Wednesday, August 6, 2014

Yes Cassie, there is a future in Primary Care

My daughter recently introduced me to a friend of hers via email. She is a newly minted fourth-year medical student who asked me the following question:

"I would love to hear your thoughts about the future of primary care and what it is like to work as a family medicine doctor in Louisville."

To start, I'd encourage you to read this recently published New York Times review of the state of primary care.  If you began in practice today you would quickly find yourself with more patients than you can adequately care for having just left residency and not expecting to see 25-30 patients daily. In Louisville, you will probably be employed by one of three healthcare systems. All of them have compensation based on patient volume and RVUs--I hope someone has showed you what RVUs are but I bet they haven't. Relative Value Units are supposed to measure the "time, skill, training and intensity"[1] of patient care and compensate accordingly. Unfortunately they are heavily skewed toward proceduralists. As Dr. John Mandrola,
Dr John Mandrola
a Louisville interventional cardiologist, observes in his excellent post
Thirty Dollars...Really?, a doctor is paid a lot more to do a coronary catheterization than to talk about the causes behind coronary artery disease. To understand a little more why the RVU is skewed that way, here is an excellent post on the Kevin MD blog that summarizes it nicely: The Relative Value of How Physicians are Paid Needs to Change. So in today's environment you need to see more patients than you are comfortable with, spend less time than you deem adequate with them which will promote pill-pushing over explanations. This will mean your risk of burnout will be significant. It is estimated that 43% of Family Practice physicians are burnt out according to a Medscape survey done in 2013.[2]

There is some good news. Value-based care, which bases compensation on how well you take care of patients rather than the number of patients that you see, is coming. In our corporation, systems are being put in place that will help primary care doctors take quality care of their patients and compensate those that do it well better than the ones that don't. Of course how one is measured is controversial as evidenced by this NEJM article from November: Grading a Physician's Value. And data can't be gathered without an integrated EHR (Electronic Health Record) and those are far from prime time. Being a digital native,  you've likely already noticed that EHR software on your rotations is not up to the gaming software standards you are used to.

Social Media, regardless of what city you ultimately practice in, will be the best means of keeping up with the ever-changing landscape of medical advances, political hot potatoes and healthcare tech so if are not following healthcare thought leaders already on Twitter I'd advise you to start that today. Begin with Primary Care Progress (@PCProgress), Berci Mesko (@Berci),

Mike Sevilla (@DrMikeSevilla), John Mandrola (@drjohnmd), Kevin Pho (kevinmd), the Society for Participatory Medicine (@s4pm) and me (@docnieder), of course. If you haven't found ZDoggMD,
that's another must.

Primary Care is alive and, if not well, at least no sicker than the rest of healthcare in the world but I see better things on the horizon. If I were fresh out of residency today I would get my feet wet as an employed physician for a couple of years, making sure your non-compete clause does not include going into private practice but only prevents you from moving to a different healthcare system across the street. Then I'd look long and hard at the DPC movement (Direct Patient Care) and make that my goal. Taking care of patients in an atmosphere that values the doctor-patient relationship above all other business needs is what we go into medicine to do. Physicians in DPC are happier and so are their patients. While it remains a patient care area where it is difficult for lower income patients to access, this may change as this successful way of caring for patients brings down costs and increases quality. I believe that government entities will find ways of incorporating this model into their systems. The  DPC model can be affordable for people who can't afford health insurance but still make a modest living, giving them an option for excellent healthcare at low costs. For now, a physician can use the time generated by working in an upbeat and efficient model to volunteer at community health clinics like the Family Community Clinic
offered by St. Joe's on East Washington St. in Louisville.

So, yes Cassie, there is a future in Primary Care. It is an uphill battle that we need more young, dedicated and digitally savvy doctors to join. The future is exciting. The present is, well, we have a lot of work to do but our patients make it worthwhile. 


1. RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY. Merritt Hawkins. http://www.merritthawkins.com/pdf/mharvuword.pdf
2. Lifestyle and Burnout: A Bad Marriage. Peckham, Carol. Medscape.com. 3/27/2013. http://www.medscape.com/viewarticle/781161

Sunday, January 5, 2014

New Year, New Site

OK, I haven't been silent, I've been posting on Wordpress with a new look and a new site. Come check it out! KathyNiederMD.com

KathyNiederMD.com

I'm hoping that this year, 2014, will see some other changes on the site. More patient information, maybe some guests blogs and definitely some videos. If I can only find the time.... 

Wednesday, October 16, 2013

Team Huddles Make for a Satisfying Day!

Five minutes before my day begins I discover two patients scheduled for ER followups don't have the hospital records yet in the chart. Can we get those, please? My nurse points out that Mrs. Jones, who just lost her husband, is coming in today. Good to know. My office manager asks if we can work in a late caller from the day before with a rash. Yes, let's do that at, umm, 2 pm. The scheduler says "Mr. Robert's wants to know if he can have his testosterone checked with his regular blood work?" Yes. Anyone else? OK, let's do this!


Sometime in 2012 I heard about using the Huddle Technique in medicine. When The Happy MD's blog post on the Team Huddle hit my mailbox last year I considered trying it but, not having my own medical assistant at the time, I delayed. Several months later at the ACE conference in Chicago, Marijka A. Grey presented on Care Teams using the Huddle and standing orders. I decided to implement them both in my office early September. I've been blown away by how it improves my ability to efficiently provide care. And my staff loves it.


Every morning, I go up front where my office staff is gathered. For about five minutes we inspect the day's schedule, check for issues, make sure we have the necessary referral information, look to see if an appointment's purpose is unclear and generally try to make the day smoother. For the first month, we only huddled in the am. Now my nurse and I meet in the afternoon to review the day and see where we need to follow up with a call to see how the patient is doing in the next day or so.


In regard to standing orders, we have begun slowly. My nurse determines that all patients are up-to-date on their immunizations and if not, offers to provide them with the appropriate vaccine that day. Our Zostavax (shingles shot) rate is up at least 50%. Having her review this information is much more efficient than me trying to remember it along with all the other distractions in the "fifteen minute" visit. Since our EHR is still not capable of "pop ups" that remind us when a patient needs an immunization this is working well. 


As I stated on Twitter--why didn't I think of this 25 years ago?