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Why We Must Reform Ambulatory Practice
 

Why We Must Reform Ambulatory Practice

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  • Numbers Peaked in 1997. Increasing number of spots filled by international medical grads. Pugno says that interest in FM is “steady.”
  • Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists. For 2001, the data reflect the career plans for all third-year internal medicine residents, including categorical, primary care, medicine-pediatrics, and other tracks. Data for all other years reflect the career plans of third-year residents enrolled in categorical and primary care internal medicine programs. Data for 1998 through 2003 are from Garibaldi et al.6 Data for 2004 and 2005 are from Carol Popkave, American College of Physicians. NA denotes not applicable.

Why We Must Reform Ambulatory Practice Why We Must Reform Ambulatory Practice Presentation Transcript

  • Improving academic primary care
    • Tom Bodenheimer MD
    • Department of Family and Community Medicine
    • University of California at San Francisco
    • [email_address]
  • Goals for this presentation
    • The crisis in primary care access
    • Reasons for the crisis
      • How academic primary care aggravates the crisis
    • Can we improve academic primary care practices?
  • Dwindling Numbers Pugno, Fam Med 2005;37:555 1132 2005 2340 1997 # US grads entering family medicine residency
  • Bodenheimer T. N Engl J Med 2006;355:861-864 Dwindling Numbers: Career Choices of Third-Year Internal Medical Residents
  • Dwindling Numbers
    • 2005 survey of internal medicine physicians who received board certification in early 1990s (in practice 10-15 years ):
    • Had left practice entirely
      • Primary care internists 21%
      • Medical specialists 5%
      • Sox. Ann Intern Med 2006;144:57
  • SOURCE: Colwill, unpublished manuscript NOTES: Figures include Allopathic and Osteopathic physicians, US graduates and IMGs. Total includes pediatricians. EXHIBIT 2 Generalist physician graduates, 1995 to 2005
  • NP/PAs to the rescue?
    • Nurse practitioner graduates have fallen from a peak of 8,200 in 1998 to 5,900 in 2005.
    • Physician Assistant graduate numbers have remained stable at about 4,200 for several years.
    • Probably fewer than half of NP/PAs are in primary care as they are increasingly employed in specialist offices, emergency rooms, and inpatient settings.
    • Colwill et al. Will generalist physician supply be adequate to meet tomorrow’s demand? Unpublished manuscript.
  • SOURCE: Colwill, unpublished manuscript NOTES: “Adjusted supply” - adjusted for age and gender and extends the 2001-2004 rate of decline of graduates through 2007. Adult Care: Projected Generalist Supply and Demand for patient visits Demand Adjusted supply
  • Access to primary care
    • A 2006 national survey: 24% of Medicare beneficiaries (10 million people) and 25% of privately insured patients reported having a problem obtaining a new primary care physician.
    • A Data Book: Healthcare Spending and the Medicare Program. Medicare Payment Advisory Commission, June 2007
    • A 2006 California survey: 46% of patients visiting the ED said that they went to the ED because they could not access their primary care physician.
    • Emergency Department Utilization in California. California Healthcare Foundation, Harris Interactive Inc, October 2006
  • Access to primary care
    • 49% of Massachusetts internists were not accepting new patients in 2007, up from 36% in 2006.
    • The average wait time for an appointment to see an internist was 52 days in 2007, up from 33 days in 2006.
    • Massachusetts Medical Society Physician Workforce Study, 2007
  • Access to primary care
    • In the U.S. the average time a patient spent with a primary care physician over the course of a year (2001-2002) was 29.7 minutes, compared to 55.5 minutes in New Zealand and 83.4 minutes in Australia.
    • Bindman et al. BMJ 2007;334:1261
  • Access to primary care
    • A 2006 international survey found that the US has the smallest proportion of primary care practices that provide after-hours care if needed (not ED):
      • US 40%
      • Canada 47%
      • Germany 76%
      • Australia 81%
      • UK 87%
      • Schoen et al.Health Affairs, November 2, 2006
  • The crisis in primary care
    • Patients are already having difficulty accessing primary care
    • The primary care workforce -- especially general internal medicine -- is expected to shrink while the population is aging and demand increasing
    • Patient access to primary care will get worse unless more primary care clinicians enter the workforce
  • Goals for this presentation
    • The crisis in primary care access
    • The reasons for the crisis
      • Primary care-specialty income gap
      • Uncontrollable worklife
      • How academic primary care practices aggravate the crisis
    • Can we fix academic primary care practices?
  • Median compensation, 1995-2004 -- MGMA data In thousands of dollars, before taxes
    • 1995 2004 10-yr increase
    • All primary care 133 162 21%
    • Family practice 129 156 21%
    • Internal medicine 139 169 21%
    • All specialists 216 297 38%
    • Invasive cardiology 337 428 27%
    • Noninvasive cardiology 239 352 47%
    • Dermatology 177 309 75%
    • Gastroenterology 210 369 76%
    • Heme/Oncology 189 350 86%
    • Orthopedics 302 397 31%
    • Radiology 248 407 64%
    • Surgery, general 217 283 30%
  • 2007 Medicare payment for 30 minutes physician time Complex est . Intermed new Colonoscopy Cataract $ Assumes geographic index approximately 1.0
  • The primary care-specialty income gap and uncontrollable worklife
    • Average medical student debt is $120,000 for public, and $160,000 for private, medical schools
    • The primary care pipeline is dwinding in part because of the primary care-specialty income income gap
    • An even stronger factor reducing primary care career choices is uncontrollable worklife
    • The income gap and uncontrollable worklife are related: primary care practices cannot survive without very large patient panels, and large patient panels create the uncontrollable worklife
    • Dorsey et al. JAMA 2003;290:1173, Whitcomb and Cohen NEJM 2004;351:710. Bodenheimer NEJM 2006;355:861.
  • Dysfunctional academic practices
    • Academic primary care practices are the models experienced by medical students and residents
    • When these practices do not work well, medical students and IM/FP residents hate working in them
    • As a result of these negative experiences, medical students and IM/FP residents look for any career except primary care
  • Voices of IM residents and medical students
    • “ I didn’t like the outpatient rotations one bit. They were isolating, with little social interaction. You went from patient to patient and you hardly talked with your colleagues. In-patient rotations had teams. Your colleagues were around. I liked that. Outpatient care was lonely. I hated it.”
  • Voices of IM residents and medical students
    • “ The ambulatory primary care rotation was not a positive experience. I was going to go into primary care. That made me not want to do it. It was impossible to have real continuity or longitudinal relationships with patients. It would be better to have a longitudinal clinical experience over a long period of time.”
    • “ People, especially medical specialists, told me I was too smart to go into primary care.”
    • “ When I worked with a primary care physician for a year and got to know the patients, I liked working in the clinic.”
  • Voices of IM residents and medical students
    • “ General medical clinic was not satisfying because there was no continuity of care. People talked about continuity but I never saw it.”
    • “ People in internal medicine subspecialties give you negative comments about primary care. Cardiology is one of the worst. They say that primary care docs are nice people but not very sharp. It got to the point that I was embarrassed to tell people that I was going into primary care.”
    • “ What sold me on primary care was the longitudinal clinical experience. You get to know your patients over time.”
  • Voices of IM residents and medical students
    • “ The clinic was very disorganized. The patient I saw 2 weeks ago got scheduled with another physician. More than half of the time I’m seeing someone else’s patient, which is bad for the patient, bad for me, and bad for the resident who is the patient’s regular doctor. In a year’s time, patients may see their personal physician twice and another doctor 6 times.”
  • Views from the literature on academic primary care practices
    • Weak ambulatory training fails to support the formation of continuous healing relationships between patients and physicians, undermining one of the most cherished aspects of becoming an internist. [IOM. Crossing the Quality Chasm:Washington, DC: National Academy Press, 2001]
    • Exposure to dysfunctional ambulatory settings leads students and residents to choose career paths other than general internal medicine and/or primary care. [Weinberger et al. Ann Intern Med 2006;144:927]
  • Views from the literature on academic primary care practices
    • Few internal medicine residency graduates have the skills needed to function effectively in the ambulatory setting. If one does not feel confident doing certain work, one avoids that work. [McGlynn et al. NEJM 2003;348:2635]
    • Only 13% of internal medicine residency training takes place in continuity clinic. [Bowen et al. JGIM 2005;20:1181]
    • Moreover, continuity clinic is often not continuity clinic; many residents are seeing each other’s patients.
  • Views from the literature on academic primary care practices
    • Hospital out-patient medical clinics are often frustrating, chaotic places to practice
    • Patients often see unfamiliar physicians
    • Physicians often see unfamiliar patients
    • Lack of continuity experiences is a factor turning residents away from primary care careers
    • Association of Program Directors in Internal Medicine position paper. Ann Intern Med 2006;144:920
  • Academic primary care practices
    • Leaders might respond: “It’s not our fault. Research shows that 3rd year internal medicine residents are more likely to choose primary care careers than first year residents. So we’re doing an excellent job.”
    • That’s great, but the % of internal medicine residents going into primary care dropped from 54% to 20% from 1998 to 2005 (a 30 percentage point drop), and the increase from year 1 to year 3 is 6 percentage points. Moreover, the data came from only 14% of all internal medicine residents. [Sox, Ann Intern Med 2006;145:782]
  • Summary: why is primary care in crisis?
    • Reimbursement is low compared to specialist reimbursement
    • Uncontrollable lifestyle
    • Negative experiences in medical school and residency
  • So who is falling down on the job?
  • Who is falling down on the job?
    • We are
    • We have met the enemy and it is us
    • We -- who train the nation’s primary care physicians -- must assume a portion of the responsibility for the crisis in primary care
  • Do we care?
    • Each one of us -- academic leaders -- must ask the question to ourselves:
      • Is it one of my personal goals to ameliorate the crisis in primary care?
  • Our vision of the primary care academic practice
  • The reality of too many academic primary care practices
  • Definition of specialists
    • Physicians who know more and more about less and less
    • Until they know everything about nothing
    • Primary care docs
    • Know less and less about more and more
    • Until they know nothing about everything
  • Goals for this presentation
    • The crisis in primary care access
    • The reasons for the crisis
      • How academic primary care practices aggravate the crisis
    • Can we fix academic primary care practices?
    • Would you rather see
      • Your own patients
      • Patients of another clinician?
    • As patients (because we are or will be patients also), would you rather see
      • A clinician you know
      • A clinician you don’t know?
  • Continuity of care
      • 2 adult patient surveys in the late 1990s
      • 3/4 of adults place high priority on continuity of care (seeing their PCP when they need care)
      • Only 16% prioritized access and convenient appointment times over continuity
      • Safran, Ann Intern Med 2003;138:248.
  • Continuity of care
    • Continuity of care is associated with
      • Improved receipt of preventive services including cancer screening
      • Decreased frequency of ED visits
      • Fewer hospital admits
    • There is a very strong correlation between continuity and patient satisfaction
    • Koopman et al. Arch Intern Med 2003;163:1357; Fan et al. JGIM 2005;20:226.
  • Continuity of care
    • “ Hand-offs” from one clinician to another are a necessary feature of discontinuous care
    • Communication failures in hand-offs is a major source of medical errors
    • Continuity of care is safer
    • Philibert and Leach. Qual.Saf.Health Care 2005;14:394
  • Continuity of care
    • Review of 40 studies reporting 81 outcomes
    • Positive association with continuity of care in 51/81
    • Outcomes included
      • Preventive care
      • Quality of doctor-patient relationship
      • Chronic illness measures
      • Maternity care outcomes
      • Saultz and Lochner, Ann Fam Med 2005;3:159
  • Continuity of care
    • 20 studies were reviewed for associations between continuity of care and
      • Reduced hospitalizations
      • Reduced emergency department visits
      • Declines in overall costs
    • 19/20 studies: significant association between continuity of care and cost measures. Strongest was for reduced hospitalizations
    • Saultz and Lochner, Ann Fam Med 2005;3:159
  • Continuity of care
    • Danish study of 474 primary care physicians and 1136 patients with diabetes
    • Patients who were well known by their physician had lower HbA1c than those not well known by their physician
    • Drivsholm and Olivarius, Fam Pract 2006;23:192.
  • Continuity of care
    • Patients with asthma who have increased continuity of care (seeing the same clinician) have a reduced use of the ED, fewer hospital admissions and hospital days
    • Cree et al. Dis Manag 2006;9:63.
  • Continuity of care
    • Continuity of care with a primary care physician for patients with type 2 diabetes is associated with improved processes of care and better glycemic control
    • Parchman et al. Medical Care 2002;40:137; Parchman et al. J Fam Pract 2002;51:619.
  • Continuity of care
    • According to a 2003 survey, physicians in the US place great value on personal continuity of care. On a 5 point scale, with 5 points indicating that continuity is very important, the mean score was 4.77.
    • Stokes et al. Ann Fam Med 2005;3:353
  • Continuity of care
    • It is unusual for a health system property to have so much evidence supporting it
      • Patient satisfaction
      • Outcomes
      • Costs
    • Continuity of care is a winner
  • Continuity + Trust
    • Trust is a patient’s expectation that the clinician will act to enhance the patient’s well-being
    • Trust involves patients’ perceptions of a clinician’s
      • Technical ability
      • Interpersonal skills
      • Concern for the patient’s welfare
    • Thom et al Health Affairs 2004;23:124.
  • Continuity + Trust
    • Trust and adherence to physician recommendations
      • Highest quartile of trusting the physician: 62% adherence
      • Lowest trust quartile: 14% adherence
    • Thom et al Health Affairs 2004;23:124
  • Continuity + Trust
    • Patients who trust their physician stay with their physician; those who don’t are far more likely to leave their physician. So trust increases continuity
    • Continuity (long relationships) can increase trust
    • So, trust and continuity are interrelated
    • Thom et al Health Affairs 2004;23:124.
  • Continuity + Trust
    • Safran et al linked attributes of primary care to 3 outcomes: adherence to physician advice, patient satisfaction, and health status.
    • The primary care attributes most closely associated with those outcomes were
      • Physicians’ knowledge of the patient (the “whole person”) -- which is related to continuity
      • Patients’ trust in the physician.
    • Safran et al. J Fam Pract 1998;47:213.
  • Continuity + Trust
    • For elderly Medicare beneficiaries, the longer the relationship with a physician the greater the
      • Physician knowledge of the patient
      • Trust
      • Delivery of preventive services
    • Parchman and Burge. Fam Med 2003;36:22
  • Continuity and trust: a true story
    • Friday was not a good day. Don -- my son with a history of a brain tumor with swallowing problems and aspiration -- had been admitted for pneumonia. The only person with a broad knowledge of Don’s history, whom Don trusted, was Dr. Lisa Goode, his PCP. She was out of town. I suggested to the nurse that Don should get up and start moving around since copious amounts of phlegm had accumulated in his chest.
    • “ I’ll help,” I offer
    • “ Sorry, we must call PT for that” said the nurse
    • “ OK,” I say, “can we do that?
    • “ No” says the nurse. “PT requires a doctor’s authorization”
    • “ OK, let’s ask a doctor to order it.”
    • “ No” she says, “It has to be the doctor who admitted Don”
    • “ Fine, let’s call him”
    • “ He’s off today,” she says
    • End of the line for getting anything good accomplished
    • The next day Dr. Goode returned. Suddenly everything got better.
  • Continuity of care and trust It’s beautiful
    • How do we fix academic primary care practices in order to  Make them more satisfying for students and residents?  Improve care for patients?
  • Visions of a new academic primary care practice
    • Continuity of care is the fundamental principle
    • Patients, students, residents want continuity
    • Seeing your patient is 100x more satisfying than seeing someone else’s patient
    • We are not discussing the business case. The overall vision and fundamental principle must come first; second you figure out how to make it work financially
    • Some residency programs have already accepted this as the principle and are working to implement it
  • Visions of a new academic primary care practice
    • How do we organize an academic primary care practice based on continuity of care when residents necessarily rotate?
      • Change how residents rotate (e.g. the long block)
      • Establish a team in which someone else is the glue creating continuity
      • Both
  • Visions of a new academic primary care practice
    • Full-time NP or PA as the glue
    • Patients are panelized to the NP/PA
    • A few residents become a “pod” which cares for the panel of one NP/PA. The fewer residents in each pod, the greater the continuity
    • Each resident in the pod is responsible, with the NP/PA for a portion of the patients in that panel
    • The NP/PA communicates frequently with the resident while the resident is elsewhere
  • Visions of a new academic primary care practice
  • Visions of a new academic primary care practice
    • If NP or PA is not available, the glue could be a RN
    • In that case, the care she/he could provide would be more limited and more consultations would be needed with the resident
  • Visions of a new academic primary care practice
    • Teams are proposed as the solution to almost anything
    • Research on teams is discouraging; many studies of teams reveal that they are often dysfunctional
    • One uncooperative person can destroy team cohesion
    • Team members must have clear division of labor, training, and clear modes of communication
    • A team of 3-4 people needs to communicate constantly. The more the work is divided up, the more handoffs are needed. More handoffs means more fumbled handoffs
    • Bodenheimer and Grumbach. Improving Primary Care: Strategies and Tools for a Better Practice (McGraw-Hill, 2007).
  • Teamlets
    • If the problem with teams is the transaction costs of handing off work from one team member to another, perhaps a team of 2 would allow for the advantages of a team while minimizing the disadvantages
    • At SF General Hospital Family Health Center, we have large teams; when we created small teams of 2 people we called them teamlets (a subunit of the team or a small team)
  • Teamlets
    • The teamlet concept is an attempt to address the fundamental pathology of primary care -- squeezing everything (preventive, chronic, acute, care coordination, relationship building) into the 15 minute visit
    • Instead of a doctor seeing a patient in 15 minutes, the teamlet encounter involves a doctor plus another person seeing a patient for more time -- previsit, visit, postvisit, between visit care
    • We call the other person a coach
  • Teamlets
  • Teamlets
    • Who is the Teamlet Coach?
    • It could be RN, health educator, medical assistant, community health worker
    • Coaching means helping patients and families to learn the skills and knowledge needed to be active, informed participants in their care
    • Good coaches make visits more meaningful for patients because they are longer and more things are done
    • Good coaches make worklife better for physicians because they offload work that one doesn’t need an MD degree to do
  • Teamlets
    • Teamlets can address continuity of care
    • A patient is panelized to a resident and a teamlet coach
    • If residents are in clinic 3 half-days per week, each coach works with 3 residents
    • The coach is present all clinic hours and is available to the patient during clinic hours
    • The coach can contact the resident if the patient needs a physician
    • The coach can make more or fewer decisions depending on whether the coach is RN or MA
  • Teamlets at SFGH Family Health Center
    • Coaches are mainly MA, community health worker
    • Coaches ethnic/language concordant with patients: Spanish, Cantonese, Mandarin, Burmese, Cambodian, Laotian, Vietnamese, Russian, Bosnian
    • 11 coaches working with first-year family medicine residents in Thursday afternoon chronic care clinics
    • Coaches in visit (may translate) plus do post visit and between visit care
    • Patients can call coach if problems develop between visits, and coaches can contact resident
    • Goal is continuity between patient, resident and coach -- logistically difficult to achieve
  • Final thoughts
    • There is a growing crisis in the primary care workforce, and in patient access to primary care
    • Reasons for the crisis
      • Primary care-specialty income gap
      • Uncontrollable worklife
      • Negative training experiences in academic primary care practices
    • Our responsibility as primary care educators is to fix academic primary care practices, in particular to re-design curricula and practice organization to maximize continuity of care for patients, residents, and medical students
  • Final thoughts
    • “ More than half of the time I’m seeing someone else’s patient, which is bad for the patient, bad for me, and bad for the resident who is the patient’s regular doctor.”
    • “ The ambulatory primary care rotation was not a positive experience. I was going to go into primary care. That made me not want to do it. It was impossible to have real continuity or longitudinal relationships with patients.”
    • “ What sold me on primary care was the longitudinal clinical experience. You get to know your patients over time.”