Family Medicine Paradox: Wholeness Interferes with Quality

"The Paradox of Primary Care" by Kurt Stange, MD PhD and Robert L. Ferrer, MD, MPH is a perplexing but telling article in a monograph from the Annals of Family Medicine in 2010.

"Quality of health care most commonly is measured by the application of disease-specific, evidence-based process-of-care guidelines.  This evidence fairly consistently shows that primary care clinicians deliver poorer quality care than specialists.

Evidence from the Medical Outcomes Study assesses care of patients with several chronic diseases.  The study finds that patients functional health status outcomes are similar for care rendered by specialists and generalists but that generalists use fewer resources.  Similar outcome at lower cost represents higher value.

A growing number of studies show that for patients with chronic somatic and/or mental illness, shared care between specialists and  generalists is optimal.

In further contrast, ecological studies comparing states in the United States find that a greater supply of generalists and a lower supply of specialists is associated with greater quality of care on multiple disease specific quality measures....more primary care is associated with better population health and lower cost and greater equity.

Thus, the paradox is that compared with specialty care or with systems dominated by specialty care, primary care is associated with the following:  (1) apparently poorer quality care for individual diseases, yet (2) similar functional health status at lower cost for people with chronic disease, and (3) better quality, better health, greater equity, and lower cost for whole people and populations."
 ...Stange and Ferrer

I see a couple key words to ponder:  diseases and whole people.  We (I am a Family Physician) do better taking care of whole people than specific diseases (although we do that pretty well, too).  We understand patient personal values and integrate them into clinical decisions.  We value their wholeness, which we consider one of the outcome goals of a disease process.  We want our patient to be whole and able to live the life they've intended.  The disease is not the major focus of their life and is considered in the context of the patient's goals and dreams. 

If we measured quality that means wholeness instead of measuring a narrower disease focus that is less likely to align with wholeness, we might be viewed as having high quality across the board. Maybe the paradox disappears when we use patient driven quality indicators of wholeness.  What do you think?

FMEC 2012 Cleveland: Med Students Care to Serve

What a delightful dinner I had tonight listening to the career dreams and goals of three medical students from Wright State University Boonshoft School of Medicine.  These three women didn't know for sure what specialty they would select, until a moment when they suddenly understood what their future would be:  Family Medicine.  "I took the JI (junior internship) and I knew it was "family" for me.  I didn't really know it until it hit me."  She commented further to the effect: "I enjoy taking care of patients.  That's what it's about.  I mean, isn't it?  Taking care of patients.  I love it."

I was touched by the passion and caring and love of Family Medicine.  (Way to go-Wright State!).

There is Hope at the FMEC meeting.

FMEC: The Innovator's Network Tweaks the Future of Family Medicine

I'm at the Family Medicine Education Consortium, Inc. annual meeting pre-meeting session called The Innovator's Network.  Wow, Folks!  Exciting and somewhat overwhelming.

People, health, Family Doctors, money, semantics, rejection, bureaucracy, innovation, energy, caring, holistic, integration, affordable, government, data, large numbers, small numbers, micro practice, collaboration, efficiency, effectiveness, patient satisfaction, physician satisfaction, legislation, legislature, insurance exchanges, health system change, non-system of health care, super utilizer, inclusion, exclusion, technology, workforce, nurse practitioners, physician extenders, funding, market, upgrade, friendship, loneliness, isolation, admission, re-admissions, Medicare penalties, Medicare, uninsured, Medicaid, EHR, patient, enrollment, social media, exam room, waiting room, intervention, legal, tinkering phase, iterative loops of finding efficiencies, awsomeness of tinkering, capacity, Hepatitis C, CHF, CAD, risk management, workforce pipeline, other providers, other primary care physicians, access, panel size, senior citizens, falls, delirium, independence, billing, core values, emergency room, urgent care, discounts, wrap-around insurance product, brokers, squeezede, home visits, bonus, etc.

Direct Primary Care:  What happens when it's all about the Patient and Physician?; Elder Power!  A program that helps seniors remain in their homes, connected to their Families, Friends and Communities; Sharp Health Care:  Advanced Illness and End Stage Disease Management; Project ECHO:  Strengthening the Capacity of Primary Care by building a Collaborative Relationship with Sub-Specialty Clinicians; The Oxbow EMR:  Designed by and for Family Physicians; The Super Utilizer Project were presented in the first part of the day.  The room suddenly overflowed with young FMEC meeting attendees at the start of the Super Utilizer presentation by Jeffery Brenner, MD.
Onward for innovation! 

Saying No to Authority: Black and White and Gray Perspectives

About 100,000 people die each year due to errors in health care according to the Institute of Medicine.  We have a lot of fixing to do to reduce the chance for errors that lead to those deaths.  People in health care will have to confront each other, seek clarification, forgive each other rapidly and move ahead.  When and how do we need to push back to save lives?  Who may be disappointed or angry about the tension induced by pushing back?

“Captain, I need you to fly me to these coordinates to check in with one of my companies,” said the Engineer Battalion commander near Khe Sanh in Viet Nam in 1971 during operation Lam Son 719.  I was a helicopter pilot in the engineer group headquarters flying support for one of our three battalions on that day.  I called for a clearance to fly to his unit and received word that it was a no-fly zone since an F-4 jet was just shot down in that area.  (Let’s see, if the enemy can hone in on a jet that flies really fast, they might have no problem aiming at an OH-58 (Kiowa) helicopter that flies a lot slower, keeping me from getting the  Lieutenant Colonel to his objective and eliminating us and our helicopter from the war zone- and the earth).

“Sorry, Sir, but we’re not allowed to fly there temporarily.  It’s been designated a no-fly area since a jet was just shot down there.”  “Captain, take me there immediately,” he responded.  “I’m sorry, Sir, but I don’t have clearance by our security to fly there.”  He made a couple angry, grumbling comments, sort of venting his frustration at me.  He was a leader, committed to his people,  who was willing to do whatever it took to get the job done.  His unit was not actively engaged in a fire fight or other situation that required immediate command presence for life and death decisions.  He wasn’t satisfied with my answer. 

“Sir, Let me get you the Colonel (Group Commander) on the radio so you and he can clarify our options.”  The colonel reaffirmed our inability to get to those coordinates until the no-fly was lifted, after clarifying mission issues with this battalion commander. He still was annoyed with me and not pleased.

We flew to another of his companies first after which we were cleared to fly to the previously off limits coordinates.   

On return to his battalion encampment area and before landing, I noted puffs of white smoke inside his perimeter, consistent with white phosphorus from artillery fire and, since the enemy didn’t have any white phosphorus rounds, I knew it was from our own troops.

I told him on the intercom, “Sir, your position is receiving friendly fire, we can’t land yet.”  He responded briskly, “That’s bullshit, we are not taking fire.”  “Look out your window, please, Sir.”  He exploded with a few expletives about who was attacking their unit with friendly fire, etc.  I had his unit frequency waiting for him to communicate, while I called artillery coordination to report the friendly fire.  No one was killed, fortunately.  After the white puffs stopped, I was able to deliver him back to his troops and his headquarters.

After the operation was complete, all pilots in our group HQ unit who supported his battalion during Lam Sanh 719 were recommended for, and received, the Army Commendation Medal, except one- me.  I am pleased to have not received that medal.

We do the best we can and seek clarification, but time marches on, so decisions are made, actions taken and forgiveness offered.  In health care, we will have to push back a bit more often in the name of patient protection.  Sometimes, feelings will be hurt and nerves frayed, but hopefully forgiveness will be offered rapidly and lives will be saved.

Family Medicine: God, Please Help Us

The patient sobbed and winced, accurately showing the misery of an untenable relationship violence trap.  The Family Doctor listened, and listened and listened.  No medical therapy could lift the patient back to a "human" from their sub-human prison.

"It's not your fault," the doctor pleaded, "It's not your fault."

He listened as the patient repeated an endless spewing of misery.  The tightness in his chest and upper body echoed the tension in the patient's story.  He allowed his brain to settle into the background, empty of solutions for this human suffering that was pulling him into a pit of despair. No strategy for temporary resolution allowed her to move forward intact.

The clinical decision making skills, insightful differential diagnostic abilities, awareness of clinical guidelines paled in comparison to the patient's need.

"God help her," he prayed silently.  "And help me."

He listened some more.  He waited for Heart to arrive.  Brain could think, but Heart had to connect energetically to Heart.  A transfusion of God's Grace calmed the doctor's Heart into caring mode which linked to the patient's wounded Heart and decompressed some of the tension in the room.  The nearness to death from loss of humanity faded just enough to let the tiniest ray of hope arrive.

"Thank you, God," He thought.

He offered a temporizing medical strategy that may allow a calmer review of options tomorrow.  The patient had enough energy and humanity to agree that another visit tomorrow would be OK with her.

He walked into his office, felt a surge of human emptiness draining him acutely and intensely of emotion.  Back from the abyss of human suffering, he cried.

Family Medicine: Heart to Heart with America on 9/11

Today we're heart to heart with our fellow Americans.  Prayerful and open-hearted, Family Physicians reflect your concerns about your values, goals and dreams on this unique day in American history.  We're with you. We hurt, too, but less and less each year as we start to reconcile 9/11/2011 with other aspects of our lives and those of our patients, their families, their communities and our nation.

This used to be the anniversary of Pete Rose record-setting 1492nd hit to break Ty Cobb's record.  We're remembering Pete's hit again 27 years later, but through the national 9/11 "filter".  It's slowly becoming the anniversary for other events.  My son and daughter-in-law were married on this date two years ago, painting the date with young love and commitment.  And other lives move ahead.

Each will live today in their own way, most through the memory of a shared American experience that touches us forever.  Peace.

America: 9/11/2001 Plus 11 Years

The calls from our patients came pouring in to today, Monday September 10, 2012.  I wonder if our patients are feeling the 9/11 falling mood of America.  The re-runs of 9/11 related shows started a couple days ago.  The planes are flying into the World Trade Center again.  We have to reconcile it as a reality and accept it as part of our identity as Americans.  Every year at this time, we'll get our visual reminder and reflection opportunity.  How is it going for you?

Prayer helps.

Peace to all.

Family Medicine: Replacements are Lacking for Aging Docs

OK, I'm creeping toward retirement in a few years.  My hospital(s) have committed verbally to help recruit a replacement Family Physician and another and maybe another to help us grow to three physicians.  Eight years ago we were included in their search process.  My replacement hasn't shown up, though.  One candidate did interview and agree to work with me as a full time Family Physician seven years ago.  She called a week later and apologetically withdrew her acceptance of the position because the job she really wanted had suddenly come available.  I agreed with her that she had to go with her heart and wished her well.  Oops!, she said when she called back a week later saying she made a mistake since the "dream job" she went to finalize wasn't exactly what she thought it was.  And... was the position in my office still open for her.  I reaffirmed that I thought her heart had spoken to the effect that she really wasn't supposed to be coming into my practice and something else would be the real "Dream Job".

Six months later, a very good Family Physician interviewed with me as a result of the system ad.  She was about to deliver her second child and wanted to work three days weekly.  She started a few months later and is still in the practice, along with a part time Family Nurse Practitioner, who just got a four day a week job in a geriatric house call company and will reduce her work at our practice to one day weekly.

Since then (five years), no other qualified applicants have been identified by the search process being used by my hospitals.  Eight Family Physicians have left our county and two have been replaced, one in a hospital owned practice and one in a large group practice.

I met with our hospital physician recruiter today.  It looks relatively hopeless for them to recruit another physician to our practice.  The only persons responding to their ads in Family Practice journals and online want a permanent employed position with a fair amount of security, not a small private practice, such as ours.

We are "Family Fanatics".  We only take families as patients (entire households).  It's been fun for me these last 32 years and I suspect that it would appeal to another Family Physician, as it has to the woman practicing with me.  We also just started a Direct Family Medicine track for uninsured new patients who want a "Medical Club".  They pay $80 to enroll, $60 at the end of each month and $20 per visit for basic Family Medicine (in office acute, chronic and preventive care with flu shot included, but there's a separate fee for other immunizations, outside laboratory tests and surgical procedures).

I've posted before about the inadequate number of medical students selecting Family Medicine for their specialty training.  Also, I've posted about how the two flagship hospitals for the two local hospital systems both closed their Family Medicine Residency Training Programs.  They don't even train primary care internists in my hospital system, even though they have several residency programs in several specialties.  Overall, the primary care base for the health care non-system is shrinking.  Duck.  Here come the wrong specialists to provide your primary care services.

I wonder if we are too much of a fossil practice to get a young Family Physician to join us?  I wonder if we have to find our own recruit since we're possibly lumped in with the wrong group of practices seeking another physician (hospital and large group)?

What do you think?