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 The Family Medicine Obstetrics Curriculum and Data Medicos: A New Training Model Successfully Expanding Health Care Services at a Lower Cost. Medicos: A New Training Model Successfully Expanding Health Care Services at a Lower Cost. Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia Eliminating Barriers to Family Planning: Hysteroscopic Tubal Occlusion without Anesthesia

2. Transfer of Technology Projects A 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 Services Medicos 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 2009 Hysteroscope 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. 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. 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 ………. 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. 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 attempted50 Could not place[gave IUD]1 Initially malpositioned but successfully replaced2 Returned for any kind of followup26 Returned pregnant[never followed up]1 Received HSG[1 still patent at 3 m] 22 Paid something[5 pending] 42 Denied payment for incorrect admin3 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] 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 Fam Pract 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=100Approx $600 N=100 Approx $1000 N=100Approx $70 N=50Approx $800 N=10Approx $ 950 N=10 Approx $300 Priceless opportunity to defragment care

21. The First 50 Cases Medicos over 12 months Total tubal occlusions attempted50 Could not place[gave IUD]1 Initially malpositioned but successfully replaced2 Returned for any kind of followup26 Returned pregnant[never followed up]1 Received HSG[1 still patent at 3 m] 22 Paid something42 Denied payment for incorrect admin3 Total payments$62,806 Total Cost Devices+Equipment$84,643

22. Transfer of Technology Projects A 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 Familia Un Modelo para Medicina Familiar En las montanas de informacion, hay una colina 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 las residencias y entrenemiento. A los orgullosos le sigue la destruccion. A las altanerias el fracaso. --Proverbios www.psot.comwww.psot.com wmrodney@aol.com www.psot.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