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Tuesday Oct 30, 2018
Why We Need More Physician Entrepreneurs
Monday Aug 06, 2018
Rural Locums Provide Balance for Urban Doc
Tuesday Jan 02, 2018
New Year, Same Issues. Why Does Health Care Cost So Much?
Tuesday Dec 05, 2017
Rural or Urban FP, We Both Handle Gamut of Patient Issues
Tuesday Aug 29, 2017
Health Care Debates Don't Have to Be Heated
Tuesday Jun 20, 2017
Putting Patients at the Center of My 'Clinic of the Future'
Tuesday Jul 12, 2016
Support, Flexibility at Home, Work Vital to Success in Rural Practice
I have been reflecting on this blog for several days now, waiting for a rare down moment to write about what being a rural female physician means to me. Tonight, as I finally have some time, I realize that the unique challenges of rural practice make life unpredictable and possibly difficult for other physicians to relate to.
My husband (and practice partner) had rounds this Sunday morning at the hospital, so he dropped my daughter and me off at church and headed to work. At church, I received a phone call telling me that I also was needed at the hospital for one of my obstetric patients. I let my daughter's Sunday school teacher know I would be leaving but that my husband would be back to pick her up.
DMW PhotographyMy husband, Michael Oller, M.D., and I enjoy rural practice in Stockton, Kan., where we live with our daughter, Lyla, and mastiffs Mitch and Mosi.
My husband came back to church to get me, dropped me at the hospital, finished his own work and returned to church to pick up our daughter. A favor from a friend later and we each had a car at the hospital so my husband could take our daughter home while I stayed to deliver a baby.
It might sound crazy, but these are situations we frequently encounter. With supportive partners at home and at work, as well as support from friends and our community, however, they always work out. I sit here tonight having helped bring a beautiful baby into the world but also having had to give up a large part of my Sunday. I consider it a worthwhile trade.
The impetus for this blog was a study published in the May/June issue of Annals of Family Medicine(www.annfammed.org) that sought to "understand the personal and professional strategies that enable women in rural family medicine to balance work and personal demands and achieve long-term career satisfaction." The study was based on a survey of 25 rural female physicians in 13 states.
The authors identified three things study participants considered imperative for successful rural medicine careers:
- supportive relationships with spouses and partners, parents, or other members of the community;
- reduced or flexible work hours; and
- maintenance of clear boundaries between their work and personal lives.
The United States has a severe shortage of rural physicians, including a dearth of female and minority physicians. The lack of female physicians limits access to care for female patients who would prefer a female clinician. Rural female physicians are more likely to attend births(www.ncbi.nlm.nih.gov) than our male peers, which is an important part of practice in many rural areas with a shortage of obstetric care.
Many rural physicians choose this path because it allows them to maintain a broad scope of practice. However, this broad scope often also leads to long and unpredictable hours that vary greatly from week to week. (Today's delivery was the third this week for me, leading to longer hours than usual). Creating the support system necessary to meet patients' needs while also supporting our families takes great effort.
What attracts women to rural practice? The majority of the physicians surveyed had rural life experience. However, there are others, like me, who turned their attention to rural practice after experiencing it in a rotation. I graduated from the University of Kansas Medical School, where a rural rotation is required, and I continue to firmly believe that such experiences matter greatly in the choice of future practice.
We must continue to model for medical students what is great about our specialty, and those of us who practice in a rural setting need to be willing to precept students. It is a rare month when my partners or I don't have a medical student in our practice, and often more than one of us have students at the same time. I am proof that having a female rural medicine preceptor can take a practice setting that had never even been on your radar and make it your career. (That preceptor is now one of my practice partners.)
There are many challenges of rural practice. As the Annals study points out, rural physicians have fewer community resources, work more hours and care for more patients compared with their urban peers. This produces added stress and, at times, feelings of isolation. In the study, physicians with young children and those new to rural practice described feeling the stress of maintaining balance most acutely. The guilt of leaving family to care for patients and, conversely, spending time with family at the expense of time in your practice, are frequent sources of stress.
Those with good work flexibility reported highest satisfaction. For many in the study, this meant reduced work hours, especially when their children were young.
Supportive relationships are also key. Several of the women in the study reported male partners maintaining primary responsibility for managing the household and caring for children. Many had situations similar to mine -- married to physicians in the same practice. In all of those two-physician partnerships, one or both partners worked part time.
Work partners are also important -- other physicians who are willing to help out when family obligations and emergencies arise. We are expecting twins in the fall, and although I don't know exactly what our work schedules will look like when they come, I know that owning our own practice gives us the flexibility we need.
I received an email from my practice partners this evening saying they have devised a back-up call schedule that covers the weeks leading up to the twins' due date. This is the kind of cooperation that makes rural practice, with all of its additional stresses and challenges, sustainable.
Clear boundaries were identified as key for satisfaction. Limiting work and protecting personal time were seen as essential for personal well-being. Work partners often played an important role in this. In my experience, setting expectations for patients can be hard but is extremely important in rural environments; examples include respecting physicians' days off and time with family (i.e., not approaching them with medical questions in a public place).
Corresponding author Julie Phillips, M.D., M.P.H., told AAFP News that rural physicians in the study showed "a really strong sense of devotion to their patients and commitment to their communities." Although it was clear that most physicians in the study loved their work, there were also those looking to change practice because they felt their current situation was unsustainable.
The authors of the study concluded that female physicians considering rural practice may be more satisfied if they seek flexible employment opportunities, choose communities where support is available and build support networks as they select practice settings.
Practicing self-care and setting boundaries are also important skills. These are skills, however, that we are not often taught. Perhaps they could be covered more in medical training, especially in residency. Female physicians entering rural practice need the support of those who have gone before them. These relationships can be fostered through state and national academies, rural interest groups (such as online forums offered by the AAFP), and preceptors encountered during training.
Women need opportunities in residency training to rotate with rural female physicians. Those of us who live this practice style need to be available to serve as mentors and sounding boards. Female rural physicians are more likely than their male counterparts to plan on long-term rural careers, so let's continue to evaluate and work toward making more rural female physicians a reality.
Beth Oller, M.D., practices full-scope family medicine with her husband, Michael Oller, M.D., in Stockton, Kan.
Tuesday Mar 29, 2016
So Long, New York, You Were Exactly the Trial This New FP Needed
As an osteopathic medical student in Arizona, I had a lot of classmates and professors question why I wanted to go across the country to New York City for my residency in family medicine.
The West Coast -- where I grew up -- has a strong family medicine tradition, whereas New York City is perceived to have a strong focus on specialty care. Not only have I met several New Yorkers who did not even know that family physicians exist, I have worked with medical students whose school has no family medicine department and with other medical students who question whether they can find a good job in NYC if they pick family medicine.
So why choose to be in an environment that might, at best, be skeptical of family medicine?
My residency, the Mount Sinai Beth Israel Residency in Urban Family Medicine(www.institute.org) offers a diversity and complexity of patients that is unique to New York. With patients from around the globe, we had to keep a broad differential in mind as we also learned to treat the "bread and butter" family medicine cases.
But there was something far more important to my learning as a physician than the diagnoses that I made. My patients not only came from different countries, had different socioeconomic backgrounds and spoke different languages, they often had differing views of disease processes and expectations of the patient-physician relationship.
In medical school, we learned the textbook ways to diagnose and treat, but in residency I learned how much patients' cultural backgrounds can influence their recounting of symptoms and their relationship with their own body. We know how crucial the history is to finding the right diagnosis, particularly as we try to minimize extraneous and expensive tests that add burdensome costs for our patients and our health care system. When the patient and the physician have wildly different life experiences, language is often not the only barrier that needs to be recognized in order to appropriately diagnose and care for the patient.
After residency, I continued with the same family medicine organization that my residency was affiliated with. I have spent nearly three years in the Bronx with an international patient population, many of whom have language, health literacy and socioeconomic barriers that make it difficult for them to navigate our health care system.
I am surrounded by all the subspecialists that New York has to offer -- several of whom are rated top in their field -- but the majority of my patients simply cannot access them. Their need for a family physician and a patient-centered medical home (PCMH) to support their health and the health of their family is dramatic.
When they enter my clinic and find friendly staff who know their name, speak their language, and do not judge them for a lack of insurance, employment or even basic reading skills, my patients begin to feel hope.
When we ask them questions about their ability to access healthy food and whether they feel safe in their current housing situation, my patients begin to realize that we in family medicine understand how much social determinants of health impact our community.
When our clinic goes to great lengths to obtain records from outside clinics and to call patients to come in for a visit after their recent trip to the emergency room, my patients begin to understand what it means to have a family physician and a medical home.
There are many community clinics throughout the country that have made a commendable effort to gain PCMH recognition and to be part of a safety net for their patients; our clinic is not unique in that respect. But there are times when the degree of disparity between my patients and the affluent patients who can access the "best" care in the nation clearly weighs on my patients. They are deeply aware of what they do not have and what they cannot access. And they are often resentful of the discrimination they have faced because of these disparities.
Working within this community has enabled me to witness firsthand what I learned while pursing my master of public health degree -- that a community's resources and environment can have an enormous impact on the health of its residents. It has been exciting to be part of my local AFP chapter and to contribute to the enactment of bills that can make a real difference in the health of New Yorkers, such as a lower speed limit to reduce pedestrian deaths and expansion of health coverage for pregnant women.
In a few months I'll be moving back to the West Coast, primarily for family reasons. It was a difficult decision, and there are many things about New York -- particularly the people I've come to know -- that I will truly miss. As is true with any major change, my upcoming relocation has given me the opportunity to reflect on my time as a family physician in New York. This is the only environment I've worked in as a practicing physician, and although I have encountered the occasional frustration when dealing with a subspecialist here and there, the overwhelming experience has been better than I even imagined when I applied during medical school.
Family physicians are a diverse group with a diverse set of skills to treat the communities we work (and often live) in. My work during the past several years has taught me a great deal about caring for communities that are in need of creative, evidence-based, compassionate primary care. I have built a foundation that will influence my practice of medicine wherever I go, and for that, I will always be grateful to New York and its patients.
Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.
Monday Sep 28, 2015
Questions About DPC? FMX Sessions Offer Answers
I recently received an email from a physician who was just out of residency and contemplating his future career options.
"Even as a resident, I was incredibly frustrated by the limitations placed on my primary care practice by billing and documentation demands and disillusioned by the lack of support for caring for patients beyond the four walls of the clinic," he wrote as he explored the possibility of starting a direct primary care (DPC) practice.
Since I presented at the Direct Primary Care Summit in July, I have talked with a wide range of physicians with nearly identical sentiments. Some are seeking tangible advice on starting a DPC practice, some are just venting, and others have given me words of encouragement.
Given the variations and rapid growth of DPC, it's difficult to pinpoint an exact number of direct-practice physicians. However, at least 500 DPC practices are now operating, and the vast majority of them opened in the past 12 to 18 months.
It's clear from my email inbox that there are thousands more physicians considering making the switch to DPC and many of them have questions.
This week, the AAFP Family Medicine Experience (FMX) in Denver will give physicians more opportunities to learn about DPC, including a dedicated track. "Delivering Patient Care, Not Paperwork" is scheduled for 8-11:30 a.m. on Oct.1 in Room 201. The session repeats at the same time on Oct. 2 in Mile High Ballroom 4D.
I will be joined by Josh Umbehr, M.D. and Doug Nunamaker, M.D., who practice in Wichita, Kan. Together with attorney Michael Campbell, we plan to cover a wide range of DPC topics. A key distinction between a DPC practice and a traditional, insurance-based practice is the relative simplicity of operating the business. However, there are many unique considerations when owning and operating a DPC practice. The questions I have fielded have been numerous, but here are a few of the common ones we will address:
- Should I go fully direct or keep some insurance contracts?
- How should I notify my patients if I switch to the model?
- What can I do with Medicare patients?
On a broader front, the DPC track will cover three main areas, including
- reviewing the unique features of DPC and relationships with other models;
- practical steps in starting a new DPC practice; and
- legal aspects of DPC practice, including Medicare issues.
On Oct. 3, there will be a meeting of the DPC member interest group (MIG) -- which is now the largest of the Academy's 11 MIGs -- from 8-10 a.m. The meeting will feature an open discussion of DPC-related topics, and leaders will give a legislative update and conduct elections of new officers for the group.
The flexibility of DPC allows it to fit a group of patients and a community and is one of its greatest strengths. Doctors can creatively tailor their practice to meet those needs, but we hope to first set the stage by sharing the framework and common traits of a successful DPC practice. I'm hoping the upcoming events at FMX will help further explain how DPC can be a viable option for family physicians and the health care system.
If you're not able to join us in Denver, be sure to keep an eye out for future opportunities to learn more about DPC practice. Upcoming AAFP-hosted DPC events include an Oct. 24 workshop in Dallas and an April 2 workshop in Detroit next year.
Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare(twitter.com).
Thursday Jul 16, 2015
Direct Primary Care Model Poised for Rapid Growth
Direct primary care (DPC) physicians have been connecting with each other in recent years, usually sharing tips on what we’ve learned, but also offering words of encouragement and venting frustrations. These conversations often occur on Twitter, via email or by phone, but we’ve also had a few chances to connect in small groups at family medicine events.
In the past year, a few organizations -- including the AAFP -- have hosted DPC workshops or networking events for physicians in the planning stages of starting a DPC practice, but gathering a large number of early adopters was a rare feat. That's what happened this past weekend at the Direct Primary Care Summit(www.dpcsummit.org) in Kansas City, Mo.
© 2015 Sheri Porter/AAFP
Attendees listen to a speaker at the July 10-12 Direct Primary Care Summit in Kansas City, Mo. The event drew more than 300 physicians from 45 states.
In the first few years of my DPC practice, I could easily keep tabs on the new DPC practices opening around the country, speaking to most of them at some point. The passion and vision of these physicians have been refreshing and truly inspiring. Thanks to the hard work of many people at the AAFP, the American College of Osteopathic Family Physicians and the Family Medicine Education Consortium, I knew the DPC Summit was going to be well organized and well attended.
According to the final tally, there were 317 attendees from 45 states, including 54 physicians who already were established in a DPC model and 107 who are in the early or planning stages of building a DPC practice. About half of the attendees were exploring whether DPC was a viable option for them. About 10 percent were residents.
Despite the diversity of the groups, one thing was clear from the opening night’s events: These doctors and associated DPC organizations were passionate about how to better care for patients. The energy of the entire summit was electric. A number of DPC physicians’ stories allowed attendees to see what it’s really like to be a DPC physician in its various forms. Topic-specific presentations covered the nuts and bolts of operating or joining a DPC practice. A resident led a group discussion of how DPC education can be incorporated in the education curriculum. Attorneys and policy wonks covered the legal and advocacy efforts surrounding DPC issues.
The highlight of the weekend for me was my own patient, Blaine, who shared his story about experiencing DPC in my practice. As I’ve learned from attending patient advocacy conferences, nothing is more powerful than a patient’s story. He perfectly embodied why our model can be a game changer -- and possibly kick-started his career as a stand-up comedian in the process. “That A1c is going to snitch you out,” was the single best line of the event.
How quickly will the DPC model grow? It’s difficult for me to predict any numbers with confidence, but if the summit was any indication, the model is poised for rapid growth.
One of the things the summit demonstrated to me was the adaptability of direct practice doctors/clinics based on community needs, something missing in the micromanaged status quo. Some of the DPC practices were helping large employers or unions in urban areas tackle escalating health costs, while others based in rural towns were working with a large number of uninsured patients. The creativity of DPC physicians is truly awesome.
The AAFP has upcoming events that will provide more opportunities to learn about DPC, including my presentation about starting and running a DPC practice July 30 at the National Conference of Family Medicine Residents and Medical Students. Another Kansas-based DPC doc -- Joshua Umbehr, M.D., of Wichita -- will present an even more in-depth look at DPC during two sessions Oct. 1 and Oct. 2 during the 2015 Family Medicine Experience (FMX) in Denver.
The Academy's DPC member interest group will meet Oct. 3 during FMX, providing yet another opportunity to network and learn more.
Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.
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