A Report from the Ambulatory Sentinel Practice Network

* BACKGROUND Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described.

* METHODS In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).

* RESULTS Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.

* CONCLUSIONS Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Practice recommendations

* Heighten your awareness of nonlinear patient behaviors including sensitivity to minor changes, resistance to change, sudden dramatic change in behavior, and intermittent catastrophes.

* Nonlinearity means we should expect the unexpected but limit unpredictability through in-depth knowledge of patients and context.

* Reinforce positive attractors, use small well-timed interventions, and encourage healthy variability and nonlinearity.

Had Sir Isaac Newton attempted family medicine, he likely would have been uncomfortable with its nonlinear aspect typified by unpredictable disease courses and treatment responses.

Linearity forms the basis of our knowledge … Life in a Newtonian world is ordered and predictable, where causes are directly linked to effects and behavior is linear or cyclic (periodic). In this world, stability and predictability define a healthy system. Furthermore, by understanding the parts of a system, we understand the system. As physicians, we are trained to expect this linear, predictable, reductionistic view of health.

… but it does not reflect the human system. However, humans are complex adaptive systems, characterized by multiple interconnected and interdependent parts at levels from the microscopic to the community. Interactions change over time, producing synergistic nonlinear behavior as components periodically self-organize into functional groups.

TABLE 1 compares the Newtonian world view with that of complexity science. Although all of the characteristics of complexity science are relevant to family physicians, this article will focus on the nonlinear behavior of patients as the visible, unpredictable, and often frustrating manifestation of the complexity characteristics. TABLE 2 defines specific characteristics of nonlinearity.

In understanding nonlinearity–as depicted in 4 patient cases presented here–family physicians can learn to * expect the unexpected

* reduce unpredictability by learning about patients and their context

* attack patient resistance by seeking epiphanies or using positive attractors

* recognize the sensitivity of our patients’ trajectories and use or anticipate it

* promote the healthy benefits of nonlinearity.

* Nonlinearity as a truer model of health

In this issue of JFP, 2 well-known family physician leaders, Carol Herbert and Stephen Spann,[1,2] describe a variety of threats to the specialty of family practice, warn of its potential demise, and call for its reinvention. The threats include new knowledge in genomics, new technologies, increasing patient desire for direct access to other physician specialists, increased access to information by patients through the Internet and media, evidence-based medicine (EBM), alternative and complementary medicine, nurse practitioners and physicians assistants, nurse triage systems, the abandonment of traditional roles such as hospital care, the push for higher quality of care, and the demand that costs be contained. For tangible evidence of a threat, the authors cite the decreased numbers of medical students entering family practice, decreased satisfaction among physicians, and the replacement of traditional family physician roles by other care providers.

Is our demise impending? To paraphrase Mark Twain, another Missourian: Rumors of our impending death are greatly exaggerated.

CHANGES OFFER OPPORTUNITIES

I agree we live in a time of dramatic reorganization of health care and tremendous growth in biologic knowledge and the capacities of information technology. One result of this is that patient expectations are increasing. At the same time, the rising cost of medical care is forcing uncomfortable choices in how we practice medicine. These changes can be seen as opportunities rather than threats. Our opportunity in family practice is threefold: to continue to respond to the need for patient-centered medical care, to translate emerging knowledge into improved patient outcomes, and to manage that knowledge through information technology to put it to the best use for our patients and communities. Pursuing these opportunities seriously will certainly require changes in strategies and roles for family physicians; in doing so, we must maintain the core function of the family physician as a personal physician and enhance the physician-patient relationship, not detract from it.

If a certain New Yorker had gone to medical school instead of into comedy, he’d undoubtedly be a family doctor.

“I don’t get no respect,” Rodney Dangerfield, M.D., might mutter. “Other day I’m going to work. Halfway through the crosswalk I see this classmate of mine, guy’s a neurosurgeon. He’s driving the big car. He’s wearing the diamond Rolex. He’s got the hundred-dollar haircut. I wave my lunch bag at him. I say, |Hey, how come you’re driving a Bentley and I’m hoofing it?’ He gives me one of those little Tom Brokaw grins and says, |Money talks and GPs walk.’ I’m telling yuh, I don’t get no respect.”

For America’s general practice and family physicians, the imaginary Dr. Dangerfield’s riff is a cruel truth. Patients love them, but academically and professionally, medical general practitioners (GPs) have little stature and are rapidly becoming an endangered species. In contrast to other industrial nations, where doctordom divides evenly between general and specialized practitioners, 70 percent of the doctors in the United States are specialists. “Right now we have about 100,000 more specialists than we need and 100,000 too few primary care doctors,” says George Lundberg, M.D., editor of the Journal of the American Medical Association.

Never has the United States so desperately needed family physicians; not only are they the first line of defense against disease and trauma but they are vital in combating the huge costs of specialized health care. They are as important for what they decide not to do–such as order expensive lab tests, imaging scans or surgery–as for what they do, which is perform simple and less costly in-office procedures and write prescriptions. One hour of a cardiologist’s handiwork clearing deadly clots on the surgical table costs many times more than a preemptive visit to a physician who measures– and tells you how to lower–your cholesterol level. A worst-case analysis suggests that our preponderance of specialists could cost the United States $240 billion of the $800 billion spent annually on health care.

Ukrop’s Super Markets is negotiating with a physicians’ group in its home market of Richmond, Va., to open a new food/drug combo store that will adjoin a medical center staffed by family practice physicians.In an interview at the Food Marketing Institute’s annual supermarket pharmacy conference here, Ukrop’s director of pharmacy and health services, John Beckner, revealed plans by the company to complete the new combo store in time for a grand opening this fall. Beckner said the store would adjoin the clinic and would feature a separate entrance so patients can walk right from the doctors’ office into the Ukrop’s pharmacy.

“It s a family practice group of a bout seven physicians,” Beckner commented. “We’re looking at an opening in about mid-November.”

Ukrop’s operates 27 supermarkets in northern Virginia, including 20 with pharmacies and 12 with health- and nutritional-information kiosks.

Family physician leaders are concerned about the continuing decline in the number of medical school graduates choosing family practice residencies, but they haven’t pointed the finger at any one factor as causing the decline.

“The concern about an adequate primary care foundation for the country remains,” said Dr. Perry Pugno, director of the division of medical education at the American Academy of Family Physicians in Leawood, Kan.

According to figures from the National Resident Matching Program (NRMP), family practice filled 81.2% of its residency slots, down 1.5% from its fill rate of 82.7% in 1999. The fill rate for family practice was 85.5% in 1998 and 89.1% in 1997. The fill has declined each year since 1996, when it was 90.5%.

Dr. Bruce Bagley, AAFP president, cited practice lifestyle as a possible reason for the decline. “Family practice [and other primary care specialties] involve a high degree of commitment to patients” and long work hours. Some physicians might not be willing to take that on, he said.

Dr. Greg Hinson is in the minority. He’s among the meager 13 percent of physicians in solo practice who use electronic medical records, according to a recent Commonwealth Fund survey. But Hinson is comfortable being apart from the madding crowd. He knew electronic record keeping would be the ticket to efficiencies in his practice so he traded in his hodgepodge of inadequate record-keeping techniques, said hello to an EMR geared to small and midsize practices and is engaging patients in a Web portal that puts them in the driver’s seat of their healthcare.

In August 2001, Hinson moved from a three-doctor office in rural Georgia to take over a similar size practice on Nantucket Island, Mass.–a community with a year-round population of 10,000 that quadruples the number of residents in the summer. Hinson supplemented his predecessor’s handwritten notes and paper charts with notes generated by an early, limited EMR. When the vendor phased out the EMR a couple of months after Hinson moved to Nantucket, he experimented with a mixture of handwritten notes, homemade MS Word templates, macros, checklists and dictation.

“If you opened my paper charts, you’d see notes generated in about four or five different ways,” says Hinson. “I was spending too much time documenting and way too much time hunting for paper charts. It was very confusing.”

In 2003, Hinson began searching the Internet for EMR options that would allow him to not only improve documentation, but also involve patients more in their healthcare. After seeing several vendor names pop up repeatedly on physician-driven forums like physicianonline.com and emrupdate.com, he contacted those vendors, participating in a dozen online demonstrations.

When Hinson would describe his staff size–a nurse practitioner, medical assistant and receptionist–and patient volume (approximately 45 a day), vendors would stop Hinson midsentence and say, “You can’t afford us.” The market was not friendly to small practices of fewer than 10 doctors, Hinson contends, and instead catered to medium and large physician practices of 40 to 50 docs who could justify the time and expense of customizing a product. Hinson soldiered on and after a year, narrowed his choice down to two vendors.

Delegates for Physicians with Heart returned recently from a humanitarian mission to Vietnam, where they delivered $4.25 million worth of medical supplies to Vietnam and met with Vietnamese medical professionals to promote the development of family practice. “In Vietnam, the concept of family practice is extremely new, and we are often greeted by a mixture of great interest and skepticism about the breadth of our specialty,” said Daniel Ostergaard, M.D., vice president for international and interprofessional activities at the American Academy of Family Physicians (AAFP). Five family physicians traveled to the Institute for Health Strategy and Policy in Hanoi to meet with about 20 Vietnamese medical professionals and health system researchers to provide some insight into the world of family practice in the United States. Physicians with Heart is an international humanitarian project sponsored by the AAFP, the AAFP Foundation (the philanthropic arm of the AAFP) and Heart to Heart International (a humanitarian medical relief organization). The airlift received support from pharmaceutical companies and transportation was provided by the U.S. State Department.

Responding to criticism about health care quality in the United States, the American Board of Medical Specialties (ABMS) developed a program that centers on maintenance of certification to boost confidence in the quality of physicians. Maintenance of certification, which is required of all board-certified physicians in the United States, is intended to continuously measure the competencies of practicing physicians in every specialty. Each ABMS member board will administer a maintenance of certification system tailored to its diplomates. The American Board of Family Practice (ABFP) will use a four-part framework to measure physician competencies over the seven-year certification period. The four components are professionalism, self-assessment, cognitive expertise, and practice performance. Physicians who certify or re-certify in 2003 will be the first to enter the maintenance of certification program. The American Academy of Family Physicians (AAFP) and the ABFP are collaborating on various elements of maintenance of certification to ease transition to the new system and to maximize the opportunities it presents for improving patient care.

Charles, a 70-year-old man, came in today for a routine follow-up visit for congestive heart failure (CHF). At age 45, he had an acute myocardial infarction and was treated in the standard manner of that day–rest, analgesia, nitrates, and anticoagulants. He made an uneventful recovery and returned to work. He continued to have moderate angina and was referred to a tertiary care medical center for evaluation. This occurred in the early days of coronary artery angiography and coronary artery bypass grafting (CABG). At that time, the primary indication for CABG was angina not controlled by medical treatment. When Charles was studied, he was found to have significant three-vessel coronary artery disease (CAD) and was not considered a candidate for CABG. His symptoms were fairly well controlled with beta blockers and nitrates, and he was later prescribed statin drugs for hyperlipidemia. Currently, he is active, works full time in his own business, is a happy gardener, and a doting grandfather. This example should remind us, in the current milieu of highly aggressive interventional cardiology, that medical therapy for CHF was, and can still be, an effective treatment in combination with surgical intervention or alone in many patients with CHF.