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183e6cbaf51bb2e4035cdd8bd4dd5b69-huge-aiA family physician early in her career is moved by the loss of a patient. Today on the blog, she shares a letter she wrote him after his passing. 

By Aimee English, M.D.

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.  Nobody knows what your final moments were like, but I know they were unexpected because you had been at dialysis just the day before plugging yourself into a machine that you hated, being poked by a needle that we had conditioned you to fear beyond reason, just so that your rather poorly functioning heart could keep on ticking for another day. 

When I came to work the Monday after you died, I learned of your passing in a way that illuminates the less humanitarian side of medicine—a message in my inbox from a call center representative I had never met stating I must call the coroner’s office to discuss your death and complete the necessary paperwork.  I stared at the screen paralyzed for a good minute, then realized I had ten patients on my schedule, buckled down my heartache, saw them, called the coroner, and drove home mourning your death in the privacy of my car. 
 
I am sorry, because you shouldn’t have died alone.  About two years after you had become my patient, you came to see me for chronic, intermittent chest pain.  You had previously had a coronary bypass and we knew your bypass vessels were obstructed.  You were already on the best medications possible to help your heart.  I drew a picture of your heart and labeled your blocked rerouted arteries, pointed to the nitroglycerin on your medication list, and tried to let my face show how sorry I was as I let you know there was nothing more I could do, waiting as the translator relayed each of these messages in Spanish.  I felt like a failure, notifying you of this truth.  You understood my disappointment, replying in English, “It’s okay.  You all take good care of me, more than my family.” Most people die with their families beside them if they can.  I knew you wouldn’t, but I hadn’t pictured you dying alone, and for that, I am so sorry.
 
Mr. C, the other thing I want to say to you is thank you.  Many hands helped shape me into the doctor I am today, and many of them highly trained and educated. Despite having only a sixth-grade education, you were one of my greatest teachers.  When you first became my patient during intern year of family medicine residency, you taught me so many lessons important to the early resident – how to manage diabetes, heart failure, end-stage renal disease, sick versus not sick,  and the value of provider-patient continuity.
 
As I became a better doctor, your lessons became more sophisticated.  We danced around tough topics like depression and end-of-life planning.  You taught me the importance of being honest when the news was bad, letting the unrealistically optimistic “there’s a slight chance” of intern year grow into the more respectable “what is most likely” of third year. 

You taught me how to use my team.  Our social worker helped you find housing.  Our psychologist helped you talk about depression and gave you exercises to reduce your fear of needles.  After months of sending off refills that you never received, our pharmacist discovered I had been sending them to a different Walmart several blocks down the same street as the one you were going to.  In fact, when staff around the clinic learned that you died, it was the front desk that took it hardest.
 
You taught me to be an advocate, asking your specialists to step outside of their guidelines to cater to your individual medical needs that I alone knew.  You taught me to look deeper when I realized your improved diabetes control was the result of you eating less because of worsening depression and dwindling money for food.
 
Above all, you helped me start to learn what it means to be a family doctor.  I say start to learn because now two years post-residency, I can see that understanding what family medicine is takes more time than a three-year residency.  Because of you, I know that continuity means better care, that lack of financial resources trumps recommended care, and that sometimes my job is about making a troublesome problem disappear, but mostly it’s about helping patients live with problems that don’t go away.
 
I know that you appreciated me being your doctor, because you thanked me at the end of each visit. I’m sorry I didn’t thank you back.  I think you deserved to know how much I appreciated what you taught me over the years and I think you deserved to have died with dignity.  I know that you will never read this letter, but other patients might, and I hope that in doing so, they get a glimpse of the profound effect you can have on us, even if we forget to say thanks.
 
Sincerely,
Dr. Aimee English
 
Aimee Falardeau English, M.D., is a faculty family physician at University of Colorado. Her special interests include patient engagement in quality improvement and improving care for patients with complex needs.  She completed a practice transformation fellowship at University of Colorado in 2015 and completed residency at the University of Colorado after attending medical school at University of Massachusetts Amherst.

Related reading
"Relationships draw resident to primary care" by Eunice Yu
"My first patient" by Diana Wohler
"In the ER, the call to primary care is strong" by Jennifer Stella
 
Posted by Sonya Collins on Aug 25, 2016 11:46 AM EDT
Utah logoToday on the blog we feature a Q&A with one of our sponsors of 2016's Gregg Stracks Leadership Summit, which begins this Friday, Aug. 19. The University of Utah Department of Family & Preventive Medicine exists to optimize health and quality of life in home, work and community through scholarship in Utah and around the world. Its values include intellectual curiosity, a respectful working environment, integrity, collaboration, accountability and excellence.

Primary Care Progress: The University of Utah Department of Family & Preventive Medicine was founded in 1970, and is one of the oldest and most established family medicine departments in the country. What does this legacy provide?

University of Utah Department of Family & Preventive Medicine: The department was created in 1970 to train family physicians, physician assistants and public health professionals, and to advance knowledge and practice of primary care, public health and environmental and occupational health.
 
Since it began, the department has acted as a bridge between the community and the health care system by focusing on people in a real world context. The multi-faceted disciplines housed within the department examine biological, social, environmental and occupational influences on health and well-being. Department faculty implement systems of public and personal health care to address population and primary care needs. The department protects and improves the health of individuals and communities by advancing the science and practice of primary care and prevention.

PCP: How does your mentor program improve outcomes for your students?

Utah: Faculty in our department are involved in all levels of medical education. This gives students an exposure to what a family physician can do – not just see patients, but research, education and administration. Our faculty not only guide students as teachers, but as mentors in clinic and in research. Students achieve mentorship from our student groups including the Family Medicine Interest Group and the Utah chapter of Primary Care Progress. This chapter was one of the first to be interprofessional and continues to be so, not only in students, but also in faculty leadership. Students participate in research within our Family Medicine, Public Health and Occupational Medicine divisions, again demonstrating the breadth of the department. We have increased the length of our required Family Medicine clerkship from four to six weeks in the last year, providing our students with opportunities to experience Family Medicine in a rural or urban setting.

PCP: What is your vision for primary care in the future?

Utah: Primary care is foundational to achieving the “Quadruple Aim” in health care: better care, improved health, lower cost and sustainable, satisfied health professionals. Improving care and well-being for individuals and communities is essential to sustaining every nation’s economy and vitality. As a result, our department strives to help not just Utah, but communities across the nation and around the world achieve the quadruple aim. Our physicians, advanced practice clinicians and researchers are envisioning comprehensive health and payment systems. We are looking at ways to move away from narrow focus on sick care, to preserving and promoting health. However, a holistic approach cannot be achieved by clinicians alone. Health care, especially primary care, is a team sport involving many players: patients, public health professionals, physicians, physician assistants, nurse practitioners, health coaches, care managers, nurses, medical assistants, clinical pharmacists, social workers and many others to help individuals and communities thrive by improving health and lowering cost of medical care.

PCP: Why is leadership so important when making change in health care?

Utah: Leadership is key in any type of change, and especially in today’s health care it is essential. With an emphasis on teams and relationships in health care, leadership is what will move people forward to make change. Change in health care can be complex and scary with so many moving parts and people affected; but with positive leadership from all involved, real change is possible.  
 
As health care evolves to provide robust team based care, including everyone as part of the process, we all have an opportunity to be leaders in a revolution that will make the health care industry better by providing top-notch care, reducing cost and creating a better environment for patients and providers. As leadership author John Maxwell said, “A leader is one who knows the way, goes the way and shows the way.” A leader demonstrates how important everyone’s role is in helping to make changes essential to improving health care.

PCP: Thank you for your support of PCP’s Gregg Stracks Leadership Summit. What is it about PCP's work that encouraged you to invest?
 
Utah: The decision to invest in PCP’s Gregg Stracks Leadership Summit is an easy one for our department. PCP is training the future leaders in health care: the people that will work with teams to help primary care, and therefore health care overall, flourish. As a multi-disciplined and diverse department that focuses on optimizing the quality of life for all through collaborative scholarship, our mission fits directly into what PCP is doing for the future leaders of primary care. We are happy to be a part of this summit and we cannot wait to see the changes these future leaders are going to create to help make our health care system one of the best and most cost effective in the world. 


Learn more about the University of Utah Department of Family & Preventive Medicine here.
Posted by Nate Leskovic on Aug 15, 2016 8:21 AM EDT
OptumCare logoToday on the blog we feature a Q&A with one of our sponsors of 2016's Gregg Stracks Leadership Summit, which is almost two weeks away. OptumCare is a health care organization offering coordinated care for individuals, families and older adults: "Reinventing health care by putting you first."

Primary Care Progress: Like Primary Care Progress, OptumCare is leading change in health care. Why is that so important today?

OptumCare: Our current health care system is in need of a major redesign to provide the coordinated, efficient and affordable care that people deserve. OptumCare, like Primary Care Progress, is making it easier for patients to get the care they need. We aim to keep people healthier and give them a positive health care experience. Physicians and clinicians across the health care spectrum are best equipped to intimately understand the challenges our health care system faces and to lead change. With strong and innovative leadership, we can create a better health care future for everyone.

PCP: OptumCare improves connections across health care to deliver better outcomes. What is your vision for primary care in the future?


OptumCareAt OptumCare, we recognize that primary care must have the necessary resources and infrastructure for success. We are actively working to redesign primary care to surround the doctor with a team of care providers who can help him or her get more done and deliver more personalized, attentive care. This care team may include case managers, care coordinators, social workers, behavioral health specialists, nurses and others. Through technology and workflow reorganization, we are connecting primary care to the rest of the health care system in a way that preserves the long term healing relationships that are the foundation of medicine. As this work matures, primary care will be able take its rightful place as the central principle of a health care system that works for people.

PCP: How do you utilize data and technology in pursuit of your goals?


OptumCareWe provide the latest analytics and IT support to turn vast amounts of patient data into actionable information that drives better care decisions and outcomes. This support helps identify those most in need of care and reduces the risk of illness in those who are well.

Today, there is a flood of data coming at us, while many of us on the frontlines are burdened with data entry chores. At OptumCare, we realize data means nothing unless it is served up at the right time, to the right person, and can be used to effectively change behaviors. We are redesigning information systems to create real intelligence out of unstructured data and to free up clinicians from data entry.

Digital technology also allows for new channels for communication and dialogue that can reconnect disparate venues of care, allowing primary care to realize its full potential to provide continuous, comprehensive care.

PCP: Why is leadership so important when making change in health care? What is it about PCP's work that encouraged you to invest?

Accountability is a top leadership attribute that OptumCare embraces and is in great need in health care today. We must all be accountable to the people we serve and for executing on the vision of a better system. 

Learn more about OptumCare here.
Posted by Nate Leskovic on Aug 4, 2016 12:55 PM EDT
f3abeb1495ea283f82d1ac19cec25873-huge-58PCP's 5th annual Gregg Stracks Leadership Summit is just a few weeks away. What can you expect? For one thing, an environment where students and practitioners in all disciplines are respected and embraced. Today on the blog, a nurse practitioner and summit moderator describes how she discovered PCP's interprofessional culture at the first Gregg Stracks Leadership Summit in 2012.

By Alana Rose, N.P.

I recently attended Primary Care Progress’s Gregg Stracks Leadership Summit. The summit brought together chapter leaders from around the country to get coaching in how to lead our chapters to accomplish our individual goals. 
 
I went to the summit knowing that PCP values teams – the team-based model of organizing to improve the primary care profession and the team-based model of primary care delivery.  In both cases, there would be a place for me, an RN and a nurse practitioner student.
 
But amidst the initial excitement and bustle of registering and sharing greetings with strangers, when I put on my name tag, I noted that it clearly identified me as part of an under-funded school of an under-respected profession: nursing. I recognized myself as part of a minority of non-medical students, and, despite what I knew about PCP, I wondered if I would be taken as seriously as my new weekend peers. Would medical students, residents, and doctors be as interested in networking or even just talking with a nurse?  I realized that I had internalized the historic tension between nurses and doctors and between nurses and nurses, and it occurred to me that this tension could be a possible barrier to PCP’s efforts to engage more nurses in its work. 
 
I am more of an anthropologist than a nurse or nursing student in my comments here. And I am neither the first to make this observation nor am in any way qualified to unpack the many layers of history that have colluded to keep these two groups at odds. Still, these tensions are worth bringing out in the open if the efforts of those of us involved in PCP are going to include a space for those who are not doctors or doctors in training, and in so doing, bring different perspectives and a history of (dis)empowerment to navigating the problems in health care.
 
Before I decided to go into health care, an oncologist friend cautioned me against nursing. “Do you want an M.D. or an N.P. after your name?” she asked. She warned me both as a woman from another generation and also as a clinician who greatly valued the power she saw as intrinsic to becoming an M.D. I believe many who choose medicine share my friend’s value, but ultimately I entered nursing because as a non-traditional student, I wanted to gain clinical skills and experience as quickly as possible.
 
I was both haunted by and propelled towards health care by experiences I had while working as an English-Swahili interpreter for a group of American doctors and nurses in Tanzania. There, I saw the harm that can come from efforts “to do good” through the stasis of hierarchy and at the exclusion of others. In one typical clinic, a nurse stood before a long line of Masaai tribal members seeking care outside of the handmade community structure that they had built years ago, hand prints baked into the clay walls. The doctor and resident sat within the cool spacious building and saw one patient at a time, while the nurse worked outside, assessing vital signs and watching as people, weary from many miles of travel under the hot sun, grew frustrated with such a slow and inefficient use of space and personnel. The doctors had essentially recreated the design of their offices back in the U.S. and, like they may have done back home, greatly underutilized the expertise of the nurse. In the end, the clinic ended abruptly, as the numbers of hot and tired patients kept growing and reached a crescendo when a doctor slammed a young man’s hand in the car door while trying to leave the site in haste.  Although the nurse commented throughout each and every clinic about other (perhaps better) ways to utilize space, provide care, or understand a given  problem, she rarely spoke up to express her views to the doctors. I can only assume she felt she would not be listened to or respected.  In part through this experience, I saw nursing as an opportunity to be of use to another human being in some of the most concrete ways possible. After all, the nurse was outside with the patients all day; few saw the doctor. We see in the U.S. health care system as well that nurses (and CNAs) are more often able to be at the bedside when it matters, addressing our most basic human needs. The work can be as humble as assessing a patient’s urinary or fecal output, or as profound as attending to someone in their final hours of life.
 
I knew little of the deep professional rift between nursing and medicine, and I knew even less about the complex way in which this legacy has impacted not only the way doctors and nurses work together, but also how nurses treat one another and undervalue themselves. Nurses are notorious for “eating their young,” and will not only often ignore their own needs but they also have an unfortunate legacy of hazing new nurses in ways that emphasize a culture of workaholism, co-dependency, and fear. In most clinical settings, doctors’ and nurses’ worlds are so deeply divided despite their interdependence. Even socially these divisions are maintained by many in choices as simple as with whom to sit at dinner.
 
You can imagine my relief at the summit when, during our first break-out group, I met a young med student who introduced himself by way of a story of meeting an RN at a homeless shelter and expressed his humility and respect for the clinical knowledge she had. This was one of many experiences during the weekend that opened me to the possibility that the hot buzzword of interprofessionalism is actually a living force and exists in genuine collaboration and creative exchange between diverse constituents.
 
The weekend helped me to step outside the isolation of my education program and of my future career path. The patterns of division and reactivity that have kept students and practitioners of medicine and nursing separate seemed absolved for a few days. Learning of new generations of programs that truly foster collaboration between health care trainees was radical and nourishing.
 
There is no need to reiterate the fact that our current primary care system in the United States needs a thorough overhaul. We all have stories and evidence of this need. I was heartened, however, to see that PCP chapter members I met at the summit seem to value the interprofessional matrix that primary care requires to survive this difficult time. It is my hope that all PCP members reflect that value. And I hope they do so without becoming lost in a quest for power that is equivalent to their peers in sub-specialties, but rather begin to assert an entirely new value system. As we begin our work to recreate health care delivery in the United States, it is not only good practice to bring all health care professionals to this drawing board, it is essential if we are to catalyze a new story of primary care.
 
Alana Rose wrote this piece in 2012 as a nurse practitioner student at University of Southern Maine, where she helped found a PCP chapter. Today she is a Family Nurse Practitioner.  She is committed to supporting innovations in the training and delivery of primary care and believes this can only be accomplished through rich communication and collaboration within interdisciplinary teams. She lives in Belfast, Maine.

Read archived blog posts from other members of the summit training team. 
Kat Barnes
Victoria Boggiano
Jonathan Jimenez
Michael Mattiucci
Stephanie Nothelle
David Choi
Kyle Turner

 
Posted by Sonya Collins on Jul 28, 2016 1:31 PM EDT
22069c27baec2f32b385876c2039e5de-huge-daPCP's 5th annual Gregg Stracks Leadership Summit is just one month away. Led by an interprofessional training team, the summit introduces chapter leaders to PCP’s innovative leadership framework and the variety of high-impact projects PCP chapters have used to revitalize primary care. Today on the blog, meet a member of the training team, David Choi. In this blog post from our archives, David shares his experience helping his PCP chapter open the DAWN clinic. 

By David Choi

As I write this, the DAWN Clinic will open for its first patients in 18 days, two hours and 28 minutes. The leadership team anxiously buzzes around each another at our meeting where we’re tying up loose ends and generating solutions. The tangible excitement in the room is felt by all as we finish up our respective projects. 
  
At the risk of sounding cliché, it really does seem like just yesterday that our Colorado PCP chapter held the first meeting to discuss the clinic. Students of the medical, nursing, pharmacy, physical therapy, and dental schools convene at our meetings to bring change to our surrounding community, educational institution, and the greater field of primary care.
 
At one of our early meetings about the clinic, we divided into different workgroups to take on the various tasks involved in opening a student-run free clinic. It was just an idea, that became a movement which garnered the support of the Dayton Opportunity Center and the Fields Foundation. And now we are days from opening the doors of the Dedicated to Aurora’s Wellness and Needs (DAWN) Clinic to the underserved.
 
Back then, we were a group of many students from many professions. I am amazed at how little I understood about my colleagues’ professions back then – before we became a high-functioning, interdisciplinary team.  
 
As the leader of the Pharmacy and Procurement workgroup, I was tasked with obtaining all the essential items for the clinic. How was I supposed to do this? I was a second-year pharmacy student. I didn’t know what a primary care clinic needed in order to function. I remember sitting with my co-leader Katie, trying to develop a list for the clinic, we sat there thinking “exam room table… otoscope… stethoscope… cotton balls… that’s it, right?” We knew we had a challenge and that we had to overcome it.
 
We were presented with something we were not comfortable with. But as we were taught in pharmacy school and through our work with PCP, we sought out resources and contacts to help us. We started off with the WHO guidelines for primary care clinic supplies and continuously adjusted it as we compared it to other clinics’ lists. For example, after A.F. Williams Family Medicine Center provided us with the inventory list of their current supplies, we sat down as a small group to update our own list. After one week, we had a complete list. But now we had to actually find donors to give us the items on the list. We approached clinics asking if they would be willing to donate any items. They in turn referred us to other clinics and organizations. Then we were introduced to ClinicNet and Doctor’s Care. They put us in contact with the vast network they had established to get us the items we needed. A clinic that was closing in Littleton, CO, donated roughly $15,000 worth of equipment to us. When we met with the doctor to pick up the donation, he stopped us before we left and told us he believes in our cause and our initiative. It is these experiences that demonstrate what we are capable of as students and as a team.
 
The problems of the underserved community around us are within our reach, and as health care professionals, we have a social responsibility to rise to the challenge and enact change. As students of diverse disciplines, we have the combined resources to bring together the knowledge, skills and, yes, equipment and supplies necessary to care for this population. This has truly been an interdisciplinary project. While moving closer to opening this clinic, I have learned more every day about what the different health professions are capable of. Together, we are bringing change to our campus and our community.

David Choi is a fourth-year pharmacy student at University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. David has been part of Colorado's PCP chapter since 2014. During his third year of pharmacy school, he and others worked to set up a student-run free clinic at University of Colorado called Dedicated to Aurora’s Wellness and Needs (DAWN) Clinic. David aspires to bring change to the curriculum at University of Colorado to promote primary care. He loves photography and plays piano when he has time.

Read archived blog posts from other members of the summit training team. 
Kat Barnes
Victoria Boggiano
Jonathan Jimenez
Michael Mattiucci
Stephanie Nothelle
Alana Rose
Kyle Turner



 
Posted by Sonya Collins on Jul 21, 2016 3:47 PM EDT
8ab6e4087f15be4cdc51c0e79e718ef1-huge-1ePCP's 5th annual Gregg Stracks Leadership Summit is coming up. Today on the blog, PCP's president tells the story of Gregg Stracks and why the summit is named for him. 

By Andrew Morris-Singer, M.D.

My junior year of Internal Medicine residency was a difficult, confusing time. A trainee committed to a career in outpatient primary care, I found myself spending a great deal of time on inpatient hospital wards with some of the sickest, most complicated patients I’ve ever encountered. While the medical conditions were fascinating, most were preventable exacerbations of chronic problems or late outcomes of diseases that could have been caught earlier with screening. It felt like we were perpetuating a failed health care system that did little to manage and protect patients’ health but rather waited until they got really sick, and then dumped everything we had in our medical armamentarium on them. It seemed divorced from good economic sense and completely at odds with both the skills that I wanted to learn to keep patients out of the hospital and the values that brought me into health care in the first place.

Despite the dysfunction in the system, my job was to care for those patients, manage the team of house staff and students, and strike the right balance between my clinical, educational and managerial responsibilities – a significant leadership challenge for anyone, let alone someone feeling as conflicted as I was. 

My disdain for the disconnect between the care we delivered and what patients actually needed came across to everyone I supervised. “It was impossible to see this coming,” I’d sarcastically mutter to my team as we’d re-admit a heart failure patient who’d fallen through the cracks due to non-existent communication between the previous inpatient team and the outpatient providers.
 
This is how Gregg Stracks found me when he arrived to offer leadership training to a handful of residents in our program. He found someone who was overwhelmed and jaded; someone for whom team leadership meant modeling unyielding perseverance and determination, with no allowance for emotion or vulnerability.
 
“The stuff we’re seeing is so upsetting, so backwards, I’m afraid if we let any emotions out, we’ll be unable to work,” I told him at our first meeting.
 
Get done. Get out. Keep the emotions in. That was my game plan for surviving my ward time and helping my fellow residents survive.
 
One day Gregg observed our interdisciplinary care rounds on the medicine wards. The members of our large care team were overwhelmed by a particularly difficult patient and his family. We were tired of jumping through hoops to get him the best care only to be rebuffed and manipulated by him and his family. We were also frustrated with each other, convinced that members of the team from other disciplines were making the situation worse. On rounds that day, a social worker said the situation made her question going the extra mile for any patient and their family. After a long silence, to everyone’s surprise, a nurse on the team, who was typically quite contrarian, agreed with her and said she too was having a difficult time and was also questioning her values. But, concerned about “staying on track,” I interrupted and encouraged the team to focus on concrete tasks so we could “get the work done and all go home.”
 
After the meeting, Gregg pulled me aside and in his usual kind, curious, yet direct style, he asked why I had shut down the most intimate interaction he had ever seen our team have. It was the closest we had come to connecting and building real relationships with one another. Connections around values and personal experiences, he said, are the glue that binds team members together to get their work done in a sustainable way.
 
Gregg showed me that by avoiding the emotional, I was missing the opportunity to truly lead the team. Focusing exclusively on the technical and not allowing the team to publicly voice their emotions and values, I couldn’t harness the greatest motivations that had brought every member of the team into health care in the first place: commitment to helping others; to making a difference in someone’s life; to easing unbearable symptoms when there was no hope for cure. Deep connections between team members would only form when we identified our shared motivations and values.
 
Gregg taught me the importance of tapping into the heart.  He assured me that it didn’t make our team less professional. In fact, it allowed us to expand our professional selves to bring all our values, strengths and passions to our work.
 
With Gregg’s guidance, teaching and unremitting support, my notion of leadership transformed. No longer was my job about getting the work done, the boxes checked. It was about helping each team member harness the full spectrum of their intellect, passion, commitment and values for the challenge at hand. Evoking the non-technical or non-analytical wouldn’t slow us down or take us off track. Rather, it would energize us, connect us, and keep us true to the values that seemed to frequently run counter to the system in which we worked.
 
Despite the profound impact Gregg had on my approach to clinical team leadership, the greatest gift he gave me was confidence that we could take these same team-building approaches into the world of primary care advocacy to do things that many of us never thought possible. We could use this leadership style to build new teams that could push for family medicine divisions at institutions where they didn’t exist, accelerate innovation in primary care delivery, or advocate for curricular reform.
 
Many people in primary care at the time knew that we needed a new approach to advancing the field. At Harvard, my own medical school, the primary care division had recently been defunded. At other academic medical institutions around the country, primary care and its practitioners faced constant devaluation and marginalization. We needed to bring our diverse community of primary care professionals together and depart from the traditional siloed approach that only increased animosity among primary care disciplines and professions. We needed to pull average primary care health professionals or trainees out of primary care despondency syndrome. We needed an antidote to the helplessness many of us felt. Most importantly, we needed an approach that harnessed our full potential power and raised a united voice.
 
Starting in Boston, we adopted a grassroots organizing approach that essentially builds mini-campaigns to promote careers in primary care, advance innovation in care delivery and accelerate reform in training. Three years later, over 26 chapters of this network have taken root. What unites us is a commitment to building powerful relationships between individuals and using those connections to spawn action.
 
Just like Gregg taught us, we now see that when we bring a group of people together to fix a difficult problem, we must spend as much time eliciting people’s emotional response to the problem as we do their logical response to have the best chance of creating and sustaining a new team that can solve the problem. The head steers us, but the heart is the engine that makes us go. Just like I discovered on the wards, our job as primary care leaders is to create spaces where like-minded individuals not only can brainstorm solutions to the problem, but where they can express and subsequently harness their emotions and values as well. 
 
Sharing ourselves with others and inviting others to do the same is at the heart of PCP’s effort to lead change in primary care. In my travels around the country and my communication with many of you, it warms my heart to see this leadership approach manifest in all of your great work. Your commitment to this practice has grown the network. Others join us not because their heads tell them to, but because their hearts compel them to.
 
As one faculty member recently confessed to me while we were watching a group of interprofessional students share their values and experiences at a PCP meeting, “It’s not only inspiring to watch this…it’s totally intoxicating.”
 
Gregg Stracks passed away in January of 2012, at the age of 40, from metastatic ocular melanoma, years after he had been told he had months to live. All of the work we did together – all of which occurred after he was suffering from metastatic disease – was the greatest gift I’ve ever received.
 
I believe two things helped Gregg survive so long. First, the deep love, devotion and companionship of his wife Sara and his family and friends. And second, his work with Primary Care Progress and others, helping people like me share our emotions and values and exercise our responsibility to enable others to do the same. Simply put, Gregg was energized by helping people connect with one another. It helped him survive and helped spawn a primary care movement.
 
Gregg’s passing was a great loss to everyone who knew him. He took a piece of our hearts with him, but he left a piece of his heart with us, too. He left us with an approach to leadership, connecting with others, understanding ourselves and building teams that can help each of us do our best work during whatever time we’re lucky enough to have in this life.
 
Please join me in reflecting on our collective luck at being a part of a network and movement connected to such an amazing person as Gregg Stracks, who gave so much of himself, at such a difficult time. Let’s commit to using his leadership summit to reconnect with the values that brought us into primary care. Through those values, we can connect with one another to build new visionary teams to fight for the health of our patients,  our families, our communities, and this nation.
 
Andrew Morris-Singer is a physician and former community organizer and trainer. As president of Primary Care Progress, Dr. Morris-Singer has been instrumental in igniting an interprofessional trainee-led grassroots movement to reform primary care delivery and training.  Dr. Morris-Singer writes and speaks regularly on the topics of primary care community advocacy, utilizing organizing strategies to advance primary care clinical innovation and the critical role of trainees in the revitalization of primary care. Dr. Morris-Singer is board-certified in internal medicine and is an affiliate instructor at Oregon Health and Science University. He lives in Portland, Oregon.

Read more about the Gregg Strack's Leadership Summit.
 
Posted by Sonya Collins on Jul 14, 2016 2:17 PM EDT
50d194de2607f04f2fe9a65d50bcb085-huge-unPrevention and multidisciplinary teams are the cornerstones of a transformed primary care system. Today on the blog, Dr. David Moen explains how TeamMD is putting these values to work to keep the elderly on their feet.

By David Moen, M.D.

Rose was 83, lived alone, and came to the ER by ambulance around 11pm.  She had fallen earlier that day and was unable to get up.  Over the next few hours, she slid to the phone and finally dialed 911.  When I met her, she complained of severe right hip pain and exhaustion but not much else.  I didn’t find much in her history or exam: mild cognitive impairment, mildly elevated blood pressure, and a tender right hip with no swelling or bruising anywhere.  I ordered some labs and x-rays. 

During her ER stay, she became a bit agitated.  She wanted to go back home.  I didn’t think that would work.  She couldn’t stand by herself.

I needed an admitting diagnosis to solve “my problem.”  Her hip x-ray was normal.  A broken hip would be an “easy admission” for me as an ER doctor.  Medicare wouldn’t pay for a ride to her apartment, no family responded to our calls, and no home care was available at this time of night.  Her blood work was normal.  “Fortunately” for me she had bacteria and some white blood cells in her urine (like most women her age).  Rose was admitted with intractable hip pain, possible UTI, and cognitive decline. It seemed to be the only and best option.

Rose never returned to her beloved apartment.  The night I admitted her, she became more agitated and confused.  She was experiencing delirium, just like 65 percent of all elders with any cognitive impairment admitted to a hospital.  That night she fell and struck her head.  A CT scan showed a subdural hematoma.  Then she aspirated, developed pneumonia, and after a 12-day hospital stay, she was sent to a nursing home.  Rose died 183 days later (an average-length nursing home stay). 

The hospital quality review committee determined that the night nurse “wasn’t watching Rose closely enough.”  The night nurse was reprimanded for what most of us would admit is a broader system failure.  She felt terrible and quit working nights a few months later.

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?  If so, how do we do that efficiently and how do we pay for it?

In fact, 16 percent of Medicare recipients spending over 70 percent of all funds are at risk for unanticipated hospitalizations due to falls or worsening chronic conditions.  We can find them before the crisis, and when we build a team responsive to their needs 24/7/365, they live longer and happier lives, and cost us all over 25 percent less.  And we can pay for it by combining physician fee-for-service revenue, care management revenue, and quality incentives for quality and cost performance.

United Health Care’s Venture Capital Team recently funded TeamMD to be there for the Roses of the world.  Modeled after a successful Minnesota company named Genevive, TeamMD provides exceptional primary care and comprehensive care management for frail, and mostly poor, elders.  Given Genevive’s track record in Minnesota (exceptional patient and family satisfaction, high physician and staff satisfaction, and lower costs of care), TeamMD has a high likelihood of success.

TeamMD started in its first outside-Minnesota market (Des Moines, IA) on January 1. The Iowa program now serves over 1,600 patients living in nursing homes, assisted living facilities, and their own homes. Its growth has been fueled by committed nurses, social workers, doctors, nurse practitioners, and support staff passionate about serving this “underserved and over-serviced” patient population. Recruiting clinicians hasn’t been as difficult as anticipated. That’s because well-supported clinicians and support staff find great reward caring for this challenging population.

So what makes it work? Well-trained and supported clinical teams that are paid more than clinic doctors (due to aligned payment model) find the right patients in the community sooner rather than later, answer the phone when it rings, and provide multi-disciplinary care planning for every patient and family before, during, and after each crisis.  This is a model that could be implemented in many communities across America.  It proactively addresses the physical decline, cognitive failing, and social isolation that plague many as we age. It emphasizes prevention and the value of a multidisciplinary team.  Falls, injuries, and worsening chronic conditions are more proactively and holistically addressed.  That keeps elders in their homes and prevents hospitalizations and nursing home stays that cause harm.

Our leadership team is partnering with health system leaders across the country to improve the lives of these patients.  We will reach many markets, attract the best and brightest to execute our mission, and enhance training opportunities and job growth in the markets we serve.  And the Roses of the world will get better care and live happier and longer.  To learn more, see www.TeamMD.com.  If inspired, come for a visit to learn more!  Thanks, Rose!

David Moen, M.D., is a health care consultant and board chairman of TeamMD.

Read more about team-based care.



 
Posted by Sonya Collins on Jul 7, 2016 10:02 AM EDT
06614882f36d8f07c225c12d98e4d6db-huge-5dPre-meds might get more excited about primary care if they saw it as a way to help achieve social justice.

By Phillip Zegelbone 

If we hope to improve our health care system, I believe we must motivate pre-med students to take an interest in system reform. The fresh outlook, optimism, and intellectual curiosity of young doctors-to-be are essential for progress.

Case in point: As an undergraduate at Wesleyan University, my classmates and I were inspired by the ideas and experiences we shared in a public health course offered by the sociology department: the Health of Communities (HoC). In HoC, our professor assigned each of us an internship in a community health clinic. We met in class to compare our progress in the internships and to discuss assigned readings. When the course ended, we felt the need to create a Health Care Action Network (HealthCAN) out of a shared desire to promote social justice in health care. 

Most students enrolled in HoC to learn about using social change to assist vulnerable populations. We entered the course with the notion that our contemporary models of care did not meet the health needs of vulnerable populations. Interestingly, only a few students were pre-meds or science majors.

At the beginning of the course, we believed that anyone who couldn't afford care could get it in the ER. We had no idea how difficult it can be to access care in the United States. None of us knew anyone bankrupted by health care bills and none of us had played a role in a clinic beyond shadowing. As we learned how our health system falls short, we were angered by the major obstacles patients and providers face and were frightened to learn of the major shortage of primary care doctors.

I think the real success of HoC was in translating our negative reactions into positive actions. We read case studies of social injustice in medicine, then worked toward solutions in our internships. This was my most productive period in college. The mentorship we received in our internships filled an important void and probably saved us all from feeling estranged from medicine.

The following semester, many of us continued our internships and wanted to maintain the discussion forum that had evolved in HoC, so we founded HealthCAN. Our goal was to increase student awareness of the barriers to health care access in the United States. We screened documentaries, hosted speakers, and distributed health care platform leaflets during the 2007-2008 election season.

Our group soon became politically active. Many of us had learned about single-payer health care from a HoC presentation by Physicians for a National Health Program (PNHP) and were struck by the large, and possibly needless, overhead expenditure of the private insurance industry. In our first HealthCAN meeting, I brought a PNHP activism toolkit to the table and we decided to canvass for single-payer insurance. This popular effort paved the way for my favorite HealthCAN event, in which a speaker from PNHP facilitated a lively discussion about the single-payer system. The event was widely attended and brought in many new members.

Presently, the majority of the original HoC students study or work on social justice in health care. My involvement with HoC and HealthCAN has inspired me to pursue primary care, as I now see primary care as a critical frontline in improving access to health care. More pre-medical students would tackle the problems in primary care if they knew they could gain the inspiration that my HoC classmates found in their internships and that HealthCAN members experienced with political canvassing.

When Phillip Zegelbone wrote this post in 2011, he worked in the MIT Chemistry Department as a Laboratory Manager. He has since completed medical school. 

Read more about social justice in primary care.

Posted by Sonya Collins on Jun 30, 2016 2:35 PM EDT
94078582e45dc42522cd3a8c1c3611b6-huge-clIn this team-based clinic, teammates prevent burnout by lighting the way for each other. A family medicine resident tells us how it works. 

By Cleveland Piggott, M.D., M.P.H.
 
Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, tempest-tossed to me, I lift my lamp beside the golden door! – Emma Lazarus (inscribed in a bronze plaque on the pedestal of the Statue of Liberty).
 
Part of the reason I chose primary care, and family medicine in particular, is my desire to be the lamp to those in need. Whether they need inpatient care, help with their chronic disease, a minor procedure, or just someone in their corner, I'm in a position and have the skill set to provide those services to my patients. But without a team, my lamp would burn out fast.
 
Being a member of a team is part of what makes my job as a physician so rewarding. I feel lucky to be training at a clinic that is pretty close to being my ideal work environment.
 
I work at AF Williams Family Medicine in Denver. Our medical assistants (MAs) are some of the best trained in the city. Not only do they help with vitals, but they take and document histories from patients based on the patient's chief complaints and associated question prompts in our computer system. They also identify gaps in the patient's recommended health maintenance and help close them so that the burden doesn't fall completely on the provider. After a quick huddle with the provider, the MA and provider enter the room together where the provider is able to focus more on the patient while the MA assists with real-time charting. Since the MA is already in the room, they are able to complete post-provider visit tasks, such as scheduling and blood work, without making patients wait or go somewhere else in the clinic to have this done. Providers are more present during the visit, so patients can form stronger bonds with both providers and MAs. 
 
To be successful, this model requires more MAs and a lot of upfront investment to train them. As a trade-off, providers must increase their daily patient visits but often are able to leave the office sooner due to the decreased time spent with documentation.
 
This model of care has been dubbed the Awesome Patient Experience (APEX) model and has increased our clinic's quality of care, patient satisfaction, access, and provider satisfaction.  
 
What makes this model even more rewarding for me is the other amazing team members I get to work with on a daily basis in our Patient Centered Medical Home. They allow us to provide a much broader scope of care to our patients so that we can truly meet their health needs.
 
Need an X-ray, blood drawn, or a vasectomy? We’ve got you covered. Struggling with paying bills? Let me grab our social worker to provide you with some resources. Your depression is affecting your marriage? I think our certified marriage counselor is in today, and I'll be happy to do a co-consult with our behavioral health team at your next visit. Pregnant while on seizure medication? Let me grab our pharmacist, and yes, I look forward to delivering your baby. Need a quadruple bypass surgery? Refer! 
 
I'm proud to be part of a team providing this level of care to a diverse and complex patient population. I look forward to seeing our clinic blossom as we continue to hire and train more staff to maximize the APEX model. There have been and will be growing pains, but aren't there always? No surprise, our hospital CEO has taken notice and wants to expand this model to more clinics.
 
This is the model of care in which I always envisioned myself practicing. A few years ago during residency interviews, a faculty member asked me where I saw myself five to ten years after residency.  I said, “A part of a happy, high-functioning team where members work at the top of their license to provide exceptional holistic care to patients from all walks of life.”
 
But I didn't have to wait five or ten years.
 
Cleveland Piggott, a graduate of the University of North Carolina School of Medicine, is a resident at the University of Colorado Family Medicine Residency. His interests in health care include policy, primary care work force, mental health and academic medicine.

Read more about team-based care. 
 
 
 
 
 
 
 
 

 
Posted by Sonya Collins on Jun 23, 2016 11:29 AM EDT
Sonya CollinsHere on Progress Notes, many health care providers have written about the value of team-based care. It allows health care providers of all disciplines to practice at the top of their license, doing what they do best and freeing up more time to spend face-to-face with patients. Team-based care also allows for payment models that incentivize quality of care over quantity of care. That's why providers like it, but what do patients think? That's what we wanted to find out. 

By Sonya Collins

Ridie Ghezzi was dealing with depression. Her doctor tried her on one medication, then another, then changed her dose, but it just wasn’t working for her. So she called Amanda Rice, the behavioral health specialist at Dartmouth Health Connect in Hanover, NH, where Ghezzi is a patient.
 
Rice immediately contacted Ghezzi’s primary care doctor – also at Dartmouth Health Connect – who called Ghezzi that day. The phone conversation was long and unhurried. During the call, the doctor decided to change Ghezzi’s prescription, and she made an appointment to meet with Ghezzi, her health coach, and the behavioral health specialist as a team the next month.
 
“I felt like the wagons had surrounded me in protection,” Ghezzi recalled.
 
TeamworkA same-day call back from a doctor? A long phone conversation? An appointment with three health professionals in the room at the same time? If this doesn’t sound like a typical interaction with the health care system, it’s because Dartmouth Health Connect is not a typical clinic. Its team-based model of care strikes a stark contrast to the solo doctor-does-all, seven-minute-visit model that most patients know (and few love).
 
By design, team-based practices, also called patient-centered medical homes, have the potential to redistribute provider workload, change the way health care providers get paid, and – in the best cases – put patients at the center of it all. Providers have many reasons to love the model of care, but what do patients think?
 
Research shows that patients want four things in a medical practice: whole-person care; coordination and communication among providers and between providers and patients; patient support and empowerment; and ready access.
 
If a health care model by any name delivers those benefits, patients are likely to take to it. “Patients love the concept, but if it’s not operationalized, if the practice isn’t visibly operating as a team, they won’t embrace it,” said Christine Bechtel, co-chair of the Center for Patients, Families and Consumers at the Patient-Centered Primary Care Collaborative. Bechtel co-authored the aforementioned research published in 2010 in Health Affairs.
 
What is team-based care?
 
The idea behind team-based care is that doctors cannot – and should not – do it all. They can’t see all the patients, solve all the problems, and complete all the associated administrative tasks in a day’s work. Even if they could do it all, they’re not always the best one for the job. Doctors diagnose, but pharmacists unravel complex medication regimens to discover which one is causing the unpleasant side effects. Dietitians help patients come up with a meal plan to achieve a healthy weight or manage their diabetes. Behavioral health specialists address the mental and emotional issues that may prevent us from achieving optimum health. Sure, doctors can refer patients to these and other specialists, but patients don’t always follow through. And when they do, the referring doctor may never know what happened during the visit.
 
Team-based care can bring multiple health care providers together under one roof, or it can include a care coordinator who quarterbacks care that happens in multiple settings. Team members can free up their teammates to do what they do best, whether it’s diagnose, manage medications, or optimize a diet.
 
“It’s not about a doctor just writing a prescription and telling you what to do,” said Amy Gibson, RN, who is chief operating officer of the Patient Centered Primary Care Collaborative. “It’s about bringing [providers] together as partners who can provide expertise. At any given point in time, it may be the behavioral health specialist or some other team member besides the physician who needs to be leading that team.”
 
Placing patients with the most appropriate health care provider, rather than the doctor every time, can also increase access to all providers for all patients. That’s why some team-based models may offer same-day appointments, email and telephone access to providers, and longer appointments. Team-based models may also allow for innovative payment structures. For example, payers might reimburse practices a flat monthly fee per patient rather than a fee for each service provided.
 
When it doesn’t work
 
Simply declaring a practice to be “team-based” is not enough to convince patients. Bechtel selected her current primary care provider because it was a team-based clinic. She has been a patient there for several years now. But every time she goes, she says she feels like a new patient that no one knows. She fills out paperwork for the receptionist, who asks her why she is there. She then sees the medical assistant (MA), who takes her vitals and asks her why she’s there. The MA then leaves her with a doctor, physician assistant (PA) or nurse practitioner, who again asks her why she is there.
 
Stethoscope“Where is the team part of this? I’ve just been asked why I’m here three times,” Bechtel said. “It’s so obvious to patients when they’re not operating as a team.”
 
For patients, a team-based model like this one just seems to place more barriers between their doctors and themselves.
 
“Oftentimes, what patients observe, unfortunately, is that they can’t get to their doctor because it’s ‘team-based,’” Bechtel said. “They ask, ‘Well, what does that mean?’ And the practice tells you it means that all providers can access the medical record and read each other’s notes. But that’s not a team.” Shared access to an electronic medical record may streamline the workflow for providers, but it’s not necessarily a visible improvement in the patient’s experience.
 
Even the best intentioned team-based clinics may not get full buy-in from patients if patients don’t know what team-based care is. Patients need to be fully oriented as to what the new model offers, what issues it addresses and how patients can make the most of it.
 
“If no one ever explains to patients what a team-based approach is, that you might sometimes see a different person, but that person is always going to know what’s happening with you and has full access to your doctor and your records,” Bechtel said. “If no one ever says that, the patient experience isn’t going to be good.”
 
When it works
 
Team-based care that works puts the patient at the center and addresses the patient’s needs and concerns ahead of those of the provider or payer. “We haven’t done such a good job of knowing and engaging our customer in health care, and we’re trying to make that happen through the patient-centered medical home,” said Gibson.
 
Whether patients like Ghezzi can cite precisely those four things that research says patients want, the way she describes her experience reflects these values. Her physician teamed up with the behavioral health specialist to address her complaints as a whole person. The providers communicated with each other prior to contacting her and then engaged her in a conversation with them during a group appointment. The quick call-back demonstrated their support for her and her ready access to them.
 
“Everyone is working together, recognizing that none of these things are separate from each other. Emotional and physical are interconnected,” Ghezzi said. “And you feel, by the kind of care they give, that it’s all being worked on as a whole.”
 
Is a rose a rose?
 
Many medical practices can call their model team-based, but that doesn’t predict what the patient’s experience will be. At the same time, whether or not patients even know the name of the model, they will know whether their health care providers are working together as a team with the patient at the center.
 
“If you build it will they come?” Bechtel asks in the title of her 2010 Health Affairs article on team-based care. The answer, she says, is “if you build it with them, they will already be there.”

Sonya Collins is an independent journalist who covers health care and scientific and medical research. She is the editor of Progress Notes

Read more about team-based care.
Posted by Sonya Collins on Jun 9, 2016 3:39 PM EDT
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