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Archive for June, 2016
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
5aaf45f1eb68256d210bf8a2cee92712-huge-45Today on the blog, Daniel Gordon -- a med student when he wrote this and now a physician -- shares what drew him to family medicine.

By Daniel Gordon, MD

I grew up as a patient of family doctors in Hartwell, Georgia, population 4, 287. My hometown had zero specialists, so my %uFB01rst exposure to medicine was through our family physician.

The waiting room at Dr. Stone’s office was one of the most diverse places I had ever been. The patients were young and old, black and white, and I liked this. In the exam room, I studied a model of the spine and Dr. Stone’s tools.

As soon as Dr. Stone came into the room, he’d always make me laugh.

I don’t remember the reasons for these childhood visits, but I remember that he always made me (and my parents) feel comfortable and open – and better.

Posted by Sonya Collins on Jun 2, 2016 2:12 PM EDT
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