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42d92232d11ab9d3a168004f7a565474-huge-39January is Mental Wellness Month. Mental health and wellness begin with primary care. Today on the blog, in a post from our archives, Benjamin Miller explains.

By Benjamin Miller, PsyD

Imagine this scenario. You go to see your longtime primary care provider. What you have to say you could only say to the person who has taken care of you and your family for years, has seen births and deaths. It’s still hard to say. In fact, you never thought you’d have to say it. But ever since you lost your mother, you’ve not been feeling your best. You’re eating foods you know aren’t good for you. You’re sleeping too much and not exercising at all. Your blood pressure is the highest it’s ever been, and your weight is becoming a problem. You feel down most of the time, and you’ve stopped doing the things you love. It was actually your neighbor that asked, “Are you depressed?” 

So here you are, telling your doctor that you think you might be depressed. What happens next, as you will learn later, happens to millions of others in your same situation. Your provider hands you a questionnaire, known to health care professionals as a PHQ-9, and you learn together that you have symptoms of mild depression. Of the various treatment options she describes, you think that talking to someone about the loss of your mom would be most helpful. She refers you to the local network of mental health providers saying that this is the only way she knows to get you help.

Once you leave the office, the next steps for your care are entirely in your hands.

Maybe you go back to work. Or maybe you pick up the kids from school or run a few errands. Whatever you do, you don’t make the call right away. When you finally do, you hear of wait times of up to two months. And finding someone in your insurance network is equally daunting. You finally get an appointment. The first few visits go okay, but when you check in with your primary care provider to ask her if she has heard anything from the therapist as you are curious about the team “game plan,” the answer is no. You had assumed that all your providers would communicate. You are somewhat surprised but attribute it to providers being busy. You think to yourself, “If only my providers were able to collaborate better...”
***
While it appears that the patient was getting the care they needed, fragmentation complicated things at several points along the way. And most of the time these cracks in the system prevent the patient from ever getting care. The depression goes unchecked, which impacts the diabetes, which impacts the blood pressure and so on.  
 
For decades we have known that more mental health issues are seen and treated in primary care than in any other health care setting. Some of this prevalence is due to primary care being the largest platform of health care delivery in the country. Despite this well-known fact, consider the following statistics:
  • 80% with a mental health disorder will visit primary care at least one time in a calendar year
  • 50% of all mental health disorders are treated in primary care
  • 67% with a mental health disorder do not get behavioral health treatment
  • 30-50% of referrals from primary care to an outpatient mental health clinic don’t make the first appointment
The numbers associated with mental health conditions comorbid with chronic disease aren’t any rosier. The AHRQ Medical Expenditure Panel Survey found that patients with mental health conditions on top of their chronic disease cost about 50% more than those with chronic disease alone. This would all be fine if we did a good job treating the whole person, but the health care system excels at treating parts, not wholes.

As the authors of the AHRQ study pointed out, “Carve-outs of mental health benefits (i.e., only paying for mental health care delivered by mental health professionals, high copayments for mental health treatment, and inadequate reimbursement are barriers to effective collaboration and disincentives for primary care physicians to screen for and adequately treat mental health. Fixing disparities, removing mental health carve-outs, and creating blended payment systems could improve mental health treatment in primary care. This would support integrated, patient-centered mental health care that is consistent with the principles of the medical home.”

It's no wonder that in a recent Senate hearing on mental health, experts from around the country called on the federal government to better integrate care. It seems that though we know the areas in health care that could better meld mind and body, a chasm lives between the system that we have and the system that we want.

To begin to close this chasm, we must: Maybe when we do, we can start to better understand what must be done to meet all of a person’s health care needs. After all, health is health is health.

Benjamin Miller, PsyD, is an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine where he is director of Eugene S. Farley, Jr., Health Policy Center. Under his leadership, the Farley Center has worked on four main areas: behavioral health and primary care integration, payment reform, workforce, and prevention. A clinical psychologist by training, Miller has focused his career on creating innovative solutions to fragmentation in health care. 
 
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Posted by Sonya Collins on Jan 19, 2017 9:56 AM EST
1c8b3c53225d8513fda3204a61e63b9c-huge-b9It’s an honor to share my recent and apparently startling analysis of the Affordable Care Act, published last week on Huffington Post, with those interested in our work at Primary Care Progress.  (I am a proud member of the Board.) This analysis is the bittersweet result of many decades working with leaders across our health care system to reform that system, both from within and through the workings of our increasingly difficult and often bizarre political system. The ACA was our first real hope since the early 1990s to achieve a pathway to universal coverage, and now it confronts its destruction for purely political reasons unmoored from the actual workings of the program. But independent of what will become of “Obamacare" on the altar of ideology, reform from within the system as we know it will continue. PCP’s mission is a major example of what this looks like, as we work to change the culture of medicine from within and restore dignity and meaning to the practice of medicine for current and future generations of primary care providers.

By J.D. Kleinke


There is no conservative replacement plan for Obamacare because Obamacare is a conservative health reform plan.

After six years of promising to "repeal ‘n’ replace" the President’s signature domestic achievement, Republican lawmakers have no coherent alternative to the Affordable Care Act for one good reason: the Affordable Care Act was once the market-based alternative to a real, not imagined, "government takeover" of health care.

What has always made the ACA a political pariah to Republicans, typified by the bizarre claim by House Speaker Paul Ryan (R-WI) on Wednesday that “Obamacare” has “ruined” and “dismantled” our health care system, is the plan’s namesake — far more than its necessarily complex architecture or any of its actual details, unless you count the details they made up.

And so, if only for kicks, how about some actual historic facts and context about a health reform plan that was actually decades in the making, is only three years into full implementation, and is on the eve of blind destruction by demagogues who have no idea what they’re talking about.

The chart below illustrates where the ACA sits, ideologically, relative to all other health reform plans.

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This chart places the ACA along a continuum of all serious reform options developed, debated, and discarded or ignored since the 1980s. They are all here: from the single-payer, centrally controlled models popular with those who detest corporations and the corrupting influence of money in medicine — two actual, not imagined “government takeovers of health care” — to a fully free-market, laissez faire model favored by those who detest regulation and the heavy hand of government in medicine.

On the far left, the federal (or provincial) government is the main insurer, owns most hospitals, and employs most doctors. This pure form of single-payer seems to be supported or reviled in equal measure, especially by the nation’s physicians. As a model for nationwide reform, it is as much a religion as a public policy framework — people believe it will be either health care’s Messiah or its anti-Christ — and no one will convince them otherwise. This model is the foundation for many of the systems in Europe, and the systems in Canada, Australia, New Zealand, and Singapore. Unbeknownst to many under their actual care today, there are two working systems based on this model in the US: Kaiser and the Veterans Health Administration.

The second model, Medicare-for-All, differs from the pure form of single-payer by retaining the current independence of most hospitals and doctors. This model jettisons private insurance companies and covers all Americans directly, while an all-encompassing Medicare program pays for covered care delivered by today’s crazy quilt of providers: large and small physician groups, for-profit, religious-affiliated, independent and academic hospitals, the works. This is what Medicare beneficiaries have today — except for the 31 percent who opt for privatized “Medicare Advantage” plans offered by commercial insurers. Medicare-for-all is supported by those who believe it would bring the relative efficiencies, fairness, and low administrative costs of Medicare to all of us, and it is reviled by those who think Medicare works like hell. Because there are oceans of data to support both views, this too is ultimately a matter of secular faith: government, good; government, evil.

To the right of Medicare-for-all is “managed competition,” the basis for the reform plan proposed in 1993 by President Bill and First Lady Hillary Clinton and derided as “Hillarycare.” This model is built on the traditional system of multiple private insurers and providers, but highly organizes and regulates both. It achieves universal access by mandating employers and individuals to participate and by requiring everyone — with or without current coverage — to give up what they have and commit to one of several competing vertical insurer/provider entities. The managed competition model is based on managed care theories developed in the 1970s; when proposed by the Clintons in the 1990s, it was popular with much of the Washington technocracy and vilified by conservatives. Modified versions of this model exist in Germany and Israel, and in a handful of US markets (e.g., Hawaii, San Francisco and Portland, OR, sort of) with vertically integrated providers that compete with Kaiser.

Back in the mid-1990s, most Republicans and many health industry experts attacked “HillaryCare” as cumbersome, over-engineered, and hyper-bureaucratic; it was destroyed in the court of public opinion by an insurer-funded TV ad campaign that people remember better than any details of the plan itself. Conservatives hated the plan so much, in fact, that the folks over at the Heritage Foundation came up with their own market-based alternative. The plan achieved universal access by requiring people to purchase their own insurance, but enabled them to do so through a competitive marketplace, with subsidies for the poor. Hmm. Sounds familiar, no?

The Heritage plan sounds familiar because it was the conservative alternative to government-driven plans like single-payer and Hillarycare, and because it became the basis for Mitt Romney’s health reform plan implemented in Massachusetts — which in turn was the basis for - for what? It was the basis for the plan one click from the far right of our spectrum of health reform models: President Obama’s plan, known as the “Patient Protection and Affordable Care Act,” or the ACA, until it was branded — derisively by Republicans — as “Obamacare.” (I tried to point all this out in the New York Times in 2012, while working at a conservative think tank, for which I was ridiculed by my own colleagues, excoriated on Capitol Hill, and received death threats, a few years before getting death threats for publishing actual facts was in vogue.)

Notwithstanding all the political noise that long ago drowned out all discussion of actual facts about the actual law: Obamacare is a radical endorsement and extension of the status quo. This is why everything that was ever wrong with the health insurance system — ever increasing premiums, deductibles, and co-payments, the perennial narrowing networks of providers, and all of its byzantine administrative processes — has now been laid at the feet of the plan. This is why the House Speaker has no qualms about uttering utter nonsense about Obamacare “ruining” and “dismantling” the health care system.

To minimize actual (not perceived or politicized) disruption to most people’s coverage - a major and valid criticism of the Clinton plan — the architects of the ACA retained most of the features of the traditional employer, insurance and provider systems. The ACA merely expanded the system toward universal access by mandating that most of the uninsured participate in it, unless their incomes were low enough to qualify them for an expanded version of Medicaid.

Because Obamacare requires insurers to cover all comers — and does away with caps on those with catastrophically expensive medical situations — it is funded by mandated participation by all of us too young for Medicare and too well off for traditional Medicaid, either directly or through employers. Expanding the exact same plan to include health savings accounts and allowing consumers to buy coverage across the stateliness — two line-item policy ideas Republicans tout as the major levers in their magical mystery replacement plan — could be appended onto the ACA with a dozen pages of legislation.

By contrast, the only “replacement” model of any substance that breaks to the right of Obamacare - the one free-market economists have been championing for decades — would be truly disruptive and a complete political non-starter.

This model, on the far right of the chart above, would be a truly free-market health care system. It would allow people with commercial insurance or no insurance to purchase their own coverage in an open market; and it would not require anyone to purchase insurance, nor any insurer to cover anyone they did not want to. Under this model, kicked around in the back pages of the health policy literature since the 1990s, all purchasing decisions about coverage and plan design are left to individuals and insurers.

Economists believe this Lord of the Flies model would radically reshape health insurance and downstream medical markets, by driving efficiency in pricing and reducing excess medical resource spending. They believe that market distortions created by the tax deductibility of health insurance purchasing are enormous — and that the extra political mile it would take to eliminate this tax deduction would be well worth the effort in terms of health care marketplace correction and system self-reform.

As a corollary to this belief, this “direct retail” model extracts employers from the system altogether, converting the health insurance market into something more akin to auto and homeowners insurance markets and maximizing the power of consumer market forces to control health care spending in general. Under this model, everyone is free to purchase whatever mix of insurance and services they want and can find, from whatever organization will sell to them, at whatever price the market yields. Modified versions of this model exist in China and India on top of threadbare single-payer systems incapable of serving the needs of their large and growing populations and emerging middle classes.

Proponents of the only model to the right of Obamacare believe that its inherent pricing efficiency would drive the marketplace to very high-deductible insurance plans, while converting a great deal of medical care to a cash-and-carry system. They believe this model would drive healthy Americans toward health savings accounts and greatly benefit from consumers purchasing whatever plan they wanted across state lines.

In terms of moving us toward universal access, they would augment this model by allowing lower-income people, the uninsured and others priced out of these liberated insurance markets with either a “premium support” or “voucher” program — two ideas that sound similar but play out differently as health care costs increase. The subsidy mechanism — and its associated semantic and political branding wars over “premium support” vs. “voucher” — is also the economic fulcrum in Congressman Paul Ryan’s proposal in 2013 for reforming Medicare.

That Obamacare is a right-of-center plan, especially when viewed relative to all viable alternatives, explains why it has always had so little political support from anyone. Liberals hate Obamacare because it is not single-payer, and feeds tens of millions of newly insured people to what they revile as a money-gobbling, profit-obsessed health insurance dragon. Conservatives hate Obamacare because it is the heavy hand of government choking whatever air is left out of the current, dysfunctional health insurance market, and because they cannot see beyond their political rage at President Obama to recognize their own ideas at the core of his health reform plan. Obamacare has always been a shabby political step-child.

So where is that Republican replacement plan? Don’t hold your breath. Health savings accounts and buying insurance across state lines may sound nifty to people who have no idea what that means or might look like, but they are at best minor endorsements and extensions of the status quo, chocolate and rainbow sprinkles on the same old sour ice cream.

The only meaningful right-wing replacement plan is the only one to the right of Obamacare in our chart: a health insurance market free-for-all. No tax deductibility, no employer involvement, no fuss, no muss. And what would be the actual effect of implementing that? Everyone who has insurance through their employer today - which is to say almost everybody not in Medicare or Medicaid — suddenly pays a whole lot more in taxes. Not exactly what any of the Republicans clamoring to repeal ‘n’ replace want to sell back home.

This is the real reason why, when asked for the details for their replacement plan, the Republicans in Congress have always had, and still have, exactly and only one real answer: “Our replacement plan is Obamacare sucks.”

Stay tuned for more of nothing.

J.D. Kleinke is a medical economist, author and board member at Primary Care Progress. Follow him on Twitter @jdkoneverything.
Posted by Sonya Collins on Jan 12, 2017 11:59 AM EST
4c74cc7c511d4d566b4769ab6c452636-huge-14At Primary Care Progress, we believe that at the heart of our power to create change is the connections that we make with one another through our personal stories. Progress Notes is a place to share those stories. Here's some of the heartwarming, thought-provoking stories you shared with us in 2016.


January
A student volunteer in a shelter clinic learned how to earn patient trust.
"Few other fields rely so heavily on the confiding of information so intimately connected to one’s wellbeing and personhood. However, such trust must be earned. Fortunately, patients tell us how to do so. It is up to us to listen."

February
A chief resident opens up about the challenges of intern year.
"My philosophy now is to just show up on time and go with the flow. Instead of trying to swim against the current, just let the river take you where it pleases. You may be surprised at where you end up."

March
A hotspotting team delivers truly patient-centered care. 
"What shocked us was as she began to realize how invested we were in helping her achieve her goal, she started making the changes we had been hoping for all along. She started to keep her appointments, had negative drug screens and her total number of hospitalizations began to decrease."

April
A doctor explains the value and challenges of team-based care. 
"I was trained to do all of this myself. I was not trained to share these responsibilities with nurses and pharmacists, nor was I trained in how to create, contribute to, and maintain systems of care for my patients. It was all on me, and in truth, most of us doctors have liked it that way. But we have to change these habits and most of us know it."

May
A psychology student discovers the value of team-based care.
"Initially, patients like Tina come to me to address their psychological well-being. However, they also want to improve their overall quality of life. I cannot think of a better way to improve an individual’s quality of life than through the advancements of integrated primary care."

June
A newly minted family doc learns why teams are as important for providers as they are for patients.
"Part of the reason I chose primary care, and family medicine in particular, is my desire to be the lamp to those in need. But without a team, my lamp would burn out fast."

July
An innovative care model prevents falls, which can be life-changing for the elderly.
"Patients like Rose inspired me to imagine that there might be something better.  Can we find the Roses at risk for falls and illness exacerbations in our communities before the crisis?  Can we build a team that responds to their needs proactively and prevents them from the dangerous and sometimes deadly trips to the hospital?"

August
An early-career family physician writes a letter to a patient she lost.
"Dear Mr. C., There are a number of things I’ve been wanting to say to you since you died three years ago.  The first is I’m sorry."

September
A soldier in the hospital after two mini-strokes meets a pharmacist who changes his life's course.
"That day, during my conversation with the pharmacist, I discovered my answer to how I could serve others, and a passion was ignited in me to become a pharmacist clinician."

October
A medical student learns how to make a real difference in the life of a very sick patient.
"Listening to Pam’s life’s narrative, we can validate the difficult experiences she has survived. We can also show her that her perspective is valuable in teaching us about a patient’s experience in the health care system and how to live a meaningful life in the face of serious illness."

November
A nursing-home resident and advocate fights for dignified primary care for herself and others like her.
"The health care delivery system I now have -- a community physician, scheduled appointments, private office space, confidentiality and professional boundaries -- has had a positive psychological impact on me. I have been given back my personhood, my dignity, empowerment in my health care. I am more normalized and happy. Without doubt, a community-based model of primary care is best for me."

December
A medical student earns the patient trust that eluded providers.
"My preceptor asked if the patient was interested in getting his influenza vaccine. I didn’t tell my preceptor that he already declined it. However, to my surprise, the patient nonchalantly agreed. He glanced over at me and said, 'He convinced me to get it.'”



 
Posted by Sonya Collins on Dec 22, 2016 12:26 PM EST
c375677ac09ae4d120af6eda7792990e-huge-imHofstra University Northwell School of Medicine launched a primary care track called IMPACcT (Improving Patient Access, Cost and Care through Training) last June. Today on the blog, we learn all about the program through a Q&A with the IMPACcT program’s leadership: (clockwise from top left) Dr. Lauren Block, Dr. Alice Fornari, Dr. Joseph Conigliaro, and Dr. Nancy LaVine.
 
What was the state of primary care training at Northwell Health before?
 
Like many institutions across the country, Northwell Health had few trainees entering primary care careers. Over the past five years, about five to 15 percent of graduates from our residency program have entered primary care, less than the national average of 20 percent reported in JAMA. Much as in programs elsewhere, our trainees reported that lifestyle, salary, and negative residency clinic experiences contributed to their decisions to pursue specialty and hospital medicine careers. 
 
What prompted this curriculum at Hofstra Northwell SOM? Who was involved? What role did students play and what input did they provide?
 
Our new medical school, which opened in 2011, has had strong input from general internists. Our dean, chief medical officer, several associate deans, chair of medicine, and designated institutional officer for graduate medical education are all dedicated general internists. As a result, strong primary care training is a focus of our students’ early clinical experiences. In the first few weeks of medical school, all students become part of the local community through a nine-week Emergency Medical Technician (EMT) training, and upon completion are certified EMTs, skilled in the core skills of history taking and physical exam. This prepares them for their early primary care experiences. These experiences are supported by an integrated curriculum consisting of communication skills, physical diagnosis, clinical reasoning, and professionalism to support core skills in clinical settings. Diverse student-led interest groups focus on primary care careers by introducing role models to the students early in their education. Hofstra Northwell SOM supports a student-run clinic providing hands-on experience and responsibility for the care of a group of underserved patients. Each of these opportunities ensures that role models in primary care will be available to students at a critical point in their education.
 
Bolstered by the support of general internists throughout our institution, the Division of General Internal Medicine was awarded a five-year Health Services Resource Administration (HRSA) Primary Care Enhancement Award to establish an interprofessional clinic experience we call IMPACcT. This new primary care educational and clinical program includes trainees from our internal medicine residency program, medical school, pharmacy school, psychology training program, and PA school. Adding to the momentum generated from this award, we teamed up with colleagues in family medicine and pediatrics to apply for and take part in the national PACER (Professionals Accelerating Clinical and Educational Redesign) program, which is jointly funded by the Josiah Macy Jr. Foundation, the American Board of Family Medicine, the American Board of Internal Medicine, the American Board of Pediatrics and the Accreditation Council for Graduate Medical Education. The PACER program has brought together the primary care specialties throughout our institution to work on collaborative projects and share best practices.
 
From this increasingly pro-primary care environment at Northwell Health, our Primary Care Progress chapter has blossomed. Originating from our medical school’s internal medicine interest group, our PCP chapter started in 2014 and sent its first representatives to the PCP Leadership Summit this summer. Students returned to tell the newly initiated IMPACcT clinic program about the conference and share skills and strategies learned from other chapters. PCP’s founder Andrew Morris-Singer presented at our Department of Medicine grand rounds and toured our clinical program in November, which focused attention on our PCP chapter and on the incredible resources available through PCP.
 
Who is enrolled in IMPACcT? What will they learn?
 
IMPACcT accepted ten residents, 31 students, two psychology externs, 12 pharmacy students, and eight PA students for its inaugural year. IMPACcT features a team-based approach to care in a clinic-within-a-clinic model as well as longitudinal mentoring and an interprofessional educational curriculum. Students are encouraged to take a hands-on approach to primary care as key members of the patient-centered medical home team and work alongside trainees from other disciplines. Core principles of our clinical program include a focus on continuous quality improvement, continuity of care and expanded access, all using a team-based approach. Key educational topics include health disparities, quality improvement, behavioral health, medication management, team leadership, and PCMH principles.
 
What do you hope to gain from the new primary care track?
 
Our goal is to deliver the highest quality care to our patients while providing our students with excellent clinical and educational experiences and longitudinal mentoring to encourage primary care careers across several clinical care disciplines.
 
How will IMPACcT affect your PCP chapter? How will chapter members be involved in implementation?
 
Our PCP chapter leaders are key participants in the IMPACcT program, where they find a community of like-minded individuals. We support their work to advocate for primary care nationally as we work with our colleagues to promote primary care at our institution and beyond. By inviting our PCP chapter leaders to speak at IMPACcT events and advertising PCP events to our IMPACcT trainees, we hope to achieve success together. We feel incredibly fortunate to have had Dr. Morris-Singer speak at our institution, generating support for national primary care advocacy while spreading the word on PCP’s mission and events. In the future, we hope to leverage our partnership with PCP to offer workshops in relational leadership to our trainees and faculty.

How do the students and trainees like the program so far?

Here's some of the things they've told us:
 
  • “I would totally want to be an IMPACcT patient because you all do the best comprehensive care.”
     
  • “I appreciate the patience and dedication from everyone in furthering my education and clinical skills. I will leave today as a more confident provider solely because of all your efforts.”
     
  • “Everyone has challenged me and has helped me build so much confidence in myself. I will take everything I have learned onto my next rotations.”
Posted by Sonya Collins on Dec 15, 2016 11:12 AM EST
abf76c7c6869fdd6bccaacfe879adf3e-huge-88It's National Influenza Vaccination Week. Today on the blog, read about a medical student who dispelled a patient's misperceptions about flu shots. 

By Puya Jafari

I recently saw a patient about a chronically stuffy nose and was pleased to hear that my short time with him made a difference. As a second-year student still developing my clinical acumen, I use my time to get to know patients, and it seems most patients welcome the chance to share their stories. In addition to this patient’s chief concern, our conversation touched upon his upcoming wedding and his relationship with his future in-laws. I’m married myself and close to the patient’s age. It was easy to empathize, particularly with the stress leading up to a wedding. 

At some point during the interview, I noticed he had declined the nurse’s offer of a flu shot. I wanted to understand his perspective. When I asked, he replied that he always gets sick at some point during the winter when he receives his flu shot. I acknowledged his reason and explained that the flu vaccine does not give you the flu but occasionally isn’t 100 percent effective. However, when it is effective either by preventing the flu or reducing its severity, it’ll save you a lot of trouble by not having to take sick leave or lose time planning your upcoming wedding. I left it at that and once the interview ended we went to see the physician, who is my preceptor, together.
 
The rest of the visit was routine. My preceptor asked if the patient was interested in getting his influenza vaccine. I didn’t tell my preceptor that he already declined it. However, to my surprise, the patient nonchalantly agreed. He glanced over at me and said, “He convinced me to get it.”
 
That was a proud moment for me. I helped someone understand that the flu shot was safe. My preceptor added some praise, saying that even medical students early in their training can make a difference. The moment felt like a primary care victory. But one question still lingered. I didn’t entirely understand why he had suddenly decided that getting a flu shot was worthwhile.
 
He said I convinced him. How? I didn’t cite any research studies. He knew I was a student. The nurse and the doctor were the real authorities on the subject. If it wasn’t the science behind vaccine safety or the legitimacy of the source of information, what else was it?
 
Then the proverbial light bulb went off. Maybe he changed his mind because he trusted my advice. As I mentioned, I spent time getting to know him and understanding stresses he was experiencing with the wedding planning and his relationship with his future in-laws. I empathized quite a bit during the interview. Our chat mirrored the first step we learned in school for an effective medical interview: build the relationship. My patient became an example of how a healthy, trusting doctor-patient relationship can improve health outcomes. 
 
Moments like these fuel my optimism for a career in primary care. Bonding with patients, forming trusting relationships, getting to know patients beyond their chief concern are privileges that I believe students can experience more often in primary care than other fields of medicine. Some may argue that time constraints prevent primary care physicians from effectively building relationships during an encounter. But what I’ve realized is that “getting to know your patient” isn’t merely about flexing interpersonal skills and making friends. It promotes mutual respect, trust and a good working partnership that ultimately can improve outcomes.          
 
Puya Jafari wrote this piece in 2015 as a second-year medical student at George Washington University School of Medicine and Health Sciences
 
Posted by Sonya Collins on Dec 8, 2016 1:42 PM EST
cf1f54850f53b2c0be6a23fcb65d2ae7-huge-0fAs we enter the season of giving, today on the blog, we'll look back at one of many blog posts about the students that give to their communities through many hours of volunteer service in student-run free clinics. 

By Katie Gesbeck

One evening during my first year of medical school, I was waiting by the entrance to The Salvation Army to let another student back into the free clinic.  The weekly clinic was organized by MEDiC, an organization of student-run free clinics in the Madison area.  A family with four small children was returning to spend the night at the shelter, and one of the kids saw the stethoscope around my neck.

“What’s that?” A boy who was about five years old asked.

“It’s so I can listen to hearts,” I explained. 

Then they all wanted to know if I would listen to their hearts and if they could listen to mine.  Spending that time with them, showing them how to listen to my heart, and making sure they all had a turn was the highlight of my day. I knew that I wanted to have interactions like that every day. 

That wasn’t the first time I had considered pediatrics as a career. Even as a college undergraduate I knew I was interested in pediatrics. I worked as a research assistant at the University of Wisconsin Hospital in Madison within the department of pediatrics, observing and coding data from over 400 pediatric acute care visits.  Even though most of the visits were children with upper respiratory infections, every child was different and presented a unique puzzle.  Also a puzzle was how the doctors found the right way to communicate with each family.  These challenges spurred my already-discovered interest in pediatrics that dates back to assisting in the infirmary at a summer camp when I was a teenager. 

My experiences so far as a medical student have continued to reinforce my desire to become a pediatrician.  They have also shown me definitively that I want to care for the whole child and build the long-term relationships that are possible in primary care.

While on rotations, such as neurology, psychiatry, and surgery, I found myself frustrated at focusing on only a particular organ system or problem and not on the child as a whole.  I enjoyed my time with these children so much, however, that I found it hard to say goodbye.  I still wonder how each of the patients is doing; it was hard leaving and not knowing what eventually happened with each child.  Primary care will allow me to follow children over time and watch them grow and develop.

Throughout all of my rotations, and even after each rotation ends, I try to follow the children as much as I can.  I especially enjoyed following a baby boy whom I met on my PICU rotation.  He and his family were a delight to work with. His parents even instituted a policy that everyone who entered the room had to say something positive to their son before leaving.  Two weeks after my PICU rotation ended, I stopped by to visit him.  I was thrilled to see the progress he was making.  His parents proudly showed me that he was no longer intubated, he no longer had IVs, and the only “wire” was his pulse oximeter – the finger clip that monitors the heart rate. 

I also loved following the progress of a six-year-old girl with Guillain-Barre Syndrome – a disorder in which the immune system attacks the nervous system.  It was inspiring to watch her begin breathing on her own and regaining her strength as she completed physical and occupational therapy.  Even more fulfilling was how much I could tell she was improving over the week while we painted and played games together.  A couple weeks after that rotation ended, I asked the physician who was taking care of her how she was doing, and he told me that she was ready to be discharged, so I stopped by to visit her.  She excitedly showed off her increased strength and how she could propel a manual wheelchair.  Before I returned to my clinical duties, we spent some time roaming the halls and reading one of her favorite books in the schoolroom. 

I have learned so much from all of these children and their families.  As a primary care physician, I look forward to really knowing my patients and coordinating their care with other providers or specialists when necessary.  Each patient will have unique needs, and even for patients with the same medical problem, the care and management will not be the same.  Following families over time and developing relationships with them will allow me to provide the best care and to help them improve and maintain their health. 

Katie Gesbeck wrote this piece in 2012 as a fourth-year medical student at the University of Wisconsin School of Medicine and Public Health.  

There's more on the blog about student-run free clinics.
Posted by Sonya Collins on Dec 1, 2016 12:18 PM EST
a0cdb07dd9d27a6c33b4a0053b82f910-huge-awNovember is National Diabetes Awarenss Month. Primary care providers take care of many patients with diabetes during their careers, but how often does one of those patients tell providers exactly what he wants and how he'd like to be treated? Here, in a piece from our archives, read 17-year-old Trevor Torres' refreshing perspective.

By Trevor Torres

My name is Trevor Torres, though I’m also known as the Diabetes Evangelist. At 17 years old, I’ve launched a speaking career through which I share my unique perspective with the health care community -- that of an empowered teenage patient. Before I began public speaking, I recorded a video for the Institute for Healthcare Improvement (IHI) Open School. It exploded in popularity and led to the start of my speaking career. In that video – as someone who has spent a lot of time with doctors – I talk about what I expect from health care providers. I thought the health care professionals and trainees who read this blog might like to hear my perspective, especially because they will undoubtedly take care of lots of diabetics and teenagers during their career in primary care.

There's two main things I expect from my heath care providers. One: Don't condescend. When I was first diagnosed with diabetes, the doctors said, "You can give yourself insulin in one of two ways: You can do it based on your blood sugar, so if you have higher blood sugar, give yourself more insulin. Or you can do it based on what you're going to eat, so if you're going to eat x amount, give yourself x amount of insulin." Now maybe I’m one of the smarter patients, but I was like, "Why don't I just come up with an algorithm that incorporates both variables?" That's probably a little atypical, but the bottom line is if your patient already has something like that figured out, you don't need to simplify the explanation down to what you perceive your patient's level of understanding to be. You can explain something, and then if your patient doesn't understand it, they can ask for clarification. That may be just me, but I really hate it when I feel like I'm being talked down to. And that also might be my age: I know we kids are a little uptight about that!
 
Another thing that I hate is the word "poke," as in, "I'm going to poke you." No, you're not going to poke me, you're going to stab me, okay? A poke is when you prod someone with your finger. A stab is when you insert a sharp metal object with the intent either to inject a foreign substance into the body or to draw blood by breaking the skin! In health care, you stab; you don’t poke.
 
Another thing that's important is to understand how your patient learns. I don't have all the answers about learning, but I know that I personally like to know why something's being done. If doctors say, "You need to eat this way," "You need to do this," "You need this treatment," they better tell me why I have to do it. That way I know I actually should do it. Because people tell you to do things all the time, especially if you’re a kid, and if I did all those things…well, ain't nobody got time for that! But if my doctor says, "You need to take this medication because this is what it's going to do in your body and this is what's going to happen if you don't do it," then I know exactly why I should, and I'll be much more likely to do it! If you’re complaining that your patient didn't do x, y, and z, and you didn't tell them why they should have done those things, then of course they didn’t do it.
 
People like me – teenage diabetics – have a lot of experience going to doctors and other health care providers. So we understand a lot more than we often get credit for. So just say what you mean. I don’t need my health care providers to oversimplify. I’ll understand if you tell me how my medicine works or what changes certain foods will cause in my body. And I certainly don’t appreciate a condescending tone, so just say stab, not poke!
 
Trevor Torres wrote this piece as a 17-year-old freshman at University of Michigan. Diagnosed with type 1 diabetes at age 14, he calls himself a “Diabetes Evangelist” and has started a public speaking career through which he brings his unique perspective to the health care world. For more on this topic, check out his recent keynote speech, “The 21st Century Patient's Perspective - What Millennials Expect From Healthcare” at TrevorTorres.net.


 
Posted by Sonya Collins on Nov 22, 2016 1:52 PM EST
4665fcefa45d8a892d09808b1059a4ae-huge-peA nursing home resident and consumer advocate for others like her, Penny Shaw makes the case for community-based primary care for nursing home residents. 

By Penny Shaw, Ph.D.

I’ve lived in a nursing home for 14 years, and I’m developing a community-based model of primary care because I know it will be better than what is available to me in my facility. I’m 73 years old, and I had an acute non-resolving episode of Guillain-Barre syndrome in 2001. Initially on life support, I was intubated for 5 years.

During the early years in my facility, I received primary and subacute care with 24-hour nursing. Functionally, I have had quadriparesis (muscle weakness in all four limbs) since the acute episode and am a total-care patient, except for being able to use my hands to brush my teeth, eat, read, write and use a computer. I am a lift transfer. My facility did an excellent job of keeping me alive and then removing the tracheostomy tube when I no longer needed it in 2006, but it still took several years for me to truly become my former self again. In 2010, I read my medical chart for the first time, and found I was being given six medications that I didn’t need in applesauce, as well as two medications as needed for sleep. I had all 8 discontinued. Unnecessary drugging is a well-known phenomenon in nursing homes. In 2010, I also requested and received a power chair.

By 2011, I had become a nursing home and disability advocate. I assessed whether I could live in the community. At age 68, with long waiting lists for affordable accessible housing and MassHealth personal care attendant policies which would not have met my needs, I chose to stay in my facility. I did decide to try to live as similarly as possible to my disability colleagues living in the larger world. I started by seeing outpatient specialists that I could have seen in my facility.

Over the years I outgrew the nursing home model of primary care. I didn't like the lack of dignity of talking to my physician while in bed. I didn't like being interrupted unexpectedly by him while doing creative work on the Internet. I was shocked to be asked a question in the reception area about my advance directives, which I intentionally didn't answer. Not only was it a HIPAA violation, but also a social worker came over and asked to be part of the conversation!

I didn't like having a physician, a generalist, disagreeing regularly with the treatments of the specialists I saw. I didn't like my physician not accepting my legal right to refuse his recommendation for change of orders for insulin. These are two examples of the paternalism, rather than person-centered care, nursing home residents face regularly. My physician is basically a good well-intentioned person, so it took some pondering for me to figure out what was actually happening. What I concluded is that in nursing facilities, it is more difficult to maintain professional boundaries as everyone - residents and staff - live and work in close quarters. Physicians are accustomed to making treatment decisions without informed consent, unlike in their private practices. In a published piece, a nationally-known geriatrician and medical director of three nursing facilities wrote that he does employee physicals and probably oversteps some boundaries by giving a few employees medical advice. His statement confirmed my thought that professional boundaries are porous in nursing homes.

Federal nursing home regulations permit residents to choose their own physician, and I would have chosen the other one in my facility, but there was a policy against this. Choosing one's own primary care practitioner, rather than having one assigned, is essential to developing a good relationship, good communication and trust. So I was left with no other option but community-based primary care. I knew it would be best for me. But the decision presented challenges.

The regulations regarding physician's services require not only that each resident have a physician, and another physician when the regular physician is not available, but that the physician sign all orders for care provided in the facility, as well as write, sign and date progress notes. My facility doesn’t yet allow physicians to sign electronically, so this is a barrier for a primary care physician to be willing to take a nursing home resident into their practice. Coming in person to sign takes time and isn’t reimbursed adequately.

I started by calling Fenway Health in Boston as this practice has a history of advocacy on behalf of individuals suffering from health care disparities. With openings only for a couple of recently-board-certified physicians, and given my complex medical needs, I hesitated. Through a colleague, I was directed to Rushika Fernandopulle, who graciously gave me a consultation, and helped me focus on MassGeneral Hospital where I receive my acute and specialty care. I called the physician referral service and now have a primary care practitioner at MGH. My former physician, in his role as the medical director of my facility, has agreed to sign the orders my community primary care practitioner wants. This eliminates the need for her to travel to my facility to sign. My medical director's willingness to accommodate me like this indicates his decency as a person.

The health care delivery system I now have -- a community physician, scheduled appointments, private office space, confidentiality and professional boundaries -- has had a positive psychological impact on me. I have been given back my personhood, my dignity, empowerment in my health care. I am more normalized and happy. Without doubt, a community-based model of primary care is best for me.

Having met and talked to residents and family members in other facilities, and on a toll-free nursing home helpline I answer, I know care delivery problems in nursing facilities are systemic. They are not due to lack of professionalism on the part of any individual physician. The delivery of primary care in nursing homes is thus in serious need of reform. As I work out the details of redesign for myself, I am hopeful I can develop a model of community-based primary care that can be useful to other residents.

Penelope Ann Shaw, PhD, is a former teacher of English as a second language and a doctor of French language and literature. Now a nursing home resident, she is a board member of the Massachusetts Advocates for Nursing Home Reform and of the Disability Policy Consortium of Massachusetts, as well as a policy advisor to the Nursing Home Division of Center for Medicare and Medicaid Services’ Survey and Certification Group. She is a 2016 recipient of a Consumer Voice Leadership Award from the National Long-Term Care Ombudsman Resource Center.

Related reading
The most vulnerable patients can face greatest barriers to care by James Chin

 
 
Posted by Sonya Collins on Nov 17, 2016 1:28 PM EST
ad0f9a0d52ab71ed11d24d2ccc60a4ee-huge--aIt's National Nurse Practitioner Week. Today on the blog, in a post from our archives, Jane Tuttle, Ph.D., family nurse practitioner, gives us a glimpse into the work of nurse practitioners and shows us how they expand access to care for our population's most vulnerable patients.

By Jane Tuttle, Ph.D., FNP-BC, FAANP

I was fortunate to have become a nurse practitioner (N.P.) in 1976, just a few years after Loretta C. Ford, Ed.D., public health nurse, developed the N.P. role with Henry Silver, M.D., a pediatrician. These visionary leaders recognized that registered nurses, with additional education and training, were in an ideal position to provide primary care to children in the face of the pediatrician shortage happening at the time, and indeed many children from that decade and beyond grew up knowing an N.P. as their primary care provider. 

Since then, N.P.s have proven themselves to be highly effective as primary care providers, and from state to state, they have varying scopes of practice. The N.P. role has successfully expanded to acute care, behavioral health, and other areas. I have been teaching others to be family nurse practitioners since 1985 and continue to practice in a primary care clinic serving adolescent mothers and their children. 

On a typically busy recent clinic afternoon, Jenna, the 18-year-old mother of a two-year-old girl I was seeing for a well child visit, told me that she had had unprotected intercourse with her child’s father two days earlier. She did not wish to become pregnant, so I was able to provide her with emergency contraception. We also discussed all of her options for family planning and contraception and made a plan for her to start a more reliable form of contraception.

Like Jenna, an increasing number of people consider an N.P. their primary care provider. Patients often describe us as more approachable than physicians. I can’t say how Jenna might have handled an office visit with a doctor, but her candor with me regarding unprotected sex helped prevent her from becoming a teen mom for a second time. Many teen moms, and others who struggle to access health care, might not have a primary care provider at all if it weren’t for N.P.s. We increase access to care, spend more time with the most vulnerable patients, and all for about 15 percent less than the cost of physician-delivered primary care.

As health care reform takes hold across the U.S., we expect to uncover increasing numbers of people who have previously unmet health care needs. Access and cost are going to be increasingly important issues in the years ahead. Nurses are poised to make a significant contribution in these areas, and we count on the support of patients and other providers.

The Institute of Medicine’s 2010 report, The Future of Nursing: Leading Change, Advancing Health, made the following recommendations which should inform our ever-evolving roles in 2014 and beyond:
 
  • Nurses should practice to the full extent of their education and training.
  • Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
  • Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
  • Effective workforce planning and policy making require better data collection and information infrastructure.
Nurse practitioners are a vital part of the health care team. We provide primary care in rural and urban areas, community- and school-based health centers, nursing homes, and many other settings. When I see a patient, my nursing background promotes a focus on the larger context of that patient’s life including their family. I highly value my collaboration with other team members from social work, medicine, and other disciplines, and I know that patients and families benefit from access to the comprehensive services nurse practitioners provide. As health care reform unfolds, we all need to promote and support the participation of nurse practitioners in the best interests of our patients and their health.   

Jane Tuttle, Ph.D., FNP-BC, FAANP, is a professor of clinical nursing and pediatrics at the University of Rochester and has practiced in primary care for more than 35 years. She directs the Family Nurse Practitioner Program at the University of Rochester School of Nursing and teaches in the HRSA-funded interprofessional Leadership Education in Neurodevelopmental Disabilities (LEND) Program. She co-chairs an interprofessional family research roundtable with Susan McDaniel, Ph.D.
Posted by Sonya Collins on Nov 15, 2016 1:40 PM EST
39097145815dd9f6c076ede586561362-huge-miFor all the strides we make, mental health and physical health continue to be viewed by many as two separate issues, though the two are inextricably linked. As a result, the quality of mental health care suffers. Today on the blog, clinical psychologist Benjamin Miller urges us to adopt language and actions that reflect the "oneness" of mental and physical health in order to begin to better address them. 

By Benjamin Miller, PsyD

What is health? Depending on who you ask the definition can be quite broad.

Our understanding of health is often tied to our experience in health care despite the two being quite distinct and different. Research is clear that what impacts our health has little to do with health care, which begs the question – what is health?

Health is the foundation for achievement. Without it, we cannot achieve our fullest potential and goals. We need health to make sure that we can be successful in life. While we must never ignore major issues like social determinants on our health, we also need a functional health care system that can adequately address our health needs when we are sick. 

But do we have this system? Do we have language to describe what we want? Language is important in our understanding of culture. And language has divided us in health care. Consider the wonderful breakdown of terms according to Moses et al.:

Current taxonomy is frequently misleading and fails to describe the complexity of the entirety of the US health care system. Health is a misnomer, because most activity involves illness. Health care and medical care are not synonymous. Prevention requires tools that are often unfamiliar because educational, behavioral, and social interventions, not usually considered to be part of medicine, may be most effective for many diseases. Provider does not accurately describe the dozens of different professions and organizations required for a patient’s care. Payers are paid not to pay too easily; insurers do only modest amounts of insuring because government and employers accept most risk. Economic concepts of cost and value are ambiguous, as measurement is elusive and because one segment’s cost is another’s value. Market is a misnomer because few prices are transparent and many are controlled. Above all, US health care is not a system, as it is neither coordinated by a central entity nor governed by individuals and institutions that interact in predictable ways.”

Having more precise language to describe health may actually help change health care. Consider the issue of mental health. Yes, we use this term to describe what we think of as a mental condition or need; however, science and evidence simply refute this notion concluding that our mental health is inextricably linked to our physical health. It’s really just about health.  It’s about the whole and not the part.   

Our health care system, taking a page from this limited understanding, created an entirely separate system to manage mental health. In fact, legislation passed under JFK over 50 years ago still haunts us today as Kennedy’s promise to better address mental illness was never fully realized. Then, as now, the health care system isolates mental health from whole-person health. We see a piece when we need to see a whole. Kennedy’s legislation, while undoubtedly filled with good intentions, only widened the divide between mental health and the rest of health care because the science was simply not where it is now to inform the policy decisions. Deinstitutionalizing mental health was the right move, but what happened next was a series of unintended consequences that we are still addressing today. For example, consider that there were really no mental health benefits at the time- these had to be created, and in their creation a division emerged of having two separate benefits (one for mental health and one for medical). These decisions are why the battle over mental health parity has been so critical – so that all benefits are treated as equal.

Concurrent mental health and physical health problems are quite common and often go untreated, leading to high health care utilization. Said differently, when both behavioral and physical health problems are treated in a medical setting simultaneously, improper utilization of the health care system decreases, patient outcomes improve, and money is saved. We know what needs to be done, but we are constantly running up against a culture of fragmentation and a history of fractured delivery that presents a substantial barrier for change.
Language changes culture.

While mental health is undoubtedly a critical piece to our health, it is a piece. If we want to decrease stigma around mental illness, perhaps we need to begin to think about our language. If we want our community to begin to demand and expect something different in health care for their health, maybe it’s time we begin to shift our language to be more inclusive of mental health.

To accomplish this, we need to be less afraid to talk about mental health in all settings. We need to be willing and able to have teams that include mental health clinicians. We need to recognize that every time in health care we refer or say “I don’t do mental health,” we further fragmentation and stigma. It is on us, all of us, to begin to reassess our language in service to a much more whole and complete vision of health.  

To help begin to better address mental health perhaps we should consider, at a minimum, the following:
  1. Be careful of using language that furthers the artificial divide between mind and body (e.g. that’s so mental, he/she is crazy)
  2. Provide educational materials that speak to the whole of health (e.g. brochures in a primary care practice, videos or public education efforts on the role of “mental health” in health)
  3. Advocate for payment models that are inclusive of mental health (e.g. global payments that include the cost of mental health clinicians, bundling mental health services into larger medical services)
Health is health is health, and until our health care system reflects that, we must keep pushing for our broadest understanding of health to include mental health. Together we can begin to change culture to make mental health just another facet of health. This will change practice, policy, payment, and most important people’s minds.  

Benjamin Miller, PsyD, is an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine where he is director of Eugene S. Farley, Jr., Health Policy Center. Under his leadership, the Farley Center has worked on four main areas: behavioral health and primary care integration, payment reform, workforce, and prevention. A clinical psychologist by training, Miller has focused his career on creating innovative solutions to fragmentation in health care.
 
Read more about integrating mental and physical health. 
 
Posted by Sonya Collins on Nov 10, 2016 11:03 AM EST
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Dear Penny, You give us another wake-up call. Boundaries can get loose and good habits can get worn down in the nursing home. As you say, the way that things get paid for affects the doctor-patient relationship. In my HMO, there are financial incentives to keep our patients at home. And some of our patients who need long-term care but still value the sociali...
It is a great article to know what patients want. Each medical professional must read this to know more about patients and keep them happy.
This looks intresting one and thanks for sharing. Any decision patient only input ant output important.
Thank you for sharing such ideas...
Thanks for the full summary of events and new leadership directions we need to take in primary care. Student and resident leadership is vital to the future of primary care, especially Family Medicine, where many of our senior leaders are shifting into health system, regional, state and federal roles, thus creating large need for new and emerging leader...

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