Rural Health Care - who's out there?

20% of Americans or approximately 60 million people live in rural America. Those who live in rural communities are older, poorer and have more chronic diseases than the typical city dweller. The problem: few doctors choose to practice in rural America. And the doctors who are out there are getting older themselves and are close to retirement.



Medical schools, with few exceptions, are located in urban areas. What, you may ask, about medical students who we recruit from rural areas? Are they more likely to go back?



Take a typical 18-year old female raised on a farm in Nebraska. She goes to college in a city, stays for medical school in a city and then marries an aerospace engineer. Is she likely to go back to her home town? Hmm... probably not. On a positive note, studies do report that those from rural areas are more likely to return there... but not enough of them do.



Who are the doctors out in rural areas now? They are mostly family doctors. Family physicians are the only specialty that's evenly distributed across all settings - inner city, large rural and frontier, isolated rural. Other specialties (as seen in the graph below) cluster themselves in cities, where they can actually sustain a practice. BUT, we've had fewer people entering family medicine over the 10 years (exception of this year) and, as such, the rural doctor pipeline is drying up.

Figure: Physicians per 100,000 people

To ensure the health of rural Americans, we need to have more doctors practicing in rural areas. From studies, we know the type of doctors who are likely to end up in rural areas:

• doctors in family medicine (not pediatricians or general internal medicine doctors... and definitely not sub-specialists)
  
  
• doctors with rural origins
• doctors who are married when they graduate medical school
• male doctors (not being sexist - this is a statistically proven fact)
• doctors who have rural experiences during medical school and/or residency
  
  

So what do we need to do? We need to support more residency and medical school experiences in rural communities. Possibilities include rural elective opportunities, expanding rural residency training programs or rural training tracks.



We also need to talk about rural medicine as an exciting opportunity! In rural settings, family doctors get to do everything - from deliveries to surgeries to colonoscopies... a family doctor gets to call all the shots (unless the patient's condition is really serious). A family doctor gets to practice his or her full scope of training.



Doctors, especially family physicians, are needed now in rural areas! Otherwise, in a generation's time, we may not have rural communities and rural America!

Overmedicated and confused

"I take three blues at half past eight
to slow my exhalation rate.
On alternate nights at nine p.m.
I swallow pinkies. Four of them.
The reds, which make my eyebrows strong,
I eat like popcorn all day long.
The speckled browns are what I keep
beside my bed to make me sleep.
This long flat one is what I take
if I should die before I wake."
-Dr. Seuss

It may be in a children's picture book but this often reflects the truth. When I was on my geriatrics rotation, it was quite common to see patients on 15-20 different types of medications. In fact, it was rare to see patients who weren't on any.

The problem lies in the fact that often patients forget or refuse to take their medications. When a patient has 15 similar looking bottles, with similar looking pills and miniscular writing differentiating between the pills, this isn't surprising. Heck, I know that when I have to take one pill once a day for 2 weeks, I'll forget on at least 1 or 2 of those days. Not to mention when someone has some level of dementia and is somewhat sight impaired.

This doesn't even take into account that the directions that we write on the bottles (when the patient actually figures out how to read them) are just as confusing as not reading them. Take for example: "take three pills three times a day for 7 days." Does that mean I take 3 pills in the morning, 3 at noon and 3 before bed? Or 1 pill in the morning, 1 pill at noon and 1 pill at bedtime? Or should I space them out to exactly 8 hours apart?

With all this confusion, we've started developing pill organizers and blister packs. Either the patient, a loved one or the pharmacy will organize meds into AM, noon, PM and night time meds. However, studies have shown no difference in compliance levels from using pill organizers.

Ultimately, I believe that thinking of new ways to organize meds or remind patients is not the solution. The ultimate solution is that we need to re-evaluate each medication that each patient takes and try to focus on compliance with the most important of the meds. Does a 95 year old female need to be on a statin? Should a 30 year old male be taking calcium supplements? Maybe or maybe not. But as primary care doctors, it is our imperative to dive in deep and look at whether each and every medication is necessary - to stop specialists from piling on the meds for their unique specialty and to take a step back and look at the bigger picture.

Last week in my dermatology rotation, an attending physician was explaining to a patient's mother the treatment regimen for atopic dermatitis that he wanted to put her son on over an interpreter phone. The patient was to use triamcinolone when there was rash except on the face, tacrolimus on weekends only when there was no rash and hydrocortisone on the face with or without the rash. The poor resident typing the prescription had to ask the attending twice to clarify the correct directions. Now, what are the chances that the mother (a) understood what the doctor was telling her in a different language and/or (b) would be able to find someone to read the directions in English to her?

As physicians we must take a patient-centered approach to prescribing medications. What does the patient want? What is the patient willing to do? And before we get frustrated when a patient returns 2 months later "noncompliant" to our treatment regimen, we must also take a step back and reflect if we were the patients, whether we would be able to be "compliant" ourselves. This reflection will help us become more compassionate and more effective physicians.

Shared Decision-Making is a Two-Way Street

There is one word in ACO that stands out to me – Accountability. Physicians are held to be accountable for coordinated patient care. Likewise, patients must be equally accountable for their own health and personal decisions. The success of our future ACOs may depend upon the mutual interplay between these two circumstances. Negligence on either side will necessarily result in failure. The effort to reduce health care costs starts and ends with the patient – under the guidance and support of a focused and committed family physician.

Education: Simple education – the distribution of information and materials – will not be sufficient. Education is useless without empowerment. Even the greatest teacher will struggle to connect with a lackluster and disengaging lesson plan. Patients must become owners of their own health and outcomes must be linked as much to medical care, as personal choice. Presently, the Institute of Medicine is working to develop guidance for just such an educational venture.

As it stands, CMS has mandated that all marketing of ACOs must be approved by their internal office. Considering the, as of yet, purposefully vague definitions of ACOs – this is a misstep. In commentary to CMS head Donald Berwick, the AMA offered that, “The requirement that CMS approve all ACO marketing materials is an unprecedented, unnecessary, inappropriate, and unworkable requirement.” Wow. That is harsh and bold language. But, I believe that speaks to just how important it is that robust patient education be featured on the nature of their role within ACOs.

Think of shared-accountability as an analogy to a car owner. Most patients aren’t necessarily the best drivers or caretakers of their own car. Everyone that owns a car must get some regular maintenance, inspections, and repairs – this keeps the automobile running well (hopefully). The provider of these services is usually a specialist in that area of car care. However, between these visits, it is up to the owner to ensure the car is maintained. It would be ludicrous if someone were to suggest putting water in the gas tank – yet Americans struggle coming to terms with the right type of fuel to keep their own bodies running and energetic.

Some cars look nice, others are maintained well – and these are always perceived as reflections on the owner. No one looks to the Jiffy Lube guy that changed the oil as being responsible for the well-tuned car. He is certainly an important, and necessary part of the process. But it is the owner’s responsibility to see through the spectrum of car and maintenance. Why, then, do we often view health care and our own bodies in such a different light? Why can’t a physician be viewed as a specialist mechanic that is ready for a quick tune-up, or even an overhaul every once in a while?

At any rate, I certainly understand and appreciate that our bodies are much different from our cars. However, I do believe that the relationships and care can be viewed in parallel. Doctors can teach us how to drive our cars - perhaps even read us the owners manual – but then hand over the keys and let us drive solo for awhile. That is true accountability.

Take the Accountability out of ACOs, and the Care Organization will falter. But, this accountability falls as much on the role of the provider, as it does the patient. Be vigilant that our patient population not fall into complacency, or expect anything less than a working and actively cooperative relationship with their family physicians.

Do ACOs Stack the Deck Against Private Practice Family Medicine?

ACOs have been shopped as possessing flexible application along the spectrum of clinical practice. Indeed, comments by CMS administrators have explicitly contended that the model was created to allow all physician practice groups – large to small – to have the opportunity to join in the shared savings program. However, once you dig into the regulations behind the rhetoric, it quickly becomes apparent that small private practice is meant to quickly sink, and private practice in general may barely be able to swim. It is beyond clear that the specifics of the ACO rules and regulations are outside of the scope of outpatient medicine, if not exclusionary to the private practice setting altogether.

1) Start-Up Cost

The cost of starting an ACO is the first preventive hurdle – and it is quite a big hill. While CMS conservatively proposed an estimated cost between $1,700,000 - $1,800,000, the American Hospital Association (AHA) sees it more in the range of $5,315,00 - $12,000,000. And those are just estimated start-up costs, they do not take into account annual maintenance requirements. Needless to say, this is well beyond the scope of most private practice settings.

Robert Jeibenluft recently suggested in the New England Journal of Medicine that, “provider networks that do not achieve meaningful clinical integration will probably not receive shared savings from Medicare, and most will ultimately fail”1

2) Quality Measure Reporting

ACOs will be required to measure and report along 65 specific quality metrics. This is an all-or-nothing approach, and each ACO has no flexibility in reporting. Most importantly, there is some concern that it will be impossible to meet all 65 requirements outside of the hospital setting. For example, among the discussed quality measures to report include hospital readmission numbers and assessment of the nine hospital-acquired conditions. How does a large scale family practice setting adjust to these requirements?

A flood of comments were submitted to CMS regarding these concerns. While the regulations are still a product of the proposed rule, it is to be seen how CMS will respond. At this stage in the game, awareness is fundamental. While the ACO model has been marketed well from a national standpoint – and it is gaining traction and popularity – it is important to recognize this is not necessarily an all-inclusive or all-applicable solution. Sure, the big hospitals have the chance to buy into the shared-savings program. But, let’s just hope it doesn’t drive out the little guy at the heart of medicine – the private practice family physician.

1. Leibenluft, Robert F. J.D. (2011) ACOs and the Enforcement of Fraud, Abuse, and Antitrust Laws. New England Journal of Medicine, 364: 199-101.

An Appetite for Authority: Psychological Subtleties of Choosing a Specialty

I recently had an interesting conversation with three fellow medical students over a jar of nutella. Two were MS IVs training at a major academic medical center (one budding peds oncologist, one future family physician), and the third was a canadian medical student. I am an osteopathic medical student comitted to pursuing primary care. The conversation started with romantic pursuits, Harry Potter, what to dip into the nutella, but soon evolved into a dynamic discussion about medical specialization, and why we do choose to do it.

Many people believe that the temptation to super-specialize is driven solely by salary…specialties pay more than primary care; they get you out of debt quicker and may allow for a cushier lifestyle. These are undoubtedly key factors for many students choosing a career path in medicine. However, money is an easy scapegoat. When salary is taken out of the equation, much more complex issues of personal investment, ego, and authority begin to surface.

The Canadian medical student in my nutella conversation was quick to remind us that our neighbors to the north don’t pay specialists much more than primary care physicians. Yet, in her view, young Canadian doctors still overwhelmingly prefer to specialize. People want to be experts. It's human nature. The pride that comes with knowing you could be the leading authority on something, and that people would come from all over the world (or all over the hospital) to hear your opinon is incredibly enticing to students. The high salary that specialists get in America is icing on a cake that already looks deliciously prestigious.

As we overdosed on chocolate hazelnut and the jar became pretty unappetizing, our conversation shifted from what’s enticing about specialties to the other side of the coin – what psychological factors turn students off of primary care. The future pediatric oncologist hit the nail on the head. She was telling us about her current sub-internship, working under general pediatricians on complex cases. Each of her patients saw a minimum of seven consults, sometimes up to nine or ten. In most cases, her attending knew exactly what the endocrine guy or the genetics department was going to say. Even as a medical student, she could predict how these consults were going to go, and yet, the culture of a medical center with limitless resources is to cover all bases, gather as many cooks into the kitchen as possible. It made the generalist’s job seem a less important. Even though he was supposed to have the final say on the treatment plan, my friend described a shifted power dynamic that made her attending the low man on the totem pole, a triaging traffic cop. “This is why I’m glad I want to specialize,” she explained. She didn’t work this hard to not be the authority on anything.

Primary care is not for everyone. This friend is going to be a fantastic pediatric specialist, and a caring physician. It would be incredibly short-sighted for me to claim that all students who choose to specialize are motivated by pride and ego. But it would also be naïve to discount these factors in ourselves. Choosing a field of medicine is a complex process that is ideally driven by geunine interest and passion, but often heavily affected by financial and lifestyle concerns, as well as the desire to validate the years of work we have put in to achieve our goals. There is nothing wrong with wanting to practice at a prestigious institution, garner respect from colleagues and be valued as a prominent physician. From time to time, however, it is important to step back and ask ourselves how much the desire to impress others is affecting the choices we make. A primary care physician might never be world’s leading expert on nutella allergies, but family doctors are the authority on their patients. The best ones take ownership of this more subtle authority, even in a kitchen full of cooks.

Redesigning Residency... the pilots

12 + 4 + 4 + 3 = 23 years. From grade school through college and medical school to residency, that's how long it takes to become a family medicine doctor right now. How about changing the 3 at the end to a 4? Asking that question to various classmates interested in family medicine, I've received a range of answers from "WHAT! No way!" to "ah, 1 more year, what's that in the long scheme of things?" to "That's a great idea!"

A 4 year residency program is just one of the 14 different innovations considered by the P4 project (Preparing the Personal Physician for Practice). P4 is a 6-year pilot project started in 2007 in which 14 family medicine residencies across the country are participating. These residency programs range from university-based to community-based and urban to rural. Each residency program is experimenting with some new innovation to improve family medicine training with the goal of preparing residents with real life skills for practice.

Okay - great, so let's get down to the nitty gritty. What are these innovations that are being considered? As I first mentioned, a number of programs are experimenting with either a mandatory or an optional fourth year of training. These programs generally encourage or require residents to choose a "track" or a "focus" that is either incorporated throughout the four years or is focused upon during the fourth year. For example, Middlesex FMRP in Connecticut requires each resident to complete four years while JPS in Texas and Waukesha in Wisconsin have optional 4th year tracks.

Tufts, on the other hand, is focusing on training its residents predominantly in the outpatient setting, since that's where the majority of family medicine actually practice. Meanwhile, University of Colorado is focusing explicitly on teaching its family medicine residents about the Patient Centered Medical Home. University of Missouri-Columbia is allowing 4th year students at its school who are decided on family medicine to start intern-like rotations, because, honestly speaking, the 4th year of medical school (unless really intentionally designed not to be by self-motivation) is generally speaking a waste of time. That's just to name a few of the 14 innovations (not selected by any favoritism but randomly).

We are now more than half way through the 6 year innovation period. The question is then: what are we doing with this P4 information? Do we want all family medicine programs to be 4 years long? Or do we want to start eliminating the 4th year of medical school? Or do we want to be more intentional about where are residents are training and what they are learning?

These are all questions that are being studied and analyzed. This month's issue of Family Medicine, STFM's academic peer-reviewed journal, focuses specifically on these questions. As we approach another RC review (the committee that determines residency guidelines), what changes do we want to make as the future of family medicine so that we can better train physicians to be prepared to serve their future patients? Better yet, what can we as family physicians do to advocate to the ACGME and to the American public about the needs of family medicine training?

Medicine IS Politics

As I sit here cramming in a few last hours of study before sitting for my American Board of Family Medicine exam tomorrow, my smart phone repeatedly lights up. The #saveGME campaign is underway.

While I should keep studying, I cannot. Over the past several days, I have been reading articles and blog posts about the most recent spin in the deficit reduction “circus”—cut GME dollars out of the Medicare and Medicaid budgets. Neither of these issues has gotten traction in the mainstream media, and I know why. None of the journalists had the knee jerk reaction I did to the news: how will we train new doctors? While it is bad enough that most Americans, many of them eager to cut “entitlement” programs, don’t appreciate that about a quarter of our insured population is covered under government insurance (http://www.gallup.com/poll/125417/americans-reliant-government-healthcare-2009.aspx), a.k.a. “socialized medicine”, I presume even fewer residents—doctors in training, a.k.a “medicine’s future”—realize that their paycheck and much of the funding that keeps their training program up and running, comes from the Medicare and Medicaid budget. And if you are in a primary care program, one that is unable to generate tons of income from your services due to a flawed, procedure-based reimbursement system, you are especially dependent on these government funds.

And if the money dries up, the programs close. The vulnerability of primary care programs has been outlined in other blog posts here and elsewhere. The pre-existing shortage of primary care physicians is well known. Heck, the ACGME even titled its 20^th report last year “Advancing Primary Care” (a title that sounds ironic at this moment), and mandated the U.S. increase its proportion of primary care physicians from the current 32% to at least 40%, the critical point at which health outcomes improve and costs decrease.

Despite this, GME funds are on the table.

So as the baby-boomers age, and the generation known as “the first to not outlive their parents’ life expectancy” enter adulthood and pile on their chronic, life-style-induced diseases, and as a morally just health reform law requires more Americans be given affordable health insurance, the roster will bloom with patients. These patients will be sick; they will have multiple disease processes, limited resources, and will demand increasingly complicated and expensive technology in their treatments. And if the GME cuts go through, and specialty programs survive by simply doing more procedures to generate more income for them and more debt for the American public, and the primary care programs shrink instead of grow, our nation’s health will suffer deeply.

The AAFP is mobilizing its members to contact their representatives. It has been lobbying members of Congress for a GME primary care carve-out that would send some funds directly to community-based primary care training programs (currently 100% of GME dollars are distributed to hospitals, who then decide which programs to fund), and it has iterated several more demands to the President directly. But it can do more. In my mind, the fact that most Americans, and most residents, don’t know that Medicare and Medicaid dollars are the key funding source for training all the doctors in this country is not acceptable. We need to use the media better and educate the public on how healthcare is delivered in this country. I think if they knew, they would be outraged.

Tomorrow I will be tested on knowledge that will allow me to say I am Board Certified in Family Medicine. Sadly, out of hundreds, there may only be a single question that tests my knowledge on the politics of medicine. And that’s too bad—because these days, medicine is all politics.