Friday, October 14, 2016

Ohio Association of Free Clinics Annual Meeting Opening Session 10/14/16

I'm here as Board Chair and Medical Director of the Open Arms Health Clinic in Bellbrook, OH. This is a good group to get to know. 

A room pulsing with love and caring is what I sense immediately.  We had the welcome by Deb Miller, Executive Director - who knows how to help people know that they matter.  Susan Labuda Schrop did the Roll Call covering the whole state of Ohio.

Nicole Lamoureaux, CEO of the National Free and Charitable Clinics spoke of the “Changes in Free and Charitable Clinics Nationally”.   Thirty clinics have closed.  Six million patient visits annually were increased by 100,000 after the ACA was implemented.  Clinic missions changed as the “insured” turned out to be “underinsured” and continued to come to Free clinics.  The evolution was from a Free Clinic model to a Charitable Clinic model.  Now many have a sliding fee scale, a suggested donation, a free-will donation, Medicaid, Medicare, Private Insurance etc.  They remain flexible as the needs change.
Also many have evolved from the Free Clinic Model to a Hybrid Model.  Questions asked are “Why aren’t you an FQHC?’, etc.  Many opt to avoid the federal connection and remain “Independent”.
Some are wearing multiple hats such as being a FQHC three days per week and a Free Clinic two or three days per week.  Mix and match, flex and evolve is the name of the game.
Overall patient demand did not decrease with the implementation of the Affordable Care Act.  The underserved have changed some, but the numbers aren’t diminished.
A lively discussion about variations on populations served and evolving models of care was a who’s who of patient situations in the state of Ohio and an eye opener for those in the jam-packed room.  Screening patients for need is common.  Honoring the donors was another important fact for the free and charitable clinics in attendance.
EIghty-three percent of the patients are in the workforce nationally.  The numbers of veterans seeking care at these clinics has increased.   It is painfully obvious that the primary care workforce is woefully inadequate.
Problems:  Recruiting Volunteers, Fundraising and Development, Cost of Pharmaceuticals, Primary Care Volunteeer availability, etc.

Send us your stories!  Was the last message from Nicole.  You give something that our country’s missing.  Caring for those in need.

OSU and The Primary Care Workforce

I enjoyed a visit to Ohio State for my 40th reunion of the Class of 1976 from the College of Medicine.  I have intense concerns about the Primary Care Physician Workforce.  A big flinch for me came with a comment from Dr. Quinn Capers, Dean of students at OSU College of Medicine, my alma mater, at the Alumni Meeting, that 41% of the graduates go into primary care specialties.  The stats when broken down on the slide listed Family Medicine 8.7% which is pretty accurate and consistent with national percentages.  The other specialties and percentages were NOT accurate and not consistent with national percentages of actual practicing physicians.  The numbers were accurate as to the percentage of students matched into those residency categories.  It is widely known, especially by the Alumni office, that less than 5% of those entering internal medicine residencies enter primary care practice.  Less than 10% of those entering pediatric training enter primary care pediatric practice.  I assume that Dr. Capers wanted to just give the match stats for senior students, not actual practicing physician stats, but he didn't say so.

Less than fifteen  percent of medical students actually enter a primary care practice.  "The Dean's Lie" as it's known in Family Medicine, is saying otherwise.  The only excuse for this could be that the federal support for residency training reimburses hospitals for residency training, giving extra "primary care training" money for ALL internal medicine training slots, even though less than 5% of the slots will actually train a primary care physician.

The creation of hospital medicine specialists has created thousands of jobs caring for hospitalized patients.  Increasing amounts of medical student debt plus these jobs equals a great opportunity for career and financial satisfaction and fewer residents selecting to practice primary care internal medicine or primary care pediatrics.

I was disappointed that the Dean gave no indication that the COM is sensitive to workforce needs and the national and Ohio dilemma with inadequate numbers of Primary Care physicians.  Some things never change.

Wednesday, October 12, 2016

Family Medicine: Paradigm Lost

The new narrative in health care is here.  The alphabet soup of the next era is here.  Technology wins, patients lose.  
I remember the dream.  The dream of living in a small community and caring for its people as their Family Physician. The dream of helping people to be healthy.  The dream of knowing people, science and medicine at the same time in a useful way.  The dream of helping people to know that they matter. 
Then Family Medicine showed up:  "Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences."...American  Academy of Family Physicians.
It was billed as a relationship based specialty.  It delivered.  Over and over.
Then things changed.  It didn't secure its borders and its core.  It devolved with the so-called Patient Centered Medical Home (which could be called the Payment Centered Medical Home).  
It turned away from patients in favor of "Bonus- Based Medicine", aligning with misguided "quality" initiatives run through Electronic Medical Records.  It drooled over "Meaningful Use" bonuses.  It turned into a group of data entry clerks, far removed from thoughts of The Principles of Medical Ethics.  Patient Autonomy be damned.  Employers, insurers and Statins became more important than patients.
Family Medicine went on the defensive and stayed there (with the rest of medicine when the Affordable Care Act pushed medicine passively over a cliff).  
It was "The Counter Culture", a hope for the people to have good health care, pushing against the technology and subspecialty driven approaches that now are bankrupting our nation.
Family Medicine:  Is it time for a Hospice consult?

Or is it time for Direct Family Medicine?  The Family Medicine version of Direct Primary Care?  The New Counter Culture?
It's time to get a paradigm that's on the offensive.  There is only one of them:  The Direct Primary Care Movement.  

Saturday, October 1, 2016

OSU College of Medicine: 47% Non-Ohioans--Why?

I was blessed to get to attend the best medical school in the world at the time -- The Ohio State University College of Medicine in the Class of 1976.  About 90% of us were from Ohio.  At our Homecoming and 40th Reunion Celebration weekend, we received the traditional update from the COM administration during the COM Alumni Association meeting.  The demographics of the current student body were impressive in their response to inclusivenes with 26% under-represented minorities, 54% women, 46% men.

I flinched, though, at this statistic:  53% from Ohio and 47% from out of state.  When questioned, Quinn Capers IV, MD, the Dean of Admissions answered that the College needed to get that many out of state students to get the type of diversity (cultural and other) they want.  I strongly disagree. What is missing in Ohio born applicants?  What is missing in the culture of Ohio?

What do pre-med students from Ohio think of being denied 100 (of the 202 or so) entry level medical student slots at Ohio State?  What do the state legislature and the tax payers of Ohio think of this approach to admissions?  What do alumni think of this approach to admissions?