive review published in 1994 found less than 30 studies of 5, 000 that were prospective comparisons of diagnostic accuracy or therapeutic choice. Clinical evaluation, appropriate patient selection, and matching supply to legitimate demand might be viewed as secondary forces. Laparoscopic cholecystectomy was introduced at a professional surgical society meeting in late 1989. There was an associated increase of 30% in the number of cholecystectomies performed. Because of the increased volume of gall bladder operations, their total cost increased 11. The mortality rate for gall bladder surgeries did not decline as a result of the lower risk because so many more were performed. When studies were finally done on completed cases, the results showed that laparoscopic cholecystectomy was associated with reduced inpatient duration, decreased pain, and a shorter period of restricted activity. But rates of bile duct and major vessel injury increased and it was suggested that these rates were worse for people with acute cholecystitis. Patient demand, fueled by substantial media attention, was a major force in promoting rapid adoption of these procedures. The major manufacturer of laparoscopic equipment produced the video that introduced the procedure in 1989. Doctors were given twoday training seminars before performing the surgery on patients. In 1992, the Canadian National Breast Cancer Study of 50, 000 women showed that mammography had no effect on mortality for women aged 4050. Incidence of adverse drug reactions in hospitalized patients: a metaanalysis of prospective studies. Patient, provider and hospital characteristics associated with inappropriate hospitalization. Fourth Decennial International Conference on Nosocomial and HealthcareAssociated Infections. Malnutrition and dehydration in nursing homes: key issues in prevention and treatment. Nationwide poll on patient safety: 100 million Americans see medical mistakes directly touching them [press release]. Characteristics of medical school faculty members serving on institutional review boards: results of a national survey. Peer reporting of coworker wrongdoing: A qualitative analysis of observer attitudes in the decision to report versus not report unethical behavior. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Clinical pharmacy services, hospital pharmacy staffing, and medication errors in United States hospitals. The incidence and severity of adverse events affecting patients after discharge from the hospital. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Prescriptions of systemic antibiotics for children in Germany aged between 0 and 6 years. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989 1999. Impact of antibiotics on conjugational resistance gene transfer in Staphylococcus aureus in sewage. Combined in situ and in vitro assessment of the estrogenic activity of sewage and surface water samples. Ozonation: a tool for removal of pharmaceuticals, contrast media and musk fragrances from wastewaterfi Determination of neutral pharmaceuticals in wastewater and rivers by liquid chromatographyelectrospray tandem mass spectrometry. Trace determination of fluoroquinolone antibacterial agents in urban wastewater by solidphase extraction and liquid chromatography with fluorescence detection. Determination of antibiotics in different water compartments via liquid chromatographyelectrospray tandem mass spectrometry. Prescription of nonsteroidal antiinflammatory agents and risk of iatrogenic adverse effects: a survey of 1072 French general practitioners. Economic analysis of conventionaldose chemotherapy compared with highdose chemotherapy plus autologous hematopoietic stemcell transplantation for metastatic breast cancer. Does inappropriate use explain geographic variations in the use of health care servicesfi

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Insulin iation in hyperandrogenic women infiuences the findings of abnormal resistance in the sisters of women with polycystic ovary syndrome: as metabolic and cardiovascular risk parameters arthritis definition dictionary purchase diclofenac 100 mg mastercard. J Clin Endocrinol Metab sociation with hyperandrogenemia rather than menstrual irregularity arthritis in knee causing back pain discount 50mg diclofenac with visa. Endocrine disorders associated with inappropriately high aroma Surv 2004;59:141–54 arthritis in neck from cracking generic diclofenac 100 mg without prescription. The indepen Prevalence of 21hydroxylasedeficient nonclassic adrenal hyperplasia dent effects of hyperandrogenaemia arthritis in knee after acl surgery purchase genuine diclofenac online, hyperinsulinaemia, and obesity and insulin resistance among hirsute women from Puerto Rico. Ad hyperandrogenic symptoms: implications for the management of poly verse lipid and coronary heart disease risk profiles in young women cystic ovary syndrome. Clin Endocrinol (Oxf) tein lipid concentrations and cardiovascular risk in women with poly 2003;59:282–8. Maternal thyroid deficiency during pregnancy and sub with insulin resistance in women with polycystic ovaries. Am J lence ofthyroid disordersin a middleaged female population, with spe Med Genet 1998;76:337–42. Screening for 21hydroxylasedeficient nonclassic adrenal Thyroid disorders in the general population of Hisayama Japan, with hyperplasia among hyperandrogenic women: a prospective study. Natural history of thyroid abnormalities: prevalence, incidence, and re N Engl J Med 1990;323:849–54. Bjoro T, Holmen J, Kruger O, Midthjell K, Hunstad K, Schreiner T, 1993;168:889–95. Acquired adrenal hyperplasia: with special reference oxidase antibodies in a large, unselected population. Lateonset adrenal steroid 3 betahydroxysteroid dehydrogenase de Prolactin has a direct effect on adrenal androgen secretion. Studies of 3 betahydroxysteroid dehydrogenase genes metabolic clearance rate of dehydroepiandrosterone sulfate in normal in infants and children manifesting premature pubarche and increased and hyperprolactinemic subjects. J Clin Endocrinol Metab 1986;62: adrenocorticotropinstimulated delta 5steroid levels. Clinical review 56: Nonclassic ad Identification of virilizing adrenal tumors in hirsute women. The Cushing syndromes: changing views of diagnosis and plasia: the great pretender. Androgenrelated effects on peripheral glucose metabolism tory value of signs and symptoms aiding early diagnosis. Cushing’s syndrome [erratum appears in N Engl J Med 1995 Mol Genet Metab 2000;71:527–34. Infiuence of different genotypes on 17 ing’s syndrome in obese women with and without polycystic ovary syn hydroxyprogesterone levels in patients with nonclassical congenital drome. J Clin Endo notypegenotype correlation in 56 women with nonclassical congenital crinol Metab 2003;88:2634–43. Menstrual abnormalities in women thosis nigricans syndrome: a common endocrinopathy with distinct with Cushing’s disease are correlated with hypercortisolemia rather pathophysiologic features. Midnight salivary cortisol for the initial diagnosis of Cush plasma androstenedione to 5 alphaandrostanediol glucuronide in ing’s syndrome of various causes. A clinicopathologic analysis of 17 cases and review of the investigation of hirsutism in a Turkish population: idiopathic hyperan literature. Ferriman Gallwey association of ovarian tumors with polycystic ovaries with review of the selfscoring I: performance assessment in women with polycystic ovary literature. Consensus on infertility treatment related to renal adenoma with studies on the steroid content of the adrenal venous polycystic ovary syndrome. Diagnosing the diagnosis: why we must standardize the defin Gynecol 1979;53:36–43. Am J Obstet Gynecol 1988;158: utility, limitations, and pitfalls in measuring testosterone: an Endocrine 1313–22. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. Management of severe asymptomatic hypertension (hypertensive urgencies) in adults. Ophthalmology Conjunctivitis – Bacterial Symptoms – Discharge purulent dischargefi crusted in morning Physical Exam – Copious purulent discharge Treatment – Erythromycin ointment q6 x7 days – Trimethoprimfipolymyxin B 0. Ophthalmology Pterygium – Symptoms Eye irritation, unilateral, can impair vision – Physical Exam Conjunctival tissue thickening from medial to cornea – Treatment Benignfi rewetting drops Ophthalmology consultfi surgery if progressing or vision impairment 11 ure 13. Photograph showing orbital cellulitis which is a bacterial infection of the periocular tissues. A study on the use of imiquimodfor the treatment of genital molluscumcontagiosumand genital warts in female patients. Evaluation of the Utility of the Fournier’s Gangrene Severity Index in the Management of Fournier’s Gangrene in North India: A MulticentreRetrospective Study. Perianal mantle cell lymphoma mimicking an external thrombosed hemorrhoid: a case report. Heart rate/min Respiratory rate/min Accessor Inhalation Wheezin Oxygen <3 years fi3 years <6 years fi6 years y muscle g saturatio old old old old use exhalatio n % n ratio (room air) 0 <120 <100 fi30 fi20 None 2:1 None 96fi 1 120–140 100–120 31–45 21–35 Mild 1:1 End 93–95 expirator y 2 141–160 121–140 46–60 36–50 Moderate 1:2 Inspirator 90–92 y and expirator y wheeze, good aeration 3 160< 140< 60< 50< Severe 1:3 Inspirator <90 y and expirator y wheeze, decrease d aeration ure 3. International Journal of Chronic Obstructive Pulmonary Disease 2006 Dec 1 (4):355fi361. Annals of Allergy, Asthma & Immunology: Official Publication of the American College of Allergy, Asthma, & Immunology, 107(1), 22–28. Seasonal Influenza in Adults and ChildrenfiDiagnosis, Treatment, Chemoprophylaxis and Institutional OutnreakManagement: Clinical Practice Guidelines of the Infectious Disease Society of the Americas. Reliability and construct validity of the Participation in Life Activities Scale for children and adolescents with asthma: an instrument evaluation study. American Thoracic Society Consensus Guidelines on Management of CommunityfiAcquired Pneumonia in Adults. An Official American Thoracic Society Statement: Update of Mechanisms, Assessment and Management of Dyspnea. Modified Medical Research Council scale vs Baseline Dyspnea Index to evaluate dyspnea in chronic obstructive pulmonary disease. Removal of Ear Canal Foreign Bodies in Children: What Can Go Wrong and When to Refer. Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Disease Society of America. Dermatology Varicella Varicella (chicken pox) Symptoms Very pruritic rash, fever Physical Exam Vesicles central umbilication or crustingfi diffuse Treatment Supportive 7 ure 5. Dermatology Molluscum Contagiousum – Symptoms Papules, spreading, painless – Physical Exam Pearly papules with central umbilication – Treatment Spontaneous Resolution within one year Surgical removal Topical PreparationsfiCantharadin, Imiquimod, Salicylic Acid, Retinoids Systemic Medicationsfi griseofulvin, cimetidine 12 ure 13. Dermatology Burnsfi Cont’d – Determine Body Percentage Covered by Burn Rule of 9’s Lund and Browder Scale 29 ure 36. Referral – I & D Obtain and document informed consent Anesthetize Clean Site Dermatology – Wide Incision – Drain and Culture – Explore – Pack – Sterile Dressing – Antibiotic Prophylaxis 32 ure 38. Treatment of burns in the first 24 hours: simple a practical guide by answering 10 questions on a stepfibyfistep form. British Association of Dermatologist’s guidelines forthetmanagement of cutansouswarts2014. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Efficacy and safety of terbinafine hydrochloride 1% cream vs eberconazolenitrate 1% cream in localised tinea corporisand tinea cruris. The Prevalence and Pattern of Superficial Fungal Infections among School Children in IlefiIfe, SouthfiWestern Nigeria. A Clinical and Statistical Survey of Cutaneous Changes in the First 120 Hours of Life. Treatment of burns in the first 24 hours: simple and practical guide by answering 10 questions in a stepfibyfistep form. Sternoclavicular joint septic arthritis with chest wall abscess in a healthy adult: a case report. PsychiatryfiAnxiety/ Depression GoalfiImmediate Referral versus Short Term Follow Up Are they causing harm to themselves or othersfi Know your local resourcesfi outpatient and inpatient 4 PsychiatryfiViolent Patient Clues to escalation Trusting Gut instincts Knowing how to get help Panic Button Psychiatry Clues to Escalation – History of Violence – Verbal threats, Loud, Angry or aggressive speech – Physical agitationfi pacing, squirming, fist clenching, wall punching – Provocative behavior – Actual Violence Occurring 5 Psychiatry Violent Patient – Do not hesitate to get out and get help – Never allow patient to position themselves between you and exit Psychiatry Reporting – Mandated Reporters for Suspected Elder Abuse Child Abuse/ NeglectfiAll 50 States Sexual Assault Abuse of Vulnerable Persons Gunshot Wounds 6 Psychiatry Complete! Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis.

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Some physicians devote most of their time to arthritis in neck arm pain discount 100 mg diclofenac with visa highrisk obstetrics and operative deliveries living with arthritis in feet buy generic diclofenac 50mg online, and others man age a harried clinic full of adults rheumatoid arthritis knee injections cheap 100 mg diclofenac visa, children rheumatoid arthritis diet youtube buy diclofenac online, and elderly in varying states of well ness and sickness. In the tradition of this communitybased specialty, family physi cians are well integrated into their communities and actively address issues in their patients’ lives other than medical problems. This is why family medicine doctors serve as advocates—for patients, health care systems, and social change. No matter the role, these physicians emphasize health maintenance, disease pre vention, and medical treatment, always aware of the psychosocial dimensions of their patients’ lives. It is no wonder that many medical students contemplating a calling in fam ily practice have some trepidation about assuming such a breadth of practice in a single specialty. For others, this very breadth of practice motivates them to se lect family medicine as their career. No other specialty can possibly match fam ily practice when it comes to its diverse practice environments, wide spectrum of patient demographics, and embrace of the entire breadth of clinical medicine. Being a family physician requires the ability to solve challenging problems of all 199 Copyright © 2004 by the McGrawHill Companies, Inc. Because of the extreme diversity within this specialty, family physicians are responsible for most of the health care delivered in the United States. In 2000, of the 822 million patient visits to physicians, 199 million were to family physi cians, compared to general internists (126 million visits) and general pediatricians (104 million visits). You may wonder how these other specialists can require 3 to 5 years to master any one of these fields, while family physicians spend only 3 years on all of the above. The answer: as all residents discover upon entering the world of pri vate practice, completion of residency confers upon its graduates competency, not mastery. A physician who receives training in family medicine can compe tently manage patients presenting with diverse clinical and social complaints and also speak confidently about the nature of that complaint and how to diagnose and treat it. No properly trained graduate, however, will be able to say that he or she knows everything. It comes as no surprise Enjoys taking care of entire that family physicians must be adept at families. The variety of diagnoses is rather extensive, so family physicians must ade quately address these complaints to practice competently. Many times they have to take what may seem to be vague symptoms—weakness, dizziness, lower back pain, abdominal pain—and make the correct diagnosis to start treatment or make the appropriate consultation. If the problem at hand is beyond their experience or knowledge, they initiate a specialist referral. In a recent survey, the majority (62%) of patients stated that they had a family physician as their individual source of care. In addition, family physicians often see patients with a variety of symptoms but no preestablished diagnosis. In fact, 40% of patient visits to family physicians are for reasons classi fied outside the 25 most common complaints in primary care visits, refiecting the broad scope of family practice and the diversity of its diagnostic challenges. There are many officebased diagnostic tests that family physicians perform, such as electrocardiography, excision of suspicious moles, endometrial biopsy, spirom etry, vasectomy, colposcopy, and obstetrical ultrasound. Of course, if you choose to include obstetrics as part of your practice, you will definitely have a lot of hands on work delivering babies and even performing caesarean sections (depending on your training and experience). Over a span of months or years, the em phasis during office visits is on continuity, prevention, and health maintenance (unlike specialty clinics or inpatient settings where visits are sporadic or single problemfocused). It may be acute or chronic, and may have resulted from any number of medical, surgical, or social factors that greatly impact that person’s ability to function in his or her job, family, or spiritual life. So the prac tice of family medicine, with its many dimensions of medical care, is as much a philosophy as it is a body of medical knowledge or clinical skill. They derive great satisfaction from preventing disease—just as much as they do in treating disease. Routine physicals, wellchild checkups, school and camp physicals, and cancer screenings are all important parts of this type of care. These physicians epitomize what primary care medicine is all about: preventing disease, maintaining health, and being the entry point into the health care system. They also practice costeffective medical care, taking into account the scientific and clinical evidence, the patients’ specific medical needs and preferences, and the values of the patients and their families. As generalists, the skills and knowledge they need differ according to the patient population of the particular community. For instance, family physicians working in the inner city have to address differ ent types of problems than those working in rural geographic areas. Inevitably, physicians responsible for familycentered primary care confront complex interpersonal social and behavioral issues. As such, all residency pro grams include family and individual therapy as part of training. For example, if a child presents with enuresis and encopresis (inability to control urination and defecation) at the age of 12, it would not be uncommon for other family mem bers to feel some effect of their loved one’s medical concerns. For instance, a par ent may suffer from depression while attempting to cope with this situation. Other siblings may feel alienated if the focus of the family turns heavily toward one in dividual, perhaps further exacerbating the situation. Although pediatricians and internists are well trained to address the individual concerns of the children or adults, in this scenario the family physician is uniquely trained among primary care physicians to handle the behavioral and medical concerns of everyone in volved. Due to their large numbers and broad medical focus, family physicians con tribute immensely to public health and primary medical care. For instance, in areas of the country with a large supply of primary care providers, colon and breast cancers are more likely to be detected at earlier stages, leading to higher cure rates. The United States relies on family physicians more than any other physician to supply primary health care to underserved areas. Family physicians typically spend every appointment discussing issues in their pa tients’ lives that may not have anything to do with their current complaint. Fam ily physicians guide patients through illnesses, problems, and other landmarks of life, from delivering babies to controlling high blood pressure, from treating can cer to coping with the loss of loved ones. Many patients consider you part of their family, especially family physicians practicing in small, intimate communities where everyone knows each other. Only in family medicine does continuity with patients span the entire life cy cle and all the biological and social infiuences that bear upon it. It is not un common, for example, for a family physician to deliver and care for multiple gen erations of newborns in a single family. Even within the context of a single medical problem, the primary care physician is the one who integrates contri butions from various specialists into a single treatment strategy. After establishing a plan and passing the acute phase of a disease, family physicians are able to man age most of these conditions. As you can see, family physicians have the unique opportunity to care for all the members of a family simultaneously. When emphasizing preventive measures, they always take the family unit into consideration. Take a family with a long his tory of diabetes and high blood pressure, for example. Family physicians can tar get all of the family’s members and teach them proper nutrition and exercise as a means of primary prevention (for the children) and secondary prevention (for the adults). You cannot simply educate a teenager about avoiding an unhealthy diet without addressing the eating habits of members of the entire household. Family physicians are also often called upon to initially manage complex medical problems in the context of “the family. They can easily encourage them to seek appropriate counseling and diagnostic testing. Although physicians in other specialties certainly participate in family centered care, few other physicians share the same level of involvement with all family members. Family physicians know that their relationships with patients are special be cause they take into account everything about the patient when making clinical diagnoses. Listening to their symptoms and examining for physical signs of dis eases are just the beginning. Family doctors also listen to the patient’s feelings, look at his or her behavior, and take into account the social and family history. If your patient presents with a chronic cough, you should still ask about his or her family, job, children, or anything else going on in his or her life. Some just have problems that are bothering them and need someone to talk to and express their feelings.

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