Community Response to Disaster Shows Beauty of Rural Practice
An epic flood ravaged her town, but what Kimberly Becher, M.D., remembers most are the selfless acts of kindness that helped her patients put their lives back together.[Read More]
Family Physicians Can Cut Unnecessary Surgeries
Robust clinical trials demonstrate relevant outcomes of various surgeries. Does a surgery extend a patient's life? Does the surgery decrease a patient's pain? Does it improve the patient's quality of life? Answering these questions, along with weighing risks and other treatment options, should help guide decisions regarding whether to pursue surgery. But even with better data, unnecessary surgeries are still common.
Family physicians are able to take a holistic, unbiased and evidence-based view that can play a vital role in counseling patients on appropriate treatment options.[Read More]
Prior Authorization Call Shows Inefficiency, Absurdity of Process
Family physicians waste hours each and every week on prior authorizations. Ryan Neuhofel, D.O., M.P.H., recorded one such call to illustrate the inefficiency of the process. [Read More]
Support, Flexibility at Home, Work Vital to Success in Rural Practice
I have been reflecting on this blog for several days now, waiting for a rare down moment to write about what being a rural female physician means to me. Tonight, as I finally have some time, I realize that the unique challenges of rural practice make life unpredictable and possibly difficult for other physicians to relate to.
My husband (and practice partner) had rounds this Sunday morning at the hospital, so he dropped my daughter and me off at church and headed to work. At church, I received a phone call telling me that I also was needed at the hospital for one of my obstetric patients. I let my daughter's Sunday school teacher know I would be leaving but that my husband would be back to pick her up.
DMW PhotographyMy husband, Michael Oller, M.D., and I enjoy rural practice in Stockton, Kan., where we live with our daughter, Lyla, and mastiffs Mitch and Mosi.
My husband came back to church to get me, dropped me at the hospital, finished his own work and returned to church to pick up our daughter. A favor from a friend later and we each had a car at the hospital so my husband could take our daughter home while I stayed to deliver a baby.
It might sound crazy, but these are situations we frequently encounter. With supportive partners at home and at work, as well as support from friends and our community, however, they always work out. I sit here tonight having helped bring a beautiful baby into the world but also having had to give up a large part of my Sunday. I consider it a worthwhile trade.
The impetus for this blog was a study published in the May/June issue of Annals of Family Medicine that sought to "understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction." The study was based on a survey of 25 rural female physicians in 13 states.
The authors identified three things study participants considered imperative for successful rural medicine careers:
- supportive relationships with spouses and partners, parents, or other members of the community;
- reduced or flexible work hours; and
- maintenance of clear boundaries between their work and personal lives.
The United States has a severe shortage of rural physicians, including a dearth of female and minority physicians. The lack of female physicians limits access to care for female patients who would prefer a female clinician. Rural female physicians are more likely to attend births than our male peers, which is an important part of practice in many rural areas with a shortage of obstetric care.
Many rural physicians choose this path because it allows them to maintain a broad scope of practice. However, this broad scope often also leads to long and unpredictable hours that vary greatly from week to week. (Today's delivery was the third this week for me, leading to longer hours than usual). Creating the support system necessary to meet patients' needs while also supporting our families takes great effort.
What attracts women to rural practice? The majority of the physicians surveyed had rural life experience. However, there are others, like me, who turned their attention to rural practice after experiencing it in a rotation. I graduated from the University of Kansas Medical School, where a rural rotation is required, and I continue to firmly believe that such experiences matter greatly in the choice of future practice.
We must continue to model for medical students what is great about our specialty, and those of us who practice in a rural setting need to be willing to precept students. It is a rare month when my partners or I don't have a medical student in our practice, and often more than one of us have students at the same time. I am proof that having a female rural medicine preceptor can take a practice setting that had never even been on your radar and make it your career. (That preceptor is now one of my practice partners.)
There are many challenges of rural practice. As the Annals study points out, rural physicians have fewer community resources, work more hours and care for more patients compared with their urban peers. This produces added stress and, at times, feelings of isolation. In the study, physicians with young children and those new to rural practice described feeling the stress of maintaining balance most acutely. The guilt of leaving family to care for patients and, conversely, spending time with family at the expense of time in your practice, are frequent sources of stress.
Those with good work flexibility reported highest satisfaction. For many in the study, this meant reduced work hours, especially when their children were young.
Supportive relationships are also key. Several of the women in the study reported male partners maintaining primary responsibility for managing the household and caring for children. Many had situations similar to mine -- married to physicians in the same practice. In all of those two-physician partnerships, one or both partners worked part time.
Work partners are also important -- other physicians who are willing to help out when family obligations and emergencies arise. We are expecting twins in the fall, and although I don't know exactly what our work schedules will look like when they come, I know that owning our own practice gives us the flexibility we need.
I received an email from my practice partners this evening saying they have devised a back-up call schedule that covers the weeks leading up to the twins' due date. This is the kind of cooperation that makes rural practice, with all of its additional stresses and challenges, sustainable.
Clear boundaries were identified as key for satisfaction. Limiting work and protecting personal time were seen as essential for personal well-being. Work partners often played an important role in this. In my experience, setting expectations for patients can be hard but is extremely important in rural environments; examples include respecting physicians' days off and time with family (i.e., not approaching them with medical questions in a public place).
Corresponding author Julie Phillips, M.D., M.P.H., told AAFP News that rural physicians in the study showed "a really strong sense of devotion to their patients and commitment to their communities." Although it was clear that most physicians in the study loved their work, there were also those looking to change practice because they felt their current situation was unsustainable.
The authors of the study concluded that female physicians considering rural practice may be more satisfied if they seek flexible employment opportunities, choose communities where support is available and build support networks as they select practice settings.
Practicing self-care and setting boundaries are also important skills. These are skills, however, that we are not often taught. Perhaps they could be covered more in medical training, especially in residency. Female physicians entering rural practice need the support of those who have gone before them. These relationships can be fostered through state and national academies, rural interest groups (such as online forums offered by the AAFP), and preceptors encountered during training.
Women need opportunities in residency training to rotate with rural female physicians. Those of us who live this practice style need to be available to serve as mentors and sounding boards. Female rural physicians are more likely than their male counterparts to plan on long-term rural careers, so let's continue to evaluate and work toward making more rural female physicians a reality.
Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.
Stranded Patients, Lost Meds Are Just the Beginning of Flood Disaster
In medical school I took a wilderness medicine course, but after two years of practice in rural West Virginia, I think of that training as "West Virginia medicine."
In a relatively short time, our community experienced a chemical spill in our water supply, blizzards that stranded patients at home, and the temporary loss of our grocery store. The latest crisis, however, is far worse, and its results could be long-lasting.
On June 23, areas of West Virginia received as much as 10 inches of rain in just a few hours. The flood that followed was the most devastating in the state since the Civil War and resulted in at least two dozen deaths.
Photo courtesy of Tabitha ClendeninA church and cars in Clendenin, W.Va., are surrounded by floodwaters. The state suffered a 1,000-year flood on June 23.
The topography of West Virginia demands development at lower elevations because the mountains are often too steep, too prone to slips or mudslides, or just too difficult to build roads or housing on. Many of the state's residents live at low elevations, and the steep surrounding mountains create sluices for rainwater.
When I got to work on Thursday, June 23, my office had no electricity or broadband connectivity, but that isn't a rarity. We can function with a propane-powered generator, and we often do. But as the day went on, the rain did not stop.
I made it home that evening, but within a few hours water was running over the top of my pond's dam. My house is at the top of a hill, but I knew my patients and neighbors were in serious trouble because the strongest of the expected storms had not yet arrived.
Water rose so quickly out of stream banks that people didn't have time to leave their homes, move their cars, or grab valuables or medications. By Friday morning, I couldn't leave my house because all routes were under water. I had cell phone service, so I could see news reports and photos of the devastation as rivers continued to rise. I saw my own town in aerial photographs broadcast on the Weather Channel's and CNN's websites. I recognized some of my patients' submerged homes.
I was able to log into my electronic health record on my phone and looked up patient phone numbers, but the landlines were long gone and I was unable to reach anyone who didn't have cell phone service. Still, I was grateful that those who I had shared my cell number with were able to update me on their conditions.
I was scheduled to work Saturday, and the water receded just enough for me to trudge through mud-covered roads. Around every turn was one heartbreaking sight after another. Floodwater isn't just a wet mess, it carries raw sewage, chemicals and everything else imaginable. The water leaves behind foul-smelling mud that coats everything it touches.
Before going to my office, I stopped at the gas station for water. Within 15 minutes I was able to find out news about quite a few of my patients because the store and its parking lot were full of them, their friends and their relatives since it was the only business in town with power and water.
My office remained dry, so other than having no power, phone, Internet or drinking water, it was not affected by the flood. On Saturday, I only saw a handful of patients, but I also wrote paper scripts for those who had lost theirs or were unable to access meds.
One of my patients was seen driving around town. I knew her trailer had been damaged, and I was really worried because she had recently had a stroke and struggled to control her blood sugar. I feared she would be homeless. When I managed to find her Saturday, she was disoriented and dehydrated because floodwater had breached her trailer, knocked over her refrigerator and prevented her from accessing her insulin.
It's rare for me to see just one person in a given family. One of my patients called Saturday distraught because she had lost everything and was stranded in an area left completely inaccessible due to road damage. I also care for her brother, a complicated patient who lost all of his home health equipment. I wrote them new paper scripts because no pharmacy had e-script or fax capacity. A friend picked up the prescriptions for the patient, but they didn't know when they would see each other.
By the end of the day I had written 50 scripts for meds lost in the flood, and those were for the more fortunate people who still had phone service or were able to relocate to a safe place. I also saw families with sick children who were depending on the good will of friends for a place to stay.
I had no water at home so I went to the grocery store but found none. I stood in the drink aisle with my patients, all of us deciding which flavor of Gatorade to buy.
In the parking lot I saw 10 more patients, all making it out of their hollows for the first time since the rain started, still in their mud-covered clothes, not sure where they were going next.
On my way home, I passed countless people walking along creeks looking for belongings, retrieving dog houses.
One of my former residency classmates called and offered to take me on horseback to any patients I knew were inaccessible by motorized vehicles. I have almost all of my homebound patients accounted for so I haven't yet taken her up on the offer, but I will definitely keep it in mind.
Yesterday we ran reports of patients on meds for high-risk conditions and called each of them to ensure they had their medications and could get out of their homes if an emergency were to arise. Many people live near privately owned bridges that have been damaged or completely destroyed, so they are safe but isolated.
As I sit in my office typing this, emergency storm sirens are going off and rain clouds are rolling in. It literally looks and sounds like a war zone. The number of people reaching out to offer help has been impressive, but with so much destruction and so much unknown (What will the Federal Emergency Management Agency condemn? Will there be emergency housing? When will the water lines be repaired?), it's hard to know where to start or what is most urgently needed.
Some families I care for are sleeping in tents because they have absolutely nothing, and unlike an isolated event such as a house fire, this flood has left an entire community in need. So I've focused on little things with direct impact, like buying people socks and underwear, providing manual labor to carry damaged furniture and carpet out of houses, or delivering pizza and water to people who have no transportation to get to distribution centers.
The governor has encouraged anyone wanting to contribute to flood relief to use the West Virginia Voluntary Organizations Active in Disaster website. I've also suggested contributions to the Clendenin Volunteer Fire Department. Not only did these volunteers save many lives via water rescues, but their station was damaged by 5 feet of floodwater. Some fire engines were still inside because crews were out on boats. One of my neighbors continues to take vacation time from his paid job to volunteer extra shifts for the fire department.
I feel like a broken record, but we must all be prepared for disasters. We all should have a plan for addressing the possibility of losing access to food, water or electricity. And as family physicians, we need to be familiar with disaster response protocols for our communities and our practices, or at least know where to find necessary resources or guidelines.
Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.
Clinical Case Managers Improve Chronic Care Outcomes
Every primary care physician is familiar with the complex challenges involved with comprehensive health care delivery. The task can seem particularly daunting when facing communication barriers or when treating the underserved, the disabled and the elderly. Because of this, there is a great need for third-party facilitation through care coordinators, case managers, social workers and lay medical workers.
I first experienced this when I was a resident in the South Bronx. I was intrigued by the benefit of utilizing community health workers as physician extenders who reached out to their communities through patient education and coordination, both in the clinic or hospital and in patients' homes. Now a family physician in my third year of practice, I find great value in care coordinators who facilitate and streamline transitions of care between inpatient and outpatient settings. In our medical home, I frequently use licensed clinical social workers to provide counseling and patient education in smoking cessation, weight management, chronic pain, illness and addiction recovery.
We also have added a clinical caseworker for chronic care management to ensure optimal communication and continuity of care with our Medicare patients. This service has closed gaps in communication and maximized educational opportunities that might have been missed in the past. Chronic care management also provides a significant opportunity for improvements in medication reconciliation, care coordination, patient retention and appointment follow-through.
Despite these benefits, two main limitations prevent some Medicare patients from taking advantage of chronic care management. One is the challenge of communicating to the patient the benefits of having access to a clinical case manager. The other is the added expense incurred by the patient. Even though the cost is minimal, many patients on fixed incomes view it as an obstacle. It's important to note that when patients have supplemental insurance, we are able to reassure them that the copay likely will be covered and they usually are more willing to sign up.
Despite these barriers, I have had many patients agree to the service, and they have found it to be quite beneficial.
I had one patient in particular who was completely unclear about the appropriate use of his medications. He had the misconception that he could take all his medications according to his own sliding scale. His reasoning was that he was concerned about side effects and the risk of becoming dependent. This patient had insulin-dependent type 2 diabetes, as well as hypertension, hyperlipidemia and testosterone deficiency, all of which was clearly out of control by the time my case manager reached him.
Through a collaborative approach, patient education and consistent reinforcement, we were able to rein him in and get him to the point where the medications listed in his medical record actually matched what he was taking. He was proof that the more eyes on the chart and the more communication with the patient, the better.
After seeing successes like this from a physician's point of view, I wanted to hear more from others who make this physician-led collaboration work in my practice. Here's my interview with clinical case manager Cindy Cody, R.N., who joined the program when it began in 2015. It has been edited for clarity.
Q: What do you like most about this position?
A: Helping people to feel better about themselves and to realize that they are only human. So often, while working with patients to lose some weight or lower A1c levels, we can get so focused on the number and think they failed if they are not seeing big results. But it really changes your perspective when you talk with the patient and learn that they cut down from drinking five sodas a week to three or started eating a salad for a meal, etc. Little changes deserve to be recognized and can add up to the big results. That recognition often helps provide the additional motivation they need to make further changes.
Q: What do you like least about this position?
A: The chronic care management program is paid for by Medicare, but sadly it often leaves a copayment for patients. Most of these patients are either disabled or elderly and living on a fixed income. This copayment is the reason many patients do not enroll in the program.
Q: What works really well about this service?
A: Helping to ensure all is being done for patients to improve their health and develop positive outcomes. I also find patients will be more forthcoming in a phone call in their own home environment than in conversations during an actual office visit. Patients often tell me things during these phone calls that they might be reluctant to say in the office. I also love how it's a check for these patients between visits. I have ladies in their 90s who really need that additional personal call each month to check in on their safety and health status. With these patients, I often work to help decrease fall risks and injuries. These patients then have an open line to call their clinical case manager directly during the day, where they can talk to someone they know if they have a question or problem. Many like having that security.
Q: What could use some improvement?
A: Honestly, I often hear physicians voice that they do not see the need for this program and will not utilize it, or at least not to its full potential. It can be such a benefit to the patient, as well as an extension of the physician's hands so they can reach these patients at home between clinic visits. When we are utilized to our full potential, it benefits both patients and physicians. For example, if an M.D. changes diabetic or blood pressure medications, you can ask the clinical case manager to call them in two weeks and get home readings. In doing so, a clinical case manager may also be able to provide a little additional education or reiterate what was already given to the patient to help improve results. Getting those numbers to the M.D. may provide an opportunity for another dose adjustment before the patient's followup visit. The clinical case manager can follow up again with that patient to clarify new medication instructions and verify that the desired results are achieved.
Q: What have you learned that opened your eyes to the need for this service?
A: So often things can fall through the cracks, and there is such a need for someone to be looking for these lost items.
There are limitations to using case managers as physician extenders. However, the more we take advantage of the services they offer as part of a physician-led team, the better we are able to coordinate care, close loopholes, improve patient education and fill gaps in physician-patient communication.
Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.
FP Salaries Increasing, But How Much?
Editor's Note: Physician search and consulting firm Merritt Hawkins and the Medical Group Management Association recently released their annual reports on physician salaries. Both groups noted sizable increases in compensation for primary care. A few family physicians who are regular contributors to this blog changed jobs in the past year, so we asked them to offer their opinions on those reports and their insights on the job market.
Peter Rippey, M.D., Bluffton, S.C.
The most intimidating thing I had to do during my residency and fellowship training had nothing to do with patient care. It was negotiating my first employment contract.
Of course, one of the most important parts of the contract for new physicians, who often have $200,000 or more in student debt, is the starting salary. Merritt Hawkins recently announced that for the first time in the history of the search firm's annual report on physician salaries the average starting salary for family physicians eclipsed $200,000. In fact, based on the thousands of search and consulting assignments Merritt Hawkins conducted on behalf of its clients from April 1, 2015, to March 31, 2016, the firm said the average starting salary for family physicians increased 13 percent to $225,000.
The Medical Group Management Association recently released similar findings in its annual survey, stating that median primary care physician compensation rose more than 4 percent to $250,000.
Family medicine was Merritt Hawkins' most requested specialty for the 10th consecutive year. It's no secret there is a shortage of primary care physicians. Add the fact that a well-trained family physician can fill virtually any primary care void and you have a recipe for high demand, which is one driver of higher compensation.
But before all of our third-year residents start salivating over these numbers, this is where I put an important asterisk.
* Individual results may vary.
I would love to tell you that all new FPs can expect these high salaries. However, this was not my experience when I changed jobs last year. We have to mind the demographics of Merritt Hawkins' sample. The majority of the settings involved were hospital-based, employed positions and in communities with populations of more than 100,000. Salaries also vary by region and practice setting.
Also keep in mind that Merritt Hawkins is a recruitment firm, so employers using these services may have more resources, which could translate to higher salaries. It's also possible that using a recruiting service could indicate more trouble hiring or retaining physicians, which may cause salaries to skew higher.
Personally, I am not making anywhere close to the average Merritt Hawkins is reporting, and I have a certificate of added qualifications in sports medicine to boot. I think these reports can give us a starting point for negotiating a fair salary, but I would be careful about doggedly expecting to start out making that kind of coin.
Also keep in mind there is more to a job than a salary. I have worked jobs where no amount of money could have made me stay. For me, considerations such as location and type of practice are just as important as the salary. Let's also not forget that job benefits -- including insurance, retirement and bonuses -- are not created equal.
However, it is promising that salaries are trending up given the increased demands and responsibility of primary care physicians. I think this breeze is indicative of larger winds of change where increasingly primary care is stepping up responsibility for coordinating patient care, improving health care outcomes and increasing the efficiency of health care delivery.
The importance of primary care's central role in a vibrant health care system is finally starting to be recognized, respected and valued.
Natasha Bhuyan, M.D., Phoenix
The shortage of primary care physicians is expected to reach 31,100 by 2025, according to the Association of American Medical Colleges. There isn't a magic bullet to alleviate this shortage; it will require health care delivery reform, incorporation of technology into health care, increased funding for residency training, and team-based care with more advanced clinical practitioners. In the meantime, groups desperate for physicians are responding to market demand with vigorous recruitment.
As a resident in search of employment last year, I was pleasantly surprised to see how aggressively family physicians are recruited. Of course, there are the standard recruitment techniques of endless mass mailings and targeted headhunters. However, with increasing primary care demand, recruitment strategies are growing more sophisticated and responsive to physicians. The most obvious recruitment tool is a competitive salary with impressive signing bonuses (an average of $40,000 in Phoenix) or loan repayment.
Many places I interviewed offered high base salaries with reasonable quality performance bonuses as well. Each interviewer offered $10,000 more than the last. I also quickly learned employers are flexible in all areas of contract negotiations, including non-compete clauses, CME and even paying for examinations/licensing and professional membership dues.
Non-financial aspects also are used as recruitment tools: better call schedules, sophisticated electronic health record systems and minimized administrative burdens. I was particularly glad to see that many places I interviewed valued primary care physicians through leadership and governance. Some have compensated committee roles for physicians -- a move that shows our ability to transform care delivery is valued as well as our direct clinical skills.
With the trends in health care, I anticipate family physician salaries will continue to increase. However, job satisfaction isn't dictated simply by money. Rather, the structure of health care delivery will have to change for primary care physicians to truly deliver on the quadruple aim of better health, better delivery, lower costs and higher physician job satisfaction.
Helen Gray, M.D., Kirkland, Wash.
In November, I wrote about my move from Nevada to Washington in this blog. I learned a lot about changes to costs of housing and living. Keeping this in mind, I made sure that when I negotiated my contract my salary would be fixed and guaranteed for the first two years, and that I would be receiving compensation commensurate to the increase in spending I would experience in a different state and bigger city.
Although the numbers are available, I had a difficult time finding data on average compensation for the location I was moving to. Eventually, after Googling for what felt like days and asking numerous colleagues in the area, I felt like I had a good idea of what I should ask for without getting laughed at when it came time to negotiate.
Negotiating and contracts are not things I'm fond of, though it's worth noting that the AAFP has resources that can help. So imagine my relief when my initial offers from the potential employers I was considering were actually comparable to the community's market. My salary increased 20 percent with the new job.
I will say, however, the starting salary offered to me as a physician now four years removed from residency in an urban area with a high cost of living is not the number noted by Merritt Hawkins.
I was involved in recruiting for my Nevada practice prior to relocating, and I can say that the starting salaries there were even lower than those here in Washington. The Merritt Hawkins numbers were a little surprising to me and my colleagues with whom I discussed the results.
It is great, though, that family medicine is becoming more desirable and that salaries are going up. This could help to address the primary care shortage.
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