Improving academic primary care

1
Improving academic primary care

• Tom Bodenheimer MD
• Department of Family and Community Medicine
• University of California at San Francisco
• TBodenheimer_at_fcm.ucsf.edu

2
Goals for this presentation

• The crisis in primary care access
• Reasons for the crisis
• How academic primary care aggravates the crisis
• Can we improve academic primary care practices?

3
Dwindling Numbers
Pugno, Fam Med 200537555
4
Dwindling Numbers Career Choices of Third-Year
Internal Medical Residents
Bodenheimer T. N Engl J Med 2006355861-864
5
Dwindling Numbers

• 2005 survey of internal medicine physicians who
  received board certification in early 1990s (in
  practice 10-15 years )
• Had left practice entirely
• Primary care internists 21
• Medical specialists 5
• Sox. Ann Intern Med 200614457

6
EXHIBIT 2 Generalist physician graduates, 1995 to
2005
SOURCE Colwill, unpublished manuscript NOTES
Figures include Allopathic and Osteopathic
physicians, US graduates and IMGs. Total includes
pediatricians.
7
NP/PAs to the rescue?

• Nurse practitioner graduates have fallen from a
  peak of 8,200 in 1998 to 5,900 in 2005.
• Physician Assistant graduate numbers have
  remained stable at about 4,200 for several years.
  
• Probably fewer than half of NP/PAs are in primary
  care as they are increasingly employed in
  specialist offices, emergency rooms, and
  inpatient settings.
• Colwill et al. Will generalist physician supply
  be adequate to meet tomorrows demand?
  Unpublished manuscript.

8
SOURCE Colwill, unpublished manuscriptNOTES
Adjusted supply - adjusted for age and gender
and extends the 2001-2004 rate of decline of
graduates through 2007.
Adult Care Projected Generalist Supply and
Demand for patient visits
Demand
Adjusted supply
9
Access to primary care

• A 2006 national survey 24 of Medicare
  beneficiaries (10 million people) and 25 of
  privately insured patients reported having a
  problem obtaining a new primary care physician.
• A Data Book Healthcare Spending and the
  Medicare Program. Medicare Payment Advisory
  Commission, June 2007
• A 2006 California survey 46 of patients
  visiting the ED said that they went to the ED
  because they could not access their primary care
  physician.
• Emergency Department Utilization in California.
  California Healthcare Foundation, Harris
  Interactive Inc, October 2006

10
Access to primary care

• 49 of Massachusetts internists were not
  accepting new patients in 2007, up from 36 in
  2006.
• The average wait time for an appointment to see
  an internist was 52 days in 2007, up from 33 days
  in 2006.
• Massachusetts Medical Society Physician
  Workforce Study, 2007

11
Access to primary care

• In the U.S. the average time a patient spent with
  a primary care physician over the course of a
  year (2001-2002) was 29.7 minutes, compared to
  55.5 minutes in New Zealand and 83.4 minutes in
  Australia.
• Bindman et al. BMJ 20073341261

12
Access to primary care

• A 2006 international survey found that the US has
  the smallest proportion of primary care practices
  that provide after-hours care if needed (not ED)
  
• US 40
• Canada 47
• Germany 76
• Australia 81
• UK 87
• Schoen et al.Health Affairs, November 2, 2006

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The crisis in primary care

• Patients are already having difficulty accessing
  primary care
• The primary care workforce -- especially general
  internal medicine -- is expected to shrink while
  the population is aging and demand increasing
• Patient access to primary care will get worse
  unless more primary care clinicians enter the
  workforce

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Goals for this presentation

• The crisis in primary care access
• The reasons for the crisis
• Primary care-specialty income gap
• Uncontrollable worklife
• How academic primary care practices aggravate the
  crisis
• Can we fix academic primary care practices?

15
Median compensation, 1995-2004 -- MGMA dataIn
thousands of dollars, before taxes

• 1995 2004 10-yr increase
• All primary care 133 162 21
• Family practice 129 156 21
• Internal medicine 139 169 21
• All specialists 216 297 38
• Invasive cardiology 337 428 27
• Noninvasive cardiology 239 352 47
• Dermatology 177 309 75
• Gastroenterology 210 369 76
• Heme/Oncology 189 350 86
• Orthopedics 302 397 31
• Radiology 248 407 64
• Surgery, general 217 283 30

16
2007 Medicare payment for 30 minutes physician
time

Colonoscopy
Cataract
Complex est.
Intermed new
Assumes geographic index approximately 1.0
17
The primary care-specialty income gapand
uncontrollable worklife

• Average medical student debt is 120,000 for
  public, and 160,000 for private, medical schools
• The primary care pipeline is dwinding in part
  because of the primary care-specialty income
  income gap
• An even stronger factor reducing primary care
  career choices is uncontrollable worklife
• The income gap and uncontrollable worklife are
  related primary care practices cannot survive
  without very large patient panels, and large
  patient panels create the uncontrollable worklife
• Dorsey et al. JAMA 20032901173, Whitcomb and
  Cohen NEJM 2004351710. Bodenheimer NEJM
  2006355861.

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Dysfunctional academic practices

• Academic primary care practices are the models
  experienced by medical students and residents
• When these practices do not work well, medical
  students and IM/FP residents hate working in them
  
• As a result of these negative experiences,
  medical students and IM/FP residents look for any
  career except primary care

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Voices of IM residents and medical students

• I didnt like the outpatient rotations one bit.
  They were isolating, with little social
  interaction. You went from patient to patient and
  you hardly talked with your colleagues.
  In-patient rotations had teams. Your colleagues
  were around. I liked that. Outpatient care was
  lonely. I hated it.

20
Voices of IM residents and medical students

• The ambulatory primary care rotation was not a
  positive experience. I was going to go into
  primary care. That made me not want to do it. It
  was impossible to have real continuity or
  longitudinal relationships with patients. It
  would be better to have a longitudinal clinical
  experience over a long period of time.
• People, especially medical specialists, told me
  I was too smart to go into primary care.
• When I worked with a primary care physician for
  a year and got to know the patients, I liked
  working in the clinic.

21
Voices of IM residents and medical students

• General medical clinic was not satisfying
  because there was no continuity of care. People
  talked about continuity but I never saw it.
• People in internal medicine subspecialties give
  you negative comments about primary care.
  Cardiology is one of the worst. They say that
  primary care docs are nice people but not very
  sharp. It got to the point that I was embarrassed
  to tell people that I was going into primary
  care.
• What sold me on primary care was the
  longitudinal clinical experience. You get to know
  your patients over time.

22
Voices of IM residents and medical students

• The clinic was very disorganized. The patient I
  saw 2 weeks ago got scheduled with another
  physician. More than half of the time Im seeing
  someone elses patient, which is bad for the
  patient, bad for me, and bad for the resident who
  is the patients regular doctor. In a years
  time, patients may see their personal physician
  twice and another doctor 6 times.

23
Views from the literature on academic primary
care practices

• Weak ambulatory training fails to support the
  formation of continuous healing relationships
  between patients and physicians, undermining one
  of the most cherished aspects of becoming an
  internist. IOM. Crossing the Quality
  ChasmWashington, DC National Academy Press,
  2001
• Exposure to dysfunctional ambulatory settings
  leads students and residents to choose career
  paths other than general internal medicine and/or
  primary care. Weinberger et al. Ann Intern Med
  2006144927

24
Views from the literature on academic primary
care practices

• Few internal medicine residency graduates have
  the skills needed to function effectively in the
  ambulatory setting. If one does not feel
  confident doing certain work, one avoids that
  work. McGlynn et al. NEJM 20033482635
• Only 13 of internal medicine residency training
  takes place in continuity clinic. Bowen et al.
  JGIM 2005201181
• Moreover, continuity clinic is often not
  continuity clinic many residents are seeing each
  others patients.

25
Views from the literature on academic primary
care practices

• Hospital out-patient medical clinics are often
  frustrating, chaotic places to practice
• Patients often see unfamiliar physicians
• Physicians often see unfamiliar patients
• Lack of continuity experiences is a factor
  turning residents away from primary care careers
• Association of Program Directors in Internal
  Medicine position paper. Ann Intern Med
  2006144920

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Academic primary care practices

• Leaders might respond Its not our fault.
  Research shows that 3rd year internal medicine
  residents are more likely to choose primary care
  careers than first year residents. So were doing
  an excellent job.
• Thats great, but the of internal medicine
  residents going into primary care dropped from
  54 to 20 from 1998 to 2005 (a 30 percentage
  point drop), and the increase from year 1 to year
  3 is 6 percentage points. Moreover, the data came
  from only 14 of all internal medicine residents.
  Sox, Ann Intern Med 2006145782

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Summary why is primary care in crisis?

• Reimbursement is low compared to specialist
  reimbursement
• Uncontrollable lifestyle
• Negative experiences in medical school and
  residency

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So who is falling down on the job?
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Who is falling down on the job?

• We are
• We have met the enemy and it is us
• We -- who train the nations primary care
  physicians -- must assume a portion of the
  responsibility for the crisis in primary care

30
Do we care?

• Each one of us -- academic leaders -- must ask
  the question to ourselves
• Is it one of my personal goals to ameliorate the
  crisis in primary care?

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Our vision of the primary care academic practice
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The reality of too many academic primary care
practices
33
Definition of specialists

• Physicians who know more and more about less and
  less
• Until they know everything about nothing
• Primary care docs
• Know less and less about more and more
• Until they know nothing about everything

34
Goals for this presentation

• The crisis in primary care access
• The reasons for the crisis
• How academic primary care practices aggravate the
  crisis
• Can we fix academic primary care practices?

35

• Would you rather see
• Your own patients
• Patients of another clinician?
• As patients (because we are or will be patients
  also), would you rather see
• A clinician you know
• A clinician you dont know?

36
Continuity of care

• 2 adult patient surveys in the late 1990s
• 3/4 of adults place high priority on continuity
  of care (seeing their PCP when they need care)
• Only 16 prioritized access and convenient
  appointment times over continuity
• Safran, Ann Intern Med 2003138248.

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Continuity of care

• Continuity of care is associated with
• Improved receipt of preventive services including
  cancer screening
• Decreased frequency of ED visits
• Fewer hospital admits
• There is a very strong correlation between
  continuity and patient satisfaction
• Koopman et al. Arch Intern Med 20031631357
  Fan et al. JGIM 200520226.

38
Continuity of care

• Hand-offs from one clinician to another are a
  necessary feature of discontinuous care
• Communication failures in hand-offs is a major
  source of medical errors
• Continuity of care is safer
• Philibert and Leach. Qual.Saf.Health Care
  200514394

39
Continuity of care

• Review of 40 studies reporting 81 outcomes
• Positive association with continuity of care in
  51/81
• Outcomes included
• Preventive care
• Quality of doctor-patient relationship
• Chronic illness measures
• Maternity care outcomes
• Saultz and Lochner, Ann Fam Med 20053159

40
Continuity of care

• 20 studies were reviewed for associations between
  continuity of care and
• Reduced hospitalizations
• Reduced emergency department visits
• Declines in overall costs
• 19/20 studies significant association between
  continuity of care and cost measures. Strongest
  was for reduced hospitalizations
• Saultz and Lochner, Ann Fam Med 20053159

41
Continuity of care

• Danish study of 474 primary care physicians and
  1136 patients with diabetes
• Patients who were well known by their physician
  had lower HbA1c than those not well known by
  their physician
• Drivsholm and Olivarius, Fam Pract 200623192.

42
Continuity of care

• Patients with asthma who have increased
  continuity of care (seeing the same clinician)
  have a reduced use of the ED, fewer hospital
  admissions and hospital days
• Cree et al. Dis Manag 2006963.

43
Continuity of care

• Continuity of care with a primary care physician
  for patients with type 2 diabetes is associated
  with improved processes of care and better
  glycemic control
• Parchman et al. Medical Care 200240137
  Parchman et al. J Fam Pract 200251619.

44
Continuity of care

• According to a 2003 survey, physicians in the US
  place great value on personal continuity of care.
  On a 5 point scale, with 5 points indicating that
  continuity is very important, the mean score was
  4.77.
• Stokes et al. Ann Fam Med 20053353

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Continuity of care

• It is unusual for a health system property to
  have so much evidence supporting it
• Patient satisfaction
• Outcomes
• Costs
• Continuity of care is a winner

46
Continuity Trust

• Trust is a patients expectation that the
  clinician will act to enhance the patients
  well-being
• Trust involves patients perceptions of a
  clinicians
• Technical ability
• Interpersonal skills
• Concern for the patients welfare
• Thom et al Health Affairs 200423124.

47
Continuity Trust

• Trust and adherence to physician recommendations
• Highest quartile of trusting the physician 62
  adherence
• Lowest trust quartile 14 adherence
• Thom et al Health Affairs 200423124

48
Continuity Trust

• Patients who trust their physician stay with
  their physician those who dont are far more
  likely to leave their physician. So trust
  increases continuity
• Continuity (long relationships) can increase
  trust
• So, trust and continuity are interrelated
• Thom et al Health Affairs 200423124.

49
Continuity Trust

• Safran et al linked attributes of primary care to
  3 outcomes adherence to physician advice,
  patient satisfaction, and health status.
• The primary care attributes most closely
  associated with those outcomes were
• Physicians knowledge of the patient (the whole
  person) -- which is related to continuity
• Patients trust in the physician.
• Safran et al. J Fam Pract 199847213.

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Continuity Trust

• For elderly Medicare beneficiaries, the longer
  the relationship with a physician the greater the
  
• Physician knowledge of the patient
• Trust
• Delivery of preventive services
• Parchman and Burge. Fam Med 20033622

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Continuity and trust a true story

• Friday was not a good day. Don -- my son with a
  history of a brain tumor with swallowing problems
  and aspiration -- had been admitted for
  pneumonia. The only person with a broad knowledge
  of Dons history, whom Don trusted, was Dr. Lisa
  Goode, his PCP. She was out of town. I suggested
  to the nurse that Don should get up and start
  moving around since copious amounts of phlegm had
  accumulated in his chest.
• Ill help, I offer
• Sorry, we must call PT for that said the nurse
• OK, I say, can we do that?
• No says the nurse. PT requires a doctors
  authorization
• OK, lets ask a doctor to order it.
• No she says, It has to be the doctor who
  admitted Don
• Fine, lets call him
• Hes off today, she says
• End of the line for getting anything good
  accomplished
• The next day Dr. Goode returned. Suddenly
  everything got better.

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Continuity of care and trust Its beautiful
53
How do we fix academic primary care practices in
order to ?Make them more satisfying for
students and residents? ?Improve care for
patients?
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Visions of a new academic primary care practice

• Continuity of care is the fundamental principle
• Patients, students, residents want continuity
• Seeing your patient is 100x more satisfying than
  seeing someone elses patient
• We are not discussing the business case. The
  overall vision and fundamental principle must
  come first second you figure out how to make it
  work financially
• Some residency programs have already accepted
  this as the principle and are working to
  implement it

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Visions of a new academic primary care practice

• How do we organize an academic primary care
  practice based on continuity of care when
  residents necessarily rotate?
• Change how residents rotate (e.g. the long block)
• Establish a team in which someone else is the
  glue creating continuity
• Both

56
Visions of a new academic primary care practice

• Full-time NP or PA as the glue
• Patients are panelized to the NP/PA
• A few residents become a pod which cares for
  the panel of one NP/PA. The fewer residents in
  each pod, the greater the continuity
• Each resident in the pod is responsible, with the
  NP/PA for a portion of the patients in that panel
• The NP/PA communicates frequently with the
  resident while the resident is elsewhere

57
Visions of a new academic primary care practice
58
Visions of a new academic primary care practice

• If NP or PA is not available, the glue could be a
  RN
• In that case, the care she/he could provide would
  be more limited and more consultations would be
  needed with the resident

59
Visions of a new academic primary care practice

• Teams are proposed as the solution to almost
  anything
• Research on teams is discouraging many studies
  of teams reveal that they are often dysfunctional
• One uncooperative person can destroy team
  cohesion
• Team members must have clear division of labor,
  training, and clear modes of communication
• A team of 3-4 people needs to communicate
  constantly. The more the work is divided up, the
  more handoffs are needed. More handoffs means
  more fumbled handoffs
• Bodenheimer and Grumbach. Improving Primary
  Care Strategies and Tools for a Better Practice
  (McGraw-Hill, 2007).

60
Teamlets

• If the problem with teams is the transaction
  costs of handing off work from one team member to
  another, perhaps a team of 2 would allow for the
  advantages of a team while minimizing the
  disadvantages
• At SF General Hospital Family Health Center, we
  have large teams when we created small teams of
  2 people we called them teamlets (a subunit of
  the team or a small team)

61
Teamlets

• The teamlet concept is an attempt to address the
  fundamental pathology of primary care --
  squeezing everything (preventive, chronic, acute,
  care coordination, relationship building) into
  the 15 minute visit
• Instead of a doctor seeing a patient in 15
  minutes, the teamlet encounter involves a doctor
  plus another person seeing a patient for more
  time -- previsit, visit, postvisit, between visit
  care
• We call the other person a coach

62
Teamlets
63
Teamlets

• Who is the Teamlet Coach?
• It could be RN, health educator, medical
  assistant, community health worker
• Coaching means helping patients and families to
  learn the skills and knowledge needed to be
  active, informed participants in their care
• Good coaches make visits more meaningful for
  patients because they are longer and more things
  are done
• Good coaches make worklife better for physicians
  because they offload work that one doesnt need
  an MD degree to do

64
Teamlets

• Teamlets can address continuity of care
• A patient is panelized to a resident and a
  teamlet coach
• If residents are in clinic 3 half-days per week,
  each coach works with 3 residents
• The coach is present all clinic hours and is
  available to the patient during clinic hours
• The coach can contact the resident if the
  patient needs a physician
• The coach can make more or fewer decisions
  depending on whether the coach is RN or MA

65
Teamlets at SFGH Family Health Center

• Coaches are mainly MA, community health worker
• Coaches ethnic/language concordant with patients
  Spanish, Cantonese, Mandarin, Burmese, Cambodian,
  Laotian, Vietnamese, Russian, Bosnian
• 11 coaches working with first-year family
  medicine residents in Thursday afternoon chronic
  care clinics
• Coaches in visit (may translate) plus do post
  visit and between visit care
• Patients can call coach if problems develop
  between visits, and coaches can contact resident
• Goal is continuity between patient, resident and
  coach -- logistically difficult to achieve

66
Final thoughts

• There is a growing crisis in the primary care
  workforce, and in patient access to primary care
• Reasons for the crisis
• Primary care-specialty income gap
• Uncontrollable worklife
• Negative training experiences in academic primary
  care practices
• Our responsibility as primary care educators is
  to fix academic primary care practices, in
  particular to re-design curricula and practice
  organization to maximize continuity of care for
  patients, residents, and medical students

67
Final thoughts

• More than half of the time Im seeing someone
  elses patient, which is bad for the patient, bad
  for me, and bad for the resident who is the
  patients regular doctor.
• The ambulatory primary care rotation was not a
  positive experience. I was going to go into
  primary care. That made me not want to do it. It
  was impossible to have real continuity or
  longitudinal relationships with patients.
• What sold me on primary care was the
  longitudinal clinical experience. You get to know
  your patients over time.