Saturday, September 27, 2008

Patient-Centered Medical Home

The Patient-Centered Medical Home (PC-MH) is an approach to providing comprehensive primary care established by the...
  • American Academy of Family Physicians (AAFP)
  • American Academy of Pediatrics (AAP)
  • American College of Physicians (ACP)
  • American Osteopathic Association (AOA)
These groups, representing about 333,000 physicians, created a set of 7 principles for the PC-MH:
  1. Each patient is entitled to a personal physician
  2. The physician is the leader of a team of individual practitioners
  3. Whole person orientation
  4. Care is coordinated and/or integrated using the latest and most appropriate technology
  5. Quality & safety
  6. Enhanced access to physicians
  7. Payment schemes that reflect the value of the PC-MH for patients' health.
Indeed, since the development of this model, it has been touted as a potential solution to the challenges of providing quality health care for the entire US population. According to the Commonwealth Fund,
The Commonwealth Fund 2006 Health Care Quality Survey finds that when adults have health insurance coverage and a medical home—defined as a health care setting that provides patients with timely, well-organized care, and enhanced access to providers—racial and ethnic disparities in access and quality are reduced or even eliminated.
Find out more about this New Model for primary care at the following events at Boston University Medical School.

Upcoming Events

Tuesday, Sept. 29th, 2008 @ 12:00pm
BMC Family Medicine Grand Rounds
The Medical Home, physician reimbursement plans, and other solutions to the crisis Primary Care
Dr. Charles Williams
Dowling 1 Conference Auditorium
Free Food

Tuesday, Oct. 7th, 2008 @ 12:00pm
--National Primary Care Week--
Solutions: The Patient-Centered Medical Home
Sponsored by FMIG
Dr. Charles Williams (BMC Family Medicine) will facilitate a lunchtime discussion on the Patient Centered Medical Home as a potential solution to the crisis in primary care. Participants are encouraged to attend Dr. Williams' talk at the Family Medicine Grand Rounds.

Dr. Williams' Bio


References

Monday, September 22, 2008

Mass Crisis: Is This The Future of Health Care?

The recent Massachusetts legislation to mandate health insurance has been touted by many as a victory in health care reform. Implementation of this experiment in solving to US health problems, however, still presents many challenges.

Mandatory Health Insurance...plenty of patients but where are the doctors
?

A recent article in the Boston Globe (Sept. 22, 2008) highlights a few of the upcoming challenges that Massachusetts will face as a result of the upcoming implementation of the MA health insurance mandate. The most immediate of these is the lengthy wait times for receiving an appt. with a primary care physcician (PCP). The average wait time to see an Internist was 52 days and 46 days to see an OB/GYN.

These long wait times are the result of a shortage of PCPs, lack of focus on preventive health care, administrative burdon, and misdirected physician compensation schemes. According to MMS President Dr. Bruce S. Auerbach, who recently addressed a session of the National Congress on Health Reform in Wasington, D.C., there are severe labor shortages in:
  • Internal Medicine
  • Family Medicine
  • Vascular Surgery
  • Neurosurgery
  • Cardiology
  • Anesthesiology
  • Psychiatry
  • Gastroenterology
  • Urology

How to Increase PCP Supply?

In an attempt to increase the availability of PCPs, the federal and state government have funded a number of programs, including:

  • loan forgiveness programs
  • advanced medical home pilot projects
  • expanded primary care training
Medical school for free?!?!?!

From the Boston Globe article...
The Massachusetts law includes $1.5 million this year to help the University of Massachusetts Medical School expand its class size - from 103 students to as many as 125 - and to waive tuition and fees for students who agree to work as primary care doctors in Massachusetts for four years after they finish training.
This is indeed a crisis situation. If the state is moving towards free education for medical students interested in primay care, it is a clear sign of the dire circumstances facing the population of Massachusetts, and the rest of the United States.

So what can be done about this?

There are several proposed solutions. Together with AMSA, FMIG has planned a series of events for National Primary Care Week (Oct. 5-11) to highlight the challenges and potential solutions facing health care in the United States of America. Come and find out for yourself what we can do as future health professionals to best prepare for the difficult sitations waiting for us upon graduation.

References
Resources

Wednesday, September 17, 2008

Study showing fewer medical students intending to become primary-care physicians

Check out this new report and the corresponding JAMA article.
http://jama.ama-assn.org/cgi/content/full/300/10/1154

NBC Nightly News (9/9, story 10, 0:30, Williams) reported that a new study shows that few medical school students plan to become primary-care physicians. Most "are going into specialized fields instead."

USA Today (9/10, Rubin) reports that "medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest baby boomers head into their senior years," according to a study published in the Sept. 10 issue of the Journal of the American Medical Association.

In fact, "only two percent of graduating medical students say they" were considering practicing as primary-care physicians, the AP (9/10, Johnson) adds. By comparison, a similar survey conducted in 1990 showed that nine percent of medical students were interested in primary care. The data showed that "paperwork, the demands of the chronically sick, and the need to bring work home are among the factors pushing young doctors away from careers in primary care." Lead author Karen Hauer, M.D., of the University of California-San Francisco, pointed out that "it's hard work taking care of the chronically ill, the elderly, and people with complex diseases -- 'especially when...doing it with time pressures and inadequate resources.'"

For the study, researchers surveyed "1,177 medical students last year, found just 24 wanted to practice primary care, while 23 percent were interested in internal medicine, whose subspecialties include cardiology and cancer care," New York's Newsday /Bloomberg News (9/10) notes.

Salaries in primary care dissuade medical students from the field. The Columbus Dispatch (9/10, Hoholik) reports that "fewer U.S. medical students are choosing careers in family medicine because of long work hours and low pay," according to a research letter published in the Sept. 10 issue of the Journal of the American Medical Association.

Mark H. Ebell, M.D., of the University of Georgia, "examined whether there is an association between specialty selection and anticipated incomes using current data," MedPage Today (9/9, Groch) added. He used "residency information...from the National Residency Match Program," and "mean annual salary in 2007 came from the annual American Medical Group Association survey of physician salaries."

Dr. Ebell found that "family medicine had the lowest average salary ($185,740), and the lowest percentage of filled residency positions (42.1 percent)," Modern Healthcare (9/9, Robeznieks) noted. And, "internists, with the third-lowest salary of $193,162, had the third-lowest residency fill rate: 55.9 percent." In contrast, "radiologists -- whose average salary was $414,875 -- had a residency fill rate of 88.7 percent; and orthopedic surgeons -- whose average salary was $436,481 -- had a fill rate of 93.8 percent." Dr. Ebell wrote that "the correlation between salary and primary-care physician shortages -- which, in turn, may be tied to higher all-cause cardiovascular, cancer-specific, and infant mortality rates -- has persisted since his original research on this issue was published" in 1989.

Researchers say racially diverse medical schools may better prepare students. HealthDay (9/9, Preidt) reported that "attending medical schools with high levels of racial and ethnic diversity may better prepare white medical students to care for minority patients," according to a study published in the Sept. 10 issue of the Journal of the American Medical Association. Somnath Saha, M.D., of the Portland VA Medical Center, and colleagues, "analyzed data from a Web-based survey of 20,112 graduating medical students from 118 medical schools." The researchers "found that white students at medical schools with the highest quintile (one-fifth) for student body racial and ethnic diversity, measured by the proportion of underrepresented minority (URM) students, were 33 percent more likely to rate themselves as highly prepared to care for minority patients than white students at medical schools in the lowest diversity quintile -- 61.1 percent vs. 53.9 percent, respectively." Notably, "this association was strongest in schools in which there was positive interracial interaction."

The study also showed that "students from under-represented minorities were significantly more likely (at P<0.001) than either white or non-white/non-URM students to plan to work with the underserved, at 48.7 percent, versus 18.8 percent, versus 16.2 percent, respectively," MedPage Today (9/9, Smith) added. The authors of an accompanying editorial argued that these findings "might persuade medical schools to do more to encourage diversity." The St. Louis Post-Dispatch (9/10, Bernhard) also covers the story. This week's JAMA Report video features the study.

Monday, September 8, 2008

Sports Medicine Series

Dear all,

The Family Medicine Interest Group is presenting a year-long workshop series in Sports Medicine, featuring Dr. Alysia Green, a Sports Medicine doctor at BMC.

Dr. Green will be giving an Introduction to Sports Medicine talk on Wednesday, September 10th from 11:30-12:30 in room L-110. Lunch will be provided!

Each month, Dr. Green will be presenting on a different aspect of her practice as a Sports Medicine physician. Students will be able to learn about these exams and practice interactively on each other with assistance from Dr. Green. Workshops and seminars include:
-boarding
-joint exams
-taping
-concussions

If you are interested in going to any of the workshops this year, you MUST attend this Wednesday's talk! Each workshop will be open to sign-up on a first-come, first-serve basis after that.

Thursday, September 4, 2008

FM Scholars program

Dear FMIG members,

Marcel suggested I post here to be sure you all know about our Family Medicine Scholars program. You can learn about it at:

http://www.bu.edu/familymed/medstudenteducation/scholars.html

We currently have 4 active scholars, and more joining shortly. If you are interested in learning more about this program, which is unique to our department, please contact me. My email is: John.Wiecha@bmc.org


John Wiecha, MD, MPH

Director of eLearning / Director of Predoctoral Education
Department of Family Medicine, Boston U. School of Medicine
eLearning website: www.bu.edu/familymed/distance/index.htm
Second Life: http://slurl.com/secondlife/Teaching%209/21/132/23

Friday, August 22, 2008

Medical Tourism and Family Medicine

Perhaps you have heard about it from Robin Cook's latest medical thriller, "Foreign Body," or from Atul Gawande's description of the Shouldice Hernia Clinic in his book "Complications", or in news articles about Coretta Scott King's death at the Santa Monica Hospital in Rosarito, Mexico...medical tourism, the travel of patients (mostly from the USA) abroad for medical care, is on the lips and in the minds of hospital administrators, insurers, and health care professionals all over the United States of America. Two recent articles in the Economist, "Importing Competition" and "Operating Profit" (both from Aug. 14th, 2008), describe an unprecedented globalization of health care that will see 10 million people (mostly US citizens) traveling abroad for medical care, a total estimated market size of $21 billion.

So how will this new movement affect physicians and physicians-in-training domestically? The two MD's hosting the "MBA for MD's" seminar at theis year's AAFP national conference believe that, just as we have seen the outsourcing of medical transcription, record-keeping and radiological interpretation, we will see increased outsourcing of non-urgent surgeries. While these jobs will be in jeapordy in the US, they predict a surge in the need for primary health care providers to take care of these patients post-op. Perhaps the more efficient (and effective) private clinics outside of the US will, in their quest to provide the highest quality services, help to compensate primary health care practitioners at home. So, this is seemingly good news for the field of Familiy Medicine.

But what about the effects of medical tourism in the host countries? The Economist article author's predict a potential for a win/win situation. They claim that an increased demand for medical specialist services in host countries will force a reverse brain-drain, where former ex-patriot physicians will be able to return to their home countries to practice medicine. This could potentially increase funding for medical education institutions as well.

Indeed there are examples of successful Centers of Excellence abroad, including the Heart Institute of the Caribbean in Jamaica and the Arvind Eye Clinic in India. Both of these clinics use a "Robin Hood" mission to provide the highest quality specialty medical services to everybody that enters their doors (i.e. "Excellent care without exception"). Each of these clinics offer a sliding-scale payment structure, similar to many Community Health Centers in the US, to share the cost of relatively expensive services across their population; the higher-income patients pay for the lower-income patients. But do all of the international specialty service clinics share this philosophy? Is their mission to provide lower cost services to medical tourists and to the local population?

As stated in the articles, medical tourism is bringing the international competitors to the local health care market. The local hospital is in direct competition with the Bumrungrad hospital in Bangkok, which claims to be the world's largest private clinic. We are no longer able to view the fast-paced innovations in health care abroad as quaint or interesting, nor can we ignore the impacts of our domestic health problems on the exodus of our "medical refugees."

Let us know what you think about this new "flattening of the health care world."
  • Will the ex-patriot doctors now returning home still be mostly treating the wealthy who previously sought treatment in the US?
  • How will medical tourism affect our future job opportunities as physicians?
  • Will Primary Care see an increase in pay scale over the next 5-10 years?
  • Should FMIG host a talk/discussion to bring these issues to the table at BUSM?

Wednesday, August 20, 2008

FMIG Kickoff Event!

Tuesday's kickoff event for FMIG, "What is Family Medicine", had a great lineup of panelists who demonstrated the diversity of opportunities in practicing family medicine. Over 120 BUSM students came to hear what the panelists had to say, and to enjoy the free Thai food. (By the way, we are sorry for those of you who didn't get food -- we were expecting 80! We'll make sure you are well fed at our next event.) Dr. Brian Penti is currently a hospitalist in Family Medicine at BUMC. He spoke about his wealth of international experiences in Bolivia, Guatemala, Vietnam, and Cambodia and his current involvement in training programs for doctors in Vietnam. Dr. Alysia Green shared her stories of "sideline medicine" as a sports medicine family doctor and how her passion for sports had a major impact on her career choice. Dr. O'Brien shared her career path, which began in rural private practice and has led her to BUMC where she is involved in Labor and Delivery and pursuing her MPH in Maternal and Child Health. Dr. Shah discussed what life is like in a community based health center in Boston and gave advice to the students on how to key into their personal interests in a career path. Finally we got to hear from Kevin Kless, a fourth year at BUSM, who shared his own reasons for choosing family medicine. After hearing from first and second years after the panel, the event turned out to be an incredibly informative first glance at Family Medicine.

Tuesday, August 19, 2008

Pictures from "What is Family Medicine?" Panel

We just completed our first FMIG event: "What is Family Medicine?" Panel. We had five panelists come and speak.The Panelists represented a broad spectrum of family medicine. From left to right in the photo below:
  1. Dr. Brian Penti: Family Medicine with a focus on International Health
  2. Dr. Alysia Green: Family Medicine with a focus on Sports Medicine
  3. Dr. Michelle O'Brien: Family Medicine with a focus on Obstetrics. Currently completing a MPH in Maternal/Child Health.
  4. Dr. Madhavi Shah: Family Medicine practicing in a community health center
  5. Kevin Kless: 4th year medical student applying for family medicine residency
Photos of all the students who attended the lunch talk.

One of the student leaders, Marcel Tam, introducing the speakers.
Come back soon for a more complete executive summary of the panel.

Friday, August 15, 2008

"What is Family Medicine?" Panel

The Family Medicine Interest Group (FMIG) is presenting a "WHAT IS FAMILY MEDICINE?" speaker panel next week, Tuesday, August 19th, in room L-110 (first classroom on your right to the left of the security desk), from 1130am-1230pm.

Come listen and learn and ask questions about family medicine, and what doctors are doing with family medicine: sports med, international work, research, community vs. private practice. NO COMMITMENT needed to attend (we won't make you go into family medicine because you came to the talk)--come see if family medicine is something you would be interested in, or to come learn something new!

Food and drink will be provided so come by for our first lunch talk of the year!

Sunday, August 3, 2008

Reflections

Now that my sleep deprived self is back in Boston I wanted to share some final reflections:

Through this conference, the importance of family medicine became very apparent. From the opening talk on family medicine's contributions and roles to the different workshops that explain family medicine's approaches to the plethora of family medicine residency programs at the exhibit, the different structures that make up family medicine became apparent. And family medicine no longer seems like the "dead end" road that it has been touted as by so many. There are academic tracks, rural tracks, urban tracks, international opportunities, double board with preventive medicine tracks, residencies with dual MPHs or MBAs.

I entered into this conference not really with a directed purpose. I wasn't a fourth year medical student desperately trying to impress residency directors at the exhibits, I wasn't a delegate fighting for an elected position on AAFP (I wasn't, unlike Marcel, trying to blog every second of my time at the conference). But I came away with a better sense of the scope of family medicine and the impact it has on individuals and families' lives. Mentally, I revisited my med school applications and looked at my motivations for becoming a doctor throughout the conference - and I realized that family medicine and my motivations fit like an fitted enzyme-substrate complex.

Saturday, August 2, 2008

NC'08...We're all in this together

As the last couple of sessions draw to a close, the crowds are getting scarcer and scarcer. MS-4s have walked the exhibit hall floor in their sleep, chanting "Hi, I'm a 4th year student at____, and I'm interested in ______. Tell me about your program." Residents know the lines and have perfected their responses and the way they will integrate the variety of brochures, freebies, and posters into their sales pitch. The military recruiters are still in full dress. Conference organizers are taking down the now-outdated session posters. The last of the Monopoly-like food tickets are being used at the food stands. Yes, the the 2008 AAFP National Conference for Residents and Students is almost over.

People attended sessions ranged from "Reading a 12-Lead ECG" to "Financial Planning for Residents and Students." In doing so, as with most conferences, a sort of group culture was developed. With the conference theme being "Global Health," one of the major group perspectives was that the field of Family Medicine has the unique position to be a potential coordinator & bridge-maker for groups from different backgrounds that need to work together in the field...whether that is internationally or domestically, in rural or urban environments, or with people of all ages, genders, and ethnic backgrounds.

Given this movement of students/residents/faculty/practitioners, Boston University School of Medicine has a great potential to become a bastion for Family Medicine, and thus, the future of medical practice. We have strong international collaborations, a history of working with community clinics in Boston, an excellent School of Public Health only steps away, and integration into a hospital with progressive programs in health care that have national renown. Perhaps Boston University faculty, residents and students can be a major force at the 2009 AAFP National Conference.

Yes, the sessions were interesting, the variety of residency programs was impressive, and the featured speakers were inspiring. However, the most important and immediate result from this conference was the personal bonding that occurred between people interested in providing primary health care for other people. MS-4s discovered people and programs that they only dreamed existed. MS-2s connected with students, residents, and faculty members from their own schools and in sharing trials and experiences, emerged more unified and optimistic. This showed that there's a great potential for changing the world, and changing ourselves, if we choose to work together.

Friday, August 1, 2008

MBA for "MD-ummies"



The University of Missouri-Kansas City Family Practice Residency program offers a MBA that's integrated into their 3-year program. The residency director and one resident, both who have completed the MBA program, gave their version of the...
Top 10 Things a Medical Resident and Student Should Learn from an MBA.

#1 Change Management
#2 Marketing
#3 Leadership
#4 Economics
#5 HIPAA/EHR/Technology
#6 Outsourcing & Offshoring
#7 Quality
#8 Balance Sheet
#9 Advocacy
#10 When you don't know why something is the way it is...Money is the answer.

The skills that they talked about directly related to the practice of Family Medicine. They made a strong argument for understanding these concepts, if not for getting an MBA. It was stressed that the residents who got an MBA didn't do so to go into finance or insurance or some other higher-paying job, but to be more effective in their current positions as administrators, patient advocates, and physicians.

Given some of the ties between BUSM and the BU School of Management, it might be interesting for FMIG to host a workshop/lecture on the "Business of Family Medicine."

Workshop: Dental Emergencies and Procedures

Two months ago I would have wondered why a workshop on dental care was relevant to a medical conference. But having researched on the effects of dental problems for the past 7 weeks, I was delighted that such a workshop was included!

Why is dental care important to a family doctor?
  • dental problems is the most common childhood disease (40% prevalence)!
  • rural communities and minority groups often do not have access to dentists
  • dental pain can interfere with intellectual, social, emotional development and daily functions
  • even in places where there are dentists, family doctors often serve to screen for dental problems in check-ups
  • the teeth are a part of the body and affect the rest of the body holistically; it cannot be looked at in isolation from the rest of the body by dentists only
The speaker was from rural Maine where almost no one has access to dental care and he does dental screening, extractions, anesthesia and other basic dental procedures. He spoke about diagnosing different dental problems and discussed that antibiotics are over prescribed by most medical doctors for dental problems when they are not effective.

To learn more about oral health to treat your future patients: www.fmdrl.org or stfm.org/oralhealth.

Global Health Panel

This panel is talking about Global Health in general and the Family
Physician's role in health care internationally. They mention WONCA (http://www.globalfamilydoctor.com), an international organization or organizations of which the AAFP is a member.

Q&A:

A comment was made by a student from Alabama about the importance of recognizing underserved populations domestically that have very similar problems to those internationally.

(applause)

Q: What value does an "outside" health care professional offer to a population internationally?
A: The goal is not to bring US system abroad, but to listen to the community and provide necessary resources for the local population. This includes education and material support. The first step is listening.

Q: What is the Family Medicine community doing to be more known in the field of Global Health?
A: WONCA is part of the WHO and are trying to implement policy to promote FM. There is also a lack of individual promotion of work being done by Family docs internationally.

Some publication that were mentioned:
- "Health System Change: the contribution of Family Medicine" (WHO & WONCA)
- "Directory of Residencies with International Rotations" (AAFP)

Closing Remarks:
We have a responsibily to promote FM without paternalism & arrogance. We have a lot to learn about health care as a human right, about equity in a society, and about population medicine. So, at the end of the day, let's make sure that wherever we go, that place is better off for us having been there.

-----
Comments:
The Global Health movement is combining international health with health of underserved populations domestically, realizing that they have similar challenges. I can imagine that the next step in this logic is really redifining "health care" as a human right. That a human is a human is a human, no matter the geography. That the health of a population, as determined by system-wide structures, matters to the health of an individual. I see Family Medicine as uniquely poised to lead the way in this movement and that's why I am choosing this path!