Reflections on The Future of Family Medicine

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• Reflections on The Future of Family Medicine
• Daniel Lasser, MD, MPH

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Counterculture
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Counterculture
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Basic values

• Continuity
• Comprehensiveness
• Coordination
• Common issues
• Caring
• Contextual
• Commitment
• Community

• Longitudinal
• Problem oriented
• Emphasis on the Dr-patient relationship
• Response to a public need
• Service orientation
• Educational reform

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Development of Medical SpecialtiesTwo
SeparateTracks

• Acquisition of
• information

• Public perception of lack
• of access to a personal physician

• Definition of Primary Care
• Establishment of teaching programs

• Reductionism
• Redefinition into smaller disciplines

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Imposed from Without

• The Primary Care Physician
• First contact medicine
• Assumes longitudinal responsibility for the
  patient regardless of the presence or absence of
  disease
• Serves as the integrationist for the patient
• Alpert, JJ and Charney, E, The Education of
  Physicians
• for Primary Care. US Dept. of HEW, 1973

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Imposed from Without

• Federal funding to medical schools and
  residencies
• New state-supported medical schools with primary
  care written into mission statements
• Coincident with other publicly-funded initiatives
  to improve access to care

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Intellectual Basis of Family Medicine
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Intellectual Basis of Family Medicine
The Relational Model
Lynn and Joan Carmichael
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Intellectual Basis of Family Medicine

• Dont confuse knowledge with information
• Information changes over time
• The defining factor for family physicians is
  patient management
• Managing problems, not diseases
• Counterculture
• G. Gayle Stephens, 1975

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Development of Family Practice Residencies

• The Model Family Practice Unit

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Basic values

• Continuity
• Comprehensiveness
• Coordination
• Common issues
• Caring
• Contextual
• Commitment
• Community

• Longitudinal
• Problem oriented
• Emphasis on the Dr-patient relationship
• Response to a public need
• Service orientation
• Educational reform

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Incumbency
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Incumbency
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Growth of the Specialty
Source Robert Graham Center
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Accredited Family Practice Residencies
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Accredited Family Practice Residencies
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Accredited Family Practice Residencies
Diversity of Program Types Family Practice
Residency Programs by Structure, 2001-2002
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Assuming Leadership Roles

• Within medical schools
• Family Medicine Departments have focused on the
  process of medical education
• Early courses have become institutionalized
• Many Family Physicians provide leadership within
  academic Deans offices
• Family Practice clerkships are often rated
  highest in the curriculum
• Within hospitals
• Credentialing battles are less common than in the
  past
• Family Physicians are assuming leadership roles

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Who sees patients in the office?
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Who sees patients in the office?
Distribution of Office Visits by Physician
Specialty and Professional Identity United
States, 2001
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Did we improve access to care?
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Did we improve access to care?
Primary health care professions shortage areas
that would be created by the removal of all
family physicians in 1999
Source Robert Graham Center
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Did we improve access to care?
Source Robert Graham Center
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Did we improve access to care?
Source Robert Graham Center
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Did we improve access to care?
Source Robert Graham Center
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Are Primary Care Physicians Effective?
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Are Primary Care Physicians Effective?

• There is good published evidence to demonstrate
• First contact Lower costs, more efficient
  specialist utilization better outcomes for
  primary care problems
• Longitudinal care
• Better problem and needs recognition
• More accurate and earlier diagnosis
• Less Emergency Room use and fewer
  hospitalizations
• Lower costs
• Fewer unmet needs
• Moderate evidence for
• Fewer prescriptions
• Higher patient satisfaction

Starfield
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Are Primary Care Physicians Effective?

• There is good published evidence to demonstrate
• Coordination
• Better incorporation of information when a
  physician is following up after himself or
  herself
• Better incorporation of information about a
  patient visit to another facility when the
  patient has been referred by a PCP

Starfield
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Are Primary Care Physicians Effective?

• Primary Cares Contribution to a Health System
• Countries with strong primary care systems have
  lower health care costs than those with weaker
  primary care systems
• States with more primary care resources tend to
  have better health outcomes
• Primary care availability is positively
  correlated with lower mortality rates, lower
  infant mortality, stroke mortality, and higher
  life expectancy
• PCPPopulation ratios reduce the rate of
  hospitalization for at least six ambulatory
  care-sensitive conditions
• Adults with a PCP as their personal physician
  have 1/3 lower costs of care, and are 1/5 less
  likely to die

Starfield
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Crisis
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(No Transcript)
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Problems Within
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The Model Family Practice Unit
Problems Within

• Inefficient
• 15 part-time doctors doing the work of 5
• Dual mission teaching and clinical service
• Lacking continuity

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Problems Within

• The distinction between Knowledge and
  Information has been difficult to manage
• Family doctors office designed to provide care
  for brief, acute visits
• There is an increasing burden of chronic disease
  that is difficult to manage in 10-15 minute time
  slots
• We vary in our management of conditions

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Changing Society

• Use of complimentary and alternative medicine
• Use of on line health information
• Over-the-counter availability
• Role of other primary care clinicians
• Primary care internists, pediatricians
• Nurse Practitioners, Physician Assistants
• Society turns to a 24/7 orientation
• Information-based economy

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Changing Society

• Industrial Economy
• Top-down management
• Controlled access to information
• Limited access
• Silos
• Company driven
• Periodic measurement
• Constricted flow of data

• Information Economy
• Team management
• Open access to information
• Open/continuous access
• Connected
• Consumer driven
• Continuous measurement
• Seamless flow of data

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Effects of Managed Care

• Advocacy and Relationship-based care
• became
• Agency and Business-based care
• Increasing complexity of practice

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Hamster Care
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Source AAMC Graduation Questionnaire
1990 is estimated
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Change
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Change
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Im leaving you, Mitchell. Youve never had
tunnel vision you never will.
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The Entire Health Care System is in Crisis

• Variations
• There are marked geographic variations in health
  care delivery
• Discharge rates for Medicare enrollees with COPD
  living in Boston are 2.2 higher than those for
  enrollees in New Haven
• Overall, discharge rates for medical conditions
  are 60 higher in Boston than in New Haven, and
  are directly related to the supply of hospital
  beds
• Within Boston, there are considerable differences
  in readmission rates for Medicare beneficiaries
  who were initially hospitalized for one of five
  common indications

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The Entire Health Care System is in Crisis

• Medical Errors
• Health care is dangerous
• Tens of thousands of Americans die each year from
  errors in their care
• Hundreds of thousands suffer or barely escape
  from nonfatal injuries that a truly high quality
  health care system would largely prevent
• 7 of hospital patients experience a serious
  medication error
• More Americans die from medical errors each year
  than die from motor vehicle crashes or HIV/AIDS
  or Breast Cancer
• Cost of preventable adverse events is estimated
  to be 17 to 29 billion annually

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The Entire Health Care System is in Crisis

• Uninsured
• 41 million US residents were uninsured for all of
  2001
• 80 of the uninsured were either employed or had
  an employed parent
• Nearly 75 million US residents (about 1/3 of the
  non-elderly population) lacked health insurance
  for at least part of 2001-2002
• About 25 (18 million) lacked coverage throughout
  the period

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The Entire Health Care System is in Crisis
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The Entire Health Care System is in Crisis
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The Entire Health Care System is in Crisis
Infant Mortality For Various OECD Nations,
1980-2000
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The Institute of Medicine Perspective

• The American health care delivery system is in
  need of fundamental change. The current care
  systems cannot do the job. Trying harder will
  not work. Changing systems of care will.
• Primary care is the logical foundation of an
  effective health care system

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Future of Family Medicine Project

• Sponsors AAFP, AAFP Foundation, ABFP, ADFM,
  AFPRD, NAPCRG, STFM
• Three year processes, Five Task Forces, (then a
  sixth focused on reimbursement strategies)
• Report issued March 30, 2004
• Issued a commitment to change, based on behalf of
  the public good

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Future of Family Medicine Project

• Market Research Revealed Two Major Problems
• Americans dont understand Family Practice
• Despite its 30-year history, neither the general
  public nor health care professionals understand
  all that family practice represents.
• Americans are obsessed with science and
  technology
• More is better
• Faster is better
• Technology is better

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Future of Family Medicine Project
Market research reveals What do people want
from a Family Doctor?
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Future of Family Medicine Project

• What patients want
• from their Family Doctor
• First, patients in large urban markets want
• A physician in their insurance plan
• A convenient location
• Availability for an appointment
• Basic communication skills
• Age, experience
• Second, they want
• A personal physician
• Someone who will coordinate their care

Market Research, Future of Family Medicine
project, 2003
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Future of Family Medicine Project

• What subspecialists see
• in a Family Doctor
• Subspecialists see family physicians as a
  distinct group of physicians who
• Are motivated to serve people
• Display a humanitarian, empathetic approach to
  health care
• Are best suited to deliver preventive medicine
• Are best suited to manage complex patients

Market Research, Future of Family Medicine
project, 2003
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Future of Family Medicine Project

• What students and residents see
• in a Family Doctor
• Family Medicine is seen positively
• People-focused, self-confident, intelligent and
  idealistic
• Offering greater personal satisfaction than other
  specialties
• Providing two key attractions freedom and
  flexibility
• It is seen negatively
• Providing a less preferable lifestyle and more
  limiting opportunities
• Receiving less compensation, less prestige
• Coping with health system interference
• Poorly promoted at medical schools

Market Research, Future of Family Medicine
project, 2003
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The AAMCs PerspectiveAttributes of the
Successful 21st Century Physician

• Cost-conscious
• Quality driven
• Internet savvy
• Service oriented
• Knowledge based

• Advisor
• Behavioral coach
• Team player/leader
• Coordinator of care
• Manager of chronic illness(es)

A blueprint for the new primary care physician!
Jordan Cohen, MD
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Future of Family Medicine Report

• Six Aims for Care Identical to IOM Aims(Safety,
  Effectiveness, Patient-Centeredness, Timeliness,
  Efficiency, Equity)
• Ten Rules for Care Identical to IOM Rules
• Ten major recommendations

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Future of Family Medicine Report
Recommendations

• Family Medicine in Academic Health Centers
• Family Medicine Workforce
• Communications
• Leadership and Advocacy

• New Model
• EHR
• Education
• Lifelong Learning
• Enhancing the Science of Family Medicine
• Quality of Care

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Future of Family Medicine Report
The Challenge Operationalizing The New
Model
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The New Model

• Old Paradigm
• Top-down management
• Controlled access to information
• Limited access
• Silos
• Company driven
• Periodic measurement
• Constricted flow of data

• New Paradigm
• Team management
• Open access to information
• Open/continuous access
• Connected
• Consumer driven
• Continuous measurement
• Seamless flow of data

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The New ModelAccess
We cannot provide effective care for our
patients in office practices where flow was
designed for acute care in brief visits,
scheduled at times weeks in advance

• The medical office is a bottleneck of episodic
  care
• which does a poor job of healing and meeting
  peoples needs
• Joe Sherger
• The more you can move demand away from office
  visits, the more time youll have to deal with
  patients who really need personal interaction.
• Donald Berwick

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The New ModelAccess
We cannot provide effective care for our
patients in office practices where flow was
designed for acute care in brief visits,
scheduled at times weeks in advance

• Barriers to access vs Open access
• Synchronous vs Asynchronous
  communication communication
• Individual oriented vs Population-oriented
• Individual visits vs Group visits
• Everyone gets doctor vs Multiple ways to
  time interface with the system

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The New ModelLongitudinal Management
We cannot provide effective care for chronic
problems with clinical approaches that were
designed for acute problems

• About 100 million people (40 of population)
  have one or more chronic conditions, accounting
  for more than 2/3 of health care expenditures

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The New ModelLongitudinal Management
We cannot provide effective care for chronic
problems with clinical approaches that were
designed for acute problems

• Haphazard vs Planned, systematic
• Doctor is the main vs Multidisciplinary
  source of care team
• Office is the primary vs Care across
  settings, source of care clinicians, time
• Care based on experience vs Disease management
  protocols
• Individual visits vs Group visits

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The New Model Information Technology
We cannot deliver effective care without a
robust electronic record, and without a series of
asynchronous communications tools

• Paper record vs Paperless record
• Doctors record vs Patients record
• Control of information vs Open access
  to information
• Doctor-centered vs Patient-centered

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The New Model Information Technology
We cannot deliver effective care without a
robust electronic record, and without a series of
asynchronous communications tools

• Interactive web site
• Data Lab results, etc
• Focus on chronic illness care
• Behavioral coaching
• Management of minor acute problems

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The New ModelQuality and Safety
We cannot deliver effective care without
bridging the quality chasm through ongoing
measurement and quality improvement activities
outside the hospital setting

• Quality assumed vs Quality measured
• Safety assumed vs Safety built in
• Experience-based vs Evidence-based
• Knowledge rules vs Information rules

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The New ModelLifelong Learning
We cannot deliver effective care without
becoming absolutely clear about the difference
between knowledge and information, and without
becoming masters at accessing, assessing, and
utilizing information

• Use of knowledge vs Use of information
• Control of patient vs Management of
  information patient information
• Learn, then practice vs Lifelong learning

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The Future Family Doctor
Today Tomorrow

• Personal care ? Personal population-based care
• System built for the MD ? System built for the
  patient
• The doctor controls ? Patient controls clinician
  trusted advisor
• Defined roles, autonomy ? Interdependent team
  player
• Hand off to specialists ? Provide Medical Home
  Coordinate all care
• Care in office ? Care where the problem is
  handled best
• Care in hospital ? Care where the problem is
  handled best
• Expert-based practice ? Knowledge
  Information-based practice
• React to external profiling ? Constant review od
  data and improvement
• Paid for process ? Paid for results

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Source AAMC Graduation Questionnaire
1990 is estimated
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Wise Words from Dee Hock

• Substance is enduring, form is ephemeral.
  Failure to distinguish clearly between the two
  is ruinous.
• Success follows those adept at preserving the
  substance of the past by clothing it in the
  forms of the future.
• Preserve substance modify form know the
  difference.