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Showing posts from March, 2017

The Academic Family Medicine Mismatch

Family medicine leaders still cling to traditional academic medicine. Many of the major family medicine efforts arise from family medicine departments and from medical school based family medicine programs. Soon family medicine will have a 50th anniversary. Should family medicine tolerate another 50 years of stagnation? Constant Strain in the Academic Family The relationship between academic institutions and family medicine has always been strained - when academia was getting started, when formal family medicine training was started, and continuing to the present.Family practice general practice predates modern academia in the United States. The dominant physician 100 years ago were connected to local populations across origin, training, and practice. The academic designers consistently built up what became formal academic training. The consequences of such training were seen in just a few decades. Flexner conceded that the distribution of physicians was impaired by the new model, but…

Two Forces Shaping Declines in Outcomes in Health Education and More

Cries of victory may ring out today after the apparent defeat of the misguided Republican Replacement Plan, but the sand people will be back and in greater deception. The designs over past decades will continue to be shaped by those with their own agendas - agendas that are a poor fit with the needs of most Americans or true improvements in health outcomes.

The first realization that must be made is that the designers will be back with plans that work for them, but not for most Americans.

The second realization is that good intentions taken to excess have consequences as seen in austerity focus and in runaway health care costs.

Austerity FocusRunaway Health CostsCuts or prevents or diverts investments in areas that shape local determinants of outcomesIncrease so rapidly that federal and state dollars are diverted to health care and away from the determinants of outcomesThe Determinants of Health, Education, Economic and Other Outcomes include housing, nutrition, senior reso…

Mastering Well Being for Residents Physicians and Patients Takes Time

During this time of "value" focus, we have apparently replaced the temporary focus upon reflective practice. Recent patient care experiences confirm the value of reflection as there are so many dimensions of learning available, especially compared to the few via biomedical focus. Well being is about restorative time. Across residency training and primary care practice, there is an assault on this time and the value of such efforts. A major theme for practice or for patients or for those in training is the value of rest and reflection time.

The most important learning requires rest and reflection - and these require time. Well-being is compromised when rest, reflection, and sleep are compromised.

Too often it is easier to just work toward the end of the day. It is easier to speak too soon, listen too little, or jump to treatment as seen in too much medication. It is harder to insure best communication or to go the extra mile to impact the care experience of a child or a new …

Match Hype Hinders Health Access Solutions

In this time of avoiding the Truth, perhaps primary care training will be exposed to the truth as well. Each year the annual residency match generates numerous promotions of various types of programs as being primary care solutions. Sources low yield for primary care are not good sources for care where needed. The Match may indicate more medical students who begin training in primary care, but few will enter primary care and even fewer will stay in primary care.

Claims of nurse practitioner and physician assistant solutions for primary care are just as spurious. Those entering primary care and remaining in primary care continue to fall to lower levels. 

This year the claims of international graduates as solutions for underserved areas are prominent. About 50 - 90% of the services provided where the underserved need care are provided by primary care. International graduates fail as good sources of care where needed due to

20% loss to home or other nations45% choosing lowest primary care y…

Payment Prevents Primary Care Result - No More Match Follies

Year after year various primary care associations get excited to find out the results of the match or residency choices of medical students. It is quite interesting to see how so little change is promoted so much. Even a small increase of a few dozen graduates is celebrated.

Such celebrations hide the tragedy shaped by primary care payment design. This is best seen in family medicine, by far the best remaining source of primary care.

Changes over time indicate the likely result of increased family medicine graduates. The increase from 2900 to 3200 seems significant at 10% growth. But over the same time period family medicine residency graduates have been choosing other career paths involving emergency care, hospitalist careers, urgent care, and other specialties. The specialty once 90% retained in primary care is down to below 70%. The impact of the actual primary care result is shown below:


Annual GraduatesIncrease in GraduatesActive in FM Positions Over CareerActual FM Result By Clas…

Can Primary Care Survive Devaluation by CEOs and Government

Unprecedented decreases in morale and productivity have been seen across primary care in recent years. It is very clear that team members have faced rapid changes and increasing care demands along with declining support while patients and situations have increased in complexity. Health care leaders are not paying attention. There has been no progress to improve support or to decrease the challenges.

Even worse, primary care leaders get poor ratings as they spend their time and effort and scarce resources on areas that will not reverse marginalization, burnout, turnover, and productivity problems.

A recent RAND study was very relevant and indicated increasing concerns regarding the ability to best care for patients and have been sent through formal family medicine channels. Studies document the proliferation of additional work hours before and after patient care. Numerous studies indicate the higher costs from HITECH to MACRA and for primary care medical home. These are designs that can …