Tuesday Jul 12, 2016

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 Photography
My 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.

Tuesday Mar 29, 2016

So Long, New York, You Were Exactly the Trial This New FP Needed

As an osteopathic medical student in Arizona, I had a lot of classmates and professors question why I wanted to go across the country to New York City for my residency in family medicine.

The West Coast -- where I grew up -- has a strong family medicine tradition, whereas New York City is perceived to have a strong focus on specialty care. Not only have I met several New Yorkers who did not even know that family physicians exist, I have worked with medical students whose school has no family medicine department and with other medical students who question whether they can find a good job in NYC if they pick family medicine.

So why choose to be in an environment that might, at best, be skeptical of family medicine?

My residency, the Mount Sinai Beth Israel Residency in Urban Family Medicine offers a diversity and complexity of patients that is unique to New York. With patients from around the globe, we had to keep a broad differential in mind as we also learned to treat the "bread and butter" family medicine cases.

But there was something far more important to my learning as a physician than the diagnoses that I made. My patients not only came from different countries, had different socioeconomic backgrounds and spoke different languages, they often had differing views of disease processes and expectations of the patient-physician relationship.

In medical school, we learned the textbook ways to diagnose and treat, but in residency I learned how much patients' cultural backgrounds can influence their recounting of symptoms and their relationship with their own body. We know how crucial the history is to finding the right diagnosis, particularly as we try to minimize extraneous and expensive tests that add burdensome costs for our patients and our health care system. When the patient and the physician have wildly different life experiences, language is often not the only barrier that needs to be recognized in order to appropriately diagnose and care for the patient.

After residency, I continued with the same family medicine organization that my residency was affiliated with. I have spent nearly three years in the Bronx with an international patient population, many of whom have language, health literacy and socioeconomic barriers that make it difficult for them to navigate our health care system.

I am surrounded by all the subspecialists that New York has to offer -- several of whom are rated top in their field -- but the majority of my patients simply cannot access them. Their need for a family physician and a patient-centered medical home (PCMH) to support their health and the health of their family is dramatic.

When they enter my clinic and find friendly staff who know their name, speak their language, and do not judge them for a lack of insurance, employment or even basic reading skills, my patients begin to feel hope.

When we ask them questions about their ability to access healthy food and whether they feel safe in their current housing situation, my patients begin to realize that we in family medicine understand how much social determinants of health impact our community.

When our clinic goes to great lengths to obtain records from outside clinics and to call patients to come in for a visit after their recent trip to the emergency room, my patients begin to understand what it means to have a family physician and a medical home.

There are many community clinics throughout the country that have made a commendable effort to gain PCMH recognition and to be part of a safety net for their patients; our clinic is not unique in that respect. But there are times when the degree of disparity between my patients and the affluent patients who can access the "best" care in the nation clearly weighs on my patients. They are deeply aware of what they do not have and what they cannot access. And they are often resentful of the discrimination they have faced because of these disparities.

Working within this community has enabled me to witness firsthand what I learned while pursing my master of public health degree -- that a community's resources and environment can have an enormous impact on the health of its residents. It has been exciting to be part of my local AFP chapter and to contribute to the enactment of bills that can make a real difference in the health of New Yorkers, such as a lower speed limit to reduce pedestrian deaths and expansion of health coverage for pregnant women.

In a few months I'll be moving back to the West Coast, primarily for family reasons. It was a difficult decision, and there are many things about New York -- particularly the people I've come to know -- that I will truly miss. As is true with any major change, my upcoming relocation has given me the opportunity to reflect on my time as a family physician in New York. This is the only environment I've worked in as a practicing physician, and although I have encountered the occasional frustration when dealing with a subspecialist here and there, the overwhelming experience has been better than I even imagined when I applied during medical school.

Family physicians are a diverse group with a diverse set of skills to treat the communities we work (and often live) in. My work during the past several years has taught me a great deal about caring for communities that are in need of creative, evidence-based, compassionate primary care. I have built a foundation that will influence my practice of medicine wherever I go, and for that, I will always be grateful to New York and its patients.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

Monday Sep 28, 2015

Questions About DPC? FMX Sessions Offer Answers

I recently received an email from a physician who was just out of residency and contemplating his future career options.

"Even as a resident, I was incredibly frustrated by the limitations placed on my primary care practice by billing and documentation demands and disillusioned by the lack of support for caring for patients beyond the four walls of the clinic," he wrote as he explored the possibility of starting a direct primary care (DPC) practice.

Since I presented at the Direct Primary Care Summit in July, I have talked with a wide range of physicians with nearly identical sentiments. Some are seeking tangible advice on starting a DPC practice, some are just venting, and others have given me words of encouragement.

Given the variations and rapid growth of DPC, it's difficult to pinpoint an exact number of direct-practice physicians. However, at least 500 DPC practices are now operating, and the vast majority of them opened in the past 12 to 18 months.

It's clear from my email inbox that there are thousands more physicians considering making the switch to DPC and many of them have questions.

This week, the AAFP Family Medicine Experience (FMX) in Denver will give physicians more opportunities to learn about DPC, including a dedicated track. "Delivering Patient Care, Not Paperwork" is scheduled for 8-11:30 a.m. on Oct.1 in Room 201. The session repeats at the same time on Oct. 2 in Mile High Ballroom 4D.

I will be joined by Josh Umbehr, M.D. and Doug Nunamaker, M.D., who practice in Wichita, Kan. Together with attorney Michael Campbell, we plan to cover a wide range of DPC topics. A key distinction between a DPC practice and a traditional, insurance-based practice is the relative simplicity of operating the business. However, there are many unique considerations when owning and operating a DPC practice. The questions I have fielded have been numerous, but here are a few of the common ones we will address:

  • Should I go fully direct or keep some insurance contracts?
  • How should I notify my patients if I switch to the model?
  • What can I do with Medicare patients?

On a broader front, the DPC track will cover three main areas, including

  • reviewing the unique features of DPC and relationships with other models;
  • practical steps in starting a new DPC practice; and
  • legal aspects of DPC practice, including Medicare issues.

On Oct. 3, there will be a meeting of the DPC member interest group (MIG) -- which is now the largest of the Academy's 11 MIGs -- from 8-10 a.m. The meeting will feature an open discussion of DPC-related topics, and leaders will give a legislative update and conduct elections of new officers for the group.

The flexibility of DPC allows it to fit a group of patients and a community and is one of its greatest strengths. Doctors can creatively tailor their practice to meet those needs, but we hope to first set the stage by sharing the framework and common traits of a successful DPC practice. I'm hoping the upcoming events at FMX will help further explain how DPC can be a viable option for family physicians and the health care system.

If you're not able to join us in Denver, be sure to keep an eye out for future opportunities to learn more about DPC practice. Upcoming AAFP-hosted DPC events include an Oct. 24 workshop in Dallas and an April 2 workshop in Detroit next year.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Thursday Jul 16, 2015

Direct Primary Care Model Poised for Rapid Growth

Direct primary care (DPC) physicians have been connecting with each other in recent years, usually sharing tips on what we’ve learned, but also offering words of encouragement and venting frustrations. These conversations often occur on Twitter, via email or by phone, but we’ve also had a few chances to connect in small groups at family medicine events.

In the past year, a few organizations -- including the AAFP -- have hosted DPC workshops or networking events for physicians in the planning stages of starting a DPC practice, but gathering a large number of early adopters was a rare feat. That's what happened this past weekend at the Direct Primary Care Summit in Kansas City, Mo.

© 2015 Sheri Porter/AAFP

Attendees listen to a speaker at the July 10-12 Direct Primary Care Summit in Kansas City, Mo. The event drew more than 300 physicians from 45 states.

 

In the first few years of my DPC practice, I could easily keep tabs on the new DPC practices opening around the country, speaking to most of them at some point. The passion and vision of these physicians have been refreshing and truly inspiring. Thanks to the hard work of many people at the AAFP, the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium, I knew the DPC Summit was going to be well organized and well attended.

According to the final tally, there were 317 attendees from 45 states, including 54 physicians who already were established in a DPC model and 107 who are in the early or planning stages of building a DPC practice. About half of the attendees were exploring whether DPC was a viable option for them. About 10 percent were residents.

Despite the diversity of the groups, one thing was clear from the opening night’s events: These doctors and associated DPC organizations were passionate about how to better care for patients. The energy of the entire summit was electric. A number of DPC physicians’ stories allowed attendees to see what it’s really like to be a DPC physician in its various forms. Topic-specific presentations covered the nuts and bolts of operating or joining a DPC practice. A resident led a group discussion of how DPC education can be incorporated in the education curriculum. Attorneys and policy wonks covered the legal and advocacy efforts surrounding DPC issues.

The highlight of the weekend for me was my own patient, Blaine, who shared his story about experiencing DPC in my practice. As I’ve learned from attending patient advocacy conferences, nothing is more powerful than a patient’s story. He perfectly embodied why our model can be a game changer -- and possibly kick-started his career as a stand-up comedian in the process. “That A1c is going to snitch you out,” was the single best line of the event.

How quickly will the DPC model grow? It’s difficult for me to predict any numbers with confidence, but if the summit was any indication, the model is poised for rapid growth.

One of the things the summit demonstrated to me was the adaptability of direct practice doctors/clinics based on community needs, something missing in the micromanaged status quo. Some of the DPC practices were helping large employers or unions in urban areas tackle escalating health costs, while others based in rural towns were working with a large number of uninsured patients. The creativity of DPC physicians is truly awesome.

The AAFP has upcoming events that will provide more opportunities to learn about DPC, including my presentation about starting and running a DPC practice July 30 at the National Conference of Family Medicine Residents and Medical Students. Another Kansas-based DPC doc -- Joshua Umbehr, M.D., of Wichita -- will present an even more in-depth look at DPC during two sessions Oct. 1 and Oct. 2 during the 2015 Family Medicine Experience (FMX) in Denver.

The Academy's DPC member interest group will meet Oct. 3 during FMX, providing yet another opportunity to network and learn more.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Tuesday Dec 09, 2014

Direct Primary Care Doc Sets Record Straight

Since starting a direct primary care (DPC) practice nearly three years ago, I've become accustomed to skepticism and even the occasional criticism. Given the status quo, I understand it's difficult for some to envision a model that could be better for family physicians and our patients than traditional fee-for-service practice.

Two common concerns about DPC have emerged during my conversations with fellow docs, and those concerns were reflected in the comments on a recent AAFP News article on the topic. I will try to address both issues here.

"Many Patients Cannot Afford to Participate in a DPC Practice"
Affordability should be of concern to all physicians. One of my chief motivations for starting a DPC practice was to serve patients who I saw struggling to afford care in the standard fee-for-service practice. Most DPC docs I know report the same.

Here I am examining a patient at my direct primary care practice. I opened a DPC practice in Lawrence, Kan., nearly three years ago.

It is our current mish-mash of public and private managed care -- not DPC -- that has inflated health care costs for all parties. Although employers and governments can (for now) subsidize absurdly high premiums for some individuals, having coverage doesn't automatically equate to being able to afford care. For many of those with insurance plans, meeting out-of-pocket costs remains a big burden. I routinely see patients with insurance who tell me they avoided seeking primary care -- often at their peril -- for years because of high or uncertain out-of-pocket costs. I suspect hurried physicians, shielded by their billing departments, do not always hear these concerns from patients directly. It's easy to overlook the unseen.

Some media outlets and critics of the DPC model have offered examples of docs charging higher "concierge" rates. In reality, there is a wide range of DPC "retainer" fees, with most being between $30 and $150 per member per month. Newer and quickly growing DPC practices typically charge prices at the lower end of that spectrum. My average membership fee is about $42 per member per month, and many families pay less than $30 per member per month.

Most DPC docs return that value to patients in a number of ways. Being membership-supported -- and not needing to make a profit on ancillary services -- we can offer drastic discounts on labs, diagnostic testing, medications, procedures and more. Just last week, I was able to provide nine doses of sumatriptan to a new patient for $8.12. She had previously been paying more than $100 per month through her insurance for the same amount of the drug.

I also recently managed a forearm fracture in an uninsured patient for a total cost of $45 ($10 for a splint, $25 for an X-ray, and $10 for cast a few days later). These patients certainly don't think our membership fee is unaffordable.

Many of my patients, including those with insurance, save more money on these ancillary services (versus traditional prices) than they pay for their membership each month. And they get unlimited visits with their personal physician without copays.

With improving technology, scalable models and use of physician extenders, I believe DPC membership prices can and will continue to trend even lower. What level of DPC pricing would be low enough to deem it universally affordable? I rarely hear critics give an acceptable dollar figure. I recognize some people may struggle to afford even $10 per month, but does this sad reality invalidate the entire concept of DPC?

Many critics often jump to the conclusion that direct payment models are proposing abolishment of all forms of government assistance for health care. This certainly does not need to be the case.

In the past year, there have been some creative partnerships in payment models to support DPC. Qliance in Washington is caring for members of a private Medicaid managed care plan. Iora Health is providing care to Medicare Part D members in Phoenix. Turntable Health in Las Vegas is available to all members of the exchange-subsidized Nevada Health Co-op. Many employers and unions have also opted to support quality primary care using DPC across the country.

Regardless of whether these payer partnerships represent the best way to organize things, they do show that third parties can help individuals and families secure access to DPC. Alternatively, we could also allow individuals receiving government assistance to control a portion of that money directly to purchase routine care how they see fit.

Finally, let's not forget the fact that many primary care docs are juggling too many patients and too much paperwork, which itself has profound downstream impacts on our expensive system. I realize there will not be a simple fix to our health costs, but higher-quality primary care must be a part of that solution. I haven't seen any other solution that fits that requirement better than DPC.

"The DPC Model Will Worsen Our Primary Care Workforce Shortage"
Our national shortage of primary care physicians was created by decades of perverse incentives. Despite numerous carrots and sticks, there is no significant reversal of that trend. Intuition may dictate that physicians taking on smaller patient panels in a DPC model will exacerbate this problem, but that's not the whole story.

I've heard DPC critics claim that docs taking "only 600 patients are abandoning other patients" (previous or potential). From my perspective, however, this is an odd critique, given that virtually every doctor in traditional insurance-based practice must also close his or her practice to new patients at some point.

Some primary care physicians stop taking new patients at 2,000 active patients, and others take on more than 4,000. Is the doctor with a smaller panel of 2,000 abandoning patients? In other words, what is an ethically "sufficient" panel size for a primary care physician? And who should be the arbiter of this theoretical obligation? I trust individual physicians to make that decision for themselves.

We all know that overburdened family physicians are retiring early or finding nonclinical positions. I have met a number of burned out colleagues who are considering both options, but DPC has given them some hope of continuing clinical practice. For my part, I would posit that a doctor who still actively cares for 600 to 1,000 patients per year provides more value to the health care system than one in retirement.

Regardless of how few or how many patients we each take on, ultimately, the only long-term solution is for more students to choose primary care and have long careers. Medical students contact me regularly and tell me that the promise of DPC is what is encouraging them to enter or consider family medicine. Given that choosing between primary care and subspecialty care is a zero sum game, if DPC tips the balance in our favor, I think we can all agree that patients are better off.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Monday Nov 24, 2014

Here to Help: Launching Free Clinic Is Culmination of a Dream

One of the reasons -- probably the biggest reason -- I chose a career in medicine was to help people. I know it sounds trite because we all write about "helping people" somewhere in our medical school applications or our residency personal statements. But for many family doctors, helping people is truly a life's pursuit, a calling.

I first realized I wanted to be a doctor when I was in high school, and for a long time, I have wanted to find a way to give back to my hometown. Two years ago, I started taking steps to make that long-time dream a reality. The mayor of Falmouth, Ky., approached me about improving access to care in my home county of Pendleton, and that opened the door to discussions about free health care for the residents of the county.

Back in 1997, my junior year of high school, flooding along the Licking River submerged the city of Falmouth under several feet of water. Costs for repairs and rebuilding were in the millions, and many of the town's 2,000 residents left, never to return. The city and the surrounding county lost more than buildings and money. They lost hope.

To add insult to injury, the burden of chronic disease has increased in the area in recent years. For example, nearly 30 percent of the population smokes cigarettes. It doesn't help that according to the Health Resources and Services Administration (HRSA), there is just one doctor for every 7,349 residents in the county. Before the flood, access to care was an issue, but enticing new physicians or even hospital-related services became harder when businesses started closing down and the population declined.

As the mayor and I discussed these depressing statistics, we quickly realized that improving the health of the population would require more than just a free clinic. There's more to health than simply not having a chronic condition such as diabetes, taking the right medication, or even seeing your doctor on a regular basis. Health encompasses all aspects of our lives, from the food we eat to our ability to have a safe and restful place to sleep. The goal for the project became meeting not only the physical needs of the population, but building a sustainable culture of health by helping folks better communicate with each other and use their talents to support each other.

My vision, as I speak with representatives from groups like the health department or the Cooperative Extension Service, involves tapping the resources of individuals that utilize the clinic. Every person has something they can contribute to build community. If a middle-aged, self-employed father of three with hypertension comes to the clinic for treatment, the plan is for one of the registration staff to ask him about any special talents or skills he might possess. Let's say he's a carpenter, and he's willing to volunteer his skill and time in that area if a need arises. It's not a requirement for getting medical care, and we are taking great care to make sure patients understand they have no such obligation. But let's say he volunteers. This means that next week, when elderly Mrs. Smith, who's otherwise healthy but is virtually stuck in her home because she can't navigate her front stairs any longer, comes into the clinic for her arthritis, I would have a resource to tap to help build her a ramp.

While this is just an example, the idea of citizens helping each other forms the foundation for the project. Rather than assuming I know everything or have everything that people need, the plan is to help the members of the community discover how they can help each other. Too many times, free clinics open to provide only disease management, forgetting about health.

Like most things I tend to write about, this story doesn't have an ending yet. The group involved with the clinic has grown from two or three people to encompass multiple individuals, local organizations, and even city and county governments. We recently learned that the building we've been hoping to use as a base of operations will be ready for business in early December. As the process continues, I plan to post updates, mostly as an encouragement to others to continue giving their time and talents to help underserved populations.

Although time pressures and financial demands can make the process of providing free care daunting, multiple entities exist to help physicians -- particularly primary care physicians -- provide low-cost or no-cost care in urban and rural areas with the highest need. Via the National Health Service Corps, HRSA provides grants, loans, loan repayment, and scholarships for physicians agreeing to practice in federally designated health professional shortage areas. The federal government also extends medical malpractice coverage to free clinics via the Public Health Service Act, Section 224(o), and the Federal Tort Claims Act through an application process.

The AAFP Foundation provides assistance to no-cost clinics via the Family Medicine Cares USA program. The foundation offers grants to purchase equipment or supplies for new and existing free clinics in underserved areas. Applications for the program can be found on the Foundation's website, and the deadline for the next award cycle is March 15.

The plan for our group involves utilizing all of the above and even seeking some outside-the-box sources of funding, such as federal telemedicine grants. We're now working thanks to the generosity of private donations of time and money, but to maximize efficacy, the team is considering multiple different funding sources. We may eventually pursue creating a federally qualified health center.

My story, thank goodness, is not unique. Hundreds of doctors, medical students and allied health professionals across the country serve the needs of underserved populations. As new physicians, time and economic pressures may hinder us from helping others beyond the scope of our everyday practice, but multiple groups exist to help alleviate those stressors. I encourage you to check out the links above, whether you're already providing indigent or no-cost care or want to start. And feel free to add other resources for physicians in the comments field below.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Wednesday Sep 03, 2014

Frequently Asked Questions -- and Answers -- About Direct Primary Care

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the eighth post in an occasional series of blogs that will look at the different roles family physicians can play.

"Is that actually working for you?"

© 2014 Michael Laff/AAFP

I recently participated in a panel discussion at the AAFP's National Conference of Family Medicine Residents and Medical Students along with Abbas Hyderi, M.D., M.P.H., left, and Lilia Cardenas, M.D., center. Students and residents had a lot of questions about my direct primary care practice.

"What if a patient gets hit by a bus?"

"What about patients who are publicly insured?"

Whenever I discuss my direct primary care practice, I expect a barrage of questions. After opening my DPC practice more than two years ago, I think I've heard them all.

When I participated in a panel discussion recently at the AAFP National Conference of Family Medicine Residents and Medical Students, I was ready for all comers. The panel covered a range of family medicine topics, so I only briefly spoke to questions regarding DPC. But afterward, a sizable group of curious students and residents approached me. Several had already thoroughly researched DPC, but most had just recently been introduced to the idea.

A few themes -- and perhaps misperceptions -- emerged. I will try to address a few of them here.

Q: How do your patients get labs, meds, specialists or surgery?

A: My chief concern is my patients' care when I am sitting in the room with them. Family physicians can provide comprehensive care to 80 percent to 90 percent of people at most times in their lives. Enhancing our services should be our main focus. How can we provide the best primary care in an efficient and affordable manner? The better we do our job, the fewer hospitalizations, consults and coronary stents patients will need.

I do have a good portion of patients who have ongoing needs for chronic conditions. A membership-based direct model has allowed me to do innovative things to assist in those areas. We provide labs, meds and procedures at huge discounts. We subcontract lab services and provide members most routine labs (lipids, A1c and many more) for no charge and others with minimal fees. Selling wholesale medications directly to patients often results in hundreds of dollars in savings per month for individual patients. Most procedures are $10-$20 to cover the cost of supplies.

Q: What about insurance?

A: Direct primary care is not anti-insurance. Sometimes, although rarely, people really do get "hit by a bus." Insurance is absolutely necessary for certain types of care. Some events and conditions are inherently expensive. I encourage all my patients to have an insurance plan in case of such an event.

However, hypertension management and radiation treatment for brain cancer are radically different things. Why should we pay for them in the exact same manner? For better or worse, the move toward higher deductible insurance plans has created a demand for transparency among patients. Direct primary care can help fill that void. For many of my patients, combining a high-deductible health plan (a "bronze" level plan on insurance exchanges) with a DPC practice membership with us is a significant savings versus a Cadillac, low copay plan ("gold" or "silver").

Despite my recommendations, many of my patients are uninsured. This is not ideal, but they will
continue to get stellar, continuous care with us in the meantime.

Q: What about someone who cannot afford the DPC membership?

A: The main reason many people cannot afford health care is because it's too dang expensive. Most of my patients found us because they could not afford insurance premiums and/or out-of-pocket expenses under the current system. They could not afford to be without direct primary care.

Although "affordable" is a relative term, I recognize some people have trouble paying even modest DPC membership fees out-of-pocket. There are many ways we could assist people in obtaining care outside of the status quo.

When DPC physicians advocate that insurance be removed from the primary care picture, many people jump to the conclusion that we are therefore calling to end all public assistance. But this is not the case.

There are a variety of alternative funding mechanisms -- outside of subsidized managed care -- that could assist people in getting better primary care. Some progressive health insurance plans and DPC practices, such as Qliance (Washington) and Turntable Health (Nevada), have partnered and are available on state-based exchanges, which is allowed for in the Patient Protection and Affordable Care Act. Also, permitting a portion of public assistance funds to be controlled by patients directly -- via health spending accounts -- could help pay for DPC practice membership fees.

Q: Is DPC really a viable option for me and my patients?

A: There are a number of factors that should be considered before switching to this model of practice -- both personally and from a business standpoint. Despite some stereotypes, DPC practices are not monolithic. Many docs have succeeded with varying models and in a wide variety of communities and populations. However, growing a practice is not easy or without risk. Research and a solid business plan are required.

An increasing number of resources are available to help doctors start and manage a DPC practice. The AAFP recently created a member interest group for DPC, and the Academy also is offering a series of DPC workshops, starting in November.

Even without systemic changes, patient demand for high-quality, affordable primary care will grow. I hope more family physicians will join in meeting that demand.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Tuesday Aug 12, 2014

Sense of Community: CHCs Offer Way to Battle Health Disparities, Social Injustice

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the seventh post in an occasional series of blogs that will look at the different roles family physicians can play.

I am coming up on the two-year anniversary of starting my first clinical practice in a community health center. The joys have been great -- as have the challenges.

I've been passionate about working in a community health center (CHC) since I first learned about the opportunity as a medical student. The biopsychosocial model of care that is a hallmark of family medicine strongly resonated with me, and it made perfect sense that a CHC would be the ideal place to bring that model of health care to life given that these centers provide comprehensive primary care to medically underserved communities and vulnerable populations.

The team-based model of care used in our community health center helps me meet the complex needs of my patients. Here I am (far right) with my medical assistant, team assistant and case manager.

With a directive for half of a CHC's board of directors to hail from the local community, there is a built-in mechanism to ensure these clinics are responsive to the greater context from which their patients come. They were founded on a basic social justice mission of promoting health care equality by addressing not only medical care for individuals but also the social determinants of health within a community.

When it was time to choose a residency, I couldn't imagine training anywhere but a community health center. And as a National Health Service Corps scholarship recipient, I knew I needed to be prepared to practice in a CHC. My alma mater, the Family Medicine Residency of Idaho in Boise, is affiliated with a community health center that was designated one the of the country's first teaching health centers.

Training in a CHC, where fees are adjusted based on a patient's ability to pay, was an invaluable experience. I not only learned how to care for a panel of patients, I learned how to care for patients with no insurance or means to get certain medications or testing and patients with concurrent mental illness who lack access to higher levels of psychiatric care. And it's all amid the day-to-day battle against the social determinants of health that can foil delivering even the best evidence-based medicine.

There are times when even the most starry-eyed, optimistic types (such as me) can feel burned out. I can't always get my patients the medications or tests they really need or the subspecialist visit that might help augment their care. Mental illness is prevalent and presents a challenge for many patients in navigating their health care and the community at large. Sometimes, I'm not sure how to intervene.

But even with these daily roadblocks, I still believe in the mission of caring for anyone who walks through my office door regardless of their payer source, and I love the moments when patients say our clinic was the first place in the health care system where they felt they were treated with dignity.

I like the challenge of figuring out if I really need to order a particular lab or test -- especially if my patient might be getting the full bill. At times, I feel I am trying to live the mission of social justice and equality, and also of the triple aim (improving population health, enhancing the patient experience and reducing costs) to which our whole health care system should strive.

CHCs also are already designed to follow the patient-centered medical home model using team-based care, which at our site includes physicians, nurse practitioners, physician assistants, nurses, medical assistants, clinical pharmacists, therapists, case managers and dietitians. I could not take care of the complex needs of my patient panel without this team!

Although CHCs can be a challenging environment in which to practice, I am grateful to be a physician among those serving in our nation's community health centers. I cannot imagine another place where I could better live the values of family medicine in the biopsychosocial model of care while addressing health disparities and social injustice on a daily basis.

Amy McIntyre, M.D., M.P.H., is a family physician at the Butte Community Health Center in Butte, Mont., and her practice includes full-scope outpatient care, maternity care, and long-term care and hospice.

Thursday Jun 05, 2014

Practicing Workplace Medicine at the Point of Care

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the sixth post in an occasional series of blogs that will look at the different roles family physicians can play.

Traditionally, a family doctor would set up shop, and patients would come in to the office for most of their care, with the physician stepping out for hospital visits and house calls as needed. For better or worse, that paradigm slowly shifted over time to clinic-based care, and now a large proportion of family physicians practice exclusively in outpatient clinics.

As a medical student, I dreamed of returning to my rural home, opening a solo practice and doing it all, like "Marcus Welby, M.D.," or "Doc Hollywood." From delivering babies to holding the hands of elderly patients breathing their last, I wanted to be the quintessential Family Doctor, capital “F,” capital “D." The modern health care system -- with long waits for patients and mounting paperwork hassles for physicians -- didn’t (and still doesn’t) appeal to me.


Here I am talking with a patient at my on-site primary care clinic, which provides care for local government employees and their family members.

I tried initially to circumvent those problems by opening a direct primary care (DPC) practice. My father and I had moderate success, but the area where we chose to practice couldn’t really support two physicians.

Thus, I jumped at a chance to work as the family doctor for local government employees and their families. I took a job with a corporate primary care group serving Kenton County and the city of Covington in northern Kentucky, initially caring for about 1,500 individuals. My patient panel has since expanded to include the employees and families of a neighboring city and a large manufacturer in the area. In conjunction with another clinic, we provide broad-spectrum primary care, with a focus on employee health and wellness.

As discussion abounds about DPC, defining the framework for this approach to family medicine practice requires some outside-the-box thinking. Many of the old ideas about taking care of patients “where they are” inform the new models of practice, with some physicians opting to hold traditional office hours, and offer full-spectrum care with house calls and hospital care for a set fee. Others choose to see patients in some fixed setting other than an office, which is often more convenient to the patient.

My current practice falls into the latter category. I am an employee of a company that provides corporate primary care -- sometimes called on-site primary care -- for corporations and businesses across the country. In essence, I provide DPC at the jobsite.

Several different models of corporate primary care exist, although most consist of some combination of basic insurance and an on-site clinic staffed by family physicians to provide primary care for employees and their dependents. Our model includes a lab and an in-house dispensary, with prepackaged medications prepared at a central pharmacy. The employer pays a per-patient, per-year fee to offset visit copays, as well as the medications in the dispensary, meaning no money is handled in our clinic. Some other clinics use a traditional copay model, but often with discounts.

From an occupational medicine perspective, I spend a lot of time talking with the human resources staff of the employers I serve, helping to coordinate their plans for wellness, organizing events such as influenza vaccination days and looking for new resources we can provide or large-scale issues we can address. We also handle things like Department of Transportation physicals and workers’ compensation issues.

Patients often comment on the convenience of our clinic, both in location and the limited time spent waiting. We use open scheduling with a Web-based component, allowing patients to schedule up-to-the-minute appointments, each covering a 20-minute block. The intake process, given the lack of copay and the prearranged interface with insurance, consists of obtaining vitals and eliciting the chief complaint, leaving much of the 20-minute appointment block for the face-to-face visit between patient and physician. Many of the annoyances of the traditional doctor visit, such as copying insurance cards or collecting payment, have been eliminated.

I like the structure of this style of practice because it puts the focus of the visit back on the patient, gives more time for adequate history-taking and allows me to discuss the treatment plan in depth. I don’t walk into the room of a patient who waited for two hours to see me for just eight minutes and feels cheated out of even that meager amount of time by the hassles of registration and waiting. The scheduling system and the dispensary reduce many barriers to care, and the focus on preventive medicine encourages employees to take control of their health.

Many of the 20- to 30-year-old patients who come through the clinic for acute visits have not had a health assessment since their last visit to a pediatrician’s office, but once they realize the clinic is on-site and there’s no copay, they are eager to go over their history and health behaviors.

I spend a lot of time talking about the preventive care aspects of medicine that we all learned about as medical students but rarely have the time to emphasize in private practice. I discuss appropriate nutrition and exercise. I get to do in-person smoking-cessation counseling, and the clinic even has a smoking-cessation counselor on staff. I spend time going over medication lists, immunizations and medical histories, and patients have time to tell their stories. It’s also satisfying to know that the patients with multiple chronic diseases are leaving the clinic with medications in hand and don't have to worry about how they are going to pay to have a prescription filled.

I do miss providing hospital care for my patients, and I’m still an employed physician, but my employer practices good communication and works to ensure autonomy for clinical decision-making and patient care. I do my own prior authorizations and call-backs, and I still have to use ICD-9 (eventually ICD-10) codes.

But I get to take care of patients, coordinate their care and make sure they get plugged in to the resources they need. I’m free to take care of people, instead of worrying about the financial bottom line. It’s even freed me up to pursue other projects, like a rural outreach free clinic.

On the flip side, the employer gets guaranteed, accessible, coordinated care for employees and their families, often resulting in fewer lost hours and healthier employees. The companies using corporate primary care also end up saving money on insurance premiums, even with the DPC fees. It’s a win-win situation.

If you have questions about corporate primary care or want to debate the merits of cash-pay systems, drop me a line on Twitter or respond using the comments feature below.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Friday May 30, 2014

Family Medicine: Make It What You Want

Editor's Note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the fifth post in an occasional series of blogs that will look at the different roles family physicians can play.

One of the factors that attracts many of us to family medicine is the diversity of practice settings. This can manifest as having the freedom to choose a particular practice location or a certain practice model, but it can also mean choosing to focus on a patient population that shares a common background or set of diagnoses. Yet even though I knew about these variations, I never anticipated being in the type of practice I’m in.

I have learned more about psychiatry and neurology on the job because caring for patients with developmental disabilities required it.

I work at the Neurobehavior Healthy Outcomes, Medical Excellence (HOME) Program in Salt Lake City. It is a novel patient-centered medical home (PCMH) that provides care for individuals with developmental disabilities (DD). We provide primary care, case management and full-spectrum mental health services (psychiatry, therapy and behavioral interventions) for people of all ages who have developmental disabilities. We are an official Utah Medicaid HMO, meaning that individuals have to be accepted into the program, and we receive a per-member per-month capitated payment for each of the nearly 900 individuals who are enrolled. We spend one hour with each patient to allow us the time to address their many needs and to better coordinate with other members of the care team.

I always envisioned myself working with an underserved population, but I never would have guessed that I would be working with this particular group of patients. I did not have any specific training that covered the unique health care problems individuals with developmental disabilities face. In fact, I have had to learn on the job the past couple of years to properly care for them. I applied for the job after it was suggested to me by a residency faculty member who saw an interest and ability that I was unaware I had. He recognized that the way I interacted with patients and the way I thought about medicine in general would be a good fit with this population.

At first, I was more curious about the model of care then the population itself. I had wanted to work in a PCMH so I would have the proper team in place to care for patients, so the idea of working with psychiatrists, therapists, case managers and others strongly appealed to me. But now that I have been working for some time in this setting with oftentimes challenging but always interesting and rewarding patients, I have grown to love it and wouldn’t trade it for any other practice.

My story is not unique in family medicine. Many of us end up in a niche practice based on a specific population need or personal interest. It is obviously a challenge to be an expert in all areas of family medicine, so many of us naturally gravitate to a certain area. And this change often comes about a little more organically than deliberately. But that’s the great part of family medicine -- you make of it what you want.

In some ways, a practice like this narrows my skills. I do not practice obstetrics because that is not a common issue faced by my patients. I do fewer procedures than I was trained to do because many of my patients require sedation in the operating room. I have decided that this is an appropriate trade-off because working with this population has increased my knowledge and skills in other areas. There are few physicians around the country who have a deep understanding of the health care needs of individuals with developmental disabilities. I likely have learned more about psychiatry and neurology than the average family physician because caring for my patients required it. These added skills are an asset I use to teach residents, students and others. If I end up in a different practice setting in the future, these skills can be used to supplement those of others in the practice. I can also retrain in specific areas at a future time if I choose to do so.

There is often some anxiety that accompanies a decision to narrow one’s practice after having received such broad training, but we should not be afraid to tailor our practice to our needs or interests. This is one of the great beauties of family medicine – you’re free to make it what you want.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Thursday Apr 24, 2014

Locum Tenens Work Offers Freedom, Control

Editor's note: More than 85 percent of new physicians are employed, compared with 63 percent of all active AAFP members. This is the fourth post in an occasional series of blogs that will look at the different roles family physicians can play.

My mom was born and reared in Vietnam, but neither of us had visited her native country in several years. So I took three weeks off from work in March to travel with her. We reconnected with family, experienced the culture and ate amazing food.

My schedule for this summer promises to be equally interesting because I’m leaving my home in Seattle to spend a month working in a small community hospital in Alaska. I’ll be practicing full-scope inpatient and outpatient family medicine, including obstetrics, while exploring the town of Kodiak and experiencing an Alaskan summer.

Working locum tenens has allowed me to set my own schedule. In March, I took a three-week vacation with my mom to Vietnam, including a visit to Ha Long Bay.

And I’m keeping nearly a month of my work schedule open in August for my wedding and honeymoon.

My point isn’t to brag about the frequent flyer miles I’m accumulating but to point out that for some physicians, working locum tenens can be a fantastic opportunity.

My fiancé is a third-year medical student who hopes to match to a pediatric residency. Given that there is only one such program in our area, relocation is a real possibility in just a little more than a year from now. For me, it didn't make sense to sign on to a full-time job if I wasn't going to stay in the area. So while many residents around the nation were searching for jobs last spring and summer, I was looking for locums positions in the Seattle area.

In fact, a large portion of my residency graduating class elected to do locums. It might seem like we’re delaying the inevitable and avoiding what brought us to primary care in the first place (care continuity), but how are we are supposed to know what kind of work environment we would like to wind up in if we don’t try different options?

Every practice is different and has its own ways of doing things. As a new-to-practice physician, how do you know what kind of clinic environment you need? Working locums provides an opportunity to see where you might fit best and what might keep you happiest.

I started my first position at a private practice, slowly, last July. I was only working one or two days a week at first, and that gradually increased to three or four days a week. The clinic needed a lot of help, and for a while it seemed like I was a regular employee, experiencing the benefits of continuity of care and having my own patients.

Eventually, the clinic's need decreased, and I started having shifts cancelled. I also realized that maybe private practice wasn’t the best fit for me, and maybe the patient population didn’t fulfill all of my needs. But soon after that realization, I started a role as a “float provider” with a health system that has more than a dozen locations in my area.

With so many physicians on staff, the clinics have vacancies, maternity and other medical leave, and vacations to cover. I’m paid an hourly rate and can plan my schedule months in advance. I fill in for a variety of internal medicine, family medicine and pediatric physicians, which makes things interesting. There are days I see only pediatric patients, some days that are all adult medicine and some days that are mixed.

The pediatric days, in particular, have been excellent for my training. I’ve solidified my ability to talk with kids, and I’m more confident in my skills after those shifts.

I work for the health system three to four days a week, which leaves me one or two days for precepting at my residency program. This flexibility allows me to work on mentoring and honing skills that I hope to use in the future in a faculty position at a residency program.

There are a few drawbacks to not being a full-time employee, most notably the lack of health insurance. But with no husband or children, I was able to find a reasonable plan for myself.

The lack of continuity of care also is a drawback, but so far, I’ve been able to see some patients on return visits because I’m working somewhat steadily at these clinics. I’ve heard that some physicians doing locums might run into a paucity of work, but I have yet to experience this.

For me, the benefits of my current career choice have far outweighed any negatives. What's the biggest perk of locums after three years of residency training?

Freedom.

My schedule, including vacations, had been dictated to me for my entire life, from early childhood through high school and on to college, med school and residency.

Locum tenens gives me a chance to build my own schedule. I can take a four-day weekend if I want. Or I can work seven days and take seven days off. I’m a planner, and this is all about managing my own time and having control of my professional and personal life.

Right now, I’m planning my wedding, which is like a job in its own right. When my fiancé matches, I might be ready to settle down and pick a clinic. After working in a variety of locations, I think I’ll have a better idea of what I’m looking for in an employer. And if we stay in this area, I hope the employers that have had me as a locums provider will feel confident in hiring me as a full-time employee.

One thing is certain. If I had taken a regular job last summer, I wouldn’t have been able to do many of the incredible things I’m doing now. And I wouldn’t want to miss any of it.

Jennifer Trieu, M.D., is a family physician in Seattle.

Thursday Apr 17, 2014

Benefits of Rural Practice Make Sacrifices Worthwhile

Editor's note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the third post in an occasional series of blogs that will look at the different roles family physicians can play.

I grew up in a town of 40,000 people. In the region where southwest Missouri meets southeastern Kansas and northeast Oklahoma, that passes for a metropolis.

During my time at nursing school and later during my first year of medical school in Kansas City, it never occurred to me that I might wind up in a small, rural practice. I hadn't grown up in a rural area, and the possibility of moving to one wasn't on my radar.

Stockton, Kan., hadn't had its own physician for more than a decade when my husband and I opened our practice in the small, rural community.

But during my second year of med school, we had the option to experience a rural health weekend. We were paired with a rural physician and allowed to see what they do and how they do it. Fortunately for me, I was matched with family physician Jen Brull, M.D., in Plainville, Kan.

It didn't take long for her to make an impression. I met one family Jen had delivered two babies for. She also cared for the mom and dad, grandparents and even great-grandparents. The relationship she had built with that family grabbed by attention. I was definitely intrigued.

Coming from the University of Kansas Medical School in Kansas City, I knew how easy it was to get lost in a big practice. In Plainville (population 1,900) I saw what a big difference a family physician could make in a small town.

During our third year, we were required to complete a rotation in family medicine. I asked if I could do mine in a rural setting rather than in the local, metro area. Given that option, I went back to Jen's practice in Plainville. I got away from the large, academic medical center and watched this small-town physician connect with her patients and her community in a meaningful way.

I loved my experience in Plainville, and I was eager to go back. So when it was time for a rural rotation during my fourth year, you probably can guess where I went.

If KU hadn't provided opportunities for us to experience rural practice, my husband (who also is an FP) and I never would have wound up in rural medicine. By the time we completed medical school and residency in 2011, we knew we wanted to settle in a rural, underserved area.

At a time when most of our peers were seeking employment, my husband and I were looking to open our own practice. Sixty percent of AAFP members are employed physicians, and AAFP surveys tell us that only 13 percent of those employed FPs have an interest in becoming practice owners. Furthermore, only 11 percent of active AAFP members practice in rural areas.

But off we went to become business owners in small-town Kansas.

And it was terrifying.

There are plenty of reasons that the trend is toward employment -- fewer headaches and greater financial security being two of the obvious factors. But it also is true that as the number of small practice owners shrink, it becomes harder and harder for medical students and residents to find mentors who have done it.

Fortunately, we found someone who is running her own small, rural practice and doing it well. In fact, Jen was one of three physicians in the area who were running their own practices and sharing overhead expenses. We joined them by opening our own practice in Stockton, which is about 15 miles north of Plainville. Our little town of 1,300 hadn't had its own physician for more than a decade.

Our decision has come with some sacrifices. We don't make as much money as our residency colleagues who are hospital or large-group employees. We're not there yet.

You don't learn how to run your own business in med school or residency, either. We realized we needed a good business manager, so we hired one. However, we still have to be more involved in tracking billing, insurance and collections than our employed colleagues.

We're also responsible for things like paying for rent, supplies, utilities, staff salaries and more. When you're employed, you know the lights are going to be on when you show up for work. As practice owners, we have to worry about all these things.

Some days, I think it would be easier if it was someone else's headache. But there also is a lot to like about being your own boss. We like having flexibility and control of our schedules. I don't have to rush my patients. When I have a new patient with multiple conditions, I give them an hour so that we can address everything they need. You can't put a price on that.

We allow our staff to bring their babies to work until the children are 6 months old. After my daughter was born, I went back to work feeling comfortable because she was with me.

And I never go home frustrated because someone was unhappy with my productivity or wouldn't allow me to practice medicine the way I want to.

We like it here, and we're happy caring for our small town.

Beth Loney Oller, M.D., practices full-scope family medicine in Stockton, Kan.

Friday Apr 04, 2014

Those Who Need Guidance and Those Who Guide

Editor's note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the second post in an occasional series of blogs that will look at the different roles family physicians can play.

If anyone had told me I would be faculty five years ago, I would not have believed it. I actually may have thought he or she was a little bit weird because I had no intentions of working in a residency program. My supposedly well-thought-out, short-term plan ended at getting a job at a clinic in a community where I could make a difference. Well, so much for the best-laid plans. 

Here I am (at right) talking to intern Latoya Lee, M.D., during clinic hours. Working as an assistant professor of family medicine at the University of South Carolina has allowed me to teach and practice full scope family medicine.

After residency, my husband and I were living in Honduras on a mission trip when a brigade from the University of South Carolina (USC) came to work in the rural clinics. Jeff Hall, M.D., assistant professor of family medicine, was one of the faculty on that trip who recruited me.

I interviewed at USC -- and with other, nonacademic practices -- and realized that my desires to continue practicing obstetrical care and to teach and interact with medical students and residents were virtually impossible in a nonacademic setting. I had always enjoyed teaching, but I never thought it would pay my salary.

I’ve been at USC for a little more than a year, and I am really enjoying myself. As a faculty member I am able to continue practicing full scope family medicine and remain on the cutting edge of new therapies, interventions and technology. This is one of the reasons I chose academic medicine instead of private practice.

The residents keep me on my toes and up-to-date with their questions and presentations about what they are learning. They help me remain evidence-based and energetic. They remind me of the youthful curiosity and intrigue that one faces when dealing with a difficult patient or engaging a community. The medical students are comparable, but they ask the real tough questions -- questions that remind me of pathophysiology and those that prove gross anatomy labs were really important.

I work full-time in a salaried position. My time is split between clinical and teaching responsibilities, with about 20 percent each going to direct patient care, supervision of residents and research. I also use research time to become a better teacher by working on lectures and other administrative duties, which includes an obesity project I lead. The remaining time I get to practice one of my first loves -- delivering babies.

Aside from the residents and students, being faculty has enriched my life through the mentorship and wisdom I've received from more experienced faculty. As I'm still fresh out of residency, it's comforting to know that I can ask a physician with 20 years of experience how he or she would manage a problem. It’s also comforting being able to ask them questions like "Is it OK if I'm still figuring out what I want to be when I grow up?"

Being faculty is much more rewarding than I ever expected.Although I may not have the answer to what I’ll be doing in 20 years, I believe God designed this position for me for this time in my life. I've found a community of those who need guidance and those who guide. I've found a balance and an opportunity to remain true to myself as a family physician -- caring for everyone in every stage of life. Side note: The pay isn't bad either!

As faculty, I found what I was looking for -- my dream job; maybe you will too. Who gets that straight out of residency?

Meshia Waleh, M.D., is an assistant professor of family and preventive medicine at the University of South Carolina School Of Medicine.

Monday Mar 03, 2014

Private Practice Has Its Rewards, Challenges

Editor's note: More than 85 percent of new physicians are employed, compared to 63 percent of all active AAFP members. This is the first in an occasional series of blogs that will look at the different roles family physicians can play.

When I made the decision in medical school to become a family physician, I pictured myself working in a rural private practice. In my mind's eye, this looked something like a Norman Rockwell painting. As my residency and fellowship training drew to a close and I began the job search in earnest, my idealism was met with a stark reality: Private practice seemed to be vanishing.

Peter Rippey, M.D.

During the past 25 years, the number of active AAFP members who identified themselves as employed physicians increased from 29 percent to 63 percent. During the same time, the ranks of solo practitioners decreased by 27 percent. Many of the positions I considered in rural areas were hospital owned.

I eventually found a position as the seventh physician in a rural private practice. But practicing in a rural area has not insulated me from the changes occurring in our country. The uncertainty of the health care landscape as the Patient Protection and Affordable Care Act continues to be implemented -- along with the challenges related to payment, electronic health records (EHRs), meaningful use and ICD-10 looming on the horizon -- seems to have spurred a mass exodus from private practice to employed positions.

In my area, I have seen a few older physicians retire instead of dealing with the latest round of health care upheaval. Other practices have been absorbed by hospital systems or merged with larger physician organizations. Those who are struggling to stay in private practice have seen their overhead increase and their payments cut.

At a time when everyone is clamoring about the high cost of health care, forcing physicians out of private practice seems foolish. Payment rates for private outpatient clinics are less than those for hospital clinics for the same service provided.Many clinics can provide urgent care services (suturing, fracture care, etc.) at a fraction of the cost of the local ER. It would seem in many ways that a well-run private practice could provide quality patient care at less cost.

At a time when the United States spends more money on health care as a percentage of gross domestic product than any other industrialized nation and has some of the worst health outcomes, is the extinction of private practice really a step forward?

Private practices are a vital means for health care access, especially in rural areas where the next closest option may be more than an hour away. As these practices disappear, medical students and residents will have even less exposure to private practice; fewer and fewer may consider it a viable option. This could lead to further decline in the future of private practice.

That's a shame, because I have found private practice to be extremely rewarding. I am providing high quality, efficient care for my patients. In private practice, I also get to decide what hours I work, what procedural services I provide, what my scope of practice is, when I take vacation and who I have assist me.

In contrast to some employed settings, there us less pressure to see a certain number of patients a day. I can make that decision based on how many patients I think I can manage appropriately. If I want to take a vacation or time for CME, there is no schedule to coordinate with , no need to give significant advance notice and no need to ask for permission. I simply block my clinic schedule.

I think one of the most important benefits of private practice is that all the decisions affecting the practice are made by clinicians, those who understand what it means to be a physician and what it takes to provide care to patients.

In medical school and residency, I was taught that as physicians we are stewards of the health care system. In my practice, I provide the care patients deserve while helping to control costs. But the future seems murky. My practice has had to make many stressful decisions regarding EHRs and is trying to lower overhead due to payment cuts. As a father trying to support a family and pay off a mountain of medical school debt, this uncertainty has often put an extra furrow in my brow.

I understand all too well the reasons many have flocked to employed positions, but do all these changes really mean the demise of private practice? Or is this simply a pendulum, sure to swing the other way in time? To quote the wisdom of The Clash, "Should I stay or should I go now?"

Peter Rippey, M.D., is a board-certified family physician who practices in private practice in rural Missouri. He enjoys a full spectrum practice with a focus on community and collegiate athletic coverage.

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