In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices

Many thanks to Dr. Iliff for sharing his positive experience in primary care, and for echoing many of the conclusions of our study. We agree regarding the importance of integrating rather than fragmenting care: when a patient can see their primary care physician for management of one problem there is the opportunity to touch base on the patient's other conditions and to build trust and relationship. Such integration is lessened when the patient is sent to multiple providers for their clinical care. We also agree about the net value of 3:1 clinical staffing, particularly when it is the same people each day. In our own practice we each work with 3 Associates Degree RNs while in clinic, a set-up we consider optimal for patient care and for financial stability.

There are many different compositions of "teams." While some practices have successfully divided up the clinical aspects of primary care among multiple providers, often in independent care episodes (pharmacist for hypertension care, nurse for diabetes care....) we personally prefer a more tightly integrated model with fewer remote or electronic handoffs. In our "Collaborative Care Model" the nurse stays with the patient from the beginning to the end of their appointment, acting as the patient's advocate, guide and health coach. During the first component the nurse obtains vitals, performs medication reconciliation, gathers information relevant to the appointment, helps the patient set the agenda and begins to record the history. She also ensures the patient is up to date with all prevention measures and explains the laboratory results to the patient, engaging in motivational interviewing and self-management support for weight loss, smoking cessation, or other issues. The physician then joins the appointment, builds on the history, performs the exam, and together with the patient and nurse, helps to craft a plan. It is a three way conversation, with the nurse also recording some of the visit in real time. One explicit goal is to increase the time the physician is able to provide undivided attention to the patient (i.e. hands-off-the-keyboard, eyes-out-of-the-chart time.) After the physician component, the nurse stays with the patient, operationalizing the plan and reinforcing instructions. In some cases the nurse will make between visit calls to follow up on the patient's symptoms or their progress with a lifestyle modification.

We also agree with Dr. Iliff regarding the challenges of this first generation of EHRs, which too often display, as he says, much "clutter of unnecessary information," thereby adding to the time and cognitive workload of the nurses and physicians. While we would not chose to return to the pre-electronic era, we believe EHR usability must improve dramatically for the hoped for benefits associated with its widespread implementation to be realized.

Competing interests: None declared

I appreciate the thrust of this article, Dr. Young's thoughtful suggestions, and the careful response of the authors. When we ask this question, our specialty is headed in the right direction. So I'm going to toss in my two cents, having written extensively on this subject starting in an FPM article from 1998 (http://www.aafp.org/fpm/2003/1000/p23.html) and continuing with my "Making It" blog (http://blogs.aafp.org/fpm/makingit/) while I served on the FPM board of editors. My concern is that the selection criteria for practices in this study, which include PCMH certification and EHR use, precludes consideration of practices like mine-- and therefore fail to examine an old-fashioned but time-honored way of doing things which many of us dinosaurs have found to be joyful. Let me stipulate: my income for 27 years has always been double the FP median; I work 40 hours per week and rarely get paged, despite taking my own call Monday through Friday and every third weekend; I deliver all my own babies, averaging 16 per year; but I have given up rounds at the two local hospitals to hospitalists, because they do a better job than I can. I am not stressed. I don't have any "difficult" patients, although some are more challenging than others. When I was chosen at random to participate in a focus group at the national meeting last October, I was stunned by the hostility of my younger colleagues toward their chosen profession. They were not having any fun. How could this be? What has changed since I graduated the first family medicine fellowship in 1979?

Here are some questions for reflection or research:

1. Is the "team" concept as efficient as advertised? I work with 3 RNs every day, and some of the time they are doing work which could be delegated to less-educated MAs; on the other hand, I get very few questions, because they know what I'm going to say. Since communication must increase logarithmically as staff increases arithmetically, does all that extra chit-chat increase stress, as well as noise? Did you go into medicine to be a manager?

2. Is the EHR ready for prime time? I'm an early adopter, and I still won't buy one (although all my prescriptions are electronic). The EHR is a clutter of unnecessary information; I'll challenge anyone to a John Henry contest with my paper charts against their EHR in a race to record and retrieve information. My eyes are almost always on the patient, not the keyboard. Disease registers would be nice, but I still sail through NCQA and board modules by pulling random charts. Most of the HIPAA death threats I can safely ignore: no pimply Dutch teenager can hack into my records. He will have to fly to Topeka, break in to the office, evade the alarm system, and figure out how my charting system works. Power outage? No problem for me.

3. Is it efficient to share staff among providers? Dr. Laccheo and I share a building we own together, but we don't share staff. As a result, every time a patient calls my office, she will talk to someone who knows me and knows her. There's no phone tree. It's a live body every call. I don't care how big the building is. You could have 100 MD/DOs, but if you keep the staffs and phone lines segregated, every encounter feels like a personal encounter to the patient.

I could go on, but to summarize my challenge: what's the problem with being "physician-centric"? I thought fragmentation of care was the problem our specialty was called to solve. Or are we, like Humpty-Dumpty, fragmenting our offices so the "teams" can put him back together again? I've been using a PA for 26 years, but only for episodic pour-over care to assure that my patients can be seen the same day; the heavy lifting is on me. As a result, I have a practice full of long-time friends who I look forward to seeing every day I head for the office. New patients (I don't advertise like my competition, who all work for hospitals) complain that they never saw their doctor. Is this the model we have created? Does this contribute to the joie de vivre which will attract residents to family medicine? Is this why our lemming-like residents are falling into corporate practices, terrified to face the imagined rigors of the free market? Is the whole PCMH/TransforMed model an hypothesis in desperate search of confirmatory evidence, prematurely birthed upon the specialty by academics in search of tenure? Have we lost our minds?

Competing interests:   None declared

We are delighted by Dr. Young's response and couldn't agree more that fundamental changes are needed with respect to documentation requirements and tools. In fact, for primary care to add the most value and be a sustainable specialty, we believe change has to occur on many levels, including how healthcare resources are distributed, medical care is regulated and information is managed.

We also agree that the perversities in the existing evaluation and management coding rules have adversely affected the way doctors use their time and training. As we point out in the paper the visit note is too often driven by a billing template, complicating the cognitive work for clinicians. The chart risks becoming primarily a documentation tool to justify coding rather than a communication tool for clinical care. We have concerns that Meaningful Use Stage 2, which many institutions have interpreted to mean only the provider can perform computerized order entry (COE), may further burden primary care physicians. COE is a clerical task we believe, in most circumstances, can continue to be capably entrusted to clerical members of the care team.

We agree with Dr. Young's concerns about current the payment model. In our study we found practices that could afford an extended care team of social worker, nutritionist and/or pharmacist were generally those with external funding or that were in a global payment model. In our white paper http://www.abimfoundation.org/Initiatives/~/media/Files/Primary%20Care/Finding%20Joy%20in%20PracticeFULL%20WHITE%20PAPER060313.ashx we state "Primary care is unlikely to thrive at current reimbursement levels. Higher levels of practice revenue are needed to support the additional services, non-visit based care and multi-disciplinary team approaches which are anticipated to improve quality and reduce global costs of care."

We deeply empathize with Dr. Young's frustration with EHRs. While we don't advocate abolishment of EHRs, we do agree that large scale improvements in utility and usability are urgently needed. In our white paper we call for better user interfaces that require fewer clicks and scrolls, and better display of data. In our action steps http://www.abimfoundation.org/Initiatives/~/media/Files/Primary%20Care/Primary%20Care%20Action%20Steps.ashx we call for technology that facilitates greater teamwork, such as allowing multiple users in the same chart simultaneously, quick hand-offs between users and team log-ins.

Even as we work to reform CMS Evaluation and Management requirements, Meaningful Use regulations, and other policies that constrain high quality primary care, we believe that engaging the team in collaborative models of care is the path to better quality care. While documentation requirements and EMRs remain problematic, collaborative documentation with non- clinicians can alleviate the negative fall-out on patient care and clinician well-being, and that is no small thing. Beyond this our experience leads us to believe that there is intrinsic value to empowering nurses or other clinical assistants to be deeply engaged in the healthcare encounter. Within our own practice, we have found that the presence of a nurse in the medical visit ensures greater efficiency (as the clinician does not need to repeat the care plan), more health coaching, stronger care coordination and overall better care for the patient.

Striving for the payment models and policies to support high quality healthcare is of prime importance. Even as we pour our energies into that effort, it is helpful to recognize that there are exceptional practices within the current system that can help us forge a path toward better primary care and greater joy in practice.

Competing interests: None declared