IMPs 1 Listserve
PEARLS
ACCESS AND
EFFICIENCY
The answer
to "perfect care" is likely swayed by experiences beyond our
practices.
With small numbers, there is lumpiness between our practice, and that could
make some between-practice comparisons difficult.
The conversations we have about differences in approach will be very helpful as
we delve into our work, with reflection on what we do and the cards we are
dealt by our local insurance environment. Beyond insurance, some of that
irritation comes from waits and delays in specialty offices. For now we
watch our own data over time, making changes we expect will lead to improvement
in our own numbers (this makes the reasonable assumption of stable bias over
time).
Over time we might have the opportunity to shift our referrals to practices
more likely to serve our patients well. This is constrained by the
absolute supply of each specialty, but I hope over time that as we gather
weight in any particular market we can work collaboratively with our specialty colleagues
to create a more seamless experience for our patients.
Access and No Shows
I think the
diary is a good solution. Interviewing these folks later sounds cool and
I can see an article out of it (think of Family Practice Management). Look for
subtle signs that your practice is doing something that does get in the way of
"today's work today" but also allow for the fact that some folks out
there want things that just don't fit. I had one guy call me a number of times
over a couple of weeks, trying to work out an appointment for his
fiancee. Nothing I offered seemed to work, finally I asked "What is
going to work for her?" His response: “Anything after 9PM on a weeknight,
but not Friday.” My response:
”She's going to have to find some other practice, I just don't work like that.”
If you are coming from a place where you truly believe and live the idea that
service to your patients is paramount, you have a reasonable starting point for
a conversation around requests that truly don't fit your practice. If the practice doesn't have an orientation
of true service, a lot of patient behavior may appear outrageous, but the root
of the outrage may be our problem and not the patients.
Regarding same day no show: Your choice on how high you set the bar. Once
you've eliminated access delays, see patients on time, offer superb continuity,
I think you have the right to set a reasonable standard. Standard setting
has some rules:
1: Make the rules reasonable.
2: Make the rules transparent.
3: Stick to them, but make reasonable allowances.
I'm not a big fan of signs in the waiting room "COPAY OR NO
VISIT" or "NO-SHOW RESULTS IN $25 CHARGE." I feel that
those signs make everyone feel punished. Rather, have a private conversation.
First offense: "I see you've missed an appointment This messed
up what we could do for others, so next time please give us X notice."
Second offense: "I see you've missed again and didn't notify.
Next time, consequence X"
Third offense: your call.
Another option:
Some folks you may not wish to discharge, yet they have a pattern of
no-show.
You can minimize the negative effects on the practice by booking them towards
the end of a patient session and double booking.
If they no show: you have the time booked with productive activity
If they show: roll out the red carpet, praise them, see them first.
Why?
They behaved as you wanted them to: they showed up on time. If you give
them any negative stuff based on prior behavior, they feel punished for showing
up and it degrades the relationship.
One
advantage we have over other practices is data. Take a look at your data
on access. I'd guess that you're doing better than average.
Judy and I get into the negotiation on available slots within narrow windows of
opportunity as well. The degree to which a practice can convince folks to
come in "today" and get the work done drives future
availability. Some folks just don't want "today," others might
be swayed.
A few
things come to my mind as to why my score was higher. I do today's work today.
When setting up my office, I put a lot of thought into efficiency. The things I
need are stored where I use them. I usually know what a patient is scheduled to
see me for, so I usually have everything ready ahead of time. If I know I'm
going to need a urine, I get a quick history before sending them to the BR so
that I can start the note while they are getting the specimen. The same for
strep screen, I get that started before I finish the exam. I know some
patient's always need more time, so I schedule them more time, so as
to not hold up the next patient in line. I explain to each patient that I
want them to get their labs done at least a week prior to their visit.
That way I have it in hand to discuss with them. I think there is a
bias on the part of my patient's also. The office I came from was run by
another physician and his wife. One of the major reasons I moved on was their
lack of efficiency. Most of my patients experienced that office prior to my
current arrangement. It's like night and day. I had a graduate student come
observe my office. She was doing research on physician's use of time. She was
impressed with the thought that went into each task I do, and how I set things
up to be at hand.For example, I have all of my pelvic/pap supplies on a cart
that is kept in the utility room, I don't have to go all over collecting
everything I need, I just bring in the cart. She also pointed out
that my memory of each patient saved me from needing to look things up. I have
designated times that I will see sales reps, so they never bog me down, and I
don't have to give them the bum's rush (unless I want to). Throughout the day,
whenever their is a few minutes between patient's I am checking labs and faxes.
Whatever needs done with these, gets done right then.If it is a
normal result, the patient gets called, or the post card is prepared
right when I get the result. If it a prescription
request, I decide then if it gets renewed, or not, and fax it
back. I found that me calling a patient to schedule an appointment
to discuss their abnormal test result was a waste of time. They
expected me to discuss it right then. Having my daughter call the patient
to schedule an appointment works better. I am trying
to provide prescriptions with enough refills until the patient is
scheduled again. That way, when a patient calls for a refill on a routine med,
that triggers that a visit gets scheduled for the patient, rather than calling
in a script. I'm pretty sure all of you are doing the same types of
things, it's just the contrast from the other office that made my patients
score me higher.Vanessa
Vanessa
perfectly sums up the concept of efficiency. Lots has been written about
this in non medical settings. It comes down to doing "this minute's
work this minute." I try to work very much in the way of
Vanessa. If you pick up a piece of work (or bring it up on the computer)
find out what it takes to bring the task to completion at that very
moment. Don't try to do this for all things at first - pick one piece of
work (normal labs, making referrals) and see what you can do to make it
so simple that the temptation to sort it into piles for later is
extinguished. Sorting is waste.
Gordon
Not
sure why I scored high in efficiency (or low in continuity – I’m the only
provider here, same day access, 24/7 home/cell phone access, email, etc).
I have an MA that answers the office phone (I grab it if she’s busy and I’m
not, and I’ll speak w/ a pt at their request if I’m available), we accept fax
and email messages as well. Have EMR, appts run on time, have lengthy
appts (usually an hour for chronic dz). Perhaps one reason for the
perceived efficiency is because people immediately start their appt with the MA
when they walk through the door, and don’t have to wait around. We
usually get labs, reports, calls/messages answered same day, and often my MA
can get the answer for the pt when they call because of the EMR access. Another
angle could be about half of my patients saw me in my former employment
situation – VERY inefficient.
Ditto all of the other replies - I have everything at hand
for that task, and so while people are talking I fill out and hand them the lab
slip, print out the prescriptions on my printer there, have supplies all in my
exam room to hand.
There's also open access scheduling, most rx's come by fax,
so I sign and refax them between patients.
I think alot of this is due to how grossly wasteful most
practices are of patient's time. It's easy for us to look better.
So here’s my perspective. I have worked with the same nurse since 1999 (4 years at a large paper chart fast-paced clinic and 3 years here). Before me, she had years of clinical experience both as a nurse and as a manager/director. To put it simply, she is very good. She and I work very similarly and after all this time, so she knows exactly how much time I will spend with a particular patient (or type of patient) and will arrange the schedule appropriately. I have a clock on my desk facing me (patients don’t see it) and I begin to get nervous if I am beyond 5 minutes into the next appointment. I figured out long ago how to fit the appointment into the appointed slot so if I have 30 minutes, I take 30 minutes, if I have 15, I cut out a lot of social history and issues regarding that and cut to why are you here today (which I don’t like as much). If my nurse fits a patient in, I always know in advance so I can adjust the time I am spending with a patient. I also have my window facing the parking lot so I know when the next patient is arriving and a set of chimes on the front door which ring when they enter the building. When I hear the chimes, I know it’s time to hand off the patient to my nurse for copay collection and arranging of follow-up or labs or whatever. Between all those measures, I generally am within 5 minutes of an appointed time. So summary of office efficiency in my mind:
Open Access Scheduling but having the expertise to fit patients into the right time slot
Always know what the latest schedule is
Always know what time it is (and how much time you have left)
Arrange the appointment visit so that it fits the schedule (do just today’s issue or go over everything)
Know exactly when the
next patient enters the office
I did find that it took about 2 years to get my process
smoothed out. And it takes constant refinements to adjust it to be thoughtful,
yet efficient. I would have trouble quantifying the process to pass on, because
it's so idiosyncratic and individual. I think that is one of the things the IMP
project is trying to do, though.
Have you considered a little bit of staffing to help?
I do find that some paid help makes my life doable and
does not cost enough to put me behind: I have a guy who works about 8
hours/week doing the following: billing, eobs, collections, renames and
files all my incoming faxes and labs electronically, scans in everything and
files it and prints out all medical record requests that are not urgent (like
life insurance). I know that finding the energy to hire someone like that takes
extra work and it's hard to find the energy to do it when you're behind. He's
going to business school and is appropriately compulsive. I found him with an
ad in the local paper.
I do make myself sit down and add up my hours, every once in
a while, though it's always terrifying. I do find that as huge as I think the
number is going to be, it's never as bad as the hours I spent in the old
community practice, seeing way too many patients and charting all evening. As
"efficient" as I am, I still put in time either sunday or monday
morning, when I don't see patients, catching up on charts or lab letters, etc.
Also, I'm finding my self spending more and more time on the phone, dealing
with other practice's inefficiencies - calling specialists to remind them that
they were going to see my patients this week or arrange a test for my patients,
calling ten times to every specialist and state epidemiologist to find someone
who can get on the phone with me to discuss a case of cryptosporidia gone amok.
I made 6 phone calls last week to find out that one of the disintegrating
health plans in this town doesn't even offer home nursing visits to follow
underweight newborns anymore! These poor parents were faced with dragging their
twins into my office from the next town over, so I just loaned them my baby
scale on Friday morning, to be returned Monday afternoon. I got very frustrated
this week thinking about how many hours I just spent this week propping up
other people screwed-up practices to keep my patients safe and make sure
they're getting the services they should get.
For the moment I'll label them
patient efficiency and non-patient efficiency.
Patient efficiency is very well measured from the perspective of the
patient. "Does the office waste your time?" is the ultimate
question and proof of efficiency. We know from at least one study that
perceived inefficiency is a barrier to access (see attached) and is therefore
linked to degraded outcomes.
Non-patient efficiency leads to potential failure mode due to work overload or
high overhead.
Both are critically important to IMPs.
How can we better understand non-patient efficiency?
I suspect the answer is - like most - multi faceted.
Once aspect is the work style of the individual. Batch and queue is less
efficient than continuous flow. Work time spent in batching and unbatching
is waste: (for instance, a call comes in for a referral:
you take a message
you put the message in a stack (electronic or physical)
Later, you come back to the stack and sort - do it now? do it
later? sort by insurer?
You do the work
Continuous flow mode:
Call comes in for a referral
You do the work
While part of continuous flow is work style, it is facilitated by good tools.
I suspect a big difference in our offices is the degree to which our tools
support work flow.
I can make a referral while on the phone with a patient because:
I have an integrated electronic medical record/practice management software
I have a headset for the phone so that I can use my hands while on the phone
I can call up a referral form in about 30 seconds and send in another 30
The work is documented in the chart so that there is an electronic trail
Continuous flow is impossible 100% of the time: I cannot be instantly available
on the phone for every referral request, prescription refill, nor am I at the
point where I finish every note in front of every patient (I would like to be,
though...).
Non-patient efficiency
Take a look at the steps in a process in your office
Write them out.
I'm going to send another post with a presentation on office efficiency that
describes some simple approaches to finding waste and inefficiency.
Are you doing everything yourself or do you have a
receptionist/nurse that helps out during the day? If you have someone else, I
would consider what processes might be able to be delegated. Have a conference
and discuss the process problems and see what suggestions arise. If you are
solo-solo, consider calling around to local tech schools and see if they have
med tech students or med receptionist students you could “teach” for free. You
get a warm body who can help you push the paperwork
through, and they get to see the cutting edge of medicine.
The simple things that Gordon pointed out also save a bundle of time. I always finish my note while the patient is in the room. (Yes, this can distract from the perception that I am listening, but when the patients see the completed note, most are happy). I discovered in residency that doing notes later always takes twice as long. Another issue might be with the billing. How do you do it? With the emr I have, when I sign off of my note, I have already coded the visit. Building invoices and sending them off electronically literally takes 5-10 minutes at the end of the day. Yes, putting in the EOBs when you get them back takes a lot of time, but if this is falling by the wayside, I wonder if you could pay someone to do this rather simple task. Finally, although most all of us are solo in our individual practices, I hope you don’t feel entirely alone. I know the practiceimprovement1 and impscohort1 groups have helped me keep my sanity even in the dark times. My hope is that maybe by suffering a little ourselves, perhaps we can figure out a better way of doing this and keep docs in the future from having to go through some of the difficulties we face. (I realize that is a little Calvanistic, but its easier to stomach than temporary insanity). In any case, good luck in finding your balance.
Regarding patients “chatting me up,” I found the less I answer the phone during the day the better. My voice mail picks up and my website has a big “SCHEDULE AN APPOINTMENT” button in the middle of it. I do have my CELL and HOME phone numbers on the voice mail. Patients use those VERY APPROPRIATELY and I talk to them quickly when it’s urgent but the voice mail cuts down on the random chatty oh by the way conversations. And I check my office voice mail many times during the day so I can respond quickly when appropriate.
I just have a paper list of consultants and fax numbers and I just fax a letter with note directly from Amazing charts. I don’t bother entering consultant’s info anywhere else.
I definitely finish all notes with patients in the room- even if it delays patient departure, it allows me to remember every last item I wanted to cover with them. Also, I do templates with patients in the room sometimes. This takes only seconds longer than writing the note.
Posting EOBs still takes me awhile.
I usually run through old records, pull out items I want to scan and give pt the rest or shred it. I don’t read everything unless the patient’s there because I won’t remember it at their next visit anyway. If you review old records during visit, I think you can note it and charge more accordingly. I don’t know how exactly.
I also have prolonged
catch up times-mainly before and after vacations but I find that more enjoyable
than dealing with staff.
Here's a
list of what seems to take a lot of time:
1) patients that call that just want to chat me up, it's usually never
wham-bam-thank you sam... they don't want to make an appointment, they just
want to ask me if I Think they need an appointment for a variable length list
of symptoms ; this is where it is so useful to have an MA or other person
running interference for you, though it does cut down on 'access'.
2) putting in new consultants addresses and fax numbers into my fax and EMR
databases- unfortunately they don't synch, so for a new consultant, it adds an
extra 5 minutes onto generating a referral; the following referrals are much
quicker. Gordon- does it really take you 30 seconds to whip out a
referral? - I have to amend the referral template, pull out selected lab,
studies and notes and print them all to paperport and then send them. Takes me
at least 3 minutes, more if there are lots of studies to add. How do you do it
quicker? - maybe it's an example of differing hardware/software capabilities.
3) posting EOBs- but going to electronic billing via clearinghouse as soon as I
can get around to arranging it (may take a few weeks to a month)- I did hire a
billing person a few weeks ago to handle the denials, because I am one of those
people who abhors dealing with the billing...
4) summarizing and reading through and then scanning (as needed) old records of
new patients- my heart skips a few beats thinking about this one- what do you
guys do with the giant stacks of old records that are just waiting to capture
the weekends? For this reason alone, I can't wait to stop taking
new patients.
5) adding new processes- such as starting electronic billing, setting up
Instant Medical History, moving the office next month... it just goes
on...maybe leading to less work down the road, but too much work in the
forseeable future.
6) documenting notes- I'm trying to add new templates weekly for one diagnosis
so I can finish my notes IN THE ROOM... I'm definitely not giving up on this
one..
At 18 months, I think I'm just not at maximal efficiency now but it is just is
going to take some time to get there and I don't see a short cut... However, I
am enormously heartened by the support and expertise in this group and if
anyone will be able to coach me to better back office efficiency , it will be
you guys.
TECHNOLOGY
On the
average, 65% of patients in family medicine practices use the internet (use
does vary by age, sex, income and more). Bottom line - with some variation -
most patients do have access, each year that number increases.
HYH
I had a staff meeting today to discuss the implementation of the study design into our practice and here’s what I suggested:
1) When patient calls for an appointment, set up appointment and encourage HYH
2) When patient arrives, give them care vital sign sheet and sheet (intraoffice development) to update Ack of Privacy Practices, demographics and insurance (this sheet goes back to receptionist to scan into chart)
3) When in with doctor, go through results of HYH (if done), and care vital signs and for chronic issues, develop action plan and sign consent for telephone f/u
4) Scan in the action form and consent form into the patient’s chart, fax a copy to the telephone nurse, and give the originals to the patient
5) Mark the chart as a study patient
6) Independently, send a letter to each patient household with an attached copy of the newsletter describing what we are doing and offering a free pedometer to the first 50 people (limit one per family) who do the HYH survey.
7) Separate out the Action Plan results from HYH to those who are high functioning (simply scan into chart) from those who are not (set up appointment for follow-up and follow steps above)
8) Make labels for the backs of our business cards that have the website and the access code for HYH on it
We talked about doing a small
scale approach with just our least compliant patients, but I figured it is more
practical to simply take the leap and initiate all aspects at once for all
patients. What this means is that although I have been relatively dormant over
the past month, the number of patients doing the HYH survey and getting
follow-up should go up rather rapidly once we begin full scale implementation.
HYH Medical Harm
The question on HYH casts a net
wider than just you, so don't be overly alarmed. Like any other response,
it is a conversation starter. I get into it with folks by holding up the
paper or bringing up the screen, thanking them for doing it, pointing out that
it identifies broad themes that we could discuss if they like, then point out
the items they identified, asking if they have anything they would like to
discuss.
The sad truth is that we only have to ask one or two people before we find
someone who has a close relative or have personally experienced medical
harm. When folks open up about their stories behind "possible
medical harm" you'll hear some pretty rough stuff.
The silver lining is that much of the bad stuff can be appropriately attributed
to systems flaws, and you guys are part of the vanguard working on the system
flaws.
medical harms:
please recall the question that lead to harms report: in the past year the
patient personally has experienced an event that might have injured or badly
worried them.(the next version of HYH will give you the verbatim)
there is an article being revised for JAMA from HYH (fingers crossed--it made
it through the first review ) hat points out:
1. on a spectrum from nuisance to ijury, when patient tell us about harms about
1 in 10 are "bad" enough for lawyers to take note.
2. most of the harms are related to poor communication but most of the serious
harms are treatment or diagnosistic related
3. many of the harms will have occured in he hospital.
4. the harms reported are proportional to the patient's burden of illness
5. the risk for harm is greatly reduced by great access, efficiency,
communication and patient confidence with self management.
gordon is right. all you have to do is ask what that was about. it is an issue
that you don't want to "fester" and it is usually a great chance to
learn about how o make health care better.
OVERHEAD
The cause
of this is multifactorial. I was in a "traditional" model with shared
space and staff with another PCP. When I made the leap to solo/solo, I wasn't
sure it was "for real", so I had the space built out for a
traditional practice. I have 1800 square feet that I don't share with anyone. I
have waiting room, two exam rooms,restroom, lab/utility, kitchen, and a
clerical area. I chose to stay in the area I had been in, to retain my existing
patients and because it is less than 2 miles from my home. I'm in a fairly
affluent suburb (translate, high rent). Part of the lease is in the build out. The
space is done extremely well. The build out interest was fairly low. My rent
will go down to 2200 in a year. With having the extra space, I have the option
of adding another provider. I am doing well enough that I don't feel that I
have to do this so far. I also had a terrible experience with the doctor I
previously was with, which makes me reluctant to add anyone. I am envious of
all of you with lower rents, but I wouldn't change any of the decisions I made.
It looks like a lot of people have done a fantastic job of keeping their overall costs down, but just don’t have the patient population yet to balance the numbers. I would venture to guess, the average cost/patient/month would change dramatically if we were looking at only mature IMP practices (like mine). I know in my practice, the general overhead was the same when I had 500 patients as it is now at 1500, but my cost/patient/month has been sliced dramatically. Should we try to add another column asking “predicted patient panel” and then calculate that number as well?
This also feeds back to a more basic
question of how large can an IMP practice go and still retain the IMP
philosophy. Because I like working with a nurse in my neighborhood (where I
renovated a house), my expenses are greater than someone who is solo-solo in a
rented room. Therefore I need to see more patients a day to cover these
expenses and therefore need a larger patient panel to “justify” the expenses. I
hope my quality indicators don’t end up being lower than others because of the
size of the patient panel, but perhaps this study might actually answer the
question of “at what size does quality begin to suffer?”
Many of these practices have not realized yet their
financial potential.
I think the key to my low costs/patient is twofold: I am
operating at close to my maximum capacity for my current design And - most
importantly, many of my costs are shared with two other people.
My building, fax machine, 4 telephone lines, front desk and
biller are all shared by a 3 person group. (The others are a family therapist
and a myosfascial therapist.) I think this type of arrangement is quite common
amongst therapists, who are used to seeing 30 patients a week instead of 150.
While this arrangement has been limiting, the limits are
often good, not bad, as they keep expenses way down. I have the luxury of
having my phone answered five days/week, while paying for only a portion of
that cost.
I do feel that a patient census of about 1000-1200 is
probably the most I can sustain. Patients are all like little icebergs and the
visit is only the visible portion of the work involved.
I think I have the highest overhead of just about anyone.
Probably attributable to high rent- I do have 1000 square feet in the high rent
district, but use just about 1/2 of that space (this was all that was
available at the time I needed to start up), and high medical insurance. Also
my practice numbers have not matured yet, I think I submitted a number of 430
patients but am growing the practice fairly rapidly (now have 100 more) and
plan to end up at about ?800-900. Does doubling my patient base
halve my cost per patient year? if so, I would be more in line with the lower
overhead practices, though I'm not exactly clear on the calculation that's
used.
Also, I am moving to a smaller 600 square foot space when my 2 year lease is up
in August- will cut my rent/utilities by about $700/month to $1066/month - yay!
and am working on an HRA/HSA combo to decrease my health insurance costs....
so.... I am hoping to significantly decrease my
ovehead soon...
PLANNED
CARE/PROBLEM-SOLVING
Not all
patient needs are identical. We can stratify patients in to three categories of
need. Our work is to put in place the resources necessary for each patient
cohort. Take a look at each category and assess what you have and what you will
need to put in place.
Minimal needs patients They are confident in their ability to manage their
condition(s). They have the information
they need to make good decisions (hot links to medlineplus.gov,
familydoctor.org, howsyourhealth.org)
They have unfettered access to you and your practice (open access
appointments, 24/7 coverage by you except when you have your backup covering
you).
Moderate needs patients
This cohort generally does have confidence, but slips at times and wants/needs
more
Generally has OK information, but wants/needs more
All of the above plus:
Group visits
On line group/chat in a moderated environment
Reminders via email/letter to follow through on recommendations
High needs patients
This cohort lacks confidence in their ability to manage their
conditions and lacks good information to manage
These patients need care management
Care management:
At the end of the visit you negotiate a plan with the patient. What are THEY
striving to accomplish? How can we assist? We advise based on our knowledge but
do not insist as it them becomes an empty
manifesto (lots of literature on this). We arrange follow up. Part of the
follow up is: "I'd like have you
give Judy a call next week/month to let us know how you're doing with you X.
Would that be OK? Would you prefer to come in, send an email, fax, have us call
you?"
RE: [Impscohort1]
Telephone Coaching
One re-frame to think about:
Wasson's publishing studies showing that 3 telephone problem solving calls lead
to long term improvement in patients with pain or depression.
One way to set this up with patients is to frame it like this: "I'm
working with a problem solving coach named Cathy Reda-Cheplowitz. She
could contact you a few times to help you work on your plan, would that be
helpful?"
One of the things we're exploring is the staffing burden of doing this work,
and if we can get lots of great results with a few phone interventions, we can
offer the service to more patients.
Patient self-help
tools
Even though I've known it all along, I've recently
rediscovered the self help parts of the HYH site. On the lower part of the home
page are links to Problem Solving - this is huge. I tell patients:
"the hardest thing about improving health for some is not the things we
OUGHT to be doing, but HOW to do them consistently." Patients have
responded very well to this. The Problem Solving site is aimed directly
at assisting in this work.
I tell people "Everyone has problems. Make sure you use this
resource to help you move closer to where you really want to be."
The link at the bottom:
I make the point that I find the sites reliable - this addresses the concern
that the web has a lot of junk, but that I recommend this approach.
These tools should assist my patients in self care, minimizing the impact on
me, maximizing the outcomes. HYH data will show if it works (has for
others, so I'm confident it is the right thing to do).
Collaborative approach
vs. paternalistic approach
Another take on the paternalistic approach:
Let's say you're having a wonderfully collaborative conversation and the person
comes back with "Doc, just tell me what to do." I'd be inclined
to say, "OK, I'm happy to go that rout and see how well it works.
You've said that you want to be more healthy with your diabetes. I recommend you A: Take your NPH insulin like so.... B: Test your blood like so...."
etc. We then set follow up and see how
it goes.
The "Doc just tell me what to do" then becomes a testable
hypothesis. If it works, great. If not, you have more information
to bring to the next conversation.
Self-Efficacy
Many of you may have already read the attached article on
patient self-management of chronic disease in primary care. It is a great
resource addressing collaborative care and self-management education.
There is some comparison of traditional and collaborative care, and comparison
of traditional and self-management education. Points to ponder from the
article:
Self efficacy = confidence to carry out a behavior necessary to reach a desired
goal.
"Self-efficacy is enhanced when patients succeed in solving patient -
identified problems."
"Self -efficacy theory holds that the successful achievement of the action
plan is more important than the plan itself." (Purpose of the plan is to
give the patients confidence in managing their disease.)
You may also find the ihi.org website helpful for this and other topics related
to the work of IMPs.
Coach Follow-up
with the nurse follow-up, I find the patients I feel need
the most help with problem solving skills are my poor/Medicaid patients. With
that said, they are also the ones with the least access to the internet. I am
having a hard time solving this problem. For example, I have a patient who is
just floundering and really could use simple problem solving stuff. With that
said, an action plan is not really helpful for her as she would need numerous
plans for the numerous things going on. She has no computer and no money. Is it
ok for me to consent for nurse management for her.
After all, her ailments are multiple and yet related psychosocially. Is this
someone who would benefit from the nurse manager.
Note: when I mentioned it to her she was very excited.
Problem-solving
A basic approach we're suggesting
throughout is to start with the easiest work and ramp up over time depending on
your capacity/interest/needs of your patients.
So, a typical conundrum: "I have a significant sub-population of patients
with very high needs and feel like I'm not even scratching the surface with
some of these tools." Our suggestion: Keep doing what you're doing for the
really tough patients while you develop a new, easy, and reliable process that
takes advantage of the new technology. Gradually make the new process a core
component of
your work flow (reliability) while you see how far you can push its use.
We'll keep adding components to deal with the increasingly complex patients,
but as you can tell we're working from the bottom of the pyramid, i.e. building
the practice from the foundation up.
Model healthy behavior for your patients
I've found that the most effective way to promote healthy behavior in my
patients is to model it myself. I sold my vehicle and now bike everywhere, even
to the hospital to do my rounds. Quite unexpectedly, I've discovered that my
example has instilled a desire for improved health in my patients. I give small
gifts as incentives to patients who bike, walk, in-line skate, etc., to their
office visits. I also display unusual vegetables, such as watermelon radishes
or golden beets, on my desk. When patients ask about them, I offer them a bite
and a prescription that they can take to the grocery store.
Enhancing self management
What Judy and I do to enhance pt
self-management (Judy, chime in if I miss anything):
Focusing our efforts on those who lack self-confidence on HYH, we do the
following:
After visit summaries:
For those with several issues or a complex plan, I type the "discussion"
part of the note real-time with the pt in the room and print it out. This
forces me to use the same language I'm using verbally with the pt. I try
to type things in very simple terms. Here is an example for a pt with a
short-term memory problem:
Discussion:
Left toe pain
Due to the constant banging on the front of her shoe
Her AFO did not help, the insoles that she has for tendinitis did not help.
Ice is a good idea.
I think you should go to Mike Giordano - Podiatrist, to see what he can do to help
protect your toe from your shoes. 271-2050
Left thumb dermatitis
She needs to use a stronger steroid ointment.
Use betamethasone valearate ointment
Put a thin layer on the sore part of your thumb once a day for a week. Keep
this ointment off the rest of you because it is too strong, especially for face
or mucous membranes: if used too long or on very sensitive skin it can cause
permanent skin thinning (think old lady skin).
You can use this one week per month. In between OK to use Cortaid or
other over the counter steroid cream.
For the rash on your face:
Tom McMeekin MD is a dermatologist: call 424-6770 after you get the referral
number from Blue Choice member services. Call member services on Thursday
and they will give you the referral number on the phone.
For your embryonic umbilical hernia: Call Dr. Joe Johnson's office:
341-8485 to arrange consultation.
Judy and I work very hard to ask pts what they want to work on, what they want
to do.
I frequently print out handouts from familydoctor.org for specific conditions.
We have a group visit attended by some. Judy does a lot of phone
follow-up as part of our reminder protocol as well as outreach based on
collaborative care plans. I don't know which of these things has the greatest
impact.
On our last call, some suggested it
would be great to have a handout for patients to help them think through
problem solving, to get down to that honed and focues approach that appears to
be working well for Lynn Ho and some others.
I elected to take on the task of cooking up such a handout. I've made
several attempts and find that:
1: it starts to look like the consent form all over again
and that's not what we need.
We need something that helps walk a patient through the through process of
problem solving:
What is problem solving?
How can I start?
What does it look like (give me an example)?
What might I get for the effort?
Our goal is to create a handout or other simple process that reduces the work
burden for us.
If only we could hand folks something prior to their visit (if we know in
advance) or at the visit for consideration at home ('cause I don't have the
scheduled time to do the whole thing today and don't want to rush the pt
through this as I may lead them inappropriately).
While reading up on this and going to the HYH site to make sure what I was
writing is consistent, of course I came across the attached document.
Once again, I find I'm walking in Wasson's footprints.
The path looks strait and clear.
How about this:
I'm going to try handing this out to patient in the exam room (quick print) if
it comes up in a visit, and Judy and I are going to try coaching folks to
download from HYH in advance of a visit where we believe the issue will
arise.
The link is as follows:
Go to HYH
Click on "problem solving and planning your care"
In the sentence: " If you want more information about problem solving, click here"
- click on the "click here" and it will bring down the pdf.
CROSS-CUTTING
Past Due Accounts:
Not too keen on sending people to collections or fighting with them to pay. I generally send them 3 statements. If they do not pay, I zero the account (with the made up adjustment of BAD for bad debt) so I can have a better understanding of where my accounts receivable really is. I then put a note in the chart that pops up stating “patient owes money” and inactivate the chart. That way, if the patient calls for an appointment, my nurse will have to activate the chart, showing the message, and then allowing us to address the balance due prior to scheduling the appointment (and perpetuating the problem). Yes, that means I lose some money and yes it ends up being a rather laborious process, but it keeps me and my patients on pretty good terms. Note: I just started this process last month and initially wrote off about $8000 in bad debt (between insurance companies and patients). Not bad considering that represents 3 years of accumulation and thus around $850,000 in total billing. When I look at that ratio, the $8000 doesn’t look so bad (particularly compared to what I would have paid someone else to do the billing for me).
Re: [Impscohort1] Database driven workload
My ultimate goal is to demonstrate practices capable of
delivering superb care in a vital and sustainable practice - I want the whole
kahuna, just like you.
Vital and sustainable practice is made up of: Joyful (staff satisfaction) Finances
You're absolutely right that we have to show success on all fronts to
demonstrate the model, and I'm committed to doing so.
Developing processes for finding patients previously lost to follow up is
terrific work and we're going to explore that as part of our later work on
population care. That you've already devised systems to find missing
patients is terrific and I would love if you'd sketch it out in a paragraph to
give the rest of the cohort the chance of doing the same.
Since we're trying to demonstrate a new model of care that not only creates a
vital and sustainable practice, but delivers superb clinical outcomes, we also
have the opportunity to show that superbly delivered primary care results in a
net reduction in total healthcare expenses. This goal is difficult for us
to prove in this study, but is part of other work that I and others are
doing. We can touch on this issue from patient self report of missed days
from school/work, ED visits, and hospital bed days. Patient self report
on these questions is highly reliable and has a well established link to employer
expense and health costs.
Part of our new model of care is the recognition that we have an obligation to
avoid underuse, misuse, and overuse of health care resources (see
We have to avoid even the perception that we're falling into the all-too-common
trap of driving office visits purely to make ends meet. This behavior is
unfortunately very common in practice. It is NOT what John Brady is doing
when he culls his database to find patients suffering from underuse of needed
health care resources he can deliver. Because the make-ends-meet behavior
is so common, we're prone to being tarred with that brush unless we very
carefully describe what we do and how we do it. Lots of folks out there
expect the worst, believing that doctors are greedy, and some colleagues are
deeply challenged by our approach (I've heard truly frightening myths about
what makes our model work).
I know that this is a very long-winded response, but these are big issues we
face.
So now to another point: Does database culling create work? Yes. As
we explore what we can do to reach out to those with need, we will describe
process as well as how to manage the work load. This applies to testing
ideas like group visits, email with patients, phone calls, etc.
John Wasson's point: when we look for predictors of return office visit,
the greatest predictor is the habit of the doc. Illness burden and
patient preference don't even make it on to the radar. This is the evidence
behind the cynical assumption that doctors are driving office visits to make
ends meet.
Revisit Interval/Group
Visit
The best summary review of this subject was by my colleagues. Schwartz LM,
Woloshin S, Wasson JH, et.al. Setting the Revisit Interval in Primary Care JGIM
1999;14:
230-236. Bottom line, revisit is 70% dependent on doctor.
Group Visit: In one California-based
practice, physicians are structuring group visits as group individual
appointments and are billing 99213 to insurers. They have the following
documentation to support this practice: 1) Problem-focused history 2)
Problem-focused exam 3) Straightforward medical decision-making.
One of our fellows has just completed a medical review of group visits. Lots of
unkowns still and the implementation is sometimes difficult with often only
about 40% of invitees getting involved. In general, they do seem have a
positive impact on the patients.
We completed the following controlled trial (not yet published). DIGMAs
(Drop-In Group Medical Appointments) are group medical appointments that allow
patients to interact with their physician/nurse team and receive education
regarding their medical condition and self-management strategies in the context
of a support group of patients who are coping with similar issues. Patients
like this approach because they: 1) have greater access to their health care
team; 2) like the educational component; 3)
appreciate the opportunity to ask questions and hear the answers to other
patients' questions;
and 4) benefit from the supportive atmosphere and meeting other people coping
with similar problems. The physician / nurse team like the DIGMA model because:
1) they are able to provide general education in a effective, efficient manner;
2) both medical and psychosocial issues can be addressed; 3) patient
satisfaction is higher. The DIGMA approach appears to work particularly well
for patients who have psychosocial problems and high need for emotional
support, a common situation in primary care patients
with pain.
Patients with pain identified in primary care physician panels were offered an
intervention that included the Dartmouth COOP Clinical Improvement System
(DCCIS) (a paper version of HowsYourHealth) plus DIGMAs. The DCCIS, emphasizes
rapid problem identification, feedback to patients and practitioners, and
tailored educational materials for patients. For this proposal, a scanable
version, paper version of the How's Your Health Questionnaire was used, but a
web version is currently available at howsyourhealth.org. The DIGMAs were
structured to include a welcome / social period, a question and answer session,
an interactive educational session, and an opportunity for one-on-one physician
appointments with a focus on a brief review of patients' medical treatment plan.
The educational sessions were a series of three repeating seminars that focused
on: 1) basic education regarding pain management and self-management
strategies; 2) a problem-solving approach for coping with psychosocial problems
secondary to chronic pain; and 3) appropriate exercise / activity pacing.
Seven practices were recruited to participate in the study.
• One family practice clinician from Saco River Medical Group,
• Two family practice clinicians from
• Two clinicians from the Maine-Dartmouth Family Practice Residency Augusta,
ME.
• One clinician from the Fairfield Medical Group, Fairfield, ME
• One clinician has been recruited from the Dartmouth-Hitchcock Community
Health Center, Lebanon, NH
• One clinician from Community Health Center, Lebanon, NH
• Two clinicians from private practices in Littleton, NH
76% of patients invited to attend the group medical appointments actually
attended at least one. After each group medical visit, patients were asked to
provide feedback regarding the appointment. All responses were positive. The
providers were universally positive about the group medical appointments, despite
some skepticism prior to implementation. Outcomes were evaluated with patient
and provider feedback and standardized outcome measures, the SF-36 and the
Functional Pain Estimate (FIE).
Patients randomized to the intervention showed significant improvement on the
FIE (p < 0.001) at
the 3 month evaluation.
Weight Loss.
80% of the users of "Problem-solving" on HowsYourHealth.org use it
for exercise and weight loss. There is also a BLOG about this on HowsYourHealth
that patients can do and as the IMPS grow we might use these tools across all
sites so that the patients have group support and communication while they
attend to their individual circumstances too.
HowsYourHealth
I will launch your sites tomorrow and hopefully Docsite will be ready soon.
How's Your Health (the book).
Yes, social class is a major determinant of longevity and quality of life
though a recent study said that if you "adjust" for many risk factors
you the longevity advantage is reduced. But a huge number of studies suggest that
you do better with money in the bank.
Now your question about the survival of primary care versus other
specialties... First, I assume that your tongue was not totally stuck in your
cheek. Second, there is a literature on this topic given. It is not
overwhelmingly good but THANK GOODNESS YOU ARE NOT AN ANESTHESIOLOGIST!
Are Anesthesiologists Subject to Death at an Earlier Age Than Other Physicians?
Jonathan D. Katz, M.D.; Alison A. Caldwell-Andrews, Ph.D.; Zeev N. Kain, M.D. Anesthesiology,
Yale University School of Medicine,
INTRODUCTION: Anesthesiologists are exposed to a number of
occupational hazards that can adversely affect health and longevity. The
following study was designed to determine whether recently deceased American
anesthesiologists suffered death at an earlier age as compared to other physicians.
MATERIALS AND METHODS: The Physician Master File (PMF) of the American Medical Association
was queried to identify all physicians who had died in each of the years 1990,
1995, 2000, and 2001. Files on 13977 deceased physicians were examined. Each of
the deceased was categorized as to gender and medical specialty. Three
physician specialties were studied: anesthesiologists (AN; n= 475), internists
(IM; n=1498) and all other physicians (PHY; n=12004).
RESULTS: Overall, during 1990-2001, AN died at a younger age as compared to IM
and PHY. The
mean age at death for AN was 69.54 ± 15.7 years, for IM was 75.2 ± 14.1 years,
and for PHY was 75.7 ± 13.2 years (P=0.0001). Age at death for female
anesthesiologists (n=49) was younger than for male anesthesiologists (n=426),
but this difference was not statistically significant (66.5 ± 18.2 vs. 69.9 ±
15.3, p=0.15). The mean age at death increased among all specialties during the
study period (see
Figure). This increase was significantly larger for AN (1990: 65.9 ± 15.5 years
vs. 2001: 73.4 ± 15.2 years) than either IM (1990: 73.5 ± 14.8 vs. 2001: 76.8 ±
14.1) or PHY (1990: 74.5 ± 13.3 vs. 2001: 77.4 ± 12.9). In 2001 the age at
death of AN remained significantly lower than PHY (p=.038), but not
significantly lower than IM (p=.102).
DISCUSSION: It remains controversial whether or not American
anesthesiologists die younger than other physicians. Lew (1) failed to demonstrate
excess mortality among anesthesiologists as compared to a general population of
physicians. On the other hand, Alexander, et al (2) reported that
anesthesiologists died significantly younger (66.5 years) than internists (69.0
years). Similar to Alexander, et al. (2), we observed a younger average age at
death among the entire population of anesthesiologists as compared to other
physicians. However, this difference decreased in the later years of our study.
This interesting differential is temporally related to several demographic and
occupational health changes that occurred during the professional lives of our
study subjects. Further investigation is necessary to elucidate a possible
relationship between these changes and the improving longevity of anesthesiologists.
Anesthesiology 2002; 96: A1105
http://www.annfammed.org/cgi/content/full/4/2/101
(in case the
attachment doesn't come through).
The attached editorial by Barbara Starfield once again puts her at the
forefront of identifying what ails the
One important point in this article is the weakness of guidelines developed by
specialists for use in primary care. She correctly points out that the pay for
performance train is barrelling down the
track and we've been tied to the rails by specialists and academics with at
best a dim understanding of the nature of primary care.
An anecdote from a patient of mine who suffers from Crohn's, gout, and
hypercholesterolemia. "Doc, if I follow all three guidelines for what I
should eat, I'm left with nothing."
Specialty derived guidelines leave us and our patients hungry for the real work
of treating real people, not disease threads. This is exactly why I pursue
"what matters" from the perspective of those I treat.
So how do you get to "what matters?" This is one of the key features
of the Ideal Micropractices project.
Practice
Standardization
John Wasson and the Dartmouth COOP folks - feverishly at
work like practice improvement elves - have another gem for us:
1. We are standardizing patient assessment, feedback, and problem solving.
2. We are about to investigate a way to standardize processes that impact
overhead--- such as billing, mailing information, etc.
3. Here is a tool to begin our thinking about if/how we would standardize what
has been traditionally called "judgement." Since many of the case
scenarios have implications for referrals, and
referrals can be either of value or cost to IMPs and their patients, this seems
like a good way to begin.
The survey is very brief and has been recently tested nationally and will soon
be published. The authors will share national norms with us for solo
practitioners, IM, FP, etc.
The last question give me pause: For a patient with hypertension, I don't mandate
office visits, so I will interpret this to mean "how often do you
communicate with patient regarding HTN."
Standardization is the foundation of reliability. Variation in patient need
then drives the variation in our work, not "where I was trained" or
"how I like to do things" which are the two biggest drivers of
variation in the delivery of care (massive literature on this from Wennberg,
Fischer, et al).
OTHER
While I was having my
staff meeting of one, I decided to try an intervention
for the
obese patients in my practice. (Must be close to 2/3rds of the adults in
my practice). I had previously kept a log of patients who wanted
exercise
partners and tried to hook them up, but that was too cumbersome and
fell
through for lack of follow up on my part.
I decided
to start a "weight board" in my waiting room (not that anyway
ever
waits there anyway). Since I wanted to lose 10 pounds, I put my
initials,
my goal weight, diet/exercise tips and or big eating mistakes for
the week,
and my currrent weight on the board. It's a 4x3 white dry erase
board,
with room for maybe 15 other people. 3 patients have listed their
information
underneath mine so far, and they are quite happy about it. They
come in
when the practice is open (I may or may not be seeing a patient) and
write up
their information on the dry erase board. The idea behind this is
half
public shaming, and half motivational trickery! I'll let you all
know
if I get
good results. Has anyone done this type of thing before and if so,
any
suggestions? I can't see this happening in a giant group practice or a
Kaiser
type setting. I might be able to parlay this into some kind of group
visit,
although payors here will not pay for obesity unless it's "morbid"
obesity.
Lynn Ho
Cutting Waits at the Doctor's
Office
New Programs Reorganize
Practices to Be More Efficient;
Applying 'Queuing Theory'
April 19, 2006; Page D1
The dysfunctional doctor's office is
getting a makeover.
A growing number of programs around the
country are helping doctors redesign their offices to wring more profit out of
their practices and fix problems that have long frustrated patients: weeks-long
delays to get appointments, hours in the waiting room, too-brief visits with
the doctor, and the near impossibility of getting the physician on the phone.
While the goal is to improve care, the programs also aim to avert a looming
shortage of primary-care doctors who are frustrated with low pay, long hours
and rising overhead costs.
The new programs borrow lessons from
other industries to help doctors work more efficiently, especially those in
solo and small group practices who account for the majority of outpatient
office visits. One approach employs calculations used by airlines, hotels and
restaurants to predict demand: The idea is that doctors can cut patient waits
much the way restaurant chains seat diners and turn over tables efficiently.
Others involve relatively simple changes, such as leaving afternoon
appointments open for urgent visits, or having patients fill out paperwork
ahead of time online.
Doctors'
offices are seeking to improve efficiency, boost profits and cut waits.
Managed-care giant Kaiser Permanente is
launching a program to help 12,000 doctors that contract with its health plan
increase their efficiency with a new electronic-medical-records system.
Other models involve more-radical change,
such as one called "Ideal Micro Practice" that sharply reduces or
even eliminates support staff. With this blueprint, doctors rely on electronic
health records and practice-management software to quickly dispense with
administrative tasks. And they may run their offices solo, greeting patients
personally as they come in the door.
"The office practice hasn't changed
much in 50 years," says John Wasson, a
Such redesigns face significant
challenges -- including getting doctors to change age-old ways of practicing
medicine and interrupt their busy schedules to retrain staff. Even if doctors
spend more quality time, that might mean seeing fewer patients, and the
unintended consequence may be to exacerbate the shortage of primary-care
doctors, warns the
Even a pioneer of the Ideal Micro
Practice, family physician L. Gordon Moore of
It is also hard for doctors to invest in
expensive new technology when they are already faced with high overhead. But
less-expensive electronic-medical-records systems are becoming more readily
available, as is help in using them. The federal Center for Medicare and
Medicaid Services is funding a program using contractors known as Quality
Improvement Organizations to help 4,000 practices adopt electronic patient
records.
Much of the information to help doctors
redesign practices is available free. Dr. Moore offers a Web site,
idealmicropractice.org1, which shows how a practice with minimal or
no support staff can cut operating expenses to the bone, increase the time
doctors spend with each patient, and offer same-day access for urgent needs.
While the number of patients doctors can
see is usually relatively low, his own experience suggests that by averaging
just 12 patient visits a day, a doctor can earn 130% of the salary earned in a large
practice seeing 25 to 30 patients a day. Drs. Moore and Wasson are working with
about 40 doctors who are using the Micro Practice ideas, and collaborating with
business and health-quality-improvement groups to set up state programs.
For patients, the idea of better access
to doctors is a welcome change. Mary Lou Lunt, a 47-year-old artist and
marketing consultant who has a husband with diabetes and a teenager with
cerebral palsy, switched to Dr. Moore's practice after becoming frustrated with
her family's physician, whose office waits were sometimes an hour and a half,
with only five minutes for actual appointment. When she or her daughter or
husband calls with the need for an urgent visit, "I always make sure we
are showered and dressed because when we call, I know we can see him right
away," Ms. Lunt says.
Other programs avoid the drastic approach
of eliminating staff, aiming to instead help staff manage patient flow more
efficiently. The
Among the ideas it is adapting for
medical offices is smoothing "inbound logistics" -- such as making
sure the front desk has medical records on hand when a patient arrives -- and
"outbound logistics," which include making sure patients get any test
results available after the visit.
"Everyone recognizes it is critical
for American medicine to solve these problems, and figure out what is making
small and medium-sized practices struggle financially," says Michael Barr,
director of the ACP's Center for Practice Innovation. Dr. Barr says the number
of medical students and residents choosing to go into office practice has
declined sharply in the past few years, as residents flock to more-lucrative
specialties. Last year, more than 12% of third-year internal medicine residents
were training as hospitalists -- doctors who care for patients only in the
hospital -- up from zero in 1998.
ACP is pushing for dramatic changes in
the way primary-care doctors are reimbursed by Medicare and private insurers,
including financial incentives for using electronic records.
More than 4,000 medical professionals
have attended practice-redesign summits held by the nonprofit Institute for
Healthcare Improvement, which works with Drs. Moore, Kilo and Wasson and offers free
information in its IHI.org2 Web site. Among other things, its
programs show doctors how to predict supply and demand much like airlines or
hotels do, adopting such tools as "queuing theory" used by restaurant
chains to minimize customer waiting time. "Open access" programs help
doctors calculate the demand for appointments using formulas based on the
number of patients in their practice and an average no-show rate.
That differs from current practice, where
doctors may book appointments three months in advance, leading to a big logjam
in the office and no time for urgent cases. Dr. Wasson says the most efficient
way to offer same-day appointments is to leave 60% to 70% of slots open all
day, because in a typical medical practice 30% to 40% of patients will want a
set future appointment while the remainder will need urgent care or be happy to
call on a day most convenient for them.
James Brady, a
Doctors adopting the micro practice model
say they can't always manage their time perfectly -- during flu season for
example. And some have had to accept lower incomes, at least in the start-up
phase. "My income is much lower than if I took a job running a mill and
seeing people twice as fast," says Jean Antonucci, who opened a
"micro" practice in
Continuity of Care
On the
Continuity of Care issue, you mention long term follow up by the same clinician
(doc, NP or PA). Theoretically, I believe every person you place in the way of
the doctor-patient relationship dilutes the
relationship and drops quality. Although I have met many NPs and PAs who
practice great medicine, they cannot practice independently (at least not in
level provider subsequently drops quality by decreasing continuity. As an
example, I certainly can conceive of this happening in my office as I would
then be taking call for patients with acute problems treated in the office by
someone else.
comment:
1. A long time ago we published a number of controlled trials based on my
practice group that included MDs, NPs and PAs, all of whom had their own panels
of patients with no triage of certain types of patients to one type of
provider. The NPs and PAs had to present their patients and have rx approved
only.
Both studies enabled me to look at the differences in care provided by the mds
versus PA NP. I never saw anything of note and probably should have published
that result...it was a secondary analysis and I did not have a lot of time
since I was pretty much a full time clinician.
a) Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient
medical care in
elderly men: A randomized trial. JAMA 1984;252(17):2413-2417.
b) Wasson JH, Gaudette C, Whaley F, Sauvigne A, et al. Telephone care as a
substitute for
routine clinic follow-up. JAMA 1992;267(13):1788-1793.
2. the following study, published in JAMA 2000, more directly addressed your
question.
Context Studies have suggested that the quality of primary care delivered
by nurse practitioners is equal to that of physicians. However, these studies
did not measure nurse practitioner practices that had the same degree of
independence as the comparison physician practices, nor did previous studies
provide direct comparison of outcomes for patients with nurse practitioner or
physician providers.
Objective To compare outcomes for patients randomly assigned to nurse
practitioners or physicians for primary care follow-up and ongoing care after
an emergency department or urgent care visit.
Design Randomized trial conducted between August 1995 and October 1997,
with patient interviews at 6 months after initial appointment and health
services utilization data recorded at 6 months and 1 year after initial
appointment.
Setting Four community-based primary care clinics (17 physicians) and 1
primary care clinic (7 nurse practitioners) at an urban academic medical
center.
Patients Of 3397 adults originally screened, 1316 patients (mean age,
45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and
kept their initial primary care appointment were enrolled and randomized with
either a nurse practitioner (n = 806) or physician (n = 510).
Main Outcome Measures Patient satisfaction after initial appointment
(based on 15-item questionnaire); health status (Medical Outcomes Study
Short-Form 36), satisfaction, and physiologic test results 6 months later; and
service utilization (obtained from computer records) for 1 year after initial
appointment, compared by type of provider.
Results No significant differences were found in patients' health status
(nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test
results for patients with diabetes (P = .82) or asthma (P = .77) were not
different. For patients with hypertension, the diastolic value was
statistically significantly
lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant
differences were found in health services utilization after either 6 months or
1 year. There were no differences in satisfaction ratings following the initial
appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6
months differed for 1 of 4 dimensions measured (provider attributes), with
physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).
[MY COMMENT: THIS IS A MEANINGLESS DIFFERENCE]
Conclusions In an ambulatory care situation in which patients were
randomly assigned to either nurse practitioners or physicians, and where nurse
practitioners had the same authority, responsibilities, productivity and
administrative requirements, and patient population as primary care physicians,
patients' outcomes were comparable.
3. In summary, NPs and PAs can give pretty good care for a large percent
typical issues. However, in IMP practices, I am not sure that the NP or PA
offers an advantage because of the independent practice issues for 24/7 care.
by that I mean, if I were an IMP and deciding to partner (for cross coverage,
etc) I'd
probably look for another IMP minded doc since both of us would be keeping the
panel matched to our capacity.
What is structural about our
practices?
All the IMPs made the leap because we are crazy idealists who decided to go against the grain with no assurance of financial stability. Therefore, there is huge selection bias in comparing IMP practices to larger “traditional” practices. It really is comparing apples to oranges. IMPs have risked everything to re-commit to the doctor-patient relationship. Of course we are doing better in these parameters than a traditional practice because that is what we set out to do. Note: if we look at a different parameter, i.e. annual salary, we are lagging way behind.
With that said, I do believe a small practice (1-2 docs) could possibly transform into an IMP practice. Anything larger than that would be improbable or impossible. Why, because docs with jobs (not callings) hide in large practices. They go to work to collect a paycheck and that’s about it. They gripe about seeing any more patients than they need to and generally send as much of their work as possible to the other docs in the practice. They are not interested in patient centered care because they are too busy convincing the patient that they are the expert and the patient knows nothing compared to their superior intellect. They are not interested in practice transformation because it does not get them any more money or get them home faster. They are the miserable ones that make things worse for everyone. In my experience, that would be (sadly) about 25% of physicians in practices >3 docs. Secondly, any larger practice would have a practice manager to help hash out all the arguments between employees. Practice managers do not understand the doctor-patient relationship, they understand money. They get hired to bring in more revenue which translates into seeing more patients. To decrease overhead, they would have to get rid of employees, which would decrease their importance in the office. Any smart practice manager will not want to do that as it would put their job in jeopardy.
I do believe there are a huge number of physicians who will be excited about recreating medicine in the IMP image, but just because it’s better for patients and most physicians, we can’t expect everyone to buy into it. The larger the practice, the more likely there would be resistance to any changes.
Let me try to
paraphrase why large practices cannot be ideal in a slightly more helpful way:
1) Change is difficult for everyone, particularly conservative physicians. If change were easy, every practice would have an EMR. Most don’t because the fear of change, including both the actual process changes and the potential cost involvement, outweighs the potential benefits of the change. It really is a balance. The larger the practice, the more change would be necessary and the more resistance there would be to the change. In most cases, any practice over 2 providers would create such a large change that the physicians could not agree on what to do or how to implement any changes and the issue would be tabled.
2) Large practices are generally run by people who do not understand the doctor patient relationship (i.e. practice managers, administrators, etc). These people are interested in the bottom line, and really only peripherally interested in quality (as it relates to the bottom line in malpractice premiums, good word of mouth publicity, etc). They really cannot understand why a doc would want to spend more than 10-15 minutes with a patient no less why it might be necessary. This could perhaps be changed with education, but unless the docs are absolutely committed to the change (which is difficult (see above)), practice managers and administrators would not push for change.
3) A lot of docs do not want to have anything to do with the business side of medicine and really do not understand how intimately that part is tied to the clinical part. Not only does this create another barrier between the doctor and patient, but hiring someone else to do the business side increases overhead and creates the need to see more patients.
4) It’s un-American. Everything in this country is set up so that bigger is better. Stating that smaller and more intimate is better goes against the cultural grain. Although this may seem petty, I believe it is a strong force that drives a lot of business. To go against this force is equivalent to trying to swim against a rip current.
5) IMPs are a different
breed. Not to toot our own horn too much, but we risked our financial futures
and many of our clinical relationships to follow a dream of better care. The
fact that we would go against reasons 1-4 above to do what we are doing shows
an unbelievable commitment to our patients and our idealism. All of us had our
own reasons, but we have all decided that change was necessary, ignored the
warnings from “experts,” became intimately involved in practice management, and
fought against culture itself. The process is trying and difficult, but with
the encouragement of the others, we have managed to overcome many obstacles and
now stand transformed and ready to push forward. Like medical school or even
basic military training, this process of transformation is very important. Even
if there were no difference in clinical outcomes, the physicians who have been
willing to do this are exceptional.
April 2006 (table of contents)Vol.
13 No. 4
Turning Frustration Into Fulfillment
When we invite our patients to be part of the solution, even difficult
encounters can become rewarding.
Sweety Jain, MD
As family physicians, we spend a significant amount of time and energy each day
dealing with frustrations. Even the sacred doctor-patient visit is not immune,
as we often face communication challenges, cultural or social barriers,
interpersonal conflicts, and clinical uncertainty in these interactions. While
it is easy to pull away from our patients during uneasy encounters, I've found
that the best approach is to involve them.
Case in point
A few years ago, after feeling frustrated by my inability to communicate with
growing numbers of Hispanic patients in my practice, I decided to take a
proactive and creative approach: I asked my patients to teach me Spanish.
I started by asking my patients to bring in four Spanish-language words related
to medicine (body parts, symptoms, etc.) at each visit. As soon as I made the
suggestion, I could see that it gave them a sense of empowerment and
fulfillment. At the same time, I asked that they try to learn English in the
same way that I was trying to learn Spanish.
My best teachers have been my pediatric patients, who never fail in assigning
tasks to me. They feel extremely happy to teach their doctor, and we build a
great patient-doctor relationship this way. I have had several children
actually mail me my Spanish "homework." Finding these assignments in
my mailbox in envelopes addressed by my pediatric patients is an immensely
joyful experience. I still possess one of my homework assignments from an
11-year-old patient, who
wrote:
Dear Dr. Jain,
This is for you to learn.
How is your family doing?
¿Cómo esta tu familia?
How are you feeling?
¿Cómo te sientes?
Do you feel something else?
¿Sientes algo más?
Another patient, a
7-year-old boy, gave me several Spanish words to practice: arm - brazo, fingers
- dedos, ear - oreja and lips - labios. He even checked on my vocabulary at his
next visit.
Lessons learned
While I am not yet fluent in Spanish, I have picked up enough words and phrases
to improve my communication with these patients. More than that, though, this
experience has added to my joy of practicing medicine. Instead of feeling
frustrated at these encounters, I now enjoy them and feel eager to learn from
my patients. In return, many of my patients have become more compliant and
sincere
in their attempts to follow my medical advice, whether it be taking medicines
regularly or getting tests done on time.
There are so many benefits to this simple strategy that I would encourage all
family physicians who treat Spanish-speaking patients (or patients who speak
any language other than their own) to consider it. To take it a step further,
all physicians in a group or all residents in a program could come together and
share what they've learned from their patients.
This experience has taught me that when we involve our patients, we can turn
many of our frustrations into treasures. These moments are some of the hidden
joys of practicing family medicine. Exploring these joys - and sharing them
with our colleagues, residents and students - could go a long way toward
re-energizing our profession.