Friday, October 31, 2014

Direct Primary Care = Direct Family Medicine, Direct Pediatrics & Direct Internal Medicine

Direct Primary Care is a business model for medical practice that is gathering momentum with a boost from the American Academy of Family Physicians (AAFP) through the "Health is Primary" Campaign. See it here Find definitions of Direct Primary Care at

My practice, Neighborly Family Medicine in Beavercreek, OH, uses the DPC business model to practice Direct Family Medicine (DFM).  Notice that I'm differentiating the business model from the specialty practice.  The semantics are important, but take a while to understand.  Direct Family Medicine helps me to understand what I'm offering to patients.  I assume that a pediatrician would deliver Direct Pediatrics, while an internist would offer Direct Internal Medicine.  A Med- Peds physician would do Direct Med-Peds. Clarifying how the DPC business model is applied can be very helpful for patients and doctors.  The term Direct Primary Care comes up short of adequate clarification when patients seek care.  I love doing Direct Family Medicine (and saying it, too).

Direct Internal Medicine and Direct Pediatrics are needed.  The physicians in those specialties deserve to have the fun and freedom of using DPC to support their specialty.  We need a lot more internists and pediatricians in a DPC business model.  Join the movement, Folks.  We need you.  There are not enough Family Physicians to meet the care needs for America at the primary care level.  Let's team up and shift the cost curve together.

Patients:  Introduce DPC to your pediatricians and internists.  They'll love Direct Pediatrics and Direct Internal Medicine.

Tuesday, October 28, 2014

Teaching Direct Primary Care: Here We Go!

Direct Primary Care is all the rage.  It's been anointed in the "Health is Primary" initiative as a key business model for success by the AAFP (American Academy of Family Physicians).  The initiative was launched by the AAFP last week in Washington, DC.

A keynote presentation by Erika Bliss, MD CEO of Qliance at the Family Medicine Education Consortium (FMEC) in Arlington, VA two days after the AAFP announcement wowed the students, residents and even some faculty at the FMEC meeting. One big question from the students and residents:  Where can I get DPC training?  One big question from the faculty types:  How do you teach it?

Personal reflection as a DPC innovator, DPC Hybrid private practice owner and Family Medicine educator: Direct Primary Care is the only element in all of medicine that is moving ahead on the offensive.  The rest of medicine is otherwise on the defensive, hunkered down waiting for the next mis-directed initiative.  The AAFP is willing to take the risk of helping Family Physicians and their patients by going against the status quo and endorsing the DPC business model.  The "Health is Primary" Initiative allows Family Physicians to get some reassurance about the Future of Family Medicine.

How do we teach DPC along the entire Family Medicine workforce pipeline?
1.  Define our Dream (and help each individual to define theirs)
2.  Have a burning desire to achieve it (and cheer for each other as we get "fired up")
3.  Believe we can do it (and validate/reaffirm the belief of each other)

Dialog will be one of our powerful resources for spreading the word about DPC.  We are good at it.

The DPC pioneers have paved the way for the model to be accepted, proven and recommended.
The "Health is Primary"  initiative will add energy, deliver AAFP introductory workshops during the next year, and facilitate the DPC Member Interest Group which will help interested members to learn more.

Departments of Family Medicine can be pivotal in promoting DPC by updating faculty on the Health is Primary Initiative and the DPC elements in it.  DPC oriented faculty and clinical faculty and preceptors should be asked to orient faculty and departmental staff to DPC.  A Champion for DPC should be identified by interested Departments.

State Chapters of AAFP should be contacted for information or assistance with DPC resources and contacts.  The state chapter web site should connect with the AAFP "Health is Primary" initiative and its DPC elements.

Family Medicine Interest Groups (FMIG's) should get DPC speakers to introduce DPC elements to the student members at FMIG meetings.  FMIG advisors should find the online DPC info which is plentiful.  Pre-doctoral directors in Departments of Family Medicine should identify their DPC resources such as preceptors, clinical faculty and full time faculty, and social media resources for medical student use.

Students could introduce the DPC business model to preceptors for discussion during their clinical rotations. A list of online resources explaining DPC and its variations should be available on FM Department and FM Residency web sites.  Medical students could refer preceptors who are naive to DPC to these sites.

Residencies that identify how they will teach DPC should quickly add a DPC section to their web site and promotional materials.  Similar to the sports medicine, geriatric, perinatal, genomic initiatives across the last couple decades, the DPC aspect of practice management could be in place within two months for aggressive programs.

A champion for DPC should be identified for each section of the "Family Medicine Pipeline" and connected via social media.

Objectives for practice management training should be quickly modified to add a DPC component.  One key aspect of DPC in practice management is the learners attitude about business, money, commerce, ethics (business and medical), and the patient-physician relationship.

The Family Practice Model Units should explore a DPC track for patients and employers, which is doable (FYI-I was Medical Director of a University and a Community FM training practice- multiple payment models fit nicely.  None of them are inherently evil, but some faculty wondered if something they were unfamiliar with was dishonest--like capitation or fee for service.)

Residencies:  Students are hungry for this model.

All of us:  We're part of the problem as a citizen of the Medical-Industrial Complex.  Let's re-direct the ship around the iceberg with "Heallth is Primary", including DPC and what we learn as a result of having to teach about it.  How will it fit with "The Dream".

What do you think?

Friday, October 24, 2014

Family Medicine: The Myth and the Tension

What do patients expect of their Family Physician?  What do we expect of them?
As we relate to each other, one or the other may seek better connection.  They may press to create more tension to enable a more meaningful engagement.  Relationships, like poems, need tension.

Hopefully, patient or Family Doctor creates the tension to enhance the communication or someone may not get a fair consideration from the other.  Creative tension may enhance the relationship, too.  It can get toned over several engagements to allow high quality communication and better alignment with mutually beneficial values, goals and dreams.

The expectations of each party may be based on a mysterious myth about who the other person is and what has (or hasn't) happened before.  Our profession has some mythical qualities with many patients, especially those with positive expectations.  We may remind them of a TV Dr. like Marcus Welby, MD or Richard Kildare, MD (OK, these were a long time ago) or one of the newer physicians on Gray's Anatomy.  Those myths may be helpful for the patient and the doctor to accomplish their goals.  They believe in something beyond the current situation, and make it through.

What kind of tension do you create?  Or run from?

What myths might you believe about patients, Family Medicine or your Family Doctor that may help or harm your health?  Or your career?

More later from the FMEC meeting in Arlington.

Monday, October 20, 2014

FMEC Meeting: Reunion of "Geeks and Geezers in Social Media" #FMEC2014

Calling all Social Media Geeks and Geezers alumni. Starting at the Hershey FMEC meeting, several of us launched a social media era for FMEC with a session called, " Social Media for Geeks and Geezers".   Mike Sevilla, MD and Kenny Lin, MD and I noted that, after our Seminar, several blogs were initiated.  "The Future of Family Medicine" blog by Kevin Bernstein (then medical student on the AAFP Board) MD and "The Singing Pen of Dr Jen" by Jennifer Middleton, MD were among them.  Numerous persons started a Twitter account at that meeting.  It was a nice start.  After two similar sessions at subsequent FMEC meetings, including Jennifer Middleton, MD, Michael Smith, MS, Kenny Lin, MD and I in various faculty roles more people started to Tweet and blog and use social media in all sorts of venues.

Kenny Lin, MDCommon Sense Family Doctor
A. Patrick Jonas, MDDr. Synonymous
Jennifer Middleton, MD The Singing Pen of Dr. Jen 
Larry Halverson, MDFrugal Family Doctor
Mike Sevilla, MDFamily Medicine Rocks
Kevin Bernstein, MD/Andrew Lutzkanin, MDThe Future of Family Medicine

In Arlington, VA, we're inviting Geeks and Geezers to be Social Media Ambassadors via Twitter, Blogs, Facebook, LinkedIn, and Internet Radio, etc. throughout the FMEC meeting.

We'll have a breakfast discussion table for Geeks and Geezers on Saturday morning to celebrate and launch interested persons with their own Twitter, Blog, etc.

The hashtag for the meeting will be something like #FMEC2014.

Many of our tweets will also be sent to #FMRevolution #DirectPrimaryCare and others.

As we turn the corner to become "Solutionists", think about what might be the next hashtag for
what's happening in Family Medicine.  We'll discuss #the nexthashtag at the meeting, maybe in the bar Saturday night.

Who's a Geek and who's a Geezer?  Your mirror has the answer.  Mine said, "You are a geezer."
Onward to #FMEC2014


FMEC Northeast Regional Meeting: "Health for the Nation and the World: Putting People First"

Come to Arlington, VA October 23-26 and learn with the Family Medicine Education Consortium team of educators.  Medical students, residents, faculty and others involved in Family Medicine Education will celebrate together the challenge of transforming the health care system in a way that better serves individuals, families and communities.

In a time of disruption, no one knows where the healthcare system is headed or how to get it going the "right" way.  It costs too much and is misdirected,  mired in "Meaningless Use" and "Transformationitis".

Who cares enough to risk anything to do what's right?  The FMEC for one.  The meeting includes preconferences such as the Innovators Network which already has played a key role in upgrading the Direct Primary Care movement.

I love this meeting.  Medical students from the northeastern United States, Residents from fifty or more programs with displays about their programs and Family Medicine faculty from the Northeast- like five hundred people who are excited about Family Medicine.

Breakfast tables to discuss interest areas and solutions, keynoters about healthcare solutions and educational dilemmas, space to sit down and talk with others who have common interests, book authors to sign and discuss their book, Door prizes for students at the Residency Fair.

FMEC 2014 Meeting Facts                Final Program FMEC 2014 Annual Meeting

Check it out!

Monday, October 13, 2014

Is CVS too Aggressive? Customers or Patients?

Just got a call from a CVS pharmacist in Dayton, Ohio.  She identified a "gap in therapy" for one of my patients with diabetes.  "Don't you want to protect their kidneys with an ACE or an ARB?"

The patient did not meet any criteria for a "mandatory" ACE or ARB. Preventing kidney disease from ADA :  "Diabetic kidney disease can be prevented by keeping blood sugar in your target range. Research has shown that tight blood sugar control reduces the risk of microalbuminuria by one third. In people who already had microalbuminuria, the risk of progressing to macroalbuminuria was cut in half. Other studies have suggested that tight control can reverse microalbuminuria."

I pointed out to the pharmacist what the medical literature says about kidney considerations for diabetics, after she told me "there is one study" that said an ACE or ARB might be indicated.

I told her about guidelines and considerations and mandates and policies and the practice of medicine and the actual medical literature which is fairly vast in the area of diabetes.

She said, "I want my patients to get the best care possible"  After asking that "her patient" be prescribed an unnecessary drug.

What's up with CVS?  Are they foisting partially informed pharmacists on their customers (or "patients") to enhance sales?  Clearly CVS would have been the benefactor of the sale of the unnecessary drug.

Isn't there a slight conflict of interest in CVS pushing unnecessary drugs onto persons with chronic diseases in the name of "a gap in therapy"?  Or is it really a "gap in profits"?

What do you think?

Sunday, October 12, 2014

West Point and Medicine: Duty, Honor, Doctor

As a West Point graduate, I have applied learnings from the Academy during my career as a Family Physician.

Duty, Honor, Country.  The motto of West Point resonates in my brain and challenges my heart frequently. What is my Duty?  What is the Honorable thing to do, or not do?  How do I best serve my Country?

When I ask myself these questions, I often refer to the Cadet Prayer for clarification and connection to God.

"O God, our Father, Thou Searcher of human hearts, help us to draw near to Thee in sincerity and truth.  May our religion be filled with gladness and may our worship of Thee be natural.

Strengthen and increase our admiration for honest dealing and clean thinking, and suffer not our hatred of hypocrisy and pretence ever to diminish.  Encourage us in our endeavor to live above the common level of life.  Make us to choose the harder right instead of the easier wrong, and never to be content with a half truth when the whole can be won.  Endow us with courage that is born of loyalty to all that is noble and worthy, that scorns to compromise with vice and injustice and knows no fear when truth and right are in jeopardy.  Guard us against flippancy and irreverence in the sacred things of life.  Grant us new ties of friendship and new opportunities of service.  Kindle our hearts in fellowship with those of a cheerful countenance, and soften our hearts with sympathy for those who sorrow and suffer.  Help us to maintain the honor of the Corps untarnished and unsullied and to show forth in our lives the ideals of West Point in doing our duty to Thee and to our Country.  all of which we ask in the name of the Great Friend and Master of all."

This post is an introduction to a series of posts titled "Duty, Honor, Doctor."  

Saturday, October 11, 2014

Family Medicine: Are We there Yet?

I celebrate the youth and energy of our new and future leaders of Family Medicine.  You have the reigns. The AAFP meeting in Washington, DC launches the next phase of the transformation of Family Medicine. Health Is Primary.  Energy will abound. Direction will be agreed.  Movement will continue.  Then we will say, "We have arrived."


We never quite "arrive" because our patients never quite "arrive".  We are with them or we don't feel like Family Physicians.

We may be content about our near "arrival" for a moment and then remember patients who haven't "arrived" yet. We lament their situation.  This "unsatisfied contentment" is a point of pride in Family Medicine.  The celebrations are short lived because we feel obligated to help more people.  Fairness is important to us. People are important to us.

Even more than statins, bonuses, quality initiatives, CT scans, EMR's, etc.

People, People, People.

Patients, Patients, Patients.

What do you think?

Friday, October 10, 2014

Family Medicine: October

October in Family Medicine in Ohio brings another set of problems to the office.  The new Medicare year starts October 1.  Typically, on the business side of the practice, Medicare makes changes that result in delayed payments for a couple months.  Cash flow gets stuck.

The ragweed season downshifts to the damp and moldy season outdoors and dust and mold indoors. Somehow allergies beget acid reflux and respiratory infections, aided by the start of the school year which traps coughing children in tight quarters.  Upper respiratory infections sometimes make too much mucous to be tolerable and inability to breathe through the nose which causes insomnia.  The URI finds the lungs and adds lower respiratory tract infection to the code list.  Then the cough lasts 12-15 days, which can be really annoying (and good for business).

Added problems this October include the FDA labeling hydrocodone a Schedule II drug which makes it similar to Oxycodone in how we have to handle it.  One month at a time.  Patients no longer get any refills on the hydrocodone pain meds and they have to see us once monthly to get evaluated and prescribed again.

Flu shots are on more patient's minds since the threat of the Ebola virus is looming.  Airport workers may become more concerned about the Ebola uncertainty as they process passengers from Africa.

Welcome to October.