Author Archive

The super charge

Texas House Speaker Joe Straus, R-San Antonio, released the interim charges for the standing committees of the House of Representatives. As he said in the accompanying letter, these charges will set the stage for legislation considered during the 83rd Texas Legislature, which convenes in January 2013.

Of those that may affect family medicine, one assigned to the House Committee on Public Health stands out for its sheer immensity. It directs the committee to:

  • Examine the adequacy of the primary care workforce in Texas, especially considering: the projected increase in need (from an aging population and expanded coverage through federal health care reform), and cuts to workforce-building programs such as graduate medical education and physician loan repayment programs.
  • Study the potential impact of medical school innovations, new practice models, alternative reimbursement strategies, expanded roles for physician extenders, and greater utilization of telemedicine.
  • Make recommendations to increase patient access to primary care and address geographic disparities.

That about says it all, right?

Fortunately, TAFP is in a good position to positively influence the state health care reform discussion thanks to our members’ grassroots involvement through the TAFP Political Action Committee and the wise direction of big-picture strategists.

Because we’ve cultivated relationships with lawmakers, their staffs, and other capitol playmakers, they know the many benefits of primary care, family physicians’ concerns with the current system, and I’m convinced they even recognize the fonts and imagery on TAFP’s issue briefs. That means that we can actively work through the interim and the 2012 election cycle to proactively advance family medicine, and when the opening bell rings in January 2013, we’ll have laid the foundation to make substantial gains.

I invite you to use the comment section to give us your thoughts on any of the objectives above to give us direction as we move forward.

To the educators, what changes would you make to medical school curriculum that would provide the greatest benefit to the next generation of physicians?

To the innovators, actively experimenting with new practice models, what have you seen as the biggest barriers to controlling costs and providing the best care for patients?

To the rural physicians, what incentives are needed to draw more doctors to your area?

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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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Eight things I learned from my tonsillectomy

By Janet Hurley, M.D.

Having been a patient not too long ago, I am convinced that doctors should be patients more often.  As we continue to talk more in health care about “patient-centeredness” and the “patient experience,” I have a few thoughts on things I learned during my convalescence period after a tonsillectomy in 2009.

1)       My surgeon, my anesthesiologist, and the surgical center staff were GREAT.  As providers, the things we do become routine to us, but to patients they are extraordinary. Taking the time to explain a procedure carefully and thoughtfully can make a big difference.

2)      Follow directions.  Patient handouts have important information in them and the treatment team knows what they’re doing.  I must remember to listen to their advice and review the patient materials when I have questions.

3)      Don’t be your own doctor!  If you have questions about medications or symptoms, ASK SOMEONE ELSE.  You may choose to be a highly educated patient, but not your own doctor.

4)      I am not too tough for pain medications.  While I dislike the mental fogginess they create, I had to keep in mind steps I prescribe to my patients—maintain better hydration, better nutrition, and keep my throat moist—to make myself more comfortable.

5)      I will never even think about accessing my Electronic Medical Record from home until fully off narcotics.  Impairment was obvious. 

6)      When on narcotics, I communicate better with my fingers than my tongue. You can’t rush recovery, even when you know you have important work to do. E-mail communication with others kept me connected when my speech was slurred and my throat hurt.

7)      I have great clinic coverage partners.  I had no worries about who would check my messages, approve refill requests, and see my patients when I was out.  We must remember that good patient care during such times requires that we receive help from our colleagues.

8)     Don’t undervalue the significance of family and friends.  I am grateful to my husband who took care of our kids and took care of me, and the friends and neighbors who looked for ways to help out during my recovery.  It’s okay to lean on those closest to you in times of need!

Janet Hurley, M.D., is a family physician at Trinity Clinic in Whitehouse, Texas.

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Reflections of a pre-med student

As a pre-medical student and journalism/biology double major at UT, I was extremely excited when I saw TAFP’s internship posting. I thought it would be a great opportunity to learn more about what issues concern family physicians—a career I’m interested in—while applying and improving my journalistic skills. During my time at TAFP I’ve learned a lot about the issues family physicians face and that there is plenty a physician must care about outside of the exam room.

Last week I wrote a short article summarizing the results of the 2011 Main Residency Match and how family medicine fared.  I was glad to see that family medicine is on the increase, but seeing that only about half the residency spots were filled by U.S. graduates while other specialties were almost exclusively filled with these students put into perspective that family medicine isn’t an alluring future for many U.S. medical students.

Match Graph

As a pre-medical student, the Match Day data made me stop and reflect on my personal thoughts about family medicine. The first thing that came to mind is how medical debt pushes people away from the field of family medicine.

Before I was an intern at TAFP I knew about physician payment and medical school debt superficially—that family doctors aren’t the highest-paid doctors and that medical school is expensive. But, after interviewing physicians for various stories I was able to think about these issues with more depth and often draw upon a personal story they shared with me.  

One physician told me she is encouraging her daughter to look at options besides medical school because of the massive debt.  Others told me that the huge pay gap between family physicians and medical specialists plays a big factor in driving medical students away from primary care and into more lucrative fields. This certainly came through in the Match Day data as residencies in fields with the highest pay grade were the most popular.

Income Gap

I also thought about the new problems I’ve learned about, like the struggle between family docs and nurse practitioners for practice domains or how IMGs in Texas face licensing roadblocks that cause some to leave the state altogether. It worries me to see all the health professional shortage areas in Texas, then learn about IMGs leaving and U.S. medical students going to other fields. And seeing the huge pay gaps between specialties and general practice is frustrating.

Despite the problems facing family medicine, what I find more memorable are the qualities of the family physicians I have interviewed and researched for stories. Every family doc I have spoken to is a high-caliber person whose impact on their community isn’t limited to their practice. Some speak out on behalf of TAFP; others organize community events to promote wellness or lead medical trips to foreign countries to help underserved communities.

It is especially inspiring for me to talk with female family docs who are established and successful physicians and moms at the same time. When thinking about the timeline of education and residency, I’ve wondered how women find time to find a partner and start a family. It is reassuring to talk to female doctors who have done just that.

Besides talking with family docs, I’ve learned about other topics that make me feel more optimistic about the future of family medicine. I’ve learned a lot about the health care reform law and how it relates to primary care physicians, and I’m glad to see Congress includes provisions that highlight primary care physicians as an important foundation of the health care system that needs to be supported.

What makes me feel the best about family medicine are physicians deciding to turn their practices into “medical homes” where patients and doctors get to know each other and forge a trusting relationship, care is coordinated, and technology is embraced to enhance communication between patient and physician.  My grandfather, Opa as I call him, was a medical student in Italy in the 1940s; he wasn’t able to become a licensed physician because he had to escape as a political refugee. Nonetheless, the stories he tells me about practicing medicine radiate the passion he feels about caring and reaching out to the patient above all else. I believe the medical home embodies how he believes medicine ought to be practiced.

All in all, my experience at TAFP has shown me many sides to what family docs must face to care for their patients. While problems exist, I’m excited about the future of family medicine, especially with the health care reform law including provisions supporting family docs, and I hope the family residency Match Day numbers are even better next year.

 Monica Kortsha is TAFP’s spring communications intern. She is a third-year pre-med/journalism student at the University of Texas at Austin.

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Texas can improve care and cut costs with the medical home

By Greg Sheff, M.D.

I was fortunate to be one in a group of primary care physicians who met with Lt. Gov. David Dewhurst this February to discuss possibilities of payment reform in Medicaid, the Children’s Health Insurance Program, and the private insurance market.  This meeting comes on the heels of the introduction of two major pieces of legislation, Senate bills 7 and 8.  These bills would implement a host of pilot projects to test bundled payments, payments based on episodes of care, and quality incentives.  It continues the positive momentum the state needs to move us away from a fractured health care system into one that provides the right care for Texans.

The unrelenting march of increasing health care costs is unsustainable, both for Texas and for the nation. Payment reform that aligns physician and hospital incentives with our society’s goals—affordable, coordinated, evidence-based, quality-measured care—is critical to rein in health care costs.  The patient-centered medical home, driven by a strong primary care workforce, is a proven cost-effective method for delivering this coordinated and integrated care.

Earlier this year, Austin Regional Clinic (ARC) joined a multi-year medical home pilot administered by Blue Cross and Blue Shield of Texas (BCBSTX).  The pilot was initiated in large part in response to Texas legislation requiring the Employees Retirement System (ERS), the self-funded insurer for state employees, to experiment with alternate payment and delivery models in an attempt to reduce the state’s ever-increasing health care costs.  We are one of five physician groups in the state participating.  Our program serves roughly 45,000 patients, including both the ERS (whose health care benefits are administered by BCBSTX) and BCBSTX fully-insured populations.

As we have seen with our ARC Medical Home Program, there is a definite tipping-point phenomenon in getting providers to commit the resources necessary to proactively coordinate patient care.  We have been approached by a number of payers investigating our capability to transform our care delivery model.  However, not until we were approached with a payer as large as ERS were we able to make a compelling internal business case for investing the resources to transform our own workflows.

For me, this is the real pearl in the ERS Medical Home initiative: The Legislature, with control of Medicaid, CHIP, and ERS/Teacher Retirement System payments, has the opportunity to change—not by mandate but by example—the cost of care delivered across Texas.

However, a primary-care-led health care system cannot exist without actively nurturing and growing the primary care workforce.  Since its inception, ARC has emphasized the importance of long-term doctor/patient relationships, coordination of care, and a strong primary care physician base—three major tenets of the medical home model.  Drawing upon ARC’s 30 years of experience, I cannot overstate the importance of supporting initiatives to increase the number of medical school graduates choosing a career in primary care.

Payment and delivery system reform for ERS/TRS, Medicaid, and CHIP patients, coupled with an investment in growing our primary care workforce, helps not only the Texas budget in the short and long term, but provides the seeds to transform all care in Texas.

Gregory Sheff, M.D., is the medical director for the ARC Medical Home Program.

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Welcome to the Texas Family Docs blog

Welcome to the next experiment in TAFP member interaction, the Texas Family Docs blog. In a post-health-reform era of rapid changes to the practice of medicine, your Academy hopes to use this space to delve into the topics most important to the family physicians of Texas.

This means explaining measures of health reform as they are implemented and tweaked, but also providing an insider’s look into Texas health policy, sharing practice management tips for all settings, highlighting tools and resources to improve your practice experience, sharing media links from the most influential medical journals, and more.

This is where you come in. The entire project began because you asked us to bridge these tough topics in a highly active forum. We want this to be a space where members contribute to the discussion. Comment on our posts or ask us how to submit your own. Share the most pressing issues facing your practice, a story from your medical training, or a “best practice” pearl that has helped you along the way. The possibilities are endless.

As the specialty of family medicine moves forward, we hope you’ll join us. Questions? Want to become a contributing author? E-mail tafp@tafp.org.

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