Family Medicine: Taking Care of All of You

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Family MedicineTaking Care of All of You
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Is Family Medicine Taking Care of YOU?!
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The Future of Family MedicineGetting and
Keeping the Right People

• Dr. Raj Woolever, MAJ USAF MC
• Spangdahlem Air Base, Germany
• USAFP Annual Meeting, Chicago
• 3 March 2006

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Objectives

• Understand the history, revisions and enduring
  core concepts of family medicine education
• Consider the spectrum of factors that impact on
  family medicines appeal to the next generation
  of physicians
• Become familiar with the Future of Family
  Medicines vision, mission, values, core
  competencies and specific recommendations for
  family medicine education

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Why is primary care important?

• longer life spans and fewer deaths due to heart
  and lung disease
• fewer cases and deaths due to colon and cervical
  cancer
• better detection of breast cancer
• less ER and hospital use
• better preventive care
• reduced health disparities

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A typical month of health care in the United
States

• Source N England Journal of Medicine
  20013442021-25

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People rely on primary care physicians to care
for complex disease

• Source 2002 National Health Interview Survey

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What do family physicians do?

• Family physicians provide comprehensive and
  continuous primary care health care to
• individuals and families
• women and men regardless of age or disease
• infants, children and adolescents regardless of
  disease

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Family physicians provide

• Prevention management of acute injuries and
  illnesses
• Health promotion
• Hospital care for acute medical illnesses
• Chronic disease management
• Maternity care
• Well-child care and child development
• Primary mental health care
• Rehabilitation
• Supportive and end of life care

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What distinguishes family physicians from general
internists?

• Ages and gender of patients seen by family
  physicians and general internists
• Source
• National Ambulatory Medical Care Survey2002

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Percentage of Childrens Office Visits by
Specialty
Sources National Ambulatory Medical Care
Surveys, 1992-2002 AAFP Task Force On the Care of
Children, 2005
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Who are we really?
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What comprises the Family Medicine Spectrum of
Care?

• 83.2 provide inpatient care
• 21.2 do routine OB
• 22.9 surgical-assist
• 29.6 perform minor surgical procedures
• 43.2 delivered care in the CCU
• 48.0 delivered care in the ICU
• 54.4 deliver care in hospital ER
• 63.7 reported delivering newborn care
• Source AAFP Facts About Family Medicine. 2005
  http//www.aafp.org/facts.xml

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But, its not just about full spectrum

• Not defined by content (specific list of
  services)
• Not defined by age
• Not defined by gender
• Not defined by setting in which care is given

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But, its not just about full spectrum

• We are defined by the process in which we see
  patients
• Patient-physician relationship
• Problem definition and prioritization
• Family physicians use the same process in their
  approach to all patients

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But, its not just about full spectrum

• We are the expert in this process-oriented
  discipline
• Continuity
• Comprehensiveness
• Need to find better and more efficient ways of
  providing personalized care for patients - 1964

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What FP attributes are valued?

• Deep understanding of the whole person
• Act as a partner to patients over many years
• Talent for humanizing health care
• A command of complexity

Source Martin JC, Avant RF, Bowman MA, et al.
The Future of Family Medicine A collaborative
project of the family medicine community. Ann Fam
Med. 2004 Mar-Apri 2 Suppl 153-32
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Family physicians whole-person orientation and
training ensures that FPs

• Consider all of the influences on a persons
  health
• Know and understand peoples limitations,
  problems and personal beliefs when deciding on a
  treatment
• Are appropriate and efficient in proposing
  therapies and interventions
• Develop rewarding relationships with patients

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Family physicians have a unique influence on
patients lives

• Serving as partner with patients to maintain
  well-being over time
• Empowering with information and guidance that are
  needed to maintain health over time
• Providing care that includes long-term behavioral
  change interventions that lead to better health
• Developing ongoing communication between patient
  and physician

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Family physicians are relationship-oriented,whic
h ensures

• Good relationships with other physicians and
  health care providers.
• Better patient understanding of complex medical
  issues and improved participation in the care
  process.
• Less expensive and better healthcare experience
  for patient.

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Family physicians have a natural command of
complexity and

• Thrive on managing complex medical problems
• Integrate all of the medical and personal issues
  facing an individual
• Break down medical terms and complex medical
  issues to make it easier for patients to
  understand

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Lifestyle of Family Physicians?

• 50 hours per week in patient-related activities 1
• Avg. wks worked 47.2 weeks 1
• 5 weeks for vacation/CME 1
• Avg. Income by region 2
• Northeast - 142,000
• Southeast 150,000
• Midwest - 148,000
• West - 144,000

1 AAFP Facts About Family Medicine. 2005
http//www.aafp.org/facts.xml 2 Terry K. Jobs
2004. Primary care outlook. Med Econ. 2004 May
2181(10)84-7.
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Innovations in family medicine

• Group visits
• Team approach to care
• Systematic approach to care
• Chronic disease management

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Future of Family Medicine

• Market research
• Six task forces
• Family medicines new model of care
• Personal medical home
• Continuous relationship
• Basket of services

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FFMMedical Education

• Core competencies
• Vision
• Mission
• Values

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FFMMedical Education

• Core competencies
• Patient-centered care
• Interdisciplinary team work
• Evidence-based practice
• Quality improvement
• Informatics

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FFMMedical Education

• Competency
• Habitual use of communication, knowledge,
  technical skills, clinical reasoning, emotions,
  values and reflection in daily practice.

Institute of Medicine. Committee on Quality
Healthcare in America. Crossing the Quality
Chasm A New Health System for the 21st Century.
Institute of Medicine. Washington, DC National
Academy Press 2001.
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FFMMedical Education

• Vision.
• To transform family medicine residency education
  into a process-oriented phenomenon that prepares
  and develops the family physician of the future
  to deliver, renew and function within the family
  medicine system of care and to deliver the best
  possible care to the American people.

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FFMMedical Education

• Mission.
• To create a flexible, process-oriented paradigm
  in family medicine residency education that
  trains family physicians to deliver
  patient-centered care consistently, as a member
  of an interdisciplinary team, emphasizing the
  biopsychosocial model, evidence-based practice,
  quality improvement and informatics.

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FFMMedical Education

• Values of the Educational System

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building-fostering
  positive patient-physician relationships, based
  on effective communication

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety-avoiding injuries to patients while
  providing medical care

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness-providing evidence-based medical
  services

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency-avoiding waste in all areas of the
  system

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency
• Patient-centered-providing care that is
  respectful and that includes patient preferences,
  needs and values

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency
• Patient-centered
• Timeliness-care provided in a manner that
  minimizes waiting times and prevents harmful
  delays of care

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency
• Patient-centered
• Timeliness
• Equity-quality care provided in all geographic
  areas with no disparities because of gender,
  ethnicity or socioeconomic status

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency
• Patient-centered
• Timeliness
• Equity
• Accessibility-patients need to be able to access
  appropriate care when they need it

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FFMMedical Education

• Values of the Educational System
• Patient-physician relationship building
• Safety
• Effectiveness
• Efficiency
• Patient-centered
• Timeliness
• Equity
• Accessibility

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Re-taking Control

• Leadership
• Family medicine perspective at the top
• Small, incremental changes
• Rational business plans
• Re-focus on the big picture

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Re-taking Control

• Patient care
• It IS a privilege
• Be creative/innovative
• Group medical appointments
• Make the case for the procedures and/or
  appointment types you love
• Develop your Primary Care Elements

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Attitude and Leadership
Self-Awareness

• Low-level Decision Rules
• Learned in basic stages of apprenticeship
• Errors experienced, not incorporated
• Tacit knowledge not reconsidered

• High-level Decision Rules
• Learned from experience
• Errors experienced incorporated
• Tacit knowledge conscientiously revisited

Borrel-Carrio, F. and R. Epstein. Preventing
Errors in Clinical Practice A Call for
Self-Awareness. Annals of Family Medicine.
2004 2310-16
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Attitude and Leadership
Self-Awareness

• Low-level Schemata
• Ive got it
• If the patient is satisfied, why should I look
  for more?
• When in doubt, choose the most convenient
  hypothesis
• Blame the patient
• Complains a lot

• High-level Schemata
• Look beyond early hypotheses
• Always form own criteria
• When in doubt, assume the worst hypothesis
• Take a fresh look

Borrel-Carrio, F. and R. Epstein. Preventing
Errors in Clinical Practice A Call for
Self-Awareness. Annals of Family Medicine.
2004 2310-16
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The Future of Family Medicine

• Advocates for
• Formalization of clinical decision-making
  processes

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The Future of Family Medicine

• Advocates for
• Formalization of clinical decision-making
  processes
• Increased use of evidence-based medicine

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The Future of Family Medicine

• Advocates for
• Formalization of clinical decision-making
  processes
• Increased use of evidence-based medicine
• More practice-based research to provide practical
  answers to common clinical questions

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The Future of Family Medicine

• Advocates for
• Formalization of clinical decision-making
  processes
• Increased use of evidence-based medicine
• More practice-based research to provide answers
  to practical clinical questions
• Improved access to a wide variety of information
  resources

Martin, JC, Avant, RF, Bowman, MA, et al. The
future of family medicine A collaborative
project of the family medicine community. Ann of
Fam Med 2004 2(Suppl 1) 52.
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Research in the Exam RoomModified Scientific
Process

• Determine pre-test probability
• Establish a threshold
• Evaluate patient
• Interpret test results
• Update probability
• Make intervention

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Research in the Exam RoomModified Scientific
Process

• Determine pre-test probability
• Know you patient
• Know your population
• Know the environment
• Know the circumstances

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Research in the Exam RoomModified Scientific
Process

• Establish a threshold
• Consider risks/benefits
• Determine what criteria will be required to make
  diagnosis and initiate treatment

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Research in the Exam RoomModified Scientific
Process

• Evaluate patient
• Interpret test results
• The data

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Research in the Exam RoomModified Scientific
Process

• Update probability
• Given pre-test probability, now apply data to
  your patient, population and circumstances

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Research in the Exam RoomModified Scientific
Process

• Make intervention
• With updated probability, determine if threshold
  was crossed. If crossed, treat and if not
  crossed, pursue additional evaluation.

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The Clinical DecisionApplying the Product

• Patient-focused approach
• Requires consideration of
• Patients educational level
• Patient reliability and adherence
• Treatment
• Follow-up
• Patients level of support at home
• Spouse/family
• Home Health

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The Clinical DecisionApplying the Product

• Also requires consideration of institutional
  resources
• Access to follow-up
• Availability of ancillary studies
• Availability of specialist support

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The Clinical DecisionApplying the Product

• Consideration of provider factors
• Fatigue
• Stress
• Hidden agendas
• Emotional reaction to patient/situation

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Clinical Decision Making

• Heuristic encouraging investigation conducive
  to discovery
• A model of the development of a cognitive pathway
  to integrate learned knowledge into clinical
  problem solving
• Information must be representative (supported by
  experience) and available (easily remembered)

Tversky, A, Kahneman, D. Judgment under
uncertainty Heuristics and biases. Science
1974 185 1124.
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Clinical Decision MakingDevelop Your Own
Processes

• Be consistent
• Builds knowledge and experience
• Reduces risk of error
• But be willing to re-consider when picture
  deviates from the expected

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Clinical Decision MakingDevelop Your Own
Processes

• Be consistent
• Builds knowledge and experience
• Reduces risk of error
• But be willing to re-consider when picture
  deviates from the expected
• Utilize the best resource your colleagues
• They have a wealth of practical knowledge about
  your population of patients

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Clinical Decision MakingDevelop Your Own
Processes

• Be consistent
• Builds knowledge and experience
• Reduces risk of error
• But be willing to re-consider when picture
  deviates from the expected
• Utilize the best resource your colleagues
• They have a wealth of practical knowledge about
  your population of patients
• Keep an open mind
• Maintain a broad differential diagnosis
• It is usually horses, but look for the zebra

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Re-discovering the Joys of Family Medicine

• Patient care it IS an absolute privilege to
  take care of our patients
• Great colleagues there is no better group of
  people
• Smart
• Interesting
• Not surgeons

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Re-discovering the Joys of Family Medicine

• Patient care it IS an absolute privilege to
  take care of our patients
• Great colleagues there is no better group of
  people
• Doing the right thing family medicine IS the
  way it should be done
• Prevention/Life style modification
• Whole person/whole family care
• Biopsychosocial approach

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Re-discovering the Joys of Family Medicine

• Patient care it IS an absolute privilege to
  take care of our patients
• Great colleagues there is no better group of
  people
• Doing the right thing family medicine IS the
  way it should be done
• Skills needed everywhere it is all about the
  process not the setting, procedure or knowledge
  set