Tag: primary care

The Day After

Oct 18, 2012• 6

By Rob Lamberts, MD

There is nothing exciting or glamorous about doing what I am doing: building a new practice from scratch. It’s a slow and often mundane process that takes far longer than it looks like it should. There are a thousand questions I need to answer: Where will my office be? What will my logo look like? Does it matter what my logo looks like? Can I get the video of my presentation done? Why is it taking so long? Which EMR system will I use? Will I use and EMR at all, or will a PHR product suffice? Who will I hire? What will I pay them? When will I start? How many patients will I accept at the start? What will I do about my website? Who should design it? Can I do that myself? Who should run it? What about a phone system? Each day uncovers a new set of questions that need answering, and each day passes with most of them left unanswered.

There are two things I’ve been doing which have kept me from becoming discouraged or overwhelmed by this process. The first thing is something called Centering Prayer, which is well-described in the book Into the Silent Land by Martin Laird. Whether from the tradition of the middle ages or from eastern religious practice, meditation is upheld by many in science as a sound life-practice. What makes centering prayer, a form of meditation out of the Christian Tradition, different from other forms is the way one deals with distractions or worries. I’m not an expert on eastern meditation, but my understanding is that the goal is to clear the mind from any thoughts and worries, coming to a place of peace and rest in the mind. Centering prayer, however, does not push away worries or distraction, it changes the perspective on it.

Strengthening Primary Care With A New Professional Congress

Oct 2, 2012• 48

By Brian Klepper, et al.

Three months ago a post argued that America’s primary care associations, societies and membership groups have splintered into narrowly-focused specialties. Individually and together, they have proved unable to resist decades of assault on primary care by other health care interests. The article concluded that primary care needs a new, more inclusive organization focused on accumulating and leveraging the power required to influence policy in favor of primary care.

The intention was to strengthen rather than displace the 6 different societies – The American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), the Society for General Internal Medicine (SGIM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the American Geriatrics Society (AGS) – that currently divide primary care’s physician membership and dilute its influence. Instead, a new organization would convene and galvanize primary care physicians in ways that enhance their power. It would also reach out and embrace other primary care groups – e.g., mid-level clinicians and primary care practice organizations – adding heft and resources, and reflecting the fact that primary care is increasingly a team-based endeavor.

We came to believe that a single organization would not be serviceable. Feedback on the article suggested that several entities were necessary to achieve a workable design.
Continue reading…

Are Retail Clinics Dangerous?

Sep 28, 2012• 6

By Sanjay Bansu, MD

Target, Walgreens and CVS have recently started medical clinics in their stores. Opening up these “retail clinics” seems both potentially profitable and, at first blush, somehow pushes the lines on our tradition view of where medical services should be located. Giving the concept of retail clinics some thought might reveal store-based providers to be convenient and cost-effective, or alternatively full of conflicts of interest and potential harms. Should we be worried about retail clinics turning into the Walmart of medicine?

The retail clinic industry appears to have grown rapidly over the last few years. Most of these clinics are run by three large chains–Target, Walgreens and CVS–but there are also a mix of smaller providers branching out of existing chains like the Mayo Clinic. Their primary use seems to be the treatment of acute “urgent care” conditions such as symptomatic treatment of upper respiratory tract infections (lots of sore throats), or providing simple preventive care such as vaccinations. Most patients who visit these retail clinics will see a nurse practitioner. According to a recent study that tracked the growth of these clinics from 2007 to 2009, there was a four-fold rise in the number of these clinics, such that there are now over 1,200 retail clinics that see almost 6 million visits per year.

Last Week

Sep 25, 2012• 8

By Rob Lamberts, MD

This is it.

Eighteen years of practice is now condensed to my final four days seeing patients in the practice I built. While I am not bitter about what has happened (in fact, a large part of me is delighted), there is a sense of finality in this as one of my life’s major passings. This has been the stage on which I’ve been asked to perform, standing beside the stories of people’s lives and living out my own drama as theirs unfolded. This is where my life most intersected others, where I saw pain and joy, birth and death, suffering and triumph. I helped these people and learned from them in the process. I was teacher and student, helper and helped, healer and healed.

Whether I’ve profited most or gave myself dry (I’ve felt both often), it has been what I’ve done. Now I walk off of that stage onto another one, still dimly lit with little substance. I walk from the known to the unknown, the familiar to the hypothetical. I have great ideas, but now those ideas must become reality, and that reality must work well enough to justify leaving what I have left. Enthusiasm and innovation don’t pay the bills or heal the sick; it takes work.

The Wrong Battles

Sep 20, 2012• 20

By Brian Klepper

This week the American Academy of Family Physicians (AAFP) issued a new report describing its vision of primary care’s future. Not surprisingly, the report talks about medical homes, with patient-centered, team-based care.

More surprisingly, though, it makes a point to insist that physicians, not nurse practitioners, should lead primary care practices. The important questions are whether nurse practitioners are qualified to independently practice primary care, and whether they can compensate for the primary care physician shortage. On both counts the AAFP thinks the answer is “no.”

AAFP marshals an important argument to bolster its position. Family physicians have four times as much education and training, accumulating an average of 21,700 hours, while nurse practitioners receive 5,350 hours.

It is unclear how this plays out in the real world but, intuitively, we all want physicians in a pinch. Researchers with the Cochrane Database of Systematic Reviews reviewed studies in 2004 and 2009 comparing the relative efficacy of primary care physicians and nurse practitioners. They wrote “appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients.” But they also acknowledged that the research was limited.

There is no question that nurse practitioners can provide excellent routine care. For identifying and managing complexity, though, physicians’ far deeper training is a big advantage. In other words, difficult, expensive cases are likely to fare better from a physician’s care.

The Doctor-Patient Relationship. Is Over.

Sep 17, 2012• 28

By Rob Lamberts, MD

Probably the hardest part of making the change from a traditional to a direct-care practice is the effect it has on relationships. I am only taking a maximum of 1000 patients (less at the start) and will be no longer accepting insurance. These changes make it impossible for me to continue in a doctor-patient relationship with most of my patients.

For some, this transition will be more hassle than anything. Some people do everything they can to avoid my office, and so are not going to be greatly affected by my absence. They will simply choose another provider in our office and continue avoidance as always. There are others who see me as their doctor, but they haven’t built a strong bond with me (despite my charm), so the change may even be a welcome relief, or a chance to avoid initiating the change to another doctor.

But there are many people, some of which have already expressed this, for whom my departure will be traumatic. ”Nobody else knows me or understands me like you do,” one person told me this week. ”I’ve seen you for so many years, you just know so much more about me than any other doctor,” said another. I’ve seen tears, have gotten hugs, and get frequent demands for a clearer explanation as to what I am doing and why. It’s been a rough week for me, as I don’t feel I can cut off these relationships without some sort of closure. Fore someone who sometimes goes overboard in the importance of others not being mad, it’s been hell.

Dropping Out

Sep 8, 2012• 111

By ROB LAMBERTS, MD

After 18 years in private practice, many good, some not, I am making a very big change. I am leaving my practice.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job. The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve. The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk. I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

I must confess that there are still a lot of details I need to work out, and plan on sharing the process of working these details with colleagues, consultants, and most importantly, my future patients.

Here are my main frustrations with the health care system that drove me to this big change:

I don’t feel like I can offer the level of care I want for my patients. I am far too busy during the day to slow down and give people the time they deserve. I have over 3000 patients in my practice, and most of them only come to me when there are problems, which bothers me because I’d rather work with them to prevent the problems in the first place.
There’s a disconnect between my business and my mission. I want to be a good doctor, but I also want to pay for my kids’ college tuition (and maybe get the windshield on the car fixed). But the only way to make enough money is to see more patients in my office, making it hard to spend time with people in the office, or to handle problems on the phone. I have done my best to walk the line between good care and good business, but I’ve grown weary under the burden of having to make this choice patient after patient. Why is it that I would make more money if I was a bad doctor? Why am I penalized for caring?
The increased burden of non-patient issues added to the already difficult situation. I have to comply with E/M coding for all of my notes. I have to comply with “Meaningful Use” criteria for my EMR. I have to practice defensive medicine to avoid lawsuits. I have more and more paperwork, more drug formulary problems, more patients frustrated with consultants, and less time to do it all. My previous post about burn-out was a prelude to this one; it was time to do something about my burn out: to drop out.Continue reading…

Healthcare Reform’s Missing Link — Nurse Practitioners

Sep 8, 2012• 44

By Patricia Dennehy, RN

Within the next two years, if federal healthcare reforms proceed as expected, roughly 30 million of the estimated 50 million uninsured people in the United States — 6.9 million in California — will be trying to find new healthcare providers.

It won’t be easy. Primary care providers are already in short supply, both in California and nationwide. That’s because doctors are increasingly leaving primary care for other types of practices, including higher paid specialties. As the demand increases, the squeeze on providers will worsen, leading to potentially lower standards of care in general and longer wait times for appointments for many of the rest of us.

Nurse practitioners can help fill this gap. We are registered nurses with graduate school education and training to provide a wide range of both preventive and acute healthcare services. We’re trained to provide complete physical exams, diagnose many problems, interpret lab results and X-rays, and prescribe and manage medications. In other words, we’re fully prepared to provide excellent primary care. Moreover, there are plenty of us waiting to do just that. The most recent federal government statistics show there were nearly 160,000 of us in 2008, an increase of 12% over 2004, and our numbers continue to rise.

Clinics like the one I direct in the heart of San Francisco’s Tenderloin district — GLIDE Health Services — offer a hopeful glimpse into California’s healthcare future. We are a federally funded, affordable clinic, run almost entirely by nurse practitioners. At our clinic, we nurses and talented specialists provide high-quality, comprehensive primary care to more than 3,200 patients each year.

Despite the special hardships of our clientele, who daily cope with the negative effects on health caused by poverty, unemployment and substance abuse, our results routinely compare favorably with those of mainstream physicians. Our patients with diabetes, for example, report regularly for checkups, take their meds as directed and maintain relatively low average blood-sugar levels.

Bad Directions

Aug 13, 2012• 11

By Rob Lamberts, MD

I love the GPS analogy for health care. Patients need a GPS for their health, showing them the reality of their past, present, and future health. The analogy has not only shown me how I want to give care for my patients, it has also given me insight into the pitfalls of automated medical care.

Way back in the days when GPS was new, the rental care company Hertz advertised “NeverLost,” a GPS on your dashboard (if you forked out the extra money for it). I was asked to give a talk in Oregon, and decided I would try out this cool new technology (since others were picking up my bill). While I found it overall very useful, there were a couple of times it didn’t work as advertised.

I needed a sweatshirt, so I used the NeverLost for directions to a Wal-Mart. It worked! It gave me flawless directions to a Wal-Mart store…in Las Vegas (over 1000 miles away). I stopped at a gas station and they told me that there was actually a Wal-Mart 1/2 mile down the road.
Then, when I was trying to get to Crater Lake, “Never Lost” repeatedly directed me down dirt roads, some of which had trees fallen across their path. NeverLost was quite perturbed when I didn’t follow its direction, nagging me to make an immediate u-turn back toward the tree in the road.

Reviving the Pipeline: A Call to Action For All

Aug 11, 2012• 27

By Andrew Morris-Singer, MD

Annie Lowrey’s July 28 article “Doctor shortage likely to worsen with health law” in the New York Times noted the growing shortage of primary care doctors particularly in economically disadvantaged communities, both in rural and inner-city America. This problem will likely get worse before it gets better as more Americans gain coverage and seek a regular source of care. As the article suggests, training more doctors and incentivizing them to pursue careers in primary care will be a key part of the solution. And it will require a multipronged campaign, using both some of the traditional strategies for workforce renewal and a few unique tactics not typically deployed in efforts to fix health care.

The primary care workforce pipeline had dried up before the Affordable Care Act was passed. Currently, one out of every five Americans lacks access to primary care. As a result, up to 75% of the care delivered in emergency departments these days is primary care . This overcrowds and overburdens EDs, raises costs, and limits EDs’ ability to do what they were designed to do: provide acute, emergency care that makes the difference between life and death. So the primary care shortage threatens our access not only to primary care but also to emergency care.

How did we get here? Many are quick to point to primary care doctors’ low salaries compared to those of their sub-specialist colleagues. Indeed, choosing a career in primary care rather than a sub-specialty means walking away from 3.5 million dollars of additional lifetime earnings.That’s tough to do when you’re looking at $150-200,000 of debt, which is the average debt of an American medical student at graduation.But the crisis in our primary care pipeline goes far beyond the money.