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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The New Rule
Response to Dr. Kuo
Response to Dr. Green
Next Steps
CME: Low hanging fruit and a first step toward collaboration
Author response
Recognize And Support Current Multidisciplinary Actions
Collaboration in primary care is not just necessary but right
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Shari L Barkin, winston-salem, nc physician; Wake Forest University School of Medicine, Erik Lindbloom, Som Saha, Walt Schalick
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As set out in the Institute of Medicine's Simple Rules for the 21st Health Care System, new rules need to be established to ensure quality of health care. Cooperation among clinicians needs to be a priority (1). In Kutner et al's paper, "Facilitating Collaboration Among Academic Generalist Disciplines: A Call to Action," the authors call primary care academic generalists to make a clear decision to collaborate. The old rule of distinguishing unique identities among pediatricians, general internists, and family physicians needs to be retooled. We lay out some suggested outcomes here in the hope of sparking debate and action. Desired Outcome 1: Develop an integrated generalist medical student and resident curriculum, teaching the core skills of the generalist together. All generalists must manage a host of medical information and build long-term relationships while simultaneously integrating care within a complex health care system. Professional organizations and residency review committees must revisit our current standards and retool the way we evaluate and prepare generalists for practice. Issues should include length of training, site of learning, competency evaluation, and lifelong learning skills. Desired Outcome 2: Create systems to promote continuity of care. Despite evidence supporting the importance of continuity of care and continuous healing relationships (1), continuity of care is becoming less of a system priority (2). Research and quality improvement projects should be aimed at redirecting patients back to their generalist physicians when appropriate. Desired Outcome 3: Establish payment systems and develop mechanisms that support the generalist's role. A large gap persists between payment rates for generalists and other physicians, particularly those in procedure-based specialties (3). Generalist physicians need to achieve greater representation on the Medicare Payment Advisory Commission (MedPAC), and professional societies representing generalists must take on a larger advocacy role for more equitable payment structures. Yes, there needs to be a new rule. Generalists need to come together to work on achieving these outcomes and others if we are to promote and provide continuous, comprehensive, coordinated care in the 21st century. References: 1. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm : a new health system for the 21st century Washington, D.C.: National Academy Press; 2001. 2. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary. Adv Data. 2003(335):1-29. 3. Hsiao WC, Dunn DL, Verrilli DK. Assessing the implementation of physician-payment reform. N Engl J Med. 1993;328(13):928-33. Competing interests: None declared |
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Jean S Kutner, Denver, CO Division Head, GIM, UCHSC
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Thank you for providing these examples of potential joint educational venues for the 3 primary care specialties. Competing interests: None declared |
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Jean S Kutner, Denver, CO Division Head, GIM, UCHSC
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Thank you for this stirring response to the article. Having watched the Broncos game in question, I like the analogy. I just came from a discussion at the Association of Chiefs of General Internal Medicine meeting where the question was raised as to whether we should see the current primary care situation as a "crisis" or an "opportunity". I welcome Dr. Green's perspective of the "opportunities" presented. Competing interests: None declared |
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Larry A Green, Denver, USA Physician
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To each of the authors of this heartening reflection, I want to extend my thanks for publishing such a piece, together. Their ability to do so is in part a consequence of their meeting each other and working together in the Robert Wood Johnson Foundation's now concluding Generalist Physicians Scholars Program. The article itself is a testament to what can occur, working--together. The Track commentary so far has been re- enforcing of the conclusions and recommendations, as are other developments now afoot. The collapse of Title VII and perhaps HRSA, further announcements of threats to the survival of primary care, and the immediate necessity of redesigned frontline clinical practice without a captitalization mechanism are converging with a vengance. It reminds me of a piece of lore from the Denver Broncos concerning an AFC championship game. Cleveland was ahead by more than a field goal but less than a touchdown with a couple minutes left, and the Broncos were pinned down on their own 7 yard line-- 93 yards away, time running out. The story told is that John Elway entered the huddle and claimed, "Now we've got them right where we want them." Denver won that game, with a lot of teamwork, individual execution, and belief that they could. Perhaps the desperate straights of the generalist physicians and primary care in general in the United States is "right where we must be to do what must be done." With such vision, courage, and able leadership as this set of authors displays in this article, and with others like them, what are the immediate next steps that can be taken, to move beyond the rhetoric to action? Maybe the certifying boards of family medicine, internal medicine, and pediatrics and their aligned residency directors can move hard on experimenting with joint residency training with a vision of moving to a new generation of primary care physicians who identify from training with each other and other key compatriots, like nurses, public health officers, psychologists, and pharmD's. Maybe the Robert Graham Center in Washington and other concerned policy groups could host a series of meetings for the young leaders in pediatrics, family medicine, and internal medicine to state their aspirations and strategize together. Perhaps AHRQ could expand its PBRN annual meeting back toward the national primary care meetings of the early 90's. Maybe Annals of Internal Medicine, Annals of Family Medicine, and Pediatrics can all establish a new section for the collaborative restoration of primary care. Perhaps the three tribes can unite to lobby for payment reform by CMS that assures revenue sufficient to cover the costs of high performance new model primary care practice. Perhaps the next generation of primary care leaders has better ideas of how to proceed? Who calls the first meetings? Competing interests: None declared |
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David Kuo, Morristown, NJ USA General Internist, Atlantic Health System
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Kutner et al briefly mention continuing medical education (CME) as a “small” effort which could enhance collaboration among the primary care disciplines. [1] I agree that CME programs are an important and low- hanging fruit which can facilitate more expansive collaborative efforts. CME courses were attended by nearly 4 million physicians in 2004 [2], and while an increasing proportion of CME is taken in solitude by physicians through on-line programs [3], many CME programs bring the primary care disciplines together by providing programs of mutual clinical interest. For example, Harvard Medical School, which does not currently have a Department of Family Medicine, lists over thirty program offerings of primary care interest under the “Medicine” heading in its 2006 CME course listing. Courses such as “Practical Approaches to the Treatment of Obesity” and “Addiction Medicine: New Problems, New Solution” specifically list family practice and internal medicine among their intended audience. Privately sponsored CME programs such as those sponsored by companies like Medical Education Resources (http://www.mer.org) also provide successful, well-attended titles such as “Issues in Women’s Health” and “Dermatology for the Non-dermatologist.” The intended audience, listed as “primary care physicians, physician’s assistants, nurse practitioners, and registered nurses,” reminds us that future collaborative efforts may eventually need to also include other practitioners of primary care. Hospital-based grand rounds appear to be in danger of fading into obsolescence [4], however using this CME event as a forum for bringing physicians together makes sense because it unites physicians by a common desire: to maintain skills and knowledge to improve patient care. Departments of family medicine, pediatrics, and internal medicine could improve their attendance to grand rounds and economize their CME budgets by jointly sponsoring grand rounds of mutual interest and utilizing faculty interdependently. Nationally known speakers whose honoraria might otherwise be prohibitively expensive could be rendered affordable by simply splitting the bill. Jointly sponsored grand rounds would also be a means by which local issues could be discussed, such as reviewing mortality and morbidity cases or disseminating the findings of a community -based bioterrorism task force. Ultimately, putting family physicians, pediatricians, and internists in the same room would hopefully lead to more profound collaborative efforts as meaningful discussion and interaction ensues. REFERENCES [1] Kutner JS, Westfall JM, Morrison EH, Beach MC, Jacobs EA, Rosenblatt RA. Facilitating collaboration among academic generalist disciplines: a call to action. Ann Fam Med 2006; 4: 172-176 [2] ACCME. ACCME Annual Report Data 2004. Retrieved April 15th 2006, from http://www.accme.org [3] Hosansky, T. (2001, July 1) “CME Industry hits billion dollar mark” Meetingsnet.com. Retrieved April 15th 2006 from http://meetingsnet.com/medicalmeetings [4] Mueller PS, Litin SC, Sowden ML, Habermann TM, LaRusso NF. Strategies for improving attendance at medical grand rounds at an academic medical center. Mayo Clin Proc. 2003;78 (5): 549-553 Competing interests: None declared |
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Jean S Kutner, Denver, USA University of Colorado Health Sciences Center
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Thank you to David Katerndahl and Omar Khan for your voices of support for this "call to action". I agree that the annual San Antonio primary care research methods meeting is an excellent venue for cross- pollination among the primary care disciplines. Competing interests: None declared |
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David A Katerndahl, San Antonio, TX University of Texas Health Science Center
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I certainly support the Call to Action. In fact, efforts to "initiate regular generalist meetings" have been pursued for some time. The Primary Care Research Methods and Statistics Conference is an annual research methodology conference for primary care researchers that is supported by AHRQ and is in its 21st year. Its Program Committee has representation from general internal medicine, general pediatrics, and nursing, and the conference is endorsed by SGIM, the Ambulatory Pediatrics Association, STFM, and NAPCRG. Its participants include representatives from many disciplines each year. In addition, NAPCRG has been actively reaching out to other primary care disciplines in an effort to foster true multidisciplinary primary care research exchange. These efforts need to be recognized and promoted as part of the larger Call to Action so eloquently voiced by Kutner and colleagues. Competing interests: None declared |
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Omar A. Khan, Burlington, VT Univ. of Vermont Dept. of Family Medicine
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The Annals has in a relatively short amount of time contributed a body of work which is both thoughtful and thought-provoking. Even in this illustrious company, Kutner et al's article was in my view the best article I have read here thus far. The implications of their thesis are profound because they are both simple and powerful. The intuitive benefits of collaboration are recognized and discussed here in an academic forum, avoiding blame and negativity in favor of a forward-thinking and positive approach. There may be some physicians in the generalist disciplines who are so entrenched in their respective 'vertical programs' and biases that they will resist the type of collaboration envisioned. However, I would suggest there are far more who will embrace it: those who relize medicine is not a 'zero-sum' game, i.e. one group does not have to lose for another to win. The ideas presented in this article are in fact, essentially win-win. This discussion needs to be moved to the level of the Academies of the generalist specialties, and formal means of collaboration sought. Our collective humanity and our professions are owed no less. Competing interests: None declared |
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