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d8bbb0b7b006674a9ebd67690cdb3ac3-huge-13Today, in a post from our archives, then-first-year medical student Eric Lu illustrates the crucial need for primary care through a brief encounter on the street.

By Eric Lu, MD

I didn’t expect to bump into "Max" on the streets.

“I was kicked out of the house by my wife,” he sighed. Max shifted around on his feet, eyes puffy and cheeks pink.

“Did you start using again?” I asked.

Max looked down and didn’t say anything. In the three years I had known Max, an alcoholic and former drug user, he had been clean. But recently he had started struggling. He lost his job, began drinking again, experienced episodes of depression, couldn’t afford medication for his diabetes, and became overweight. Now it appeared that he was using heroin and was homeless. 

In my work with drug users in Boston through the Prevention and Access to Care and Treatment (PACT) program, I encountered many individuals like Max. I remember thinking to myself, how could I even begin to help them? When I entered medical school and thought about which field could address the spectrum of problems that people faced, I turned to primary care.

As a first-year medical student, I have not had any clinical experience, but I have observed that primary care physicians (PCPs) are able to see patients beyond their individual medical problems. Because PCPs develop a strong understanding of their patients over time, they are able to take a holistic approach to illness and manage the intersection of various disease and problems. In Max’s case, a PCP could connect his story together – that he lost his job which caused him to become depressed and take up drugs again – and find ways to tackle not just his problems with substance abuse and diabetes but also his socioeconomic problems of unemployment and homelessness.

Perhaps PCPs are no longer the all-knowing healers that they were a generation ago because today, there is simply too much to know. However, a new model of multidisciplinary team-based care is evolving to accommodate the important role of PCPs and allow them to tackle issues that fit within their interest and expertise.

Ultimately, what attracts me to primary care is the chance to work on the frontlines of medicine and to develop a solid relationship with the local community, allowing me not only to better understand my patients but also to connect them with vital resources. Although fewer medical students are pursuing primary care, doctors I’ve talked to predict a revival of the field. I am encouraged by the efforts of medical schools, such as Harvard and the University of California, San Francisco, to devote resources, energy, and time to primary care innovation and research, and by the World Health Organization’s 2008 report calling for more PCPs around the world to address issues in health care delivery. I see the current problems in primary care not as a disincentive but rather as an opportunity to go into this field, improve our health care system, and provide better care for the people we serve.

Unfortunately, I haven’t seen Max since that chance encounter on the streets, but I know that a strong primary care system would provide the resources and services that he and all of my future patients need.

Eric Lu wrote this piece as first-year medical student at Harvard Medical School in 2011. 

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"My first patient" by Diana Wohler


Posted by Sonya Collins on Feb 23, 2017 9:19 AM EST
611ee5eb26ae440a24441a177ecefb82-huge-06Today on the blog, a family physician who had grown all too accustomed to practicing in a cramped clinic, finds renewed enthusiasm for her work when her practice moves into a new space.

By Anne C. Jones, DO, MPH
The first time I walked into our clinic building, it was a foundation. No walls, only steel rods and markings for where offices and rooms would be. I gathered with my colleagues for the beam-signing ceremony, a ritual in the construction and architecture world that signifies the completion of the foundation and the transition in focus to the interior. Together, my colleagues and I ascended the stairs and walked into what would soon become our clinical care units. The smell of wood, dust and machinery was striking and created a buzz of excitement. There was a feeling of hope and positivity. The anticipation of a new space heightened once we were able to walk through and physically imagine what could be.
Six months later, we arrived for work in our new integrated medical and mental health units. There were cheers, wows, and selfies. The building smelled of fresh paint, packing tape, cardboard boxes, and shrink-wrap from recently unpacked furniture and medical supplies. That new smell continued to fuel our excitement. It reinvigorated us for our work.
And then, the first patient arrived.
We looked at each other all with the same question on our faces: How are we going to see patients here today?  In the old building, we knew what to do. We walked briskly down the halls to keep up the pace, knowing that each room (even broom closets!) was being used for something. We pivoted to the right when crossing paths, without looking up from our screens, knowing that two people could not fit side-by-side in the halls. We placed our laptops on any clean surface, ready at a moment’s notice to pick them up if someone else needed the space. We spoke in whispers behind closed doors to ensure that nothing private seeped through the walls. We worked to see every patient, even though we knew our space could not accommodate the demand of one exam room per clinician. However impractical, we did these things with ease. It was our routine.
How did we manage to see our patients those first few weeks in the new building? I’m not sure if they noticed that we were still searching through boxes to get them what they needed. Our boxes were tightly packed with otoscopes and microscopes, posters and educational materials. The first patients helped us see what we needed to unpack first. They must have sensed our excitement, many hearing that they made history as the first patients seen in the new space.
But we had brought with us so much more than boxes full of supplies. We’d brought the values that formed our foundation as an organization: a health-care system founded upon a strong primary care workforce, with care for the whole person at its core, and a partnership between clinical care and public health that enhances care for the individual and in turn, the community. This is reflected in the new space that allows for collaboration of primary care and mental health care systems to meet the integrated needs of our patients and clients.
A new building has a distinct smell. That smell of newness comes with a sense of hope, possibility and ideals. Over time, the hope turns to gratitude from patients and staff alike for the space that finally matches the quality we strive towards in our service to patients and the community.
But that new smell wears off. Staff and patients get used to new spaces. The experience, however, reminded me what it’s like to feel that newness about my work. It rejuvenated my hope for our health-care system: that it is possible to find ways to keep the excitement and newness - of space, of teams, of technology - in our daily work, and keep our daily work continually open to the new.
In primary care, it is important to create systems that are of high quality for staff and patients. It is equally important to create systems that are resilient and responsive to the needs of an ever-changing population, where the reasons that cause individuals to seek health care are different for everyone and always a bit unexpected. We must be prepared to care for the needs of everyone, but we cannot be too rigid in our thinking. By working together and staying open to the needs of the patient and community, whether on the first or last day of our practice in a particular space, we create systems that are stable in their very ability to transform.
In this time of health-care transformation, the new seems to be ever upon us. What keeps practice feeling new for you? What forms the strength of your foundation? Let us allow these questions to guide us toward the power that exists when we begin to answer them, together.
Anne C. Jones, DO, MPH, is Interim Director of Medical Services at Cornell University’s health service. She practices osteopathic family medicine and public health, serving the integrated needs of patients and the community. She is a graduate of Rowan School of Osteopathic Medicine, Maine Dartmouth Family Medicine Residency, and The Dartmouth Institute for Health Policy and Clinical Practice.

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Elbow to elbow for our patients
by Kirsten Meisinger, MD
Posted by Sonya Collins on Feb 16, 2017 10:47 AM EST
d8a4270628aa3278cf1439f47be858da-huge-jmToday is DO Match Day - the day when soon-to-be doctors of osteopathic medicine learn where they will spend their residency training. What's a DO? There are two types of fully licensed physicians in the U.S.: doctors of allopathic medicine (MD's) and doctors of osteopathic medicine (DO's). Today, in a special DO Match Day edition of Progress Notes, an osteopathic medical student explains. 

By James Raspanti

As soon as I entered the exam room to see Jackie, I could tell she was in pain. Her breathing was short and she favored her right side. I quickly introduced myself.
“Hi Jackie, my name is James. I’m an osteopathic medical student working with Dr. Jones.”
She was a regular patient at the clinic but had never been seen by Dr. Jones.  As I would soon discover, Jackie was also new to osteopathic medicine. I took a couple minutes to explain what that meant.
“There are two kinds of fully licensed physicians in the US: doctors of osteopathic medicine (DOs) and doctors of allopathic medicine (MDs). Just like the MDs you are familiar with, DOs use traditional medical, pharmacological, and surgical methods to help patients. In addition, DOs are trained to look more closely at a person’s bones and muscles. Sometimes these structures become misaligned causing pain or impaired movement. Osteopathic physicians can feel for and treat such problems with their hands.”
She gave an understanding nod and said it sounded like a chiropractor.  I agreed with the comparison and moved on to my history taking.
Three nights earlier, Jackie had woken up coughing violently.  While brief, the coughing fit left her with lingering pain and shortness of breath. To date, she was a healthy middle-aged woman with only a medical history of achalasia, meaning that the valve between her esophagus and stomach did not relax properly, making it difficult to allow food to flow through. This put her at increased risk for pneumonia. Fortunately, nothing about her history or physical exam suggested an infection or other serious problem. I suspected a musculoskeletal cause and decided to examine her back more carefully.
It is a common misconception that DOs only perform musculoskeletal manipulations. In fact, these manipulations, known as osteopathic manipulative medicine (OMM), are just a tool that DOs hone on top of the basic science and clinical courses all medical students take.  Though DOs practice in all specialties, OMM is most often used in primary care.  Osteopathic students are required to spend over 200 in-class hours practicing OMM. In OMM classes, we learn to: 1) diagnose musculoskeletal dysfunction by palpation and 2) treat musculoskeletal dysfunction with hands-on manipulation. Perhaps the most unique aspect of osteopathic training is the dedication to palpation. Learning to feel and differentiate superficial skin, subcutaneous tissue, and muscle requires regular practice.
What does an osteopath feel and assess for? Changes in tissue texture and structural asymmetry are two important exam findings. A third relies on motion testing. Detailed knowledge of anatomy tells us that the skeleton moves in predictable ways.  DOs use this knowledge to find restrictions that might cause pain or decreased range of motion. Tenderness may be present as well. I found all of these in Jackie. For her, the culprit was a rib.
“You have a rib out of place. It’s possible your cough was strong enough to displace it. I think I can fix it.” She agreed to the treatment.
I had her lie face down and began by loosening up the tight muscles along her spine. They started to relax within a few minutes. I explained what was to come next - a short quick thrust into her back. I repositioned her body to help focus the force my hands would deliver. The treatment lasted less than half a second. Afterwards, Jackie sat up so I could reassess her dysfunction. I confirmed that the rib was moving better, but the real test came when I asked her to take a deep breath. It was full and painless.
Osteopathic manipulations like the one I used on Jackie are not intended to replace the tests, medications, or procedures that comprise the typical physician toolkit. OMM will not cure heart disease or slow the complications of diabetes. However, common ailments that do respond particularly well to OMM include headaches, carpal tunnel syndrome, and back pain among others. The benefits of OMM are plentiful and include the ability to offer immediate relief, decreased need for anti-inflammatory and muscle relaxant medications, and reduce the costs associated with chronic musculoskeletal problems. A well-trained osteopathic physician can incorporate OMM alongside the standard physician toolkit in formulating a single treatment strategy.
Before entering medical school, I was intent on practicing in primary care. I chose osteopathic medicine because of its focus on preventive medicine, expanded primary care training, and hands-on approach. The opportunity to practice osteopathic medicine in primary care continues to excite and inspire me in my journey as a future DO.

James Raspanti is a fourth-year medical student and PCP chapter member at the Chicago College of Osteopathic Medicine at Midwestern University. He is applying for residency in family medicine and wants to practice as a full scope family physician.


Posted by Sonya Collins on Feb 6, 2017 10:23 AM EST
0ba53a5b164c4409210f44c60623a3a9-huge-0dToday on the blog, in a Q&A with Progress Notes, Shantanu Nundy, MD, a primary care physician who practices in the safety net in Washington, D.C., tells us about The Human Diagnosis Project, a smartphone- and web-based application for doctors to collaborate on cases, and how you can participate.
What is the Human Diagnosis Project?
The Human Diagnosis Project (or Human Dx) is an online system built by the world's doctors to understand the best steps to help any patient. We are a growing community of physicians who believe that the insights we accumulate through clinical practice and training should be available to everyone, be it a fellow doctor struggling to make a difficult diagnosis, a resident trying to master clinical medicine, or a patient trying to understand their health.
95cb2209498407f87acb9e1bd1a008e4-huge-unHow does it work?
Users log on and input a case, such as “25-year-old woman with fever, cough, and altered mental status,” and other users offer differentials to try to solve the case.
As the only physician in my safety net clinic, I use Human Dx to get help on challenging cases and to keep up my clinical reasoning and diagnostic skills. When I’m in clinic, I post cases to Human Dx when I’m struggling to figure out the next steps; for example a case with an unusual rash or EKG, or where multiple specialists have said different things and I’m stuck on what to do. When I’m not in clinic, I log in to practice solving teaching cases from all around the world. As I’m doing so, the system is encoding my thought processes and decisions and building the Human Diagnosis Project.
What impact do you imagine the Project will have in the future?
What’s exciting is that the Project is already impacting medicine today. Through Global Morning Report, which enables any doctor to solve the best teaching cases from around the world as brief case simulations, we are enabling thousands of doctors to improve their own clinical reasoning skills. Through Check, which enables doctors to freely collaborate with peers on clinical cases, we are helping doctors make better clinical decisions for their patients and learn in the process. Over time, as the community of doctors contributing to the Project grows, we will have many more opportunities to help doctors and patients and impact the cost, quality and access of health care globally.
650ae846487ffce4ddf0002770687aeb-huge-unHow can clinicians make the most of the Human Diagnosis Project – both in terms of getting the feedback they seek and making useful contributions to help build the tool?
The greatest impact clinicians can make on the Human Diagnosis Project is to simply log in and post cases they are seeing in clinical practice. Every day in primary care, we see cases that are worth sharing. Medicine is incredibly nuanced and a simple case is often more the exception than the rule. You needn’t only post cases you don’t know what to do with; if you learned from it, my guess is that your peers would, too. And by sharing it, you will learn from your peers, too, while contributing to this worldwide effort.
How does this project reflect the current and future landscape of health care?
First, the Project builds on our increasingly connected communities and networks to enable collaboration. In primary care, most of us are making clinical decisions on our own. We aspire to practice team-based care, but at least when it comes to diagnosis and clinical decision making, the clinician usually has little to no help. We don’t routinely have other clinicians see our patients with us. We don't have colleagues readily available to call and get help from. And we don’t have case conferences where we share our interesting cases and ask each other, ‘What would you have done for this patient if you were in my shoes?’ The opportunity here is to leverage social networks to collaborate on patient care.
Second, the Project builds on the increasingly data-rich environments we’re moving into in health care. Data is seemingly everywhere, but insight is still lacking. Without insight, we are getting overwhelmed by data, rather than being empowered by it. The Project is changing that.
Finally, the Human Diagnosis Project is leveraging incredible advances in computer science and machine learning to ‘augment’ the doctor. Right now, the computer in our exam room doesn’t help us deliver better patient care. It just sits there for us to record what we did for the patient after the fact. Projects like this one can help get us to the point where computers help us be the best doctors we can be, for example, by suggesting diagnostic tests to consider, giving us feedback on our clinical reasoning skills, or simply automating tasks that someone with a medical degree and years of training shouldn’t be doing.
How can members of the PCP community get involved?
I invite every doctor, provider, and trainee to join the Human Diagnosis Project and our mission to empower anyone with the world's collective medical insight. Come tell us about your interesting cases, help colleagues with their challenging cases, and earn free CME for improving your clinical reasoning skills. Most importantly, help us build the future of medicine together!

Posted by Sonya Collins on Feb 2, 2017 11:55 AM EST
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.


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.

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."

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."

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."

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."

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."

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."

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?"

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."

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."

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."

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."

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
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Most Recent Comments

You are doing really a nice job guys. Health is the most important segment of our life without it everything has no meaning. The usage of medication ought to depend on an all-inclusive psychiatric evaluation and be one part of an extensive treatment program. It's a medical emergency and immediate expert assistance is crucial! The usage of drugs and surgi...
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...

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