Archive for October 2011

From the editor: Introducing a new look for Texas Family Physician

Eleven years ago, when I came on board as managing editor of Texas Family Physician, I was fresh out of journalism school with a love for design and an eye for art, photography, and typography, but no real-world experience in producing magazines. I learned much in those first few issues about the nuts and bolts of magazine production, all the while trying to appear as though I knew something about an expanding range of increasingly complex editorial topics my new magazine was required to cover.

My first cover story tackled the problems with the financing of graduate medical education – talk about jumping in at the deep end.

During those first issues, I knew the magazine needed a new look, a form and function that could achieve the news and information focus we wanted to deliver, while keeping the warmth and conversational nature we wished to convey. In 2002, we launched the first redesign of TFP under my direction, and while we’ve worked in each issue since to refine that design, I believe the artistic concept has served the Academy well.

For the past couple of years, we’ve been working on a fresh face for our magazine, a reinvention of the basic building blocks of the design, and with our Fall 2011 issue, we’re happy to unveil the new design. With a new nameplate and cover design, a fresh set of fonts, and a commitment to packaging content in smaller, more easily digestible bits, I believe this evolution of Texas Family Physician will keep our magazine at the top of its class.

Watch your mailbox and give it a read or view the virtual issue at issuu.com/txfamilydocs/docs/4mag2011. I hope you enjoy our new and improved Texas Family Physician.

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Hart of Dixie: Feel-good family medicine hits the small screen

By Juleah Williams

Among this season’s new fall line-up comes a new drama from the CW – Hart of Dixie – featuring surgeon-turned-country doctor Zoe Hart. Full disclosure: As can be expected from most CW programming, this show is geared toward a teenage audience and includes enough love triangles and “frenemies” to keep their attention. However, exposing this young population to the benefits of primary care and emphasizing the importance of having a relationship with a personal family physician is crucial to increasing interest in the specialty down the road.

As the story goes, Zoe graduated at the top of her class from medical school and seeks to follow in the footsteps of her father, a cardiothoracic surgeon. After residency she fails to be accepted into a fellowship because her superiors deem her “too cold.” Desperate, she decides to accept the offer of a kind stranger—who turns out to be her real father—to join his family medicine practice as a general practitioner in Bluebell, Ala.

Zoe moves from New York to Alabama to find that her real father has passed away and left her half of the family medicine practice. His former partner, Dr. Brick Breeland, resents the young hotshot doctor’s presence.

As a side note, while it’s technically correct that she can enter practice as a “general practitioner” without completing a residency, they refer to her later in the episode as a family doctor. Her patient population may include entire families, but she didn’t complete her three year residency in family medicine – and this is a little misleading for viewers.

Technicalities aside, the show’s characters find themselves in mostly-realistic, but dramatized medical emergencies that you might expect in a rural setting. And it’s in these moments that family medicine really shines. In the most recent episode, Zoe is nearby when a farmer’s arm is trapped under a piece of heavy equipment. Moving the machinery will cause him to bleed to death, so she must perform an arterial clamp in the field. However, she must call her indignant practice partner Brick for assistance because…wait for it…she was bitten by a snake earlier in the episode and only has one usable hand.

When he arrives, Brick doesn’t know how to perform the procedure and he refuses to let her talk him through it; he doesn’t want to be “her puppet.” Of course he relents for the good of the patient and together they save the farmer’s arm and life. As word spreads through the town, Brick receives all of the credit and Zoe (who has been trying her hardest to fit in) gets jealous.

This is the big moment: Zoe confronts Brick, saying that he couldn’t have performed the procedure without her. He replies with the fact that after the patient was out of danger, she left. He calmed the panicked patient, rode with him to the hospital in the ambulance, spoke to his wife and reassured her that their livelihood would be okay – all part of his comprehensive care after the initial encounter. This is the “ah-ha” moment of the show as Zoe recognizes that she has a lot to learn about being a primary care doctor.

So for now, the show portrays family physicians as the quintessential doctors – able to care for medical needs while adding an extra element of having a strong  relationship with patients and a deep understanding of the community. That’s spot on. As the season continues, I’m intrigued about how the show will ultimately portray the small town family physician.

Juleah Williams is TAFP’s Student, Resident, New Physician, and Membership Coordinator.

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The unintended, but not surprising, negative consequences of hospitalism

By Richard Young, M.D.

A recent study in Annals of Internal Medicine looked at what happened when patients were cared for in the hospital by private physicians (presumably often their personal physicians) compared to hospitalists.

For a little background, hospitalists are doctors whose job is limited to taking care of patients in the hospital. They pick up new patients in shifts or cycles and almost always have no previous relationship with the patients. They rarely see patients in clinics and have no long-term outpatient relationships with patients.

This study found that hospitalist patients stayed in the hospital 0.64 days fewer than the private physician patients. This finding is consistent with previous studies. However, hospitalist patients were 18% less likely to be discharged home (more likely to a nursing facility), 18% more likely to make an ER visit in the 30 days after discharge, and 8% more likely to be readmitted to the hospital. This study was important because it measured real world performance across the U.S. after previous controlled studies showed the hospitalist approach had merit.

The hospitalist movement was born from many factors. One was the assumption that a doctor who is at the hospital can be more efficient because he can, for example, check on a patient later in the day and discharge the patient if a test performed in the middle of the day came back normal in the afternoon (while the private practice physician won’t come back to the hospital until the next morning). The private physician is paid nothing for any work past the first patient encounter each day. The hospitalist isn’t either, at least as a payable charge to Medicare or most insurance companies, but he’s at the hospital anyway so it’s not nearly as inconvenient for him to see the patient again.

To my knowledge, no study or private initiative has ever tried to preserve the personal physician-patient relationship in the hospital by paying the physician for the time it takes to do further work in one calendar day beyond the initial trip to the hospital–neither face-to-face work nor work performed electronically.

The best summary on the research of the impact of hospitalism to me is exactly what this study found — the length of stay decreases a little and is associated with a few problems down the road. Whether a patient spends three days or 10 days in the hospital has a lot more to do with how sick she is, not the kind of doctor providing the care. My biases about family medicine are transparent, but I can’t help wondering: if there is no significant improvement for a patient so sick she needs to be in the hospital to see a hospitalist, then why not create incentives and processes to encourage the pre-existing relationship with her family physician to continue in the hospital, especially when is she is the most ill, vulnerable, and scared?

The hospitalism movement is not a hindrance to improving our health care system, but it’s no solution either.

This post originally appeared on American Health Scare blog on Sept. 4, 2011. It has been reprinted with permission from Richard Young, M.D.

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Payment Reform recap: Demonstrating value

Following the most basic model for success in business means minimizing overhead and maximizing revenues, Dr. Mark Laitos pointed out at TAFP’s Payment Reform Summit last Saturday. For doctors in private practice and other health care providers, this means billing for as many relative value units, or RVUs, as possible at the best conversion rate, and maximizing ancillary revenue, when possible.

And while this strategy is simple enough, Laitos said it has reduced the “proud field” of medicine to “conveyor belt medicine.” Worse, as payers – including health insurers, employers, and patients to some extent – strive to minimize RVUs, the solution to the cost crisis in a fee-for-service system is to slash payment to physicians and deny care to patients.

Of course neither patients nor doctors (nor the organizations that advocate for them) would allow this to happen considering the scale needed to rein in escalating health care costs. The solution, then, as speaker after speaker suggested, is to trade the volume-based model for a value-based model. This is also the cover story of the latest Texas Family Physician magazine.

Dr. Laitos was the first to bring up the triple aim – three things a health system should strive to do: improve the health of the population, improve the patient experience of care, and reduce the per capita costs of care. This Health Affairs article goes into more depth, but it sounds a lot like the concept behind accountable care organizations – that care should be primary care-based, consider population health, empower patients, and integrate with other care providers on a macro level.

Dr. Eduardo Sanchez, a family physician and medical director of Blue Cross and Blue Shield of Texas agreed on two points, referencing a still-amorphous “virtual medical community” that aims to connect smaller practices currently organized as “onesies, twosies, and foursies” by providing them with a platform for information exchange and management.

He also brought up BCBSTX’s Bridges To Excellence program as a way for physicians to be recognized as high-performing. “Physicians will have to be able to capture data, analyze that data, and have ability to adjust what those data reveal. BTE and PQRS [Physician Quality Reporting System] are not the answer, but they are a way to get started and learn how to manage the system for quality improvement.”

Dr. Chris Crow of Plano, another speaker at the summit, asserted his strong belief in using data and analytics to measure quality and costs; he’s used it in his practice to provide better, more efficient, and more cost-effective care, and he can demonstrate this through real figures to any interested party. Dr. Crow said that once a physician has access to quality and cost measures, he or she can begin to implement changes to improve care services. Not knowing the metrics is like “driving a car without a dashboard.”

Dr. Laitos asserted that there will be winners and losers in health care reform. “The winners will be the doctors who know how to demonstrate value.”

To read more about the Payment Reform Summit, check out TAFP’s coverage published in last week’s QuickInfo e-newsletter. Also stay tuned for video recordings of the lectures to be published later this fall.

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With Texas health care in the spotlight, opportunities abound

As could be expected, Gov. Rick Perry’s decision to seek the Republican nomination for president has intensified state and national media scrutiny of Texas’ health care record, particularly regarding the uninsured, Medicaid, health care costs, and our medical liability climate.

TAFP has long been on record in our public positions—from “Fading Away” to “Fractured” to “The Primary Solution”—that starving down our primary care infrastructure and the continued fragmentation of care across the spectrum of settings  transcends moral concerns and translates into very real economic consequences that threaten everyone from local taxpayers to employers and families. We have been equally ardent in our position that a vibrant primary care delivery system operating in a healthy liability climate is the solution to the crisis facing our health care delivery system.

Armed with these resources, TAFP’s physician leaders, lobby team, and advocacy staff have routinely briefed top Texas political and health care writers, as well as legislators and their staffs, particularly leading up to and during legislative sessions. Now TAFP has been called upon for similar briefings and interviews by a rapidly growing body of national writers from media outlets as diverse as CBS News, NBC News, NPR, the Wall Street Journal, the Los Angeles Times, the Washington Post, the New York Times, the Boston Globe, Kaiser Family Foundation and Politico, the Hill, and others.

TAFP anticipates that over the course of the next year and possibly beyond, the national attention paid to Texas will only escalate. This creates an opportunity to continue serving as a national leader to explain the socioeconomic and delivery system challenges plaguing our system, but more important to trumpet the role of family physicians as vital to the solution.

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