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As I have to drive to Marietta Georgia to share a holiday meal with my extended family, I want to make myself feel better by believing there must be a good reason. It seems that there are many good reasons for us to drive 10 hours to do so as found here:

Eating together encourages communication (for good or for ill, I suppose)

Teenagers who eat with their families are less likely to smoke, engage in high-risk sexual activities, or illicit drugs (probably because mom and dad are at the table, making all of these activities immediately less enjoyable for the teenager)

Adolescent girls are less likely to have suicidal thoughts (and perhaps more likely to have homicidal thoughts regarding their parents)

In all seriousness, research done by Harvard University has followed the lives of many children who grew up in families who committed to family meal time. They found these children became better adjusted adults who were able to weather the stresses of adolescence thanks to the sense of protection that family meals provided.

So go out, sear some meat, and make some ice cream with a blood (or other) relative.

Happy Fourth.

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An interesting month for healthcare in Alabama. First, Southeast Alabama Medical Center in Dothan announced a $40,000,000 investment in Osteopathic medical education. Scheduled to enroll 150 students in the fall of 2012, this school will “pay back” the investment through tuition. The stated purpose of this school is to develop physicians for the delivery of primary care in Alabama. According to the hospital CEO “The backdrop for all this is the scarcity of primary care physicians. The state’s medical schools, UAB and the University of South Alabama, produce specialists, cardiologist and surgeons, but there is a need for family-care physicians, especially in rural Alabama.”

The primary for Governor was Tuesday here in Alabama. On the Democratic side, the very bright and articulate Artur Davis lost to Ron Sparks, in part by alienating his base with a vote against healthcare reform. On the Republican side, Dr Robert Bentley came out of nowhere to (if the recount doesn’t change anything) challenge Bradley Byrne for the Republican nomination. Dr Bentley is one of the few candidates who responded to the Alabama Rural Health Association’s questions to the candidates. He too feels that the answer is more doctors. He told ARHA ” We want to establish the Alabama Health Service Corp which will set aside 25% of the seats in our medical schools for primary care this includes family medicine, internal medicine, pediatrics obgyn, and general surgery. These students will be given full scholarships and a place in medical school without lowering the quality of the emission standards. Upon completion of their residencies these physicians will give back to Alabama four years of full time service in an area of need. I was involved from the beginning in the Alabama Medical Education Consortium. This program deals with the education of Alabama students in osteopathic medical schools throughout the country. This summer we will have our first group of graduates that will enter practice most of these are primary care physicians. At present we have over 150 students in this program. We are working towards evolving the AMEC program in cooperation with certain hospitals in the wiregrass are to form an osteopathic medical school. This will give us a larger number of potential primary care physicians for the state of Alabama.”

It is a shame that the state of Alabama is providing tax-payer subsidized medical education to almost 300 students annually through its two existing medical schools, and yet we have such a need that we are going to have another medical school established just to put doctors in primary care in Alabama. This school will not be subsidized but instead will require the students to pay the entire cost of their education (about $50,000 annually vs about $17,000 for the state schools).

Until we change our delivery system, I suspect these students won’t go into primary care either. In Alabama we continue to have a delivery system that rewards episodic fee-for-service care over comprehensive patient centered primary care. We are not training medical students at USA and UAB to work with the medical team in a collaborative manner . I suspect that without delivery system reform, the increases in physicians promised by AMEC will likely not translate into increased numbers of primary care physicians in Alabama just as the formation of the University of South Alabama in the 1970s didn’t relieve the shortage. It will take the primary payors (Blue Cross/ Blue Shield of Alabama and Alabama Medicaid) making delivery system reform a priority, disregarding opposition from other interests, for the shortage to be resolved.

Dr Lamar Duffy had an article published in one of our more prestigious specialty journals this past week. Several years back, we made a decision as a practice to use “e-prescribing” for all of our prescriptions (took away the pads). Lamar and Angela Yiu (among others but they were the main ones) had the vision to begin collecting data before, during , and after this transition. They found a decline in the number of after hours phone calls. Not an earth shattering finding but it proved that we can study the process of care with enough rigor to get papers published. This is important because a lot of our health care mess is due to a broken process that needs to be described and improved in a systematic fashion. Also, it showed that even in a small department like ours we can occasionally keep up with the big boys.

Now that I’m over 50, have enough grey hair, and have children in college, people occasionally ask me for career advice for their children. The question goes something like “My son/daughter thinks they might want to be a doctor. Would you be willing to talk to him/her about it?” I always am happy to have a conversation about medicine and have met some remarkable young men and women in the course of these conversations. Because it is again that time of the year, I thought I might post some of my thoughts. If you are already a doctor or have thoughts regarding the topic, feel free to add your two cents as well.

1) No matter what, we like our doctors smart. If you are even considering being a doctor you needed to start working on test skills in 8th grade because we pick our doctors based on test scores. This means that people who go to “good” school have an advantage as do people who come from wealthy families. If you struggle as a student we believe you will have trouble making it through the system. This is a real problem in rural America where the emphasis has not been on identifying smart students early and working to give them have more of an advantage. We are often not willing to take chances with marginal prospective doctors, no matter how well intentioned they are. We need more programs that help students from rural and underserved communities achieve because growing doctors from within is the best way to do it.

2) As a physician, you are guaranteed a very good living but not a great living. I realize that they tell people applying for medical school never to discuss money but I’m putting this out there. Me and my colleagues are paid at the top 5% of all earners in the richest country in the world. This allows you to live very comfortably but also puts you in an awkward position in that the majority of folks you care for will have a very different set of concerns and worries than you do. The other weird thing is that the way doctors are paid makes some doctors think they are rock stars when the money they make really reflects the weirdness of our payment system. This is problematic when the doctors feel like they are owed the money by society and the ground rules for paying change (which they do periodically). If you live up to every penny, it tends not to end well.

3) As a physician you will have to work hard, and not in the way you think. I compare myself to my chemical engineering friends. Both of us came out of school with a complex, technical knowledge base. The difference is that companies who hire engineers fully expect that after 10 years or less the knowledge will be outdated and the engineer will either move into management, attempt to stay current, or move into another field. As a physician you will need to keep up with medical literature at times when you are not seeing patients. This means a lot of after hours reading of medical journals when others are in bed, asleep. Although no one is making you, your patients and colleagues expect it.

4) You are always a doctor, even when you are off. Comes with the territory. Some of us like it, others don’t. This is more so in smaller towns where you will be recognized and asked to answer medical questions in the grocery but it happens to me in Mobile Alabama (often) and Marietta Georgia (rarely but there was one family get-together where my cousin cut a tendon with a knife…)

5) If you are nosey, it is a great job. When people are applying for medical school, I often hear “I like science” and “I want to help people” in various combinations. Liking science in the way it’s taught now isn’t a prerequisite to being a physician. Non-science majors often make the best physicians. The prospective physicians I know will do well are those who have been engaged in activities where they get to know the people that they help. Showing up on a Saturday with your fraternity to work on a Habitat project is not nearly as meaningful as volunteering for a hospice and getting to know the patient. Doctors are able to make people feel better just by being in the exam room. This can be a really cool thing. On the other hand, this is a job where people entrust you with their inner most secrets. If that doesn’t appeal to you, you’ll still get into medical school but it’ll be a long 40 years.

6) Just because you get into medical school, you can still blow it. If you are a jerk or greedy before you get in, turns out we can’t fix that in medical school. We put out some of the best doctors when all of the smart  jerks were going into dot-com jobs and we didn’t have to interview them in the first place. If you have an entrepreneurial spirit, medicine may not be for you. You have the ability to harm patients if you can’t put their interest before your own self-interest.

Other thoughts?

As I sit on the Gulf Coast of Alabama, awaiting te arrival of the biggest environmental disaster of my lifetime, I am trying to anticipate what I will need to teach physicians to do to be effective in 2015 and have to admit I am drawing a blank. I am continuing to work on the HRSA Title VII funding request. The difficulty is that they have changes the number of years that the project should be developed over to 5. In the spring of 2005, Katrina was the name of a potential storm, the healthcare delivery system was to be market based, and primary care was seen by the feds (who paid a majority of the bills) to be a quaint method of providing low intensity health services that people probably didn’t need anyway. I’m glad I wasn’t asked to predict out for those 5 years.

But I am being asked to predict what I will need to train physicians for the next 5 years. Maybe I should focus on the need for a different kind of doctor in 2015. One who can spend more time with the patients, helping them to navigate the system, working with them to make sure they are taking advantage of appropriate medical care (including preventive services), and delivering this care in a personalized manner. Oh, wait, we already have this type of provider. He or she is a family physician, underpaid and burned out under the current payment model. Unfortunately, I can’t write a grant to improve the payment structure.

Maybe I should write a grant to deal with the lingering effects of the ecological disaster of cataclysmic proportions heading to a shoreline near you. We know from Katrina that there will be an increase in depression, physical ailments related to depression, as well as ailments related to exposure to hydrocarbons. In addition, folks will lose their ability to make a living off of the land, leading to more ill effects as described above. In the long run will be an increase in certain cancers. The grant I would like to write would have been one to point out that one shouldn’t drill holes that are too deep to plug up if something goes terribly wrong. Anyway, I still want to believe in miracles. This may, however, be the grant that I write.

The other dilemma that is of potential interest to granting agencies is childhood obesity. The President’s Council on Physical Fitness began during the Eisenhower adminstration in part because of a concern that our young men and women were in no physical shape to fight another World War. After 60 years we noticed that it was working in the opposite way with the future fighting men and women of 2010 being more out-of-shape by far than their 1950’s counterparts. Doesn’t speak for the success of the President’s Council, does it.  If only we had measures that worked better than eating less and exercising more. As a physician, not a lot of either activity takes place in my office so I’ll have to think about a medical approach to this problem for a while.

Grant writing is hard work. The needs are often overwhelming and the solutions not forthcoming. I guess now it’s time to get back to my predicting on a much smaller scale.

The House of Representatives passed the Senate Health bill and then passed a packages of fixes to send back to the Senate. If the Senate does pass the package, the law will look like this. Below are highlights of the new law for Family Medicine:

  • Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program. (Establish pilot program by January 1, 2013; expand program, if appropriate, by January 1, 2016)
  • Create the Independence at Home demonstration program to provide high need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals
    to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction. (Effective January 1, 2012)
  • Establish a grant program to support the delivery of evidence-based and community based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010)
  • Provide states with new options for offering home and community-based services through a Medicaid state plan rather than through a waiver for individuals with incomes up to 300% of the maximum SSI payment and who have a higher level of need and permit states to extend full Medicaid benefits to individual receiving home and community-based services under a state plan. (Effective October 1, 2010
  • Provide a 10% bonus payment to primary care physicians and to general surgeons practicing in health professional shortage areas, from 2011 through 2015; Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations (effective January 1, 2012 through December 31, 2016); to make global capitated payments to safety net hospital systems (effective fiscal years 2010 through 2012); to allow pediatric medical providers organized as accountable care organizations to share in cost-savings (effective January 1, 2012 through December 31, 2016);and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition(effective October 1, 2011 through December 31,2015)
  • Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations.(Funds appropriated for five years beginning in FY 2011)
  • Establish a grant program to support the delivery of evidence-based and community based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas. (Funds appropriated for five years beginning in FY 2010)
  • Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011
  • Increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for Medicare payments for the expenses associated with operating primary care residency programs. (Initial appropriation in fiscal year 2010)
  • Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training
  • Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

University of Alabama, Birmingham is in the process of selecting a new Dean for its medical school. I have worked in academic medicine for almost 20 years and my father was in academics throughout the period that I was growing up so I understand the ebb and flow of the academic setting. In fact, Wallace Sayre summed up the problems very succinctly by saying “Academic politics is the most vicious and bitter form of politics, because the stakes are so low.”

This is never more apparent when it is time to hire a high-ranking executive in an academic setting. Universities typically use a “Search Committee”  to develop a list of candidates that the Provost (in this case) might choose from. Here is a quote from the University of New Mexico policy on hiring such people:

An effective search committee strategy will do much to facilitate, rather than undermine, an effective search. Keep in mind that the goal when using a search committee is to optimize the effectiveness of the search process from the perspective of all parties concerned-the hiring authority, members of the search committee, colleagues, and in particular, the applicants. Since the search process sets the stage for the future employment relationship, careful attention should be paid in effectively managing this very important phase of the staffing process.” (emphasis mine)

Imagine if  all HR departments had to run potential executives in front of a group of disgruntled folks with their own axes to grind. It would be a wonder if anybody got hired.

The reason this came up is that the Search Committee for the Dean at UAB does not contain a Family Physician, General Internist, or a General Pediatrician. The leadership in Family Medicine asked whether a differently constituted search committee might select a Dean that would place more emphasis on primary care and rural medicine.

It is my opinion that it would not and here’s why. Academic medicine sees Family Medicine as one of a number of competing clinical concerns that they need to balance as they provide education for undifferentiated students.  Traditional academic deans are concerned with maintaining or building revenue streams (typically family medicine is not helpful in this regard), maintaining the educational programs (in which case they need Family Medicine as well as Surgery, Medicine, OB, Peds, and Psych and Pathology  known collectively as the educational “six-pack plus one”), and growing research programs (typically not a Family Medicine function except at the Dukes of the world). Academic medicine in my opinion, does not seen themselves as producers of the physician workforce anymore than Colleges of Arts and Sciences see themselves as producers of the Chaucer scholar workforce. Colleges of Education tend to understand this workforce issue better than most (probably due to the initial charters under which they were founded and state mandates) but now with the charter school movement that might change.

Those of us in academic Family Medicine might see ourselves as producing tomorrow’ s healers but Deans and Provosts see us as  most equal to the others in the “six-pack.”

Medical schools typically don’t care about shortages, workforce needs, unless required to by external pressure. The reason is multi-factorial. One is that there is a lot of give in the system. We graduate 17600 allopathic physicians in this country. There are another couple of thousand osteopathic graduates. We allow almost 10,000 folks from other countries or from Caribbean schools into this country EVERY YEAR to fill the remaining slots. That’s one reason that medical schools don’t worry because this allows US schools to say that the “market” will fix things. We have been unsuccessful in the last 10 years in trying to develop a primary care workforce using a majority non-US grads.

The other reason is that the pipeline following medical school graduation is in the training hospitals and this portion of the pipeline is divorced from the medical schools. Medical schools point to the residencies and claim protection from these types of issues. The residencies point to success in the match as proof that their clinical care is vital and necessary. The way the payment structure is set up all of the grads get jobs, so why should the residencies worry? Of course, when we all get leukemia from CT exposure it’ll be a problem but more business for Oncologists as well.

What makes Deans worry about students attitudes towards a career in primary care? Mandates work for state schools. If the governor or key legislatures say “you gotta make primary care docs”, it happens. As it stands now, some in the Alabama legislature are securing funding fo an osteopathic pipeline as a response to the “shortage” but there are still no mandates in place so it’ll likely fail in this regard as well. This pipeline may have more success because folks educated in rural areas are more likely to go into primary care, all other things being equal.

What else works? Selecting the right students, educating them in a nurturing environment, and paying them (or at least not making them take out and pay loans) for doing the right thing. Paying primary care docs for doing the right thing makes students want to go into primary care. Lastly, making the communities conducive to quality care delivery works (which is why I would like to see collaboration between Schools of Public Health and Colleges of Medicine).

In summary, I suspect that UAB will select a Dean based on the weight of his or her CV and the perceived possibility of extramural funding and/or prestige regardless of the search committee composition. If Alabama wants primary care docs, the Dean will probably not matter one way or another. In fact, one Dean would argue that the Dean’s job is more of a mediator than anything else.  The Governor, on the other hand, will be a different story.

In my previous post, I sited a research project that found the average amount of journal reading in 2000 for a practicing internist was around 4 hours per month. This is not an awful lot of reading, given that there are 17,000,000 articles currently available in MedLine. Our field is especially prone to information overload, given the breadth of patients and illnesses we come in contact with. When I graduated from medical school, I did as I was told others did, browsed the medical literature, pulled out articles and put then in a “journal file”, and felt guilty about not doing enough to “keep up”. No wonder the average physicians’ medical knowledge base was directly related to when he or she graduated from residency.

Fast forward 20 years. The Internet was invented by Mr Gore and the personal computer by Mr Gates. Mark Ebell outlines how physicians should use the medical literature. He points out theat the most useful information is relevent, valid and takes little time to access. Computer accessable information is more useful that textbooks (many of which are outdated prior to hitting the shelf). Many physicians now use decision rules to help sort out complex clinical situations. These rules are typically evidence based and often have been validated in “real world” situations. Examples of such rules include the Framingham Cardiac Risk Assessment and the Wells Criteria for suspected pulmonary embolism. Services are now available which aggregate literature and offer clinical “answers to questions” that have been developed using a standardized process. Up-to-date is one such service popular with our residents. If a single journal article is used, it is important to look for those journals that have started to include an assessment of the evidence which supports the recommendations. Then there is searching the 17, 000,000 articles to find the needle in the haystack. What used to be time consuming and complex is now available to anyone on PubMed or Google Scholar.

In short, where previously 15 to 20 clinical questions went unanswered in a typical day, now access to clinical information at the point of service has never been easier. The most important thing is that it’s only going to get easier.

Live a simple and a temperate life, that you may give all your powers to your profession. Medicine is a jealous mistress; she will be satisfied with no less. 

THAYER WS. OSLER THE TEACHER, IN OSLER AND OTHER PAPERS,  

One of my internal medicine attendings, Dr George Burch,  relayed this aphorism to us while we were in our first pre-clinical year at Tulane. The power of the medical education process is illustrated in the fact that I can still see myself in that auditorium watching this (seemingly very old) man offer this and the advice on how to counteract the siren call of medicine…”get a good book and sit under a tree and read.” 

Although we’d like to believe otherwise, Osler was correct. Being a doctor still entails a lot of study prior to completing training. Although the hours that are required in training for direct patient care are limited to 80 in a week, there is no limit to the amount of study time learners must put in to learn their craft. As a program director, I have tools that I use to assess student’s and resident’s medical knowledge and their ability to synthesize it into patient care. There is no substitute for study and preparation. 

Once out of training, physicians must maintain their clinical skills. They did so traditionally through meeting attendance, journal reading, and informally through conversations in the doctors’ lounge. Now things are more formalized with continuing education credits being offered for using the right tools to look up information regarding patient care, as well as our Board requiring us to take specialized instruction to maintain certification. 

All of this takes time. Internal Medicine specialists, when polled, reported spending about 3.3 hours per week on reading. The part of the evidence based practice incorporated into the new model of care in Family Medicine will require data input and physician and staff education. At this time, none of these efforts result in money into the physicians pocket (back to the mistress…) 

Why put up with it? Aside from the fact that it pays pretty well, I find that it really is an interesting way to spend a day. I get to work with people who occasionally want to be healthier. I get to learn about stuff in the news (and occasionally be in the news). Every now and again though, I pick up a good non-medical book and think about Dr Burch. 

   

 

 

 

I have to give a presentation to the residents on “Clinical Decision Making” and this caused me to reflect on  “How Doctors Think” (Jerome Groopman’s book) and, more importantly to me, “How Should Primary Care Doctors Think?”. In an interview on NPR, Dr Groopman follows the story of a patient who lived with severe nausea, cramps, and weight loss ( mis-diagnosed  as anorexia for 15 years when in fact she suffered from a gluten intolerance) and who has seen approximately 30 physicians, none of whom are very helpful. The patient is saved when a physician (self-referred) sits down with her, elicits her entire story, then does the appropriate diagnostic test.

Dr Groopman feels that we in medicine are letting our patients down . He bemoans the fact that our training has become less apprentice like where we learn at the feet of the great clinicians. He suggests that the use of clinical algorithms  has led us to place patients in clinical “boxes” which benefit insurance companies, and pharmaceutical companies, but not patients. He feels (and I agree to an extent) that the solution isn’t following evidence based algorithms but lies in listening to the patients narrative. Where he and I differ is that where he thinks we need to focus more on critical clinical thinking in medical education and less on algorithms, I feel we need to teach folks when to rethink and how to put systems in place which limit the consequences of poor clinical thinking. The patient whose case he uses seems to me to have been let down by a system which encourages sloppy thinking, includes limited quality assurance, and rewards procedural efficiency.

First, the advantage primary care physicians have is that of time. We have done a poor job of teaching physicians how to utilize time as an aspect of disease management. In a separate interview, Dr Goopman identifies “anchoring” (when physicians latch onto a piece of information and do not change despite evidence to the contrary) as a problem which leads to missed diagnoses. If a patient such as this one is mislabeled as having a certain illness, multiple visits should offer the clinician a clue something else might need investigation. For example, abdominal cramps and intense nausea are not the diagnostic criteria for anorexia (see below) and in this patients care should have led to further investigation

Criteria for anorexia

  • Body weight < 85% of expected weight
  • Intense fear of gaining weight
  • Undue emphasis on body shape or weight
  • Amenorrhea (in girls and in women after menarche) for three consecutive months
  •  

    Secondly, in Advanced Primary Care involving the use of a high end electronic health record, algorithms can be used not to limit thinking but to confirm diagnostic labels. For example, if a diagnosis of diabetes is added to a patient’s medical record, the diagnositic criteria could be placed in front of the clinician to get confirmation that this is what was really meant and avoid mis-labeling. From a quality assurance standpoint, a diagnosis should be confirmed and the management should then be optimized based on accepted guidelines. Guidelines should be used to guide testing and therapy, not to limit thinking.

    Thirdly, we have lost critical thinking in all of medicine but it has been especially missed among subspecialists. Dr Groopman suggests that primary care docs, with only 12 minutes per visit, merely get a sketchy complaint from the patient and then route them to the appropriate “subspecialist”. In truth, the 12 minutes is a very loose average. The average primary care doc sees approximately 25 patients in an 8 hour day, resulting in approximately 20 useable minutes per patient. An ear infection takes approximately 3 minutes. We can (and do) use this extra 17 minutes to listen to and work with complex patients over the better part of an hour. What we (and patients) would benefit from in the way of subspecialty care are physicians who will listen to the patient’s story again, and work with us to help make a correct diagnosis and determine the appropriate treatment rather than calculating how to extract money from the patient’s insurance via invansive procedures. I was taught at Tulane by George Burch, C. Thorpe Ray, and others who prided themselves on being the good kind of consultant. What I try to encourage my learners to do is to find those types of consultants and latch onto them so that their patients will get complete care.

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