Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

Jonathan G. Shaw; Marcy Winget; Cati Brown-Johnson; Timothy Seay-Morrison; Donn W. Garvert; Marcie Levine; Nadia Safaeinili; Megan R. Mahoney

doi:10.1370/afm.2714

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RE: Positive Response to the Article
Kyle J MacMillan

Published on: 17 October 2021
RE: We need teams for the long haul
Thomas Bodenheimer

Published on: 29 September 2021
RE: Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support
Jeffrey D. Tiemstra

Published on: 14 September 2021

Published on: (17 October 2021)
Page navigation anchor for RE: Positive Response to the Article
RE: Positive Response to the Article
Kyle J MacMillan, Physical Therapy Student, The Ohio State University
As an aspiring physical therapist in my 2nd year of my doctoral program, I took great interest and enjoyed reading “Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care with Expanded Medical Assistant Support.” While the authors identify and discuss numerous study limitations, their findings have the potential to reshape and reimagine the structure of primary care practices in the future. Burnout is a significant problem across the health professions.

Multiple physical therapists (PTs) have shared that their workload can often be overwhelming due to limited collaboration and support. Fortunately, I completed a clinical rotation where PT assistants worked alongside PTs as part of an inter-professional team. This team-based approach seemed to noticeably improve clinic functioning as PTs were able to delegate certain tasks to PTAs. As a result, PTs were able to direct their attention to more complex patient care.

Efforts to holistically examine burnout should be a top priority across all health professions. Interdisciplinary healthcare team development has wide reaching benefits to not only improved patient outcomes, but also clinician wellbeing. Team development can help to improve work environment interpersonal relationships and clinic efficiency, which can ultimately reduce healthcare-related costs.

The authors clearly articulate that temporary transformation of a team-based model has minimal effects on both prima...
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As an aspiring physical therapist in my 2nd year of my doctoral program, I took great interest and enjoyed reading “Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care with Expanded Medical Assistant Support.” While the authors identify and discuss numerous study limitations, their findings have the potential to reshape and reimagine the structure of primary care practices in the future. Burnout is a significant problem across the health professions.

Multiple physical therapists (PTs) have shared that their workload can often be overwhelming due to limited collaboration and support. Fortunately, I completed a clinical rotation where PT assistants worked alongside PTs as part of an inter-professional team. This team-based approach seemed to noticeably improve clinic functioning as PTs were able to delegate certain tasks to PTAs. As a result, PTs were able to direct their attention to more complex patient care.

Efforts to holistically examine burnout should be a top priority across all health professions. Interdisciplinary healthcare team development has wide reaching benefits to not only improved patient outcomes, but also clinician wellbeing. Team development can help to improve work environment interpersonal relationships and clinic efficiency, which can ultimately reduce healthcare-related costs.

The authors clearly articulate that temporary transformation of a team-based model has minimal effects on both primary care physician burnout and patient outcomes. On an annual basis, consistent efforts are needed by healthcare leaders and individual employees to forge an environment that supports sustained team-based care. In the future, I would be interested to see if longitudinal studies demonstrate an inverse relationship between MA staffing ratio and primary care clinician burnout.

Thank you for sharing your insightful work and expanding my knowledge on this topic. I am eager to share these findings with my classmates and future colleagues to promote positive and sustained healthcare system change.

Sincerely,
Kyle MacMillan
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Competing Interests: None declared.
Published on: (29 September 2021)
Page navigation anchor for RE: We need teams for the long haul
RE: We need teams for the long haul
Thomas Bodenheimer, Physician, UCSF
RE: Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

This article demonstrates the importance of reporting failure. Stanford's Primary Care 2.0 experiment was well conceived and had the potential to make sweeping changes in primary care. The bedrock of the change was a 2:1 MA-to-clinician ratio, with clinician visits becoming team visits including both clinician and MA. The expanded MA included scribing, population health management, and between-visit care management. The model is based on the team-care models of BellinHealth in Wisconsin and the University of Colorado primary care redesign. In both those cases, primary care practices were able to see more patients, thereby improving access, while increasing clinician satisfaction and significantly reducing clinician burnout. The key was the in-room documentation done by the MA which liberated clinicians from the deadly documentation burden.

Why was Stanford unable to sustain this powerful intervention? It seems that health system leadership pulled its support, ending the extra MA workforce, and thereby returning to the status quo ante. There may be other reasons that the article's authors understand but that may not have been appropriate to divulge in an academic publication. Yet the primary care world needs to know when "bright spots" like Bellin and Colorado persevere while Stanford falls back. Few bright spots la...
Show More

RE: Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support

This article demonstrates the importance of reporting failure. Stanford's Primary Care 2.0 experiment was well conceived and had the potential to make sweeping changes in primary care. The bedrock of the change was a 2:1 MA-to-clinician ratio, with clinician visits becoming team visits including both clinician and MA. The expanded MA included scribing, population health management, and between-visit care management. The model is based on the team-care models of BellinHealth in Wisconsin and the University of Colorado primary care redesign. In both those cases, primary care practices were able to see more patients, thereby improving access, while increasing clinician satisfaction and significantly reducing clinician burnout. The key was the in-room documentation done by the MA which liberated clinicians from the deadly documentation burden.

Why was Stanford unable to sustain this powerful intervention? It seems that health system leadership pulled its support, ending the extra MA workforce, and thereby returning to the status quo ante. There may be other reasons that the article's authors understand but that may not have been appropriate to divulge in an academic publication. Yet the primary care world needs to know when "bright spots" like Bellin and Colorado persevere while Stanford falls back. Few bright spots last forever and many internal and external conditions can cause the brightness to dim. But for those of us who honor the commitment of leaders to create a bright spot, we become wiser both from successes and failures. As a non-Stanford person, I cannot judge what successes remain and what can be resurrected. Congratulations to the Stanford team for their excellent work.
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Competing Interests: None declared.
Published on: (14 September 2021)
Page navigation anchor for RE: Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support
RE: Primary Care 2.0: A Prospective Evaluation of a Novel Model of Advanced Team Care With Expanded Medical Assistant Support
Jeffrey D. Tiemstra, Family Medicine Residency Program Director, Advocate Aurora Health Care
The authors' conclusion that their model of team-based primary care "demonstrates team development is a plausible key to protect against burnout" is completely unjustified by their data. No significant differences in burnout were demonstrated; a nonsignificant trend of 2 data points is not evidence of a plausible key. Furthermore, their non-significant trend was wiped out completely by the loss of MAs for in-room scribing. Scribes alone have been shown to improve physician satisfaction without other practice re-design factors(1).
The authors also report in their results section lower labor costs in the case clinic, but their abstract only refers to a "suggestion of labor cost savings," and since no data is reported we can only assume no significant differences were found.
In addition, there was no improvement in any quality of care or patient satisfaction measures. This is truly disappointing since a major goal of primary care redesign is improvements in quality of care and population health.
There are also many unaccounted-for variables - how was the implementation clinic chosen, why compare just one case clinic to several control clinics, why did the case clinic use APCs and did they replace physicians or were they hired to complement them? Why were MA ratios decreased 18 months into the experiment - was it staff attrition, cost concerns, or where the quality improvements insufficient to justify them?
We could learn valua...
Show More

The authors' conclusion that their model of team-based primary care "demonstrates team development is a plausible key to protect against burnout" is completely unjustified by their data. No significant differences in burnout were demonstrated; a nonsignificant trend of 2 data points is not evidence of a plausible key. Furthermore, their non-significant trend was wiped out completely by the loss of MAs for in-room scribing. Scribes alone have been shown to improve physician satisfaction without other practice re-design factors(1).
The authors also report in their results section lower labor costs in the case clinic, but their abstract only refers to a "suggestion of labor cost savings," and since no data is reported we can only assume no significant differences were found.
In addition, there was no improvement in any quality of care or patient satisfaction measures. This is truly disappointing since a major goal of primary care redesign is improvements in quality of care and population health.
There are also many unaccounted-for variables - how was the implementation clinic chosen, why compare just one case clinic to several control clinics, why did the case clinic use APCs and did they replace physicians or were they hired to complement them? Why were MA ratios decreased 18 months into the experiment - was it staff attrition, cost concerns, or where the quality improvements insufficient to justify them?
We could learn valuable lessons from the authors if they focused on why their re-design experiment failed to yield the improvements in clinician satisfaction, care quality, or patient satisfaction that we are looking for in these new models of primary care delivery. Given the stakes for the future of primary care it is essential that we understand both what works, and what doesn't.

1. Shultz CG, Holmstrom HL. The use of medical scribes in health care settings: a systematic review and future directions. J Am Board Fam Med. 2015 May-Jun;28(3):371-81. doi: 10.3122/jabfm.2015.03.140224. PMID: 25957370.
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Competing Interests: None declared.