Changing Horses Midstream: The Promise and Prudence of Practice Redesign

I've been wanting to read this piece since it came out over a month ago. And now, during the last days of a vacation I'm finally finding the time. Should we laugh or cry at our busyness? I prefer the former, even when it's through gritted teeth.

What I loved about this piece was the acknowledgment of our struggle as family physicians--to finance what we do, take appropriate time with our patients, get the medicine right, create relationships that are the heart of our specialty, spend time with our families, find a moment to be creative, locate spaces to regenerate ourselves, etc. There are many reasons to be cynical and this piece lays some of them out. Yet the expression of this hurt is sometimes required to free us--so we can begin hoping again and get to work.

My hope is that with health care on the national agenda, common sense and (more importantly) the need for economy will force the issue. When that happens and more graduates and more money find their way to family medicine and primary care, the participants in the efforts described by Drs. Loxterkamp and Kazal will be ready. That really does make me hopeful.

Competing interests:   None declared

I do agree that family medicine is in crisis. On the other hand, I believe our future has never been brighter. Because of the unprecedented demand of our services today and in the coming years, family doctors are desperately needed.

I realized five years ago that I had to become more efficient to respond to this growing demand and to survive financially. I embarked on a course to teach my nurses to take a competent and complete history, to do all my documentation, and to implement my treatment plan. I set out on this course initially for financial reasons, but to my surprise our quality of care rose dramatically. The nurses had time to do everything I always wanted to do. Also, as a result of this change, finances have significantly increased, acute and follow-up visits are seen in a timely manner, charting is more thorough, and patient satisfaction is high.

Out of the success of my personal experience I have written a book and instructional DVD that trains capable nurses to take a competent history. If you would like to see more detailed information on the results of this initiative please visit www.familyteamcare.org.

Sincerely, Peter Anderson MD

Competing interests:   I am the author of the book "Liberating the Family Physician"

It has been gratifying and a little intimidating to read the many wonderful comments on our Reflections essay. Marly McMillen provides an excellent summary of the National Demonstration Project. TransforMED was no less responsive to change than were the participating practices; without its help and support, the Self-Directed Retreat could not have been so successful. Elizabeth Stewart was more than a guest at the retreat; she served the vital role of documentarian. She rightly reports on the need for self-reflection in the course of busy lives and the power of collaboration to achieve common goals. Hugh Silk and Ray Gerard emphasize the importance- and increasingly rare sightings- of the family in family medicine. As Randall Rickard notes, Dr. Kazal and I were rankled by the term "patient-centered," but still feel at home in family medicine. John Scott points to staff relationships as part of the healing dynamic; he hopes that all medical homes will become healing practices. Jonathan Han honored us by pairing our article with Don Berwick's excellent piece in JAMA.

I read all of the comments carefully- as I hope other readers have- knowing that only a chorus of voices can achieve the great things we hope for in family medicine.

I am especially grateful to fellow members of the Self-Directed Group, most of whom I met at our retreat. We were rejuvenated by what Chris Hawley calls "the renewed emphasis of physicians taking charge." Robin Kollman's comment, "To interact with participants who still enjoyed the practice of medicine and their relationships with patients was healing and motivating" could have been said by any of us. William Harrington makes us laugh with the image of riding a mule, but we have all shared his frustration. And Andrew Lockman quotes an old friend, someone pivotal at the start of my own career. Of the many inspiring words that Gayle Stephens left us, these are the most necessary now: "Our unfulfilled hopes are less remarkable than we hoped at all." Lastly, it has been a surprise and joy to find a friend in Lou Kazal, Jr. I have a strong feeling that our collaboration has not ended.

It has been an honor to be a part of the rekindled hope, the new model, the outflow of energy infused into the most vital role in medicine. However packaged, family medicine still requires that we care for patients without neglecting ourselves. That we help them achieve no less than what we all desire: timely attention, understanding, friendship, trust. Not everyone comes from a good home, but we are working collectively to make sure that all patients can find one.

Competing interests:   None declared

Dear Bonita,

Thank you for your thoughtful, well-spoken response to "Changes Horses Midstream." I thoroughly agree with you: it is the relationships in family medicine- between providers and patients and among the team members - that can help turn a patient's nightmare into a positive transition. So much of what consumes the time and energy of the team is not a face-to- face encounter and, therefore, cannot be reimbursed. You correctly observe that family medicine must become creative and forceful in finding non- procedural funding for the medical home.

I would differ slightly on two of your points. First of all, I never apologize to those who confuse me with a GP. My father was one, and he was far better than I in providing a generalist approach, accessible and unhurried care, and continuity. Second, family physicians should never allow ourselves to be define by what we do, even when we do it well. We are more than overseers and purveyors of services. We enter into therapeutic relationships with our patients in which we give a little of ourselves and allow them to feel befriended, cared for, brooded over, and guarded. This is not patient-centered care, or basket-of-services care, but relationship-centered care, something my father understood and our patients value most.

Competing interests:   Co-author of "Changing Horses Midstream"

TransforMED’s National Demonstration Project (NDP) has been referred to as a “learning lab,” reflecting the desire for continual learning and sharing throughout the project. We were aware (and reminded) early on that this NDP was too many years late in coming and we felt the burden of this in the planning stages. We knew that waiting over two years for publishable research would be too late, so the project was designed to elicit early learnings that could be shared along the way. The article by Drs. Loxterkamp and Kazal, formal reports by the independent evaluation team, and insights from TransforMED staff and the NDP practices themselves (found at www.transformed.com), are all examples of some of these important early learnings.

We refer to the self directed practices as a comparison group because the NDP was designed to compare different approaches to how practices transform to a new model of care. How would a facilitator work as a change agent within a practice and would practices on their own fare just as well? One NDP learning is that the answer to this question is more art than science.

Our plan of action with the NDP seemed fairly straight forward. Facilitators would be assigned to the facilitated practices and would work closely with them. Self directed practices would have access to information similar to other practices and would have the freedom to change their practices at their discretion. We conducted meetings early on with the facilitated practices and this established a firm foundation for the geographically challenged group of practices to bond, providing for strong communication and peer reliance throughout the project. The self directed practices also recognized this need and self organized their own learning collaborative meeting half way through the project. Another lesson learned: in our busy, asynchronous world it can be easy to forget the power of face-to-face interaction, especially early on in a relationship. I’m thrilled the self directed practices self organized and put together their own meeting, I only wish we would have thought to organize this for them early on in the project.

We walked into the NDP 22 months ago expecting to be able to provide family physicians in small to medium size practices fully integrated and prepackaged products and services including the know-how to help implement a new model of care with ease. One thing we have learned through the NDP is that many of the products and services are nowhere near ready for prime time. Technology is one example. We have learned that not only are some technology products not “family physician friendly,” we’ve learned that even exemplar practices may not be ready to absorb the new stressors that new technology can bring. In order to avoid automating inefficiencies, we learned that some practices require tremendous preparation and changes in workflow before they can adopt radical changes in technology. And often such changes affect the practice relationships.

TransforMED’s facilitators are highly trained experts in areas such as finance, change management, team building, and practice management. Like the practices themselves, they are also learning the best ways to manage change within the challenging context of today’s primary care setting. The NDP has afforded the facilitators the valuable opportunity to refine their skills in ways that hopefully benefits both the practice and the patient. And although the formal evaluation is still to come, we at TransforMED feel confident enough that practices CAN benefit from facilitation that we adding to our team of facilitators.

Transforming a practice is not rocket science, but that doesn’t mean it’s easy. Take weight loss for example. The formula is simple: burn more calories than you eat. It may not be rocket science either, but it is tough to be successful at it. The same can be said about transforming a practice. There is more than enough information available on how to be a medical home. The trick is sorting through the materials, websites, and toolkits to find what’s really effective. I like to refer to this as mass redundancy. Why should every practice in primary care trudge through the same materials trying to figure out the best way to conduct group visits? That, we have learned, should be one of the goals of TransforMED, to become the great sieve for primary care, sifting through the course material, leaving behind the fine nuggets.

Next month we will be holding the final learning collaborative meeting of the NDP and it will include both the facilitated and self directed practices. We are thrilled to bring both these groups together and look forward to the incredible insights that can be gained from both groups. As we move closer to May 31 (the end of the 2-year endeavor), we have spent time reflecting on what could have been done differently, and ways to make improvements for the future. The NDP has not been a perfect path, and certainly not always smooth. But it has provided a great opportunity for learning about what it takes to help an existing practice become a medical home. We find ourselves much richer for the efforts of the physicians in our NDP practices, like Drs. Loxterkamp and Kazal, and we look to the future of the specialty, primary care, and the US healthcare system with a renewed sense of optimism.

Competing interests:   None declared

As a physician in another of the self-directed practices, I can also attest to the “renewed sense of optimism and commitment,” as described by Drs. Loxterkamp and Kazal, which emerged from our group retreat last year. Sharing frustrations and victories together with a diverse group of motivated practices was just the therapy that my practice needed to move into the next phase of change. Although I feel that the practice “mule” on which I ride is even more ornery than Dr. Harrington’s, like Dr. Kollman I have become comfortable with the idea that our change process will still have a long way to run after the two year project is finished.

Some are concerned that the medical home concept may be not completely on the mark. Last spring I had the good fortune to hear a plenary address by Dr. John Saultz, who persuasively argued that our specialty is in need of more than just transformation—that our times call for a revolution! In reflecting on these ideas, it occurred to me that whatever the name we use for this process of change, simply being one of so many in Family Medicine who are actively seeking ways to better serve our patients, communities, and our specialty is a reward in itself. Dr. Saultz pointed out the following G. Gayle Stephens quote from 1979:

“We’ve had to settle for less than we had hoped for. We hoped for everyone to have access to a personal physician- we’ve discovered that not everyone wants or can utilize a personal physician properly. We hoped to produce compassionate physicians- we’ve had to settle for producing less cynical ones. We hoped to teach continuity care but found there was little time in which to do it. We wanted to educate patients but found that we ourselves lacked the education to do it. We wanted to integrate the art and science but seemed always to have to choose one or another. Perhaps our unfulfilled hopes are less remarkable than that we hoped at all.”

I’m thankful that our specialty has encouraged us all to reach for some of those unfulfilled hopes through an initiative such as TransforMED.

Saultz J. “Primary medical care for families revisited: an unorthodox rearrangement of new ideas” Family Medicine Digital Resource Library

Competing interests:   None declared

I am a RN in one of the self directed practices and have been nursing in the specialty of family medicine for more than 25 years. I cannot tell you how many times I have explained to patients that family medicine is not the equivalent of the earlier day "general practitioners", that it is it's OWN specialty. Family medicine has never gotten the respect it deserves and is most often completely misunderstood.

No specialty can surpass the value of a good family medicine physician and his/her staff in terms of positive outcomes and comfort during serious illnesses. The patient feeling supported and "not alone" along difficult pathways greatly contributes to better outcomes and quality of life while recovering or dying. The relationship with a good family physician and staff can change a difficult experience from a nightmare to a positive, memorable period of growth.

I am all in favor of all the "updates" to help us be more efficient and streamlined as practices, but I feel one major point has not been considered enough. I feel that a stable staff backing a good physician is priceless! A strong, flexible staff can make the life of an overworked physician SO much easier and more efficient by acting as part of his/her eyes, ears, hands, and heart. That brings us somewhat full circle back to the issue of adequate compensation for family medicine services; as long as family medicine physicians are not compensated adequately, staffing will remain an issue until we can be competitive in terms of salary, benefits and retirement preparation.

I see family medicine as the medical container/basket/overseer which holds all the medicial pieces of our lives, either by practicing a little of all specialties or monitoring specialty care. Without a strong container/advocate, our medical lives are more scattered and less protected. I feel that this concept could be used as a tool to re-educate the population and revitalize the specialty in addition to the other efforts already in progress.

Competing interests:   None declared

Principles not taught in medical school when I attended. It takes money to run a medical practice. Someone has to pay for medical services provided. Primary Care Medicine is the foundation of a country's health care system. A society's health is better if its primary healthcare system is adequate.

Medicare and health insurance companies do not acknowledge these principles. The AAFP is to be applauded for its willnesses to recognise the blight of primary care medicine and the willness to try to create ways to attempt to reinvigorate our primary care speciality. The physicians and staff of the practices that are involved in the TransforMED experiment are to be applauded for the willness to change their practices whether faciltated or not. The journey has not be simple or easy!

I was lucky to be a physician in one of the practices selected for this experiment. Our practice fell into the unfaciliated group. So I was privileged to be able to attend and participate in the conference described in the article by Dr.s Loxterkamp and Kazal. I was amazed by the diversity of the practices represented there and the leadership and knowledge brought to this conference by the participants. It was joyful to be with physicians and staff that wanted to do what was right for patients and were willing to embrace change for that purpose. To interact with these participants who still enjoyed the practice of medicine and their relationship with patients was healing and motivating. Yes, we all have been banged up along the way in this journey but these participants still cared.

To try to accomplish all the change TransforMED project required in two years was asking the impossible, but who said it really had to stop at two years. Most of the ideas are sound but in a small practice change requires time, money, consistancy, and teamwork. Those resources are limited so more time will be needed. I hope the AAFP will continue to be innovative for it members.

I agree with Dr. Harrington that it has been like riding a mule on this journey and I wonder at times about my intelligence when I filled out that application for this project. But is it worth it if our country does not get the importance of primary care medicine inspite of our best efforts? For me the answer is "YES!", my eyes have been further opened to the need to focus on patient needs and how our practice can address them and providing quality health care with evidence based medicine and information technology.

Competing interests:   None declared

As a family physician member of one of the self-directed groups of the NDP, what I appreciate most about this article and this project is the renewed emphasis of physicians' taking charge of their practice to fit with their ideals. Too often we look to someone else to solve our challenges in family medicine and I'm excited to see more attention focused on how we can create the ultimate practice environment for our patients and ourselves. No one else will do this for us and we are too impatient of a group to wait for the external environment to improve. In our small group that was formed 6 years ago, we all came from practice environments that prevented us from taking control and doing things "our way". Like most family physicians, we wanted relationship centered care, more time with our patients, more emphasis on pro-actively preventing illness, and perhaps most importantly, we wanted to have a fun time with our colleagues who were sharing the journey. While we have made our fair share of mistakes (and will continue to make more in the future!) the movement forward has been a thrilling adventure. This is a great time to be a family physician and not a time for despair! We have many options for improving our practice environments, if we are willing to undertake these tasks with a large dose of creativity, humility and courage. Thank you to the authors for a chance to "peek in" on your process and I look forward to what we will all learn and accomplish along the way.

Competing interests:   None declared

As a member of the National Demonstration Project Evaluation Team, it was a privilege to attend the self-directed retreat described in the insightful and stimulating commentary by Drs. Loxterkamp and Kazal. Organized and facilitated by the physicians themselves, this retreat was primarily about sharing and reflection in a discussion-based rather than didactic format. In today’s world of tightly structured CME conferences, this organic and unhurried approach worked surprisingly well to feed both the inherent professional drive for information as well as the equally important hunger to build relationships. A more detailed description of the retreat and additional thoughts on the SD practices can be found within the NDP Evaluation Report at http://www.transformed.com/evaluatorsReports/report4.cfm.

Two thoughts stay with me from that retreat. The first is the importance for busy physicians and staff to set aside time for reflection and regeneration. It may seem like a luxury when compared to daily demands, but could also be seen as a necessity to revive change-weary spirits. Perhaps such retreats may one day be viewed as a vital part of the “relationship-centered care” described by the article; i.e., doctors and staff taking time to attend to their own needs so that they can better attend to the patient.

The second thought concerned the pervasive similarities between the facilitated and self-directed groups – not just at baseline, but as the project evolves. Both groups believe in both the power of collaboration among individuals with different approaches but also a shared goal. This is true between the two NDP groups, and within each group. Both groups demonstrate an unwavering commitment to a project that boldly moves out to the farthest part of that limb, bravely forging ahead to that glorious “destination” to which Dr. William Harrington referred. And the beautiful but often exacerbating part of the NDP is that no one really knows what that place looks like - but everyone has a different vision towards which to work.

Both arms of the NDP are innovative, vibrant and forward-thinking. For this reason, the term “control” group really doesn’t fit for the self- directed practices. In their eyes, they did not receive any new model resources except a website and well wishes. But their baseline motivation and continued drive for change elevates them to an equal place at the table as the facilitated practices – the only thing missing is the facilitator.

Thus, the self-directed practices really serve as a comparison group: what can motivated practices do when left to their own devices? It turns out, quite a bit, and many times with a unique interpretation of the new model components. While it’s possible that some of the self-directed practice strategies would run against what a facilitator might advise, this is a tremendous opportunity for all invested parties to learn what practices do without assistance – and what has worked and hasn't worked. To the credit of TransforMED, it has risked raising the ire of the SD practices by leaving them alone, an approach that has been difficult for all sides but will ultimately prove to be invaluable to the NDP and the discipline of family medicine.

A final thought on the similarity between the two groups, and that is the simultaneous generation of “practice pearls.” The authors provide a table that could have also been written by a facilitated practice, a facilitator, or the evaluation team. The fact that these pearls innately sprang from an informal gathering of physicians and staff speaks to the power of the overarching NDP lessons of what change requires. One might read the list and think “well who doesn’t know this is important?” to which I would reply, you’re right. We do already "know" this, but the challenge is to demonstrate and document that it actually works so that we BELIEVE. In this way, perhaps thousands of other FM practices will be motivated to follow suit and then find, as the authors encourage, “the joy in the irrepressibility of change.”

Competing interests:   None declared

No matter the outcome of each project set forth by the participants at the retreat written about by Loxterkamp and Kazal- I think they are on track with their prescription for change. The ten pearls they outline in the table are very thoughtful and comprehensive. Communication, full staff support, a sense of joy along the way and at the finish line, and accounting for costs are essential. I will use this list for my next project to increase the chances for success. I appreciate the comment made earlier by another responder about keeping the family in family medicine. When I read the TransforMed documents, I can not find the word "family" anywhere. I believe we will help our patients, our colleagues and ourselves best if we continue to practice in a "culture of context" no matter what changes we make in our office, our specialty or our profession. We only make connections and therefore changes with our patients when we get to know where they are coming from and how they might get to a better place.

Competing interests:   None declared

I am a physician in a faciltated practice in the NDP. I have spent much time trying to get my mind around what the TransforMed model is and how we can improve ourselves using it as a guide. I am unable to digest all of my thoughts into a brief comment, but I am drawn to reflect that the concept of the Patient Centered Medical Home excites me just as it seems to rankle the authors. Our "transformation" will not be complete at the end of the NDP, but we will have come a long way, and we will have clarified both our goals and our processes. Being a "home" for our patients and engaging them tuned to their needs over ours will remain at the core of our mission. The elements of the model are just ways to make this come to pass in the best way possible.

Competing interests:   None declared

Dr. Loxterkamp and Dr. Kazal have provided a thoughtful and thought provoking critique of the TransforMed project from their unique position as both insiders and outsiders in the NDP. The acronym TransforMed was chosen to suggest that practices who implement the recommendations of the Future of Family Medicine report will experience transformation, yet as the authors point out, a more useful view is that of a tool box. Transformation requires good tools, but tools are useless without a clear vision of what we wish to create. I would argue that our primary function as family physicians is to serve as healers to the sick and that healing is mediated through relationships not only with clinicians, but with every person in our practices. My vision of transformation is therefore to create healing practices, practices where patients can have “the personal experience of the transcendence of suffering.” 1 The tools developed and refined through the experience of the NDP may prove useful in helping to build relationship-centered medical homes that have the capacity to be places of healing, healing that includes but is not limited to providing the best that scientific medicine has to offer.

1. Egnew TR. The meaning of healing: transcending suffering. Ann Fam Med. May-Jun 2005;3(3):255-262.

Competing interests:   None declared

Don Berwick’s commentary in JAMA this week, “The Science of improvement,” offers specific advice to “accelerate the improvement of systems of care and practice:” 1) embrace wider methodologies of analysis, 2) reconsider thresholds in evidence, 3) rethink trust and bias, and 4) encourage civil and respectful dialogue between academicians and practitioners. Berwick points out that the search for truth in complex systems involving social change requires broad multidisciplinary thinking, and that some of our methodologies (e.g. randomized controlled trials) may be unfit to evaluate these processes. Ultimately, as clinicians and researchers, humility is required to communicate effectively with each other to accelerate meaningful change.

David Loxterkamp and Louis Kazal, “foot soldiers in primary care“ who know “the plight of the average patient and the frenzy of our workplaces,” have written a compelling account of their experiences as participants in the National Demonstration Project (NDP). Their essay is a thoughtful and practical complement to Berwick’s commentary in JAMA. As participants in the “control arm” of the NDP study, intentionally left without the guidance of consultants, Loxterkamp and Kazal have a unique perspective on the promises and pitfalls of self-directed change.

Of the many valuable insights that Loxterkamp and Kazal describe, asking the right research questions is necessary to direct a “nuanced shift toward relationship-centered care.” The results of the NDP will be more provocative because these “controls” were biased toward action and change, illustrating Berwick’s point that certain kinds of bias can indeed be useful in evaluating underlying context and complex mechanisms.

That “healing occurs within relationships” is what practicing physicians have learned from experience, and the “renaissance in family medicine” that Loxterkamp and Kazal deem possible requires “HBM” – Humility-Based Medicine - an approach that incorporates strong clinical evidence, meaningful process research, and respectful dialogue to improve quality of care. How we develop and nurture relationships between physician and patient, and across health care delivery systems, should be the ultimate objective when we address issues of quality, access, and sustainability.

Berwick, D. The Science of Improvement. JAMA. 2008;299(10):1182- 1184.

Competing interests:   None declared

As the director of a self directed TransforMed practice, I have sometimes succumbed to discouragement with the NDP process. I do not doubt that primary care must be overhauled to survive, and I commend the founders of the National Demonstration Project for the courage and determination they have shown in initiating transformation.

Doctors Loxtercamp and Kazal framed the issues well and posed poignant questions concerning the horse we are riding into the future, but there was one factual error that I must point out to them: We’ve not been riding horses. We are on stubborn mules.

I’ve stayed up nights and worked hard trying to keep my mule on the right trail, but neither he nor I are certain of the right trail. This mule is in the habit of stopping in the middle of the trail, or taking two steps forward and one step back. At times it feels like we’ll never get there, but I’ve caught a glimpse of the destination, and it looks like a nice place. In that land, appointments are made after patients provide computer facilitated histories online. In that land, I start on time, stay on time, and finish on time…Somebody pinch me, I must be dreaming! In that land, based on computer prompted, evidence based protocols, medical assistants and nurses cue up all the refills and health maintenance orders. Unless I change the orders, a click of the mouse finishes the job. In that land, regional information networks function so well that we never get to talk to medical records’ clerks any more. E-mail reduces messaging to 10-20 minutes a day instead of hours. Even though the wicked 3rd party of the west still doesn’t pay us well, and we still have to see more patients than ever, that bothers us less, because in that land we have more time for decision making and for building therapeutic relationships with patients.

This sounds far fetched, but I’ve seen glimpses of that land, and it exists. That gives me just enough hope to keep lighting fires under that mule and just enough determination to adjust our course to get back on the right trail. We may not always be on the right trail, but at least we are headed in the right direction.

Competing interests:   None declared