TEXAS FAMILY PHYSICIAN VOL. 67 NO. 4 2016
GO TEAM! Boost Efficiency, Boost Morale, Empower Your Care Team
PLUS: After The Election, What’s Next For Health Care? Report And Photos From TAFP’s 2016 Annual Session & Primary Care Summit In Dallas Characteristics Of High-Value Family Medicine Practices
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JONATHAN NELSON
INSIDE
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TEXAS FAMILY PHYSICIAN VOL. 67 NO. 4 2016
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Teamwork makes the dream work
6 FROM YOUR PRESIDENT An excerpt from the 2016-2017 incoming president’s address 9 NEWS BRIEF Academy offers toolkit to help address opioid epidemic.
The founder of Team Care Medicine tells how he and his colleagues developed a model to empower primary care through strong exam room teams. When every member of the team is operating at the top of their training and abilities, providers and patients are happier and healthier. By Peter B. Anderson, MD
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The ‘change election’ and what comes next
With the advent of a new administration, AAFP’s senior vice president for advocacy, practice advancement, and policy presents his best prediction for what family physicians can expect in the days to come. By Shawn Martin
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The Comprehensive Primary Care Medical Home
A workgroup of the TAFP Commission on Health Care Services and Managed Care examined the patient-centered medical home and proposed a statement of what qualities and characteristics a high-value family medicine practice in Texas should exhibit. By the TAFP Commission on Health Care Services and Managed Care Workgroup on the Patient-Centered Medical Home
12 MEMBER NEWS Report and photos from November’s TAFP Annual Session and Primary Care Summit 25 RESEARCH Comprehensive services of family physicians provided in rural Texas hospitals 30 TAFP PERSPECTIVE Concussions are a childhood epidemic.
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PRESIDENT’S COLUMN
TEXAS FAMILY PHYSICIAN VOL. 67 NO. 4 2016 The Texas Academy of Family Physicians is the premier membership organization dedicated to uniting the family doctors of Texas through advocacy, education, and member services, and empowering them to provide a medical home for patients of all ages. TEXAS FAMILY PHYSICIAN is published quarterly by TAFP at 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Contact TFP at (512) 329-8666 or jnelson@tafp.org. OFFICERS president
Tricia Elliott, MD Janet Hurley, MD
president-elect vice president
Javier “Jake” Margo, MD
treasurer
Rebecca Hart, MD
parliamentarian
Amer Shakil, MD
immediate past president
Ajay Gupta, MD
EDITORIAL STAFF managing editor
Jonathan L. Nelson
associate editors
Perdita Henry and Jean Klewitz chief executive officer and executive vice president
Tom Banning chief operating officer
Kathy McCarthy, CAE
advertising sales associate
Michael Conwell CONTRIBUTING EDITORS Peter B. Anderson, MD Jon-Michael Cook, MD Chris Crawford Chris Dollar, MD Katie Kester, MD Shawn Martin Richard Young, MD Christian Zuñiga, DO
SUBSCRIPTIONS To subscribe to TEXAS FAMILY PHYSICIAN, write to TAFP Department of Communications, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. Subscriptions are $20 per year. Articles published in TEXAS FAMILY PHYSICIAN represent the opinions of the authors and do not necessarily reflect the policy or views of the Texas Academy of Family Physicians. The editors reserve the right to review and to accept or reject commentary and advertising deemed inappropriate. Publication of an advertisement is not to be considered an endorsement by the Texas Academy of Family Physicians of the product or service involved. TEXAS FAMILY PHYSICIAN is printed by AIM Printing and Marketing, Austin, Texas. LEGISLATIVE ADVERTISING Articles in TEXAS FAMILY PHYSICIAN that mention TAFP’s position on state legislation are defined as “legislative advertising,” according to Texas Govt. Code Ann. §305.027. The person who contracts with the printer to publish the legislative advertising is Tom Banning, CEO, TAFP, 12012 Technology Blvd., Ste. 200, Austin, Texas 78727. © 2016 Texas Academy of Family Physicians POSTMASTER Send address changes to TEXAS FAMILY PHYSICIAN, 12012 Technology Blvd., Ste. 200, Austin, TX 78727. 6
TEXAS FAMILY PHYSICIAN [No. 4] 2016
Back to the why: Rediscovering the meaning and joy in medicine An excerpt from the inaugural speech of the new TAFP President By Tricia Elliott, MD TAFP President community-oriented primary care center greetings colleagues. Thank you for the I trained in as a resident, seeing patients of incredible honor and privilege to serve as all ages, doing the broad spectrum of family your president of the Texas Academy of medicine, HIV medicine, inpatient and Family Physicians. I am so excited to have this ambulatory medicine, nursing home care, opportunity to serve you, advocating for our and teaching residents as a clinician educadiscipline of family medicine, our patients, tor. Returning to Texas and our communities. 14 years ago, I continI am profoundly aware ued my career in clinical of the significance of this We are the answer and academic medicine, moment in time as I stand to America’s health. seeing patients, teachhere — the first black Evidence supports ing, and serving in the woman as president of leadership roles of resithis Academy. Recently, we are the solution dency program director, a physician’s personal to ensure a health as vice chair for clinical account of a provocasystem that would be affairs in an academic tive event sparked a health center, as medical social media storm and more cost effective, director, and as managnational debate on what and provide higher ing physician in a large a physician may look like quality and healthier multi-specialty health and what gender, ethsystem. In being a family nicity, or race constitutes populations. We will physician, participating legitimacy as a physician. continue through in TAFP and AAFP and As I look across this room, TAFP and AAFP to through my leadership it’s wonderful to see the roles, I have been highly spectrum of what physibe at the forefront active in policy and cians look like. I stand of these health care advocacy around issues here before you today so delivery discussions to of physician payment, proud of this diverse state of Texas and this remarkensure we are paid for health care delivery sysand practice transable Texas Academy of all the care we provide tems formations, along with Family Physicians that for our patients. graduate medical educaembraces diversity and tion funding and physidifferences, and I proudly cian workforce concerns. declare this is what a I’ve participated in and led practice transforfamily physician looks like and this is what a mation and quality initiatives targeting the president of one of the largest family medicine Triple Aim of better care, better health and state chapters looks like. lower costs. Today, I would like to focus on I am a woman of faith, so I first express the Quadruple Aim, mainly the fourth commy deepest gratitude and love to my God ponent, physician satisfaction. for this moment and for every day of my How do we get back to the “why” and life as I live the dream. My passion and my rediscover the meaning and joy in medicine? priorities have always centered around faith, Early last year, I was excited to go to the family, and friends and 20 years ago, I added Houston Symphony. While waiting for the a fourth – family medicine. concert to start, I noticed a beautiful elderly I am a proud family doc practicing now African-American woman being escorted to for almost 18 years. I began my career and her seat. I immediately recognized her; she practice in the Bronx, New York, in the same
Reiner Consulting & Associates was my patient for whom I cared for many years in my previous practice. I first met her when she was 87 years old and even participated in her 90th birthday celebration, which was commemorated in Houston with a TV special and a front page spread in the paper. She has an exceptional life story: being one of the first Fulbright scholars, speaking fluent Italian, traveling the world as an international opera singer, and teaching music for 40-plus years at one of our historic black universities. She is now 98 years old and still sharp as a tack with incredible wit and wisdom. I rushed from my seat to her side and greeted her with our usual unique welcome we shared over the years: my best operatic “Ta-da!” With an incredible smile, she responded in kind with her melodic “Tada!” We hugged and she shouted, “This is my doctor!” After all these years, I was still her “doctor” and she was “my patient.” She sat me down next to her and inquired about my life and my current career. With her piercing eyes and her charismatic, bold voice, she shared her gratitude for the care she received from me in the past and wanted to be assured that others would continue to benefit from that care. I reassured her that I have always continued to regularly see patients. She then shared a thought with me that continues to resonate with me. “People are born with certain innate abilities, some with the ability to connect to others. That connection would start from the moment you walked into the room. Sometimes the healing was just you being there. Nothing else. Just being there.” This experience and conversation with my former patient came at a crucial time for me as I was asking “why” and battling with a conflict of conscience and identity as a family physician. I was contemplating the challenges of caring for my patients and teaching my younger physicians in training during a time that felt volatile with change and uncertainty in medicine. Additionally, I was struggling with rekindling the joy in medicine that I had felt for so many years, but now it seemed to be fading as I was bombarded with a spiraling fee-forservice health care model that was focused on generating more and more, reaching and exceeding RVU targets, seeing more patients in less time, prior authorizations, increasing paper work, a love/hate relation-
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JONATHAN NELSON
COMING SOON ON TAFP’S
CME SCHEDULE C. Frank Webber Lectureship & Interim Session April 7-8, 2017 Renaissance Austin Hotel Austin, Texas Texas Family Medicine Symposium June 2-4, 2017 La Cantera Hill Country Resort & Spa San Antonio, Texas Annual Session & Primary Care Summit Nov. 10-12, 2017 Nov. 8-9: Business meetings and preconference workshops
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
Tricia Elliott, MD, and the immediate past chair of the AAFP Board of Directors, Robert Wergin, MD, celebrate Dr. Elliott’s installment as TAFP President.
[cont. from 7]
values and how they match to our profesship with an electronic health record that sional values and our values as family phyafforded greater access to more informasicians. This member organization — our tion but added a significant amount of work Academy of family physicians — is our comafter clinic time — or WAC as we like to call munity. It’s our collaborative and supportive it — just to manage closing my encounters environment to have and deal with my “inthese conversations. We basket.” In trying to keep can foster opportunities up with all the demands, As president of TAFP, and space for networkcompassion fatigue and I look forward to ing, education, and sharthe concept of “burnout” ing best practices and starts to creep in. advocating for you tools to ensure our sucThis chance meetand being your voice cess and sustainability in ing with this 98-year-old on the broad health our practices and in life. woman reminded me of We know there are the “why,” the very founcare and systems multiple competing pridation of what it means to issues that face us in orities facing us as family be a family doc and why I our daily practices. docs. These include chose to be one. It’s about physician payment and people, connections, relaI hope to inspire health care delivery tionships, and the incredthe future family system transformations, ible ability of family phyphysicians in our the opioid crisis and the sicians to connect with patients, families, and students and residents challenges of how to begin to remedy a system communities across the to excitedly embrace that let Pandora out of biopsychosocial-spiritual family medicine as its box, ensuring a future model of care. It is our family physician workability to “be there” in all the noble and joyous force with engagement circumstances. profession it is. of our students and resiBurnout is very real dents and sustaining and happening across graduate medical educaall generations of physition funding, telemedicine, maintenance of cians. So we must also decide how we can certification, and of course mitigating physi“be there” for ourselves as individuals and cian burnout. for each other, to avoid the perils of burnAs we ride this wave of health care delivout while rediscovering our values and findery transformation from fee-for-service to a ing our joy in family medicine. We need to more value-based payment model, navigating have conversations about our own personal
NEWS BRIEF change can be scary and downright unsettling. We are flooded with acronyms such has MACRA, APM, MIPS, PQRS, ACO, PCMH, and more. How can we navigate through uncertainty? By coming together as an Academy and a unified coalition of family physicians, holding true to our values of family medicine patient-centeredness, high quality comprehensive care, true coordination of care, which we have been doing for years, we can be successful in this ever-changing environment. We are the answer to America’s health. Evidence supports we are the solution to ensure a health system that would be more cost effective, and provide higher quality and healthier populations. We will continue through TAFP and AAFP to be at the forefront of these health care delivery discussions to ensure we are paid for all the care we provide for our patients. As president of TAFP, I look forward to advocating for you and being your voice on the broad health care and systems issues that face us in our daily practices. I hope to inspire the future family physicians in our students and residents to excitedly embrace family medicine as the noble and joyous profession it is. I will also seek to work with you and our staff to develop and integrate activities, tools, and resources to support our physicians in preparing for the broad health system changes ahead. We will work to identify and create specific resources and activities to support our physicians in alleviating burnout. I am proud to serve you and be your advocate. I look forward to representing you — all of you — from the Piney Woods of East Texas, to the bustling, fast-growing North Texas, to the oil-rich terrain of West Texas, from the legendary Panhandle to the canyons of Big Bend and to the Rio Grande Valley, from the Gulf Coast metroplexes and its beaches to the beautiful Hill Country and Central Texas. I challenge you to find and remember your “why.” Reflect on those stories that once inspired you and the passions and values that brought you to this remarkable profession and discipline of family medicine. Rediscover the meaning of family medicine to you and the joy it brings. Seek to regularly “be there” for yourself – for your mind, body, and spirit. Be there for your colleagues and know TAFP and I will be there for you. My hope for you is that throughout your day, your week, and the months ahead, you will renew that joy and have that family medicine moment of affirmation where you can declare: “Ta-da!”
Academy delivers new opioid toolkit, CME to equip members By Chris Crawford The AAFP is arming family physicians with the latest resources to best combat the opioid abuse epidemic, which now include a new chronic pain management toolkit and a free CME webcast focused on chronic opioid therapy. These resources are exactly what AAFP President Wanda Filer, MD, MBA, of York, Pa., promised in a Leader Voices blog post from May 2016. “Family physicians are dedicated to being a part of the solution to help slow this national crisis, and the AAFP is dedicated to providing our members the latest information to refresh our knowledge on opioids and pain management,” Filer told AAFP News. “I would encourage us all to review carefully these valuable new members-only resources.”
CHRONIC PAIN MANAGEMENT TOOLKIT » www.aafp.org/patient-care/public-health/pain-opioids/cpm-toolkit.mem.html Because chronic pain is a complex health issue that requires a comprehensive, patient-centered treatment approach, family physicians need appropriate tools to bolster their efforts. The new chronic pain management toolkit fills this need and is designed to help family physicians identify gaps in practice flow, standardize evaluation and treatment of chronic pain patients, and facilitate conversations on pain and treatment goals, as well as identify and mitigate risk. The toolkit includes an action plan, pain inventory, work questionnaire, patient-physician medication agreement, opioid risk tool and links to additional AAFP and external resources for physicians. These tools can be used together or separately, depending on practice need. And everything included in the toolkit is consistent with key recommendations in the CDC and Federation of State Medical Boards guidelines. Additional toolkit resources include links to current opioid guidelines and policies, journal articles and patient education materials. This toolkit is a dynamic resource and will evolve as more resources are added in order to provide the most up-to-date information to Academy members. The content has been reviewed by members, and additional materials have already been suggested to help meet the needs of various practice environments.
CHRONIC OPIOID THERAPY WEBCAST AAFP members have requested more CME on chronic pain management with opioids and the Academy’s latest offering is a CME webcast on chronic opioid therapy that was recorded May 27. The hour-long presentation is available to members only and is worth one AAFP Prescribed credit. David Walsworth, MD, associate chair for clinical affairs and associate professor in the family medicine department at the College of Human Medicine, Michigan State University, East Lansing, presents the course, which teaches family physicians how to evaluate patients presenting with chronic nonterminal pain to assess for potential opioid responsiveness and opioid risk. The session also covers how to best develop an evidence-based treatment plan that involves the appropriate selection of an initial opioid, and continuous monitoring and adjustment for tapering, discontinuation, alternative therapies, or referral to a pain subspecialist. In addition, participants will learn how to use state prescription monitoring programs, patient-prescriber agreements, patient counseling documents, and documented urine drug screening to minimize physician liability when prescribing opioids.
Source: AAFP News, June 13, 2016. © American Academy of Family Physicians. www.tafp.org
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FROM AAFP
THE ‘CHANGE ELECTION’ HAPPENED. NOW WHAT? By Shawn Martin
“Wish we could turn back time, to the good ol’ days when our mama sang us to sleep but now we’re stressed out.”
— Twenty One Pilots
I
chose the above verse because it captures so many emotions that have nearly paralyzed our nation for the past 18 months. During the past year, each of us has probably wished at some point that we could just crawl into bed and hide under the covers. AAFP President, John Meigs, MD, wrote an excellent editorial in AAFP News in which he captured the wide range of emotions aligned with the election and its outcome. Nov. 8 brought to a conclusion one of the most aggressive and divisive elections in our nation’s history and certainly the most negative campaign of the modern political era. Although the results of the election have spawned mixed reactions, it is now clear who will lead our government for the next four years. There is much work to do, but I would suggest that there already was much work to do on Nov. 7. In the early morning hours of Nov. 9, after securing more than 270 Electoral College votes, Donald J. Trump became President-elect Donald J. Trump. On Jan. 20, he will be sworn-in as the 45th president of the United States of America. A few hours after President-elect Trump delivered his speech to the nation, accepting the results of the election, his transition team received a letter from the AAFP congratulating him and outlining our priorities for the next four years. Our advocacy work with the 45th president and his administration started before sunrise on Wednesday, Nov. 9 and will continue for the next four years. In our letter 10
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we outlined five policy priorities and pledged our commitment to working with the new administration to develop and implement policies that would achieve those priorities. Here are those five priorities: • • • • •
health care for all; delivery system and payment reform; health care affordability; primary care physician workforce; and promotion of prevention and wellness.
On Jan. 3, when the 115th Congress convenes, Republicans will have majorities in the Senate and the House. These majorities are smaller than those in the 114th Congress, but they are working majorities. Those margins coupled with Trump’s victory mean the federal government will be under unified Republican control for at least the next two years. We are entering a legislative session that has the potential to fundamentally reshape our nation’s health care system and safetynet programs. In addition, we likely will see policies proposed in Congress that will challenge many long-standing AAFP policies related to health care coverage and access, women’s health, and public health programs. It is impossible to predict with any accuracy what will happen in this Congress. As I have said many times in the past few days, campaigning is easy, governing is hard. The process of drafting and enacting policy is much more involved and time consuming than candidates imply during campaigns. However, we do have a decent understanding of policies that the Trump Admin-
istration and the 115th Congress likely will focus on. The following are five issues that we see as items in focus for 2017. Patient Protection and Affordable Care Act — The full repeal of Obamacare has been a priority for the Republican Party since 2010. To quote Vice President-elect Mike Pence, “We will repeal Obamacare lock, stock, and barrel.” This point of view is shared by a majority of House and Senate Republicans. Despite campaigning on the full repeal of the law, Trump has begun to nuance his policy position on the law. In an interview with The Wall Street Journal, he suggested that he would be willing to keep certain parts of the law. Repealing the ACA outright is, in reality, improbable. Any such action would unravel the insurance market and create a financial crisis for individuals and businesses. Therefore, we will see efforts to replace certain policies and, possibly, create new programs that would extend access to health care coverage — think health savings accounts and high-risk pools. Despite the complexity of repealing the ACA, I am confident that the ACA will be altered and damaged in a significant manner on Jan. 20 or shortly thereafter. MACRA — The Medicare Access and CHIP Reauthorization Act was approved by overwhelming bipartisan majorities in the House and Senate. In fact, 91 percent of the House and Senate voted for this law. Additionally, reducing the cost of health care remains a priority. Due to the continued focus on costs and the bipartisan support the law secured, MACRA will continue to be implemented. There may be slight modifications to improve the law, but these changes needed to be made regardless of who won the election. AAFP continues to make available valuable resources on MACRA, and I encourage you to review the options available to you under the Pick Your Pace program that is available for 2017. Remember, if you participate in the program at any level in 2017 you will not face negative payment updates in 2019. Medicaid — The Medicaid program, like the ACA, has been a priority for Republicans for the past several years. Speaker Paul Ryan, R-Wis., has developed and advanced an alternative to the current federal-state partnership funding formula that would utilize a state-by-state per-capita cap to fund
the program. This is different than the more traditional “block grant” proposals advanced by Republicans in the past, but the two proposals would significantly alter the Medicaid program, essentially turning the program over to individual states and eliminating the current role of the federal government in the program. I anticipate that Medicaid will get significant legislative attention in 2017. I am not confident that Republicans can rollback Medicaid expansion or change the underlying funding formula, but I am confident that they will pursue these changes aggressively. Administrative simplification — Trump discussed the negative impact of regulation on businesses throughout the campaign. Although his comments were not specifically focused on health care, we see an opportunity to potentially reduce the administrative burden of participating in the Medicare and Medicaid programs under his administration. A priority for the AAFP will be a reduction in documentation guidelines for physician services under Medicare.
Workforce — The issue of physician workforce did not come up during the campaign, but we see opportunities. Republican majorities are largely a result of rural and exurban communities, predominately in the South and West of the Mississippi River. These communities are more likely to face physician shortages as compared to urban and suburban communities on the East and West Coasts. I don’t see workforce as a top-tier issue, but it is a place where we will be pushing hard. On Jan. 23, 2009 President Obama stated, “Elections have consequences.” This statement was true then, and it is true today. We, as a nation, experience political disruption every few years. The specific consequences of this year’s elections are unknown, but AAFP is not resigned to being a passive participant in the next four years. We see opportunities to shape our specialty’s future, and we will be grinding the policy levers daily to ensure that family medicine and patient-centered policies are front and center. Source: AAFP “In the Trenches” Blog, November 22, 2016. © American Academy of Family Physicians.
Campaigning is easy, governing is hard. The process of drafting and enacting policy is much more involved and time consuming than candidates imply during campaigns.
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Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/μL) with HIV infection. HIV Medicine. 2004;5:93-8.
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By Perdita Henry
family physicians and other health professionals from around the state gathered in Dallas Nov. 4-6, 2016 for TAFP’s Annual Session and Primary Care Summit. This was TAFP’s most well-attended conference ever, with almost 600 total registrants. Attendees networked, earned CME, shaped TAFP policy at committee and commission meetings, and celebrated the specialty of family medicine. As always, attendees had opportunities to learn about a variety of topics during the scientific portion of the conference. Participants could also attend Knowledge Self-Assessment Module workshops Wednesday, Friday, and Sunday, on Health Behavior, Hypertension, Diabetes, and Well Child Care. The National Procedures Institute offered their popular X-Ray Interpretation course. The TAFP Foundation held a gourmet dinner to benefit the Tamra Deuser, MD, Endowment. Thank you to AbbVie for sponsoring the event at the Platinum level and Dr. Robert Youens, Texas Medical Association, and Texas Medical Liability Trust for being Gold Level sponsors. 12
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After a breakfast lecture on Friday morning by Edward Dominguez, MD, on emerging infectious diseases, our keynote speaker Christopher Crow, MD, MBA, opened the conference’s CME general session with a presentation on “Physician Leadership in a Time of Change.” The rest of the weekend’s CME included topics on migraine treatment and management, common teen eating disorders, an ethics talk on palliative care, a lecture on testosterone replacement therapy in women and men, and much more. AAFP immediate past board chair Robert Wergin, MD, of Nebraska addressed attendees Sunday morning providing an update on the national academy. At the TAFP Member Assembly, delegates from TAFP’s local chapters elected Emily Briggs, MD, MPH, to serve as an at-large director, and Ike Okwuwa, MD, to serve as the new physician director on the TAFP Board of Directors. Mary Nguyen, MD; Samuel Mathis, MD; and Carissa Huq were elected to serve as the special constituencies director, the resident physician director, and the medical student director respectively.
TAFP’S 2016 AWARD RECIPIENTS AND NEW OFFICERS Saturday’s Annual Business and Awards Lunch began with members present voting to adopt the TAFP bylaws changes. Next, TAFP’s top honors were announced. Here’s a list of this year’s winners. PHYSICIAN OF THE YEAR: KAPARABOYNA ASHOK KUMAR, MD Originally from India, Dr. Kumar earned his medical degree from, Osmania Medical College, Hyderabad, India. After completing an internship at Osmania General Hospital, Hyderabad, India, he went on to complete a general surgery residency at Royal College of Surgeons of Edinburgh. He would later immigrate to the United States and complete an additional residency in Family Medicine at UT Health Center at Tyler. Kumar has served as president of TAFP, is the current chair of the Healthcare Committee of San Antonio Mayor’s Fitness Council, and is a member of the Mayor’s Executive Committee. In addition to various leadership positions he is currently a professor of family and community medicine at the University of Texas Health Science Center Medical School in San Antonio and continues to mentor the next generation of family medicine medical students and residents. After accepting the award, Kumar reflected on the journey that lead him to
PHOTOS: JONATHAN NELSON
Dallas hosts TAFP’s 2016 Annual Session and Primary Care Summit
this moment. “I practiced on three continents, in India, England, and in America and I know this personally; a caring attitude and compassion transcends nationality barriers, racial barriers, cultural barriers, and language barriers. The care and compassion we provide are not tangible things any clinic or hospital administrator, or any insurance company, or lawmaking body can measure.” PHYSICIAN EMERITUS: PRESLEY JOE MOCK, JR., MD Dr. Mock graduated from Southwestern University in Georgetown, earned his medical degree from University of Texas Medical Branch Galveston, served as a Lieutenant in the United States Navy and trained at the school of Submarine Medicine. After his stint in the Navy, he returned to Texas and began his private practice in La Porte, which he ran for 51 years. He has been a longtime active member of the local Harris County
TAFP chapter, serving as president twice, has served on numerous TAFP committees and commissions, and was a long time preceptor mentoring numerous medical students over the years. He is currently retired.
Clockwise from top left
PHYSICIAN EMERITUS: NORMAN H. CHENVEN, MD Dr. Chenven is the Founder and Chief Executive Officer of Austin Regional Clinic which is one of the largest family medicine focused multi-specialty groups in the state of Texas serving more than 400,000 Central Texans. His dedication to Austin Regional Clinic helped expand the network from primary care to include OB/GYN and general surgery while continuing to strive for excellence. He continues to make his mark by holding various positions on numerous committees and task forces both locally and nationally to ensure the voices of primary care physicians are heard.
From left: Janey Wang, MD; Fozia Ali, MD; Sabari L Sundarraj, MD; Mary Anne Snyder, DO; and Marian Allen, MD, celebrate their accomplishment after completing the final installment of TAFP’s first Family Medicine Leadership Experience.
Physician of the Year, Kaparaboyna Ashok Kumar, MD, and newly installed TAFP President Tricia Elliott, MD, congratulate one another after the Annual Business and Awards Lunch.
Mary Nguyen, MD, speaks after being presented the Special Constituency Leadership Award. From left: Senator Craig Estes recieves the Patient Advocacy Award from Immediate Past President Ajay Gupta, MD. From left: Lewis Foxhall, MD, recieves Philanthropist of the Year Award from TAFP Foundation Board Chair Dale Moquist, MD. www.tafp.org
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PUBLIC HEALTH AWARD: HARLAN “MARK” GUIDRY, MD, MPH Dr. Guidry has over 20 years of experience as a local and regional health authority at the city, state, county, and regional levels. As the Executive Director and District Health Authority for Galveston District for more than 12 years, he has successfully addressed and prevented illness in various situations such as childhood lead poisoning concerns, infectious disease outbreaks, and Hurricane Ike. He has also contributed to several state and local public health policy forums and served as vice 14
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chair of the Texas Public Health Funding and Policy Committee, which made recommendations to the legislator on the improvement of public health in Texas. EXEMPLARY TEACHING AWARD: GRANT C. FOWLER, MD Dr. Fowler is currently a professor and vice chair of the Department of Family and Community Medicine at the University of Texas Medical School at Houston. In his position he oversees medical student and resident educations, instructs them in both clinical and hospital settings, and is a continuing medical education lecturer. He has received numerous recognitions and awards for his work as a professor, physician, and scholar from Texas Monthly Magazine as Top Doctor every year since 2004, Best Doctors in America every year since 1997, and the Dean’s Teaching Excellence Award at the University of Texas Medical School at Houston every year since its inception. SPECIAL CONSTITUENCY LEADERSHIP AWARD: MARY S. NGUYEN, MD Dr. Nguyen is a physician practicing at Medina Valley Family Practice. She’s been an active member of TAFP serving on multiple committees and commissions since her residency in 1999 and she has served the Alamo chapter of TAFP three times as president. She
has served on AAFP’s Congress of Delegates and written resolutions for the National Conference of Special Constituencies, where she serves as the minority co-convener, to bring awareness to the challenges facing new, minority, women physicians and international medical graduates. Nguyen was elected multiple times as the TAFP delegate to the National Conference of Constituency Leaders. She teaches and mentors medical students and is well known in her community as a dedicated physician who often volunteers. TAFP FOUNDATION PHILANTHROPIST OF THE YEAR: LEWIS E. FOXHALL, MD Dr. Foxhall is a family physician, professor, and senior leader at the University of Texas M.D. Anderson Cancer Center in Houston. Throughout his career, he has been a leader in organized medicine on all levels, including serving as TAFP president and on the Texas Medical Association Board of Trustees. He served as director of the Texas Statewide Family Medicine Preceptorship Program for more than a decade and remains a vocal champion of student interest activities. Foxhall has served on the TAFP Foundation Board of Trustees for close to 25 years, including seven years as treasurer, and is a generous monthly donor who reached the fifth level of the cumulative donor program in 2016.
JONATHAN NELSON
PATIENT ADVOCACY AWARD: SENATOR CRAIG ESTES When the Wichita Falls Family Medicine Residency Program faced the possibility of closure earlier this year, Sen. Estes brought the parties involved together to forge an agreement and save the program. Working alongside TAFP, Sen. Estes made sure everyone in the negotiations seriously considered the ramifications such a closure would have to the community, patient access to care, and future physician workforce trends. Through Sen. Estes’ hard work, the Wichita Falls Family Medicine Residency Program joined forces with a local community health center and will continue operations, serving more patients and provide residents even more clinical training opportunities than before.
TAFP POLITICAL ACTION COMMITTEE AWARD: JUSTIN V. BARTOS, MD Dr. Bartos is a longtime advocate for family medicine, working hard to develop relationships with his elected officials, and is a tireless advocate for family physicians and patients. Not only does he serve as a key contact, but he is also regarded as an expert in health policy. He has served on the TAFP PAC Board of Directors for over 12 years and remains one of the top financial contributors to the PAC over the last decade.
Following the presentation of awards, Dr. Wergin installed TAFP’s 2016-2017 officers. They are President Tricia Elliott, MD; President-elect Janet Hurley, MD; Vice President Javier “Jake” Margo, Jr., MD; Treasurer Rebecca Hart, MD; and Parliamentarian Amer Shakil, MD. In her inaugural address, Elliott thanked the many physician leaders who have gone
before her and several mentors who have guided her along her path. She encouraged family physicians to become involved in the Academy for the sake of the specialty as well as their own fulfillment. “I look forward to advocating for you and being your voice on the broad health care and systems issues that face us in our daily practices,” she told the audience. “I hope to inspire the future family physicians in our students and residents to excitedly embrace family medicine as the noble and joyous profession it is.” Mark your calendars now for upcoming symposia. The 2017 C. Frank Webber Lectureship will be held April 7-8, 2017 at the Renaissance Austin Hotel. The Texas Family Medicine Symposium will be June 2-4, 2017 at La Cantera Hill Country Resort and Spa in San Antonio, and next year’s Annual Session and Primary Care Summit will be Nov. 10-12, 2017 in Galveston. For the full 2017 schedule, go to www.tafp.org/professionaldevelopment.
Clockwise from top left TAFP’s 2016-2017 officers, from left: Treasurer Rebecca Hart, MD; Vice President Javier “Jake” Margo, Jr., MD; President Tricia Elliott, MD; Presidentelect Janet Hurley, MD; Immediate Past President Ajay Gupta, MD; and Parliamentarian Amer Shakil, MD. From left: Ike Okwuwa, MD; Anika BellGray, MD; and John Carroll, MD, join in the festivities at the President’s Party. Special guest and Immediate Past AAFP Board Chair Robert Wergin, MD, poses in his hi-roller hat. From left: Presley Mock, Jr., MD, receives the Physicians Emeritus Award from the Immediate Past President Ajay Gupta, MD. Norman Chenven, MD, accepts the 2016 Physicians Emeritus Award.
www.tafp.org
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cover story
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
Empowering primary care through strong exam room teams Peter B. Anderson, MD
T
he health care industry hasn’t been too kind to primary care physicians for many years. Perhaps some of the blame rests with our poor understanding of the necessity of primary care physicians to the general health of our society. The word “primary” is part of the problem, seeming to indicate a lower level of expertise and associated inferiority. But in reality, a primary care physician — more appropriately termed a “comprehensivist” — is the leader every patient needs for his or her health care team at every stage of life. Despite the inequalities in compensation and respect previously experienced by primary care physicians, health care reform has positioned primary care at center of an incredible opportunity. It has empowered primary care physicians like never before to address the brokenness of our health care system, offering powerful financial incentives for chronic care management and providing the framework for increased coordination between providers. Unlike what we’ve been led to believe, there’s no better time than now to be a comprehensivist. I’ve defined this role as “the familiar physician,” a clinician who provides convenient access in the context of a long-term relationship.1 This role requires whole-person care, patient panel health management and increased accountability and communication with other providers. But this level of care simply isn’t possible without innovation. While many remarkable advances in recent decades have changed health care for the better, we’ve altered our primary care delivery method very little. We may have limped along with an insufficient process for a time, but we can’t keep trying to maintain our traditional model and expect to provide the accessible, convenient, relationship-based care patients need. For too long we’ve accepted the idea that only the physician belongs in the primary care exam room. This mentality has isolated physicians and led to a delivery process that absolutely fails to make primary care accessible. And this failure of the delivery process is what prevents primary care from thriving.
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Midway through 2003, my once successful practice was struggling to stay afloat in the midst of early EHR implementation and other major industry transitions. We were $80,000 in the red, and I was working more than 60 hours per week and wishing I’d never become a family doctor.
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
Too many physicians are spending their time on data entry and other non-physician responsibilities that decrease their capacity to provide timely, focused patient interaction. Those exam room tasks — most notably accurate EHR documentation — are vital to the needs of the patient visit. The physician just shouldn’t be the person performing them. The lack of teamwork in the exam room has limited the reach of our services, ultimately driving patients to expensive emergency and urgent care because we’ve failed to provide the needed access. PROBLEMS AND SOLUTIONS IN THE EXAM ROOM I know this reality all too well. Midway through 2003, my once successful practice was struggling to stay afloat in the midst of early EHR implementation and other major industry transitions. We were $80,000 in the red, and I was working more than 60 hours per week and wishing I’d never become a family doctor. My patients were frustrated by the poor access and rushed visits and my staff morale was low. All of my time at home was controlled by the need to get back to the computer to finish charts, and I seldom had unencumbered time with my family. To be perfectly honest, I hated medicine at that point. I was desperate by the end of 2003 — I had to embark on a serious rescue mission. My previous 20 years in primary care had shown me the exam room was in critical need of innovation. Any possibility of saving my practice had to begin there. Simply working harder couldn’t fix the pervasive brokenness; I needed a completely new process. I began with modest yet significant changes in my delivery process and I started training my nurses to take a more active role throughout the patient visit. Their increased involvement inside the exam room liberated me from non-physician work and quickly improved my efficiency and quality. I could once again practice the “art of medicine” instead of focusing disproportionately on ancillary tasks that kept me from providing the access and attention my patients needed. I was able to offer renewed focus on patients and address their needs with holistic orientation — the real reason I chose primary care. With the restoration of the doctor-patient relationship and the capacity to practice the best care of my career, I fell in love with medicine again. Initially birthed from desperation, the Team Care Medicine Model emerged as the solution that saved my practice, renewed my joy of practicing medicine, and restored sufficient time for my personal life. Within a few years of implementation and refinement of the process, I realized the transformation made possible by this model could empower other physicians and their staff as well. That began a journey of working with practices across the United States to create dynamic, high-functioning teams in the exam room that facilitate increased productivity, more accurate and timely data collection, and larger, more engaged patient populations. This revolutionary process allows physicians to focus on patient care and mobilizes nurses, licensed practical nurses, and medical assistants, trained as Team Care Assistants, to work at the full capacity of their licenses. TEAMWORK MAKES THE DREAM WORK Team Care Assistants, or TCAs, perform a number of specific exam room responsibilities that enable physicians to spend less — but higher quality — time with each patient. We’ve developed several steps for each of these tasks that require initial training but quickly prepare clinical staff members to assume a more strategic role. The following skills capture the broad scope of the TCA’s responsibilities: visit control, data collection, presentation, scribing, ordering of plan, and visit closure. Those skills are put to work in the exam room. [cont. on 20]
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[cont. from 18] Step one: The TCA welcomes the patient and asks symptom or disease-associated questions (based on physician-developed protocols related to the reason for the visit) and records this preliminary information in the EHR. The TCA reviews and updates the patient’s allergy, surgical, social and family histories. Next, the TCA performs medication reconciliation with the current list in the EHR and reviews approaching or overdue health management topics, pending orders for tests or procedures, and any responsibilities given to the patient during previous visits. The TCA updates medical events occurring since the patient was last seen and reviews appropriate systems for the patient’s current needs.
Step two: When the physician begins the patient visit, the TCA communicates the preliminary information to the physician in the patient’s presence and then serves as a scribe during the examination. The physician confirms the preliminary information and further interviews the patient. The physician also questions the patient on the status of any chronic conditions and other issues in need of attention while the TCA inputs additional details in the EHR as directed by the physician.
Step three: The physician then performs the exam, verbalizing any abnormalities, which the TCA documents in the EHR. The physician develops the diagnoses and treatment plan and maintains direct communication with the patient while the TCA carries out all EHR-related tasks.
Step four: After the physician finishes discussing the plan with the patient, the physician leaves the room to see the next patient, where another TCA has done the same preliminary work. In the previous room, the TCA reviews the treatment plan again, follows up with any necessary patient education, and closes the visit.
Each step is executed in partnership with the physician and makes substantial improvements in workflow. With extra support in the exam room, physicians are freed up to do the work for which they are singularly trained. Clinical staff members gain a greater sense of professional satisfaction from increased interaction and education with patients instead of being relegated to “vital signs only” status. Patients become more engaged in their own health management because of their ongoing, convenient access to the same physician and care team. 20
TEXAS FAMILY PHYSICIAN [No. 4] 2016
While the adoption process takes some time and effort, welltrained TCAs can appropriately and expertly manage these added responsibilities and provide invaluable support to the physician throughout the entire visit. The differences between the traditional care model in contrast with the Team Care Medicine Model demonstrate remarkable gains in quality, productivity, profitability, and most importantly patient health outcomes. We saw these improvements in our own practice as we grew from seeing an average of 18 to 20 patients each day to 30 to seeing 35 patients per day. After witnessing these results, Dr. Kevin Hopkins of the Cleveland Clinic validated the value of this model.2 For the Team Care Medicine Model, we don’t encourage selftraining. There are too many habits, too much variance, and too much time investment required to make the model successful by doing it yourself. We experienced this kind of failure firsthand for our first couple years as we tried to help doctors do it themselves. I do not think this model can be effectively developed by most physicians today due to the lack of time. When we learned this process, it took us about two to three years to really get decent at it. To project a shorter time period for self-training would be unreasonable. The position Team Care Medicine has taken as a company is to develop a turnkey training program so transformation doesn’t rest solely on the already overwhelmed physician’s shoulders. EMPOWERED TO THRIVE The goals of the Triple Aim must be accomplished if we’re going to embrace the opportunity health care reform has given primary care. Those goals will require change on every level of the industry to expand access and lower overall costs. We’ve never needed innovation more than we do now. Increased coordination, access and communication, better care quality, and decreased costs can’t be achieved without a strong team approach and engaged patients in a well-functioning medical home. Building strong teams will enable the best aspects of primary care and make it what it should be: timely, convenient, affordable access, and quality care delivered within the context of great doctor-patient relationships. Reorienting our approach around the goals of the Triple Aim, while equipping our clinical staff with the training to maximize their role on the team, will make primary care truly thrive.
REFERENCES 1 The Familiar Physician: Saving Your Doctor in the Era of Obamacare by Peter Anderson; Morgan James Publisher 2014. 2 TEAM-BASED CARE: Saving Time and Improving Efficiency by Kevin D. Hopkins, MD, and Christine A. Sinsky, MD; November/ December 2014 | www.aafp.org/fpm | FAMILY PRACTICE MANAGEMENT.
Dr. Peter Anderson spent 30 years in active practice and later founded and now leads Team Care Medicine [http://www.teamcaremedicine.com], a consulting and training company. He is the author of three books and writes and speaks frequently on primary care issues and clinical care reform in the context of the Affordable Care Act. This article was originally published in the Florida Family Physician. Reprinted with permission.
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PRACTICE TRANSFORMATION
The Comprehensive Primary Care Medical Home Qualities and characteristics of a high-value, patientcentered family medicine practice for Texas and beyond The TAFP Commission on Health Care Services and Managed Care Workgroup on the Patient-Centered Medical Home Anthony Holbert, MD, chair; Kurt Frederick, MD; Richard Young, MD; Roland Goertz, MD, MBA; Justin Bartos, MD; Tamra Deuser, MD; Jamal Islam, MD; Aaron Segal, MD; Sue Bornstein, MD; and Jonathan Nelson
I
n Texas as in many other states, the implementation of the patient-centered medical home model of primary care has been hampered by a lack of enhanced payment opportunities available through private and public health plans to cover the costs associated with practice transformation. Over the past decade, pilot and demonstration projects across the nation have progressed with various degrees of success as the PCMH concept has gathered momentum among health system reform advocates and physician professional organizations. Still, without adequate payment reform, many primary care physicians simply can’t afford to add the practice infrastructure required by certifying organizations like the National Committee on Quality Assurance, which awards the most well-known PCMH designation. Many physicians believe certification processes are overly burdensome and that many required elements likely have little to no effect on the cost or quality of care. Consequentially primary care physicians have not universally supported the PCMH. As our health care delivery system transitions from payment models based on volume to models based on value, the Texas Academy of Family Physicians does not endorse one “right” way to pay for and deliver health care services. PCMH is but one approach to providing comprehensive primary care to patients of all sorts. Other models like accountable care organizations and clinically integrated physician organizations are also evolving, and the Academy is working to ensure members have the tools and information they need to make the right decisions for the success of their practices. In some cases, physicians and private insurers are entering into value-based contracts. In these contracts, physicians receive enhanced payment for achieving certain quality goals and for implementing certain measurement and reporting processes without seeking specific certifications or designations. Public payers in some states are exploring similar arrangements.
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
Research has shown time and again that when patients have ready access to primary care physicians, they receive better care at lower cost. This is a result of the continuity of care primary care physicians provide, care that depends on a set of attitudes and skills different from those possessed by other physicians. Examples include comfort with uncertainty, ambiguity, and complexity; the ability to provide a long list of intellectual and procedural services; comfort with death; the ability to develop long-term relationships with challenging patients; and a deeply-rooted concern for the health of the health care system that includes recognizing how exorbitant costs harm patients and their families. In many ways, the resurgence of the medical home concept as supported by AAFP and other national physician organizations was intended to describe these qualities to increase the perceived value of primary care among patients and payers alike. However, many of these qualities are difficult to quantify and measure, and so in the model’s implementation, the PCMH certification process has relied on simplistic and exhaustive checklists. In light of these circumstances, the TAFP Commission on Health Care Services and Managed Care convened a workgroup to explore an alternate, less burdensome path to achieving the overall goals of the PCMH. The group decided this path should focus on those qualities possessed by primary care physicians that equip them to deliver better care at a lower cost by providing compassionate comprehensive care to complex patients. What follows is the product of that workgroup, a set of qualities, capabilities, and characteristics that high-value, patient-centered primary care practices should have and should be able to demonstrate. These characteristics are focused on promoting the qualities primary care physicians possess that enable them to provide high-quality, costefficient care.
Qualities and characteristics of a high-value primary care practice
■ Prudent prescribing practices • Physicians or their team members should prescribe generic medications whenever possible. • Accomplishment of this objective could be achieved in a number of ways: computerized decision support software, embedded clinical pharmacists, or physicians simply being paid to spend more time with their complex patients. • Physicians should actively manage pharmaceutical and device company influence on their practices. ■ Leadership of intra-practice quality improvement
Comprehensive primary care physician characteristics ■ Comprehensive primary care intellectual services • Provide at least 6 of the 12 intellectual services the AAFP’s Graham Center has identified that are associated with reduced total cost of care. • Thorough medical management of common high-cost chronic diseases. ■ Comprehensive primary care procedural services • Practice provides all common primary care procedural services. ■ Continuous primary care physician-patient trusting relationships over time • Patients must feel they have a relationship with a personal primary physician they deeply trust. • This crucial trust will often carry over to family members, which is especially important in caring for patients who are unable to care for themselves. ■ Comfort with uncertainty • Physicians or their team members should rarely order tests or treatments without proven benefit. • The Choosing Wisely campaign provides an excellent foundation to begin a list of these inappropriate services that will evolve over time. ■ Comfort with death • Physicians should provide care options for patients with serious acute and chronic diseases – in the spirit of shared decision making – and continue to care for patients at the end of their lives, including management of pain, other symptoms, and emotional support. ■ Evidence-based medical decisions • Medical decisions by the physicians and their teams are based on the latest evidence from high-quality clinical trials and guidelines written by major medical societies that are consistent with primary care values. • Justified exceptions are always allowed. ■ Whole family care • The practice provides comprehensive primary care to all ages.
• At least one physician at each practice leads intra-practice quality improvement activities that incorporate traditional measurements and PDSA cycles, and includes participation by all key health care team members. • The processes of a continuous improvement culture are more important than the actual improvement activities, which should be guided by local observations and needs.
Practice infrastructure ■ Expanded access • The practice, in cooperation with nearby practices, provides evening and weekend clinic hours. • The practice, in cooperation with nearby practices, provides 24/7 phone access to a primary care physician. • The practice cares for patient needs with telephone visits or e-visits when face-to-face clinic visits are not necessary to achieve the desired outcomes. ■ Urgent care capacity • The practice has the infrastructure to care for acutely ill and injured patients. ■ Patient input on the practice • The practice regularly seeks patient input on practice services. This could be accomplished with patient surveys or patient advisory boards, or a combination of the two. ■ Team-based care • The practice defines the roles and responsibilities of members of the physician-led health care team. • The practice makes use of standing orders, protocols and procedures, and patient-specific care plans to guide team members’ actions. • The practice uses structured communication procedures or team meetings to communicate patient care plans to team members. • The practice uses structured communication procedures to track communications and care plan updates, including medication reconciliation, with consulting specialists. ■ Integrated behavioral health • The practice has some capacity for patients with mental health conditions to be seen by non-primary care physician mental health providers. www.tafp.org
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System management ■ Manage all patient concerns, symptoms, acute diseases, and chronic diseases • By being competent to diagnose and treat a wide variety of conditions with extensive accessibility to patients; primary care physicians can care for most patient needs most of the time with limited referrals to other physicians or facilities, which limits medical errors and care redundancies. • Medication management and reconciliation is an important component of this characteristic, but could also be accomplished in a variety of approaches similar to generic prescription writing. ■ Manage episodes of care including transitions • In an urban area with long travel times, this might best be accomplished with care coordinators. In rural areas, this might best be accomplished by personal primary care physicians caring for patients in several facilities including patients’ homes. Either approach is acceptable. • This service is also enhanced with claims analysis of patient utilization patterns that a few exemplary practices have been able to achieve.
■ Proactively identify and intensely care for high-risk or high-cost patients • These patients may be identified with analytic electronic approaches or by the personal physicians simply knowing which patients have the greatest needs. • Intense care may include physicians or other practice team members and includes outreach to high-risk patients in anticipation of difficulties. ■ Manage total cost of specialist care • This goal will lead to occasional conflicts between specialists, primary care physicians, and patients, but will directly reduce the inherent waste of multi-specialty care. • This service is also enhanced with claims analysis of specialist cost and utilization patterns that a few exemplary practices have been able to achieve. ■ Guide patients to low-cost health care services • Practices know their local health care markets and can guide patients to ancillary services such as physical therapy, imaging centers, and other physicians who provide decent quality care at a reasonable price.
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
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RESEARCH
Support for this project included a grant from the Texas Academy of Family Physicians Foundation.
Support for TAFP Foundation Research is made possible by the Family Medicine Research Champions.
GOLD LEVEL Richard Garrison, MD David A. Katerndahl, MD Jim and Karen White
Comprehensive services of family physicians provided in rural Texas hospitals Richard Young, MD Director of Research and Recruiting JPS Hospital Family Medicine Residency Program Katie Kester, MD; Chris Dollar, MD; and Christian ZuĂąiga, DO JPS Hospital Family Medicine Residency Program
SILVER LEVEL Carol and Dale Moquist, MD TAFP Red River Chapter BRONZE LEVEL Joane Baumer, MD Gary Mennie, MD Linda Siy, MD Lloyd Van Winkle, MD George Zenner, MD
Thank you to all who have donated to an endowment.
For information on donating or creating a new endowment or applying for research grants, contact Kathy McCarthy at kmccarthy@tafp.org.
ABSTRACT Background: The purpose of this study was to take a snapshot of how many rural Texas family physicians currently perform advanced cognitive and procedural work, how this responsibility is shared with other providers, and requirements to obtain privileges. Methods: Survey of rural hospital CEOs Results: The response rate of Texas hospitals was 77.4 percent (82/106). Hospitals had a mean of 79 beds and delivered 379 babies. There was an average of 8.0 family physicians per hospital of which 2.8 provided maternity care services and 2.5 (91 percent) performed C-sections. Seventy-eight percent of the hospitals had at least one FP who provided maternity care and FPs comprised 60 percent of all rural
Background Family physicians have provided much of the maternity care in rural America, but the number of family physicians who provide maternity care overall has been decreasing as far back as the late 1970s.1-3 The American College of Obstetricians and Gynecologists has recognized that many rural counties have no obstetricians, as most obstetricians preferentially practice in urban settings.4 A survey of Texas family medicine and obstetric residents confirmed that family medicine residents were more likely to provide maternity care services to rural areas.5 The local supply of rural maternity care physicians is critical for the best outcomes. Rural areas that lack local obstetrical
physicians providing maternity care. Most hospitals (88 percent) had no firm numbers of procedures required to obtain C-section privileges. In hospitals with ICUs, family physicians and internists were more likely to care for patients than intensivists. Family physicians could obtain privileges to perform colonoscopies in almost all rural hospitals with proof of additional training, and the number of procedures required for privileges was modest (45). Conclusions: FPs continue to provide the majority of maternity care services in U.S. rural hospitals including C-sections, and also commonly provide endoscopy and critical care services. Some family medicine residencies should continue to train their residents to provide these services to replenish this valuable workforce.
services are associated with less adequate prenatal care, higher rates of preterm delivery, infant mortality, and complications during delivery.6 Similarly, many rural hospitals have endoscopy suites and ICUs. Many studies have been published about the safety of family physicians performing colonoscopies.7-10 Less has been published on rural ICUs, particularly the involvement of family physicians in critical care.11,12 The purpose of this study was to take a snapshot of how many rural Texas family physicians currently perform advanced cognitive and procedural work, how this responsibility is shared with other providers, and requirements to obtain privileges. www.tafp.org
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Table 1. Characteristics of responding rural hospitals by maternity care services Characteristic
26
All respondents (n = 82)
Provides maternity care (n = 41)
No maternity care (n = 41)
Ownership Local government Non-profit For-profit Mixed ownership
36.6% 42.7% 13.4% 6.1%
29.3% 46.3% 19.5% 4.0%
43.9% 39.0% 7.3% 7.3%
RUCA codes (Code #) Micropolitan (4-6) Small town (7-9) Rural (10)
35.8% 44.4% 19.8%
58.5% 36.6% 4.9%
12.5% 52.5% 35.0%
Critical access hospital
51.2%
24.4%
78.0%
p < .001
Number of acute care beds
52
79
25
p < .001
Number of acute care beds 1-25 26-50 51-100 100+
54.9% 18.3% 14.6% 12.2%
29.3% 19.5% 26.8% 24.4%
80.5% 17.1% 2.4% 0%
Has an ICU
39.2%
61.5%
17.5%
p = .30
p < .001
p < .001
p < .001
Methods
Results
This was a cross-sectional survey mailed to rural hospital administrators in 15 U.S. states. A list of hospitals was accessed from the Health Resources and Services Administration Data Warehouse.13 Google searches complemented the first attempt to identify rural hospitals. No single list of rural U.S. hospitals is available. Potential subject hospitals were then categorized by Rural-urban commuting area codes, or RUCA codes.14 Those in RUCA areas of code 4 or greater were considered eligible for the study (4-6 is defined as Micropolitan, representing populations of 10,000-49,999; 7-9 small town, population 2,5009,999; and 10 is rural, population < 2,500). A modified Dillman approach was used, which included an introductory letter and three mailed surveys. We asked about basic hospital demographics including critical access status and size, who delivers babies and performs C-sections, what is required for privileges, and other related questions. Analysis of quantitative data consisted primarily of descriptive statistics. Categorical data was analyzed with chi-square. Means of continuous data were analyzed with an independent t-test or ANOVA as appropriate. SPSS was the statistical software used (SPSS 20.0, Chicago, IL). This study was approved by the JPS Health Network Institutional Review Board.
The response rate for all hospitals was 51.2 percent (437/854). For Texas, 106 hospitals in geographic areas with RUCA codes of 4-10 were identified and 82 responded (77.4 percent), of which 41 (50 percent of responding hospitals) reported providing maternity care services, 31 (35.8 percent) provided critical care, and 53 (64.6 percent) provided colonoscopies. Hospital demographics for the responding hospitals are in Table 1. A minority of surveyed hospitals were critical access (24.4 percent). Hospitals had a mean of 79 beds and delivered 379 babies. Provision of maternity care services is described in Table 2. There was an average of 8.0 family physicians per hospital of which 2.8 provided maternity care services and 2.5 (91 percent) performed C-sections. 78 percent of the hospitals had at least one FP who provided maternity care and FPs comprised 60 percent of all rural physicians providing maternity care. Most hospitals (88 percent) had no firm numbers of procedures required to obtain privileges. Compared to family physicians in other states, family physicians in Texas were more likely to perform their own C-sections and midwives were used slightly less often. The ratio of family physicians to obstetricians decreased with increasing hospital size and deliveries per year (Table 3). Family physicians were the
TEXAS FAMILY PHYSICIAN [No. 4] 2016
Table 2. Characteristics of physicians providing advanced care per rural hospital MATERNITY CARE Physician services by specialty
Texas (n = 41)
14 other U.S. states (n = 155)
p value
Number of FPs with hospital privileges
8.0
6.7
.13
Number of FPs who provide maternity care
2.8
2.8
.99
Number of OBs
1.8
1.5
.32
Number of midwives
0.2
0.4
.03
Number of FPs who perform C-sections
2.5
1.6
.013
% FPs of all physicians who provide maternity care
60%
64%
.52
% FPs of all providers of maternity care
60%
61%
.82
% of FPs providing maternity care who perform C-sections
91%
59%
< .001
ICU CARE (IN HOSPITALS WITH ICUs) % of hospitals with physician specialty providing ICU care
Texas (n = 31)
14 other U.S. states (n = 155)
Family physicians
71.0%
68.9%
.50
Internists
87.1%
71.9%
.058
Intensivists
38.7%
22.4%
.053
predominant provider of maternity care services across all RUCA codes and in hospitals with 100 beds or fewer. There was no significant difference in the percentage of family physicians who perform their own C-sections by hospital size or rurality. There was no difference in the C-section rate by rurality, hospital size, or provider mix. For ICU care, there was no difference in the percentage of rural hospitals with ICUs between Texas (n = 31) and 14 other states (n = -155, 39 percent vs. 40 percent, P = 0.88). For Texas, the average number of ICU beds was 6.7 and the average daily census was 3.3. Specific ICU services included potent IV medications at 100 percent, mechanical ventilation for at least a few days at 97 percent, and multi-organ failure at 68 percent. Family physicians provided ICU care similar to internists (71.0 percent vs. 87.1 percent) and more than intensivists (38.7 percent) (Table 2). For endoscopy, there was no difference in the percentage of rural hospitals with colonoscopy services between Texas (n = 53) and 14 other states (n = 256, 77.1 percent vs. 68.8 percent, P = 0.086). For Texas, the majority of hospitals required a fellowship or another form of extra training (64.2 percent). A minority required a certain number of procedures to obtain privileges (39.6 percent). The mean number of colonoscopies required was 45 (range 5-200).
Discussion We found that nearly half of rural hospitals provide maternity care services. The majority of physicians providing both the deliveries and the C-sections are family physicians. We also found that rural hospitals use family physicians roughly equal to internists to provide ICU care and much more so than intensivists. The majority of hospitals want some sort of documentation of extra training for colonoscopies, but the procedure numbers required to obtain privileges are modest. A few trends we recorded were expected. Family physicians were more likely to be the exclusive provider of maternity care services and C-sections in the smallest and most remote hospitals, especially critical access hospitals. Our study confirms a previous study in Washington state documenting that family physicians provided the majority of C-sections in its rural hospitals.15 A surprise to the authors was the noted absence of procedure number requirements to obtain privileges for vaginal deliveries, C-sections, and prenatal ultrasounds. This study had limitations. Hospital CEOs were asked to comment on services provided in their facilities. Their knowledge may be more limited than was assumed. There were no data on the quality of care provided except for the overall C-section rate. There www.tafp.org
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Table 3. Characteristics of FP provision of maternity care services by hospital size and rurality in Texas Number of hospital beds
1-25 (n = 12)
26-50 (n = 8)
51-100 (n = 11)
101+ (n = 10)
p value
Number of FPs with hospital privileges
5.8
5.8
9.3
11.3
p = .053
Number of FPs who perform vaginal deliveries
2.9
3.9
2.2
2.3
p = .35
Number of FPs who perform C-section
2.9
3.5
1.6
2.3
p = .24
Number of OBs who deliver babies
0.6
0.6
1.7
4.2
p < .001
0
0
0.1
0.6
p = .004
% Hospitals with any FP providing maternity care services
100%
100%
70%
40%
p = .001
% Hospitals with any FP performing C-sections
100%
100%
55%
40%
p = .001
% FPs providing maternity care who perform C-sections
100%
91%
75%
100%
p = .22
% FPs of all physicians who provide maternity care services
83%
85%
50%
22%
p < .001
Number of deliveries per year
134
249
423
725
p < .001
% Deliveries by C-section
26%
26%
32%
29%
p = .52
Number of Midwives who deliver babies
RUCA Group
Rural (n = 2)
Small town (n = 15)
Micropolitan (n = 24)
p value
Number of FPs with hospital privileges
3.5
7.1
8.9
p = .31
Number of FPs who perform vaginal deliveries
3.0
3.3
2.4
p = .50
Number of FPs who perform C-sections
1.5
3.3
2.1
p = .23
Number OBs who deliver babies
1.0
0.5
2.6
p = .001
0
0
0.3
p = .33
% Hospitals with any FP providing maternity care services
100%
93%
67%
p = .11
% Hospitals with any FP performing C-sections
100%
73%
58%
p = .04
% FPs Providing maternity care who perform C-sections
63%
100%
88%
p = .14
% FPs of All physicians who provide maternity care services
75%
83%
44%
p = .007
Number of deliveries per year
208
169
523
p < .001
% Deliveries by C-section
16%
28%
29%
p = .20
Number of midwives who deliver babies
was also no unified definition of a rural community nor a rural hospital in the United States. Other classification schemes may have given different results. We did not ask about numbers of physicians providing ICU care, so the ratios of actual physicians may be different than reported here. We did not ask for further the explanations of required extra training for colonoscopies. There has been a lively discussion recently of the role of residency education in maternity care, its requirements, and its impact on graduates’ provision of these services.16-21 Maternity care fellowships increase likelihood that the family physician will provide those services, including C-sections.19 Our study clearly showed that family physicians in rural America often perform their own C-sections, which means they must be trained for this procedure. Role modeling of this procedure is a challenge even in more family 28
TEXAS FAMILY PHYSICIAN [No. 4] 2016
medicine-friendly regions of the country. A report from the Pacific Northwest found that only 5 percent of FM faculty had C-section privileges.22 Recent experiments in family medicine residency education — the P4 project23, 24 and the Accreditation Council for Graduate Medical Education Length of Training Pilot25 — may shed more light on the connection between educational approaches and provision of advanced maternity care services by graduates of these programs. C-sections may be a particularly important component of extended training options, as previous research has found a correlation between training in this procedure and its provision in rural practice.15, 18 Whatever the best training approach, it is clear that some family medicine residencies must continue to train young family physicians to deliver babies, perform C-sections, care for ICU patients, and perform colonoscopies.
References 1. Rosenblatt RA, Cherkin DC, Schneeweiss R, et al. The structure and content of family practice: current status and future trends. J Fam Pract. 1982;15(4):681-722. 2. Chen FM, Huntington J, Kim S, Phillips WR, Stevens NG. Prepared but not practicing: declining pregnancy care among recent family medicine residency graduates. Fam Med. 2006;38(6):423-426. 3. Tong ST, Makaroff LA, Xierali IM, et al. Proportion of family physicians providing maternity care continues to decline. J Am Board Fam Med. 2012;25(3):270-271. 4. Rayburn WF, Klagholz JC, Murray-Krezan C, Dowell LE, Strunk AL. Distribution of American Congress of Obstetricians and Gynecologists fellows and junior fellows in practice in the United States. Obstet Gynecol. 2012;119(5):1017-1022. 5. Gladu R, Lange G, Groff J. Current status & future supply of providers. Texas Family Physician. 1998(Jan/Feb/March):14-16. 6. Nesbitt TS, Larson EH, Rosenblatt RA, Hart LG. Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use. Am J Public Health. 1997;87(1):85-90. 7. Cotterill M, Gasparelli R, Kirby E. Colorectal cancer detection in a rural community. Development of a colonoscopy screening program. Can Fam Physician. 2005;51:1224-1228. 8. Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a metaanalysis. Ann Fam Med. 2009;7(1):56-62. 9. Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? J Am Board Fam Pract. 2004;17(5):353-358. 10. Newman RJ, Nichols DB, Cummings DM. Outpatient colonoscopy by rural family physicians. Ann Fam Med. 2005;3(2):122-125. 11. Freeman VA, Walsh J, Rudolf M, Slifkin RT, Skinner AC. Intensive care in critical access hospitals. J Rural Health. 2007;23(2):116-123. 12. Wakefield DS, Ward M, Miller T, et al. Intensive care unit utilization and interhospital transfers as potential indicators of rural hospital quality. J Rural Health. 2004;20(4):394-400. 13. Health Services and Service Administraion (HRSA) Data Warehouse. U.S. Department of Health and Human Services, 2011. http://datawarehouse.hrsa. gov/. Accessed Jul 28, 2011.
14. WWAMI Rural Health Research Center. RUCA Data. http://depts.washington.edu/uwruca/rucadata.php. Accessed Apr 1, 2014. 15. Norris TE, Reese JW, Pirani MJ, Rosenblatt RA. Are rural family physicians comfortable performing cesarean sections? J Fam Pract. 1996;43(5):455-460. 16. Coonrod RA, Kelly BF, Ellert W, Loeliger SF, Rodney WM, Deutchman M. Tiered maternity care training in family medicine. Fam Med. 2011;43(9):631-637. 17. Meunier MR, Apgar BS, Ratcliffe SD, Mullan PB. Plans to accommodate proposed maternity care training requirements: a national survey of family medicine directors of obstetrics curricula. J Am Board Fam Med. 2012;25(6):827-831. 18. Rodney WM, Martinez C, Collins M, Laurence G, Pean C, Stallings J. OB fellowship outcomes 19922010: where do they go, who stops delivering, and why? Fam Med. 2010;42(10):712-716. 19. Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med. 2008;40(5):326-332. 20. Deutchman M, Connor P, Gobbo R, FitzSimmons R. Outcomes of cesarean sections performed by family physicians and the training they received: a 15-year retrospective study. J Am Board Fam Pract. 1995;8(2):81-90. 21. Orientale E, Jr. Length of training debate in family medicine: idealism versus realism? J Grad Med Educ. 2013;5(2):192-194. 22. Sakornbut EL, Dickinson L. Obstetric care in family practice residencies: a national survey. J Am Board Fam Pract. 1993;6(4):379-384. 23. Green LA, Jones SM, Fetter G, Jr., Pugno PA. Preparing the personal physician for practice: changing family medicine residency training to enable new model practice. Acad Med. 2007;82(12):12201227. 24. LoPresti L, Young R, Douglass A. Learner-directed intentional diversification: the experience of three P4 programs. Fam Med. 2011;43(2):114-116. 25. ACGME Pilot Project to Test Four-year Family Medicine Residency AAFP. http:// www.aafp.org/news/education-professionaldevelopment/20120427acgmepilot.html. Accessed Jan 27, 2016.
Interested in participating in practice-based research? www.tafp.org/practice-resources/research TAFPâ&#x20AC;&#x2122;s Section on Research wants you to know that Texas is home to lots of practice-based primary care research opportunities. Check out our new research page at tafp.org to learn more and to contact like-minded colleagues and find a project to dive into.
www.tafp.org
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PERSPECTIVE
Concussions: A childhood epidemic By Jon-Michael Cook, MD our student athletes are facing an epidemic and it is our job as primary care physicians to help protect our athletes. It is estimated that 1.6-3.8 million sports-related concussions occur every year with more than 300,000 occurring to high school athletes. For young people ages 15-24, only motor vehicle accidents cause more traumatic brain injuries than sports. Concussions were once thought of as a temporary injury much like a sprain or strain of the brain that would completely resolve with time. We also used to think that a hit to the head was not concussive unless there was an associated loss of consciousness. We are learning this is not the case. Studies suggest the cumulative impact of both concussive and sub-concussive impacts may lead to permanent changes in the brain and this is something that needs more attention. Studies looking primarily at professional-level athletes have shown autopsy findings similar to those seen in elderly individuals with Alzheimer’s disease. This finding has been termed Chronic Traumatic Encephalopathy, which was the basis of the recent Will Smith movie, “Concussion.” The problem with concussions is that they are subtle, usually manifesting as headache, amnesia, and sensitivity to light or sound as well as mood and sleep changes after some sort of impact. Unlike other injuries that require a cast, a walking boot, or crutches, concussions lack an outward sign to signify injury. Because of this, many parents and patients alike, question the need for caution and a slow return to play. The fear of many physicians is something known as the second impact syndrome in which a second concussion occurs before the brain has had enough time to heal from the first. Due to the brain’s inability to auto-regulate pressure, substantial swelling can occur that typically has catastrophic consequences. This is one of the primary reasons it is recommended that the athlete participate in no contact-related activities and the reason all states have passed “return to play” laws. Time and time again I have had discussions with parents about the certainty regarding the diagnosis of a concussion and the protocol sports medicine physicians and athletic trainers follow. This desire to bypass protocol stems from the importance placed — typically on the part of the parent — of some upcoming game or tournament. There is the fear of not impressing some scout or college recruiter and somehow altering their child’s life trajectory.
According to the NCAA in 2014, there were approximately 7.4 million athletes participating in high school sports (men’s & women’s basketball, football, baseball, ice hockey and soccer) per year. Approximately 460,000 or roughly 6 percent will become NCAA athletes; of those 2 percent will continue on to the professional level. What this means is that 99 percent of high school athletes will go “pro” in something other than sports. For every kid that becomes the next Wayne Gretzky, Michael Jordan, Tom Brady, or Mia Hamm, there are thousands that become people like you and me. The need for children to be involved in some sort of physical activity in today’s society is paramount. According to the Centers for Disease Control, approximately one-third of children and adolescents are overweight or obese. This rate has nearly tripled since 1980. In addition to the psychological stresses of being overweight or obese, these children are at an increased risk for high blood pressure, high cholesterol, diabetes, and other maladies. In those who participate in sports, the risk of injury and the potential for disability is increased but these risks are far outweighed by the benefits. So as important as it is to keep our kids physically active, we also need to keep them safe and capable of carrying out productive careers and lives after sports. Currently there is no single test to definitively diagnose a concussion. Clinicians take the history of events combined with physical examination looking for exacerbation of symptomatology and neurocognitive testing to see how the brain is functioning to say that someone is in a post-concussive state. Luckily symptoms will usually resolve in a matter of seven to 10 days granted there is sufficient physical and cognitive rest. As primary care physicians, you can help protect the lives and well being of these athletes by obtaining a concussion history from your student athletes. Recommend baseline cognitive testing each year, especially in those athletes that do not participate in University Interscholastic League sports like ice hockey (high school and club) or club soccer. Repeat these tests after a suspected concussion and while monitoring symptoms and deciding when to start a return to play. Know your area sports medicine physicians and your schoolbased athletic trainers. Most importantly, educate your patients and their families and be adamant in their return to play.
Studies looking primarily at professionallevel athletes have shown autopsy findings similar to those seen in elderly individuals with Alzheimer’s disease.
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TEXAS FAMILY PHYSICIAN [No. 4] 2016
Jon-Michael Cook, MD, is a PGY4 Primary Care Sports Medicine Fellow at Houston Methodist Hospital – Willowbrook.
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