The primary care doctor: someone who knows you

Fans of Downton Abbey were stunned this week at one of the more shocking plot developments in the show’s three-year history: the death of young Lady Sybil Branson, who developed eclampsia after giving birth to her first child.

Besides the drama, the episode contained multiple health messages. One was the danger of preeclampsia,  less common today than in the 1920s setting of “Downton Abbey” but still a serious and sometimes fatal threat to pregnant women and sometimes to the infant as well.

Another was “VIP syndrome,” the tendency for doctors to defer to wealthy and/or important patients and their families, perhaps at the cost of exercising sound judgment. If Sir Philip Tapsell, the eminent obstetrician hired by Sybil’s father, Lord Grantham, hadn’t been so busy ingratiating himself with the aristocracy, would he have paid closer attention to the patient’s condition and heeded her husband’s pleas to get her to a hospital?

Finally there’s Dr. Richard Clarkson, the country doctor who has known Sybil all her life but whose urging for an emergency C-section is brushed aside – with fatal consequences, as it turns out.

Do patients truly fare better with a doctor who knows them well? This is one lesson from “Downton Abbey” that’s grounded in evidence: Having an ongoing relationship with a primary care doctor is seen as one of the best things people can do to ensure their health needs are understood, met and coordinated.

Here, for example, is how the Palo Alto Medical Foundation explains the importance of choosing, and staying with, a primary care doctor:

One of the best ways to make sure you’re getting excellent health care is to have a primary care physician (PCP) with whom you can build a long-term relationship – someone who knows your medical background and understands what’s important to you.

… When you have a physician you know and trust, you feel comfortable talking about anything. And, all your basic care – including routine exams, preventive care and treatment for illnesses and injuries – goes more smoothly and easily. Your PCP also knows when it’s best to refer you to a specialist.

Doctors themselves reinforced this in a survey carried out a couple of years ago by Consumer Reports. Of the 660 primary care doctors who participated in the survey, three out of four said a long-term relationship with a primary care doctor was one of the most important things their patients could do to obtain better medical care.

Here’s more of the evidence surrounding the benefits of primary care:

- In studies carried out in the 1990s, regions of the United States with an adequate supply of primary care doctors had lower rates of premature death from cancer, heart disease and stroke, even after controlling for lifestyle and demographic factors. Later studies also linked the primary care doctor supply to longer life expectancy and decreased incidence of low birth weight.

- Researchers have documented better outcomes for patients who have a primary care doctor as their regular source of care. This seems to hold true regardless of age, health status or whether the patient has insurance.

- People who had a usual source of care were more likely to receive treatment for high blood pressure and elevated cholesterol levels – both risk factors for heart disease – than those who lacked a usual source of care, according to a 2010 study in the American Heart Journal.

- A usual source of care, such as a community health center, also appears to help reduce the effect of disparities such as income, education and environment and improve health for these populations.

Specialists are needed too. Primary care cannot fix everything that ails the patient, after all. But many bereft “Downton Abbey” fans are probably wondering whether one of their favorite characters might have been saved if the doctor who had known her all her life had been allowed to make the decision.

The looming shortage of doctors

Not too long ago, the American Association of Medical Colleges unveiled a new print ad depicting a patient sitting alone and distressed in an exam room. The stark message: “By the time you notice America’s doctor shortage, it will be too late.”

A new round of ads released this month warns, “Careful what you cut.”

What many rural communities have known for years is increasingly catching up with everyone else: The supply of doctors won’t be enough to meet future demand.

The AAMC’s workforce estimates aren’t encouraging. By 2020, the U.S. is projected to have a shortfall of 90,000 doctors, according to data collected and analyzed by the AAMC Center for Workforce Studies.

Part of the shortage is on the demand side. As the baby-boom generation ages, there will be a dramatic increase in the number of Americans older than 65 – precisely the population that tends to use health care services the most. Easier access to health insurance, the result of the federal health care reform law, also is expected to bring millions of formerly uninsured patients into the system, many of them with pent-up health needs that will need addressing.

But the absolute number of doctors is also anticipated to decline in future years. Although at least half of the projected shortage is among primary care doctors, the other half will be among specialties not customarily thought of as being in short supply – surgeons, oncologists, endocrinologists and more.

In practical terms, what it means for patients is the likelihood of longer waits in the future to see a doctor, more difficulty obtaining timely appointments, and possibly delays in care that could have long-term health consequences.

This is obviously a vastly oversimplified picture of what’s happening in the U.S. physician workforce right now. It doesn’t even touch on the many other issues churning alongside the basic math of supply vs. demand – the number of physicians who will be retiring in the next decade, for instance, or the tendency for physicians to gravitate toward non-rural practice, or the soaring cost of a medical education, or the staggering educational debt that students accumulate and its impact on their choice of specialty.

There’s another factor, though, that much of the public may be less aware of: Federal funding for residency training, which all physicians go through after completing four years of medical school, has not increased to meet current demands. The result is a bottleneck that has reduced U.S. capacity to get physicians fully trained and into the workforce.

Physicians – and indeed all the health professions – have unique training needs. Although much of their initial learning takes place in the classroom, at some point they must be unleashed on actual, live patients to hone their skills. Without this hands-on experience, there’s no other way to become familiar with health and illness and the variety of ways these manifest themselves across the spectrum of patients. There’s no other way to become proficient at diagnosing, treating, prescribing and performing procedures.

It takes time, money and resources to provide the necessary programs and supervision at teaching hospitals where residency training takes place – which is why outside funding is so critical.

The Association of American Medical Colleges has ramped up its lobbying effort with Congress this year to eliminate a freeze on Medicare funding for residency training. The freeze has been in place since 1997 – a full 15 years. Even a relatively modest 15 percent increase would be enough for teaching hospitals to prepare 4,000 additional doctors per year, the AAMC argues. The AAMC estimates that 10,000 more doctors need to be trained annually to completely address the pending shortage.

Certainly there are other sources of residency funding – state governments, private businesses and the teaching hospitals themselves, to name a few. The number of residents in training in the U.S. in fact has grown despite the Medicare cap. State governments and cash-strapped hospitals may not be able to sustain this indefinitely, however, nor does a fragmented approach necessarily ensure that the right types and amounts of primary care doctors and specialists are being trained.

Redesigning the health care delivery system to make it more team-centered could help blunt some of the growing shortfall in the physician workforce, yet this is unlikely to be the total answer. Patient care will still demand the skills and training of a doctor.

Considering the success that physician practices here in rural central Minnesota have had in hiring new doctors the last couple of years, it may seem there’s no real urgency to address a looming shortage of doctors.

But what’s critical to keep in mind is that the pipeline from medical student to full-fledged physician is long – seven years at a minimum, and usually longer for subspecialists. Is it OK to delay action until the problem becomes more painfully evident? The AAMC says no: “The United States cannot afford to wait until the physician shortage takes full effect because by then, it will be too late.”

Rethinking the medical home… again

The medical home model, seen by many as a solution to what ails primary care, continues to receive mixed reviews suggesting it may not be living up to its promise.

The latest dose of reality comes from two new studies which found that primary care medical homes 1) don’t necessarily save money; and 2) don’t increase patient satisfaction.

A little background is in order. The medical home – or, to be more complete, the patient-centered medical home – is a model developed by the National Committee for Quality Assurance to improve the delivery of primary care. Its principles are team-based care that’s coordinated, makes effective use of information technology and tracks how the patient is doing over time.

When correctly implemented, it’s supposed to improve patient care, especially for chronic conditions, by ensuring patients don’t fall through the cracks. The model also is designed to make better use of medical resources by assigning responsibility for patient care to a team that includes nurses and mid-level practitioners as well as physicians. At last count, about 4,000 medical practices in the U.S. have adopted this model.

In theory the medical home sounds terrific – the patients win, the staff wins, the practice wins. In reality the picture is less clear.

Take the study that recently appeared in the Journal of the American Medical Association, examining the relationship between quality of care and operating costs at patient-centered medical homes. Researchers at the University of Chicago found that medical homes with higher quality ratings also had higher operating costs – $2.26 more per patient per month, to be exact. This may not sound like much but over the course of a year it could add up to half a million dollars or more.

A couple of caveats are in order. First, this study only involved federally funded health centers, so the results might not apply to a privately owned medical clinic. Second, it focused primarily on cost, hence may not have fully captured the relationship between cost and value.

It provides a glimpse, however, of the fiscal dynamics that may underlie the medical home model once it’s implemented. Among policymakers who support the medical home concept, much of the emphasis has been on the cost savings that will result with fewer visits to the emergency room, fewer hospital admissions and so on. While this may save money for the system as a whole, it might not necessarily save money for the primary care clinics who are doing much of the work.

A bigger issue, at least from the public’s point of view – and one I’ve blogged about before – is whether patients like the primary care medical home.

Some of the early results aren’t encouraging. At the handful of demonstration sites that piloted the medical home model, patient satisfaction actually declined. And a new study, published last month in the Health Services Research journal, reached a similar conclusion: When 1,300 patients were surveyed about their experience at practices that had adopted the medical home model, they weren’t more satisfied.

American Medical News offered this take on the findings: Perhaps the medical home model is more about policy wonkery and behind-the-scenes restructuring than about improving the patient’s actual experience of care.

Most of the process “has been focused on talking with researchers and with academics and with clinic executives, and looking to see what makes a clinic effective, what makes the processes efficient and what makes them better able to track patients,” Dr. Robin Clarke, an assistant clinical professor at the University of California in Los Angeles, told American Medical News. “We haven’t spent a lot of time talking to patients about what they perceive to be patient-centered care and what they want to see in a primary care practice.”

Exactly.

Some months ago I was conversing with a health insurance executive when the topic turned to the medical home model. He was enthusiastic about how wonderful it was for patients. But when I pointed out that some surveys showed a decline in patient satisfaction, his response was, “Oh, people just don’t like seeing someone different,” i.e. a nurse or physician assistant instead of the doctor.

I can think of many reasons why team care might be problematic for patients, not least because of the potential for poor communication or fragmentation of care. Maybe patients instinctively sense this, or maybe they’ve actually experienced it. Either way, why wouldn’t their perspective matter?

Regardless of whether people know or care about the medical home model, their chances of encountering it are growing. Here in Minnesota, there are now 170 medical practices that are certified as medical homes, providing care for two million people.

If some of the early studies suggest the model isn’t all it’s cracked up to be, it doesn’t necessarily mean the concept is fatally flawed. Perhaps it just takes time to learn from mistakes and allow the model to mature. At the very least, however, we might want to proceed with caution.

Primary care’s bad rap

Primary care’s often-negative reputation as stressful and unrewarding apparently starts early in the medical education process – possibly before students even enter medical school, a recent study has found.

The study appeared earlier this year in the Family Medicine journal. More recently, the findings and their implications for family practice medicine were explored in an interview by the American Academy of Family Practice with one of the study’s authors, Dr. Julie Phillips. an assistant professor of family medicine at Michigan State University College of Human Medicine.

Primary care has struggled for several years with perceptions that it’s boring, stressful, demanding, low-paying and hemmed in with constraints on everything from insurer requirements to time pressures in the exam room. Whether this is perception or reality, it has had an impact: Fewer students who enter medical school are choosing a career in primary care.

The authors of the study wanted to learn more about how primary care is perceived by medical students and whether their perceptions are changed by what they experience during their training.

Surveys were conducted among 983 medical students at three medical schools between 2006 and 2008. The students were asked to rate statements such as “primary care physicians have too much administrative work to do” and “time pressures keep primary care physicians from developing good patient relationships.” Similar questions were posed about the students’ perception of specialty physicians.

Perhaps the most eye-opening conclusion of the study is this: Negative views of the daily routine of primary care were already present in many of the students at the beginning of their training. What’s more, these views didn’t really change as students progressed through medical school, even after they had a chance to directly observe and participate in patient care.

What to make of these findings? It’s clear that “contemporary physicians struggle to meet the high expectations set by patients and their profession with limited time and resources,” the authors wrote. “Our date demonstrate that students are paying attention to the struggle.”

The results were “kind of discouraging,” Phillips told AAFP News Now. She said she also was surprised that the students’ perceptions were formed so early. “That makes me think that some of their views of what it’s like to be a doctor actually don’t come from medical school but from the larger cultural perception of what physician work is like – and especially what primary care is like.”

There were some glimmers of hope. Students who completed a primary care clerkship (typically during the third year of medical school) and had seen real-life primary care in action were more positive about the ability of primary care doctors to develop good relationships with their patients, in spite of the time constraints in the exam room. “It may be that actually spending time observing physicians helps to break some negative stereotypes,” the study’s authors noted.

The researchers also learned that some students will choose primary care regardless of their perceptions about the daily grind. This suggests that individual values and goals play an important role in the career choices of medical students, the authors wrote. “The study reinforces the importance of admitting students with primary care-oriented values and primary care interest and reinforcing those values over the course of medical school, if we are to produce greater numbers of primary care physicians.”

We’ve come a long way from the romanticized ideal of the family doctor that prevailed a generation or two ago. But did the ideal ever really match the reality? If you talk to physicians privately, some of them will admit there’s a great deal of grumbling about the profession and not enough focus on what makes it rewarding. To be sure, there are all too many reasons for doctors to be frustrated and exhausted and discouraged, but at what point do the negatives start to drown out everything else?

Phillips challenged the medical profession to become more involved in supporting new models of care, such as the patient-centered medical home, that can breathe new life into primary care and make it a better career choice. Family doctors also should try to share what’s good about their specialty, she said. “Students listen to what we say. We should try to be positive about the great things in our everyday work, because there are many wonderful things about being a family physician.”

Hello, doc, I’m your mystery shopper

You know what my first reaction was to the federal government’s plan to use mystery shoppers to gauge how easy – or difficult – it is for patients to make a primary care appointment?

Bring it.

The concept has been getting a ton of negative feedback. Online critics are calling it “government snooping” and an “anti-doctor campaign.”

To recap: The Obama administration is recruiting a team of mystery shoppers to pose as new patients and call doctors’ offices to see how much effort it takes to get an appointment. One of the purposes of this research is to gauge the accessibility of primary care doctors – a key issue as millions of Americans gain health insurance coverage under provisions of the Affordable Care Act. Another purpose is to look at the extent to which physician practices might be accepting new patients with private insurance while turning away those on Medicaid and other public programs. The project, which is still only a proposal at this stage, will potentially be carried out in nine states, including Minnesota.

If this sounds subversive, consider the state of primary care these days.

It is a cold, hard fact that patients frequently have to wait several weeks to see a doctor for something that’s non-urgent. Those of us who live in rural communities encounter this reality every day. The last time I made a doctor’s appointment, the earliest available opening was seven weeks out. I’ve had other wait times ranging from 10 days to three weeks. For a specialist once, it was five weeks.

Is this a hardship? It wasn’t for me, but it might well have been for someone else. How many times do patients end up in an urgent care clinic or an emergency room because they couldn’t – or wouldn’t – wait that long?

Fact #2: Many primary care doctors already have full panels and are no longer taking new patients.

Last month the Massachusetts Medical Society released a report on wait times and physician access. Of the 838 physicians who responded to the telephone survey, 51 percent of internists and 53 percent of family doctors were not taking new patients. The average wait time to see an internist was 48 days; for family doctors, it was 36 days. Average wait times also were rising for specialists such as orthopedic surgeons, cardiologists and gastroenterologists.

Fact #3: An estimated 65 million Americans live in officially designated primary care shortage areas. Shortages are the worst in areas that are rural, poor and/or minority.

Fact #4: Publicly funded programs such as Medicaid (and, here in Minnesota, the MinnesotaCare program) are not attractive to physicians because of the paltry reimbursement. One of the most severe access problems in Minnesota is with dental care for individuals on MinnesotaCare, because so few dentists will take these clients. It is not mandatory for providers to accept Medicaid, MinnesotaCare or any of the other public programs – but when they opt out, access inevitably is diminished.

Fact #5: Access is integral to the overall functioning of the health care system. When patients do not receive timely access to care, the result can be more use of expensive emergency care, higher risk of hospital admissions and readmissions, inadequate management of chronic diseases and worse health outcomes.

I would have cringed if the mystery shoppers pretending to be patients were actually coming to the clinic and using valuable appointment time needed by real patients. Based on what I’ve read about this initiative, however, it doesn’t appear to extend beyond the appointment-making process.

To those who are already familiar with the primary care shortage, this entire proposal may sound like a product of the Department of Duh. But if the federal government is serious about addressing what ails primary care, which is the better strategy: collecting hard evidence or relying on anecdote, perceptions and personal experience?

There’s also something valuable about measuring physician access from the perspective of patients themselves – even if the patients are secret-shopper fakes. Most of what we currently know about wait times and provider shortages is derived from surveys of physician practices and insurers, not from patients. No matter how much clinicians and policymakers think they know about the patient experience, they can’t claim to truly know if they don’t include the patient’s viewpoint in their data collection.

If I have any reservations about the mystery shopper proposal, it’s this: When reimbursement for Medicaid, MinnesotaCare and other publicly funded health programs is so disappointing, there’s virtually no incentive for any practitioner to want to see these patients. It’s easy to criticize them for their refusal yet overlook how they’re financially penalized when they do accept patients on public programs. This is an untenable situation for everyone involved, and it’s to be hoped that the information collected by the mystery shoppers will lead to some genuine and constructive change.

If there’s a better way to collect patient access data than by using mystery shoppers, I’m all ears. In the meantime, it’s hard to see how a physician with a well-run practice would have much to fear from a phone call from a government-funded mystery shopper.

Addendum: Here’s the posting in the Federal Register.

Update, June 29: The heat appears to have been too much; the Obama administration announced yesterday it has shelved its plans for the mystery shopper survey. Perhaps the idea was a public-relations disaster from the start – but it was dismaying to see how much of the debate was focused on the survey methods rather than on the bigger picture of access to health care. Doctors and politicians seem to have had plenty to say; where’s the voice of patients?

Image: Wikimedia Commons

The annual physical: yes or no?

It’s almost July, which means a postcard will soon be arriving in the mail, reminding me my cat is due for her yearly visit to the veterinary clinic. As usual, I’ll make an appointment and bring her in (although I suspect she’d rather we just skip the whole deal).

Do annual visits to the doctor make sense? Are people healthier when they receive yearly checkups, or is the yearly visit something we do mostly because we think we’re supposed to?

There’s a fair amount of debate in the medical world about the value of that time-honored custom, the annual checkup. Many experts question whether it’s really necessary to subject healthy, asymptomatic adults to a battery of one-size-fits-all tests that might or might not be helpful.

As long ago as 1989, the U.S. Preventive Services Task Force, an independent panel of experts that weighs the evidence and issues recommendations on the use of screening and preventive health care services, found insufficient proof to endorse the benefits of the standard yearly checkup for otherwise healthy adults.

The task force has not suggested that people can skip seeing a doctor unless they’re sick. Rather, guidelines by the USPSTF, researchers and other physician groups increasingly have tilted in favor of individualized assessment and counseling based on the patient’s age, gender, risk factors, health history and preferences. In other words, EKGs don’t need to be administered to every middle-aged person who comes in for a physical, nor does everyone need to have annual chest X-rays or a comprehensive blood panel unless there’s a reason for doing so.

This isn’t always an easy message to convey, especially to an American public who’s accustomed to being told to get screened for everything.

The whole issue, in fact, is more nuanced than it appears. When a group of researchers undertook a review a few years ago of the evidence on the pros vs. cons of the routine physical, the results were mixed. In their findings, published in 2007 in the Annals of Internal Medicine, the researchers reported consistently clear benefits for regular cholesterol screening, gynecological exams, Pap smears and fecal occult blood testing. Regular physical exams also appeared to be reassuring for patients. But the benefits were less clear on other measures, such as whether regular checkups resulted in better clinical outcomes, fewer hospitalizations or lower health care costs.

Why, then, do we continue to have regular checkups, and why do most doctors continue to believe they’re an important part of health care? The real benefit, it seems, lies in the intangible things: the opportunity for doctor and patient to get to know each other and to develop a relationship when the patient is well rather than sick or in the middle of a crisis.

Dr. Steven Reznick, who has a concierge practice in Boca Raton, Fla., tackled this very issue last week in a guest essay at Kevin, MD. “Is it cost-effective? Does it prevent disease? It doesn’t matter,” he wrote. “It is an essential part of the development and continuation of the doctor-patient relationship.”

It’s also a way to benchmark the patient’s health from one year to the next and address important issues such as previous illnesses, family history and lifestyle, Dr. Reznick writes.

In a column that appeared a couple of years ago in the Wall Street Journal, Dr. Benjamin Brewer takes the debate one step farther:

The annual physical gets a thumbs-down from public-health researchers who find no real evidence to support its effectiveness, despite tradition and widespread use.

Physicians continue to perform the exams, patients continue to request them, and many insurers pay for them. The question is why? Should we keep spending money on a health-care intervention without a proven benefit?

My answer is yes. I believe there is more to the annual exam than researchers have studied so far. If they haven’t found a direct benefit, then I’d say they’re not asking the right questions.

Health is more than the absence of disease, and quality care is more than the sum of the tests that can be done on your organ systems. Relationship-based care has a beneficial impact on health quality, costs and outcomes that goes way beyond disease detection and health screening.

There’s nothing wrong with debating the value of the annual physical exam. Indeed, it’s a question that needs to be asked. But like many things about health care, the answer isn’t always straightforward or easy to quantify. Even though we might not be able to objectively measure the benefit of the yearly exam, it seems it’s still a worthwhile thing to do.

Everyday heroes

When you’re a member of an ambulance crew, you never quite know what your day will bring. These are medicine’s everyday heroes – the emergency medical technicians and paramedics whose work is stressful, demanding, exacting, skilled, professional and rewarding.

What is it like to spend a day in their shoes? To mark National Emergency Medical Services Week, we’re taking readers behind the scenes today with live guest-blogging by the Willmar Ambulance Service at Rice Memorial Hospital. Follow us from 7 a.m. to 7 p.m. and see how the day unfolds as entries are live-blogged continuously throughout the day. Readers are invited to ask questions or provide feedback via the comment section below; the paramedics will try to answer as many of your questions as possible. Be sure to check out the links posted above to learn more – and visit us often during the day for live updates.

7:03 a.m.: Good morning, everyone, this is Brad Hanson, the operations manager for the Willmar Ambulance Service. I will be blogging with you today as we respond to calls and bring you up to speed on a day in the life of a Willmar paramedic.

I am just heading into the office after helping my wife get the kids up for the day and off to school and day care. As the manager, I have a take-home paramedic vehicle so I can always be available if there is a major incident or have to cover call in town due to our crews being busy on other calls.

Our service responded to over 2,600 calls last year, so we have some very busy days where all five of our ambulances are being utilized. You may have seen one of our big blue ambulances in the community!

I am looking forward to giving you an inside look today, so let me know if you have any questions!

7:34 a.m.: Well, looking back over the night shift we have already been a bit busy. As I was saying earlier, I am on call pretty much 24/7. As I was making breakfast for my wife with my 8-year-old daughter this morning (we decided we were going to serve breakfast to her in bed since today is our 14th wedding anniversary), my wife Michelle was awakened by my cell phone ringing. One of the crews called regarding a transfer to St. Cloud, as they were just finishing up an intercept call to Atwater. I will explain intercepts more later. S0 much for the perfect surprise breakfast in bed…

Oh well, we had a good breakfast, and in reviewing the night I remember hearing several pages for the crews since 11 p.m. I counted five with the transfer. It makes for a long night and morning for the crew that started last evening at 7 p.m. Looks like it’s going to be a 16-hour shift for Jim and Keith. This also leaves us a bit short in town so only one crew now until 9 a.m., then back to two. Let’s see how the rest of this day goes.

7:59 a.m.: Checked in with the new 0700 crew, Lonnie and Jim B., today, having a bite of breakfast, then on to rig checks.

Our mornings start out fairly typical with equipment checks to make sure everything is on board and ready and the narcotics are counted and signed off. We are also going to be getting ready for our open house tomorrow as it is National Emergency Medical Services Week, so if you get a chance, say thanks to anyone in public safety that does medical work, from 911 dispatchers, First Responders, EMTs, paramedics, emergency room physicians and nurses.

8:36 a.m.: Sure is nice to see the sun, it can get to be a HUGE downer to do ambulance calls when the weather is nasty. I can remember many calls over the years where I was sure glad I had extra winter gloves and hats in my vehicle to hand out to crews on accident calls when it was below zero. Brrrr!

Having nice days just makes you even more excited about how you can help. It’s kind of like an unknown adventure, waiting for the pager to start blaring about an emergency. Are we going to be going to a major accident, transporting a pleasant elderly lady from a nursing home to the hospital, or something else?…  It seems some days you can just sense that it’s going to be busy and some days you wonder if you’re ever going to get a call.

I mentioned intercepts in a previous blog. Since Willmar Ambulance is an Advanced Life Support Ambulance Service, or ALS, we provide advanced care services to all the Basic Life Support Services around Willmar. In Kandiyohi County there are a total of five ambulance services: New London, Atwater, Raymond, Lake Lillian and Willmar. We also work with services outside of our county like Kerkhoven, Clara City, Brooten, Cosmos and others.

We are automatically sent out on calls anywhere in our county if the 911 call is for things like chest pain, major trauma or someone that is considered unconscious or unresponsive. We have a great working relationship with all our surrounding services and always look forward to working with them to help take care of their patients.

9:30 a.m.: We are back to full crews in town. We have two crews on street duty during the day Monday through Friday, with another crew on call either from home if they live in Willmar or at our ambulance quarters located within the Kandiyohi County Rescue Squad building just north of the E. Highway 12 Burger King on Lakeland Drive (very nice facility).

Our two duty crews have assigned tasks to keep them busy during their shifts, like getting the garage ready today for our open house, or working on any number of assigned tasks like data reports, CPR training or just making sure the trucks are looking good. I always remind our staff that we live in a fishbowl and we are driving large blue billboards, so we always need to look and be professional as we are serving the public 24/7!

10:22 a.m.: With our crews today is Jesse. He is a new casual paramedic hired recently by Willmar Ambulance and is doing his field training today. When we hire new staff, we look for candidates that will fit well within our organization and that are already trained to the National Registry EMT standards.

The Willmar Ambulance field training program trains new members how to be an EMT or paramedic on our service. Field training is done by our seasoned Field Training Officers, or FTO staff. Depending on any previous experience in EMS, this training can last up to 30 days. In this time, we schedule the new hire with FTOs for a number of shifts. They spend the day working with the duty crews going through the equipment on the trucks, checking off on a number of different competency tasks during their FTO time.

As they go on calls with us, they initially start by just watching and getting used to our process, paperwork and how we handle calls, as well as learning our medical protocols and working on mapping of the city. As time goes on and runs are accomplished, they move to being the care provider while the FTO watches their care. After each event and the end of every shift, they are evaluated on the day to see where they are at and asked how they are feeling about the position.

Quality assurance is a large part of our work and we always evaluate and make sure our protocols are being followed and reviewing our runs to maintain the best care possible!

12:09 p.m.: Hello, my name is Shar. I have been an EMT with Willmar Ambulance Service for just over eight years. Also a member of Kandiyohi County Rescue for the past 10 years. I got into this profession a little later than most of my co-workers.

At the time I decided to become an EMT I was looking at doing something different with my life, needed a career change and this was something I had wanted to do but didn’t have the opportunity, due to having small children at home.

Yes, we all start out as adrenaline junkies and get a little excited when the pagers start to go off and we hear the sirens, see flashing lights, just like little kids do whenever they see us.

A typical day for myself and my medic partner Carrie is Mon.-Fri. 9-5. We start our day with rig checks, making sure all equipment is stocked and everything is in full working condition.

After that we head into the EMS office which is located in the emergency room where we have a lot of other assigned duties to do each day. My typical duties other than 911 and back-up calls consist of entering all ambulance billings into the computer for the business office, entering our statistics into the computer, maintaining the casual and full-time schedules for all of our staff, ordering equipment and uniforms for all of our staff, making sure we have staff to cover open shifts, fill liquid O2 tank on our truck, assist ER when needed, of course cleaning of trucks, lots of paperwork and all other duties as assigned.

The 9-5 shift is also called the power shift because we cover the hours of the day when we are usually the busiest and we handle most of the daytime transfers that are sent out to other hospitals. We also do some casual calls where you don’t have to be in the office but respond if a call comes in for a third rig.

As EMTs we do a lot of patient care with our medic partners but we also do most of the driving. We have to go through a driving program and must maintain current certification and also clean driving records. We have continued education to keep our skills and certification.

Like all jobs, we have some bad days. Sometimes you have a call that just hits home, but I wouldn’t trade this job for any other out there.

12:57 p.m.: Hi, my name is Carrie Yungerberg. I am a critical care paramedic with Willmar Ambulance.

Every day I come to work, I don’t know what to expect. I may be sitting in the office working on projects, I could be transferring a patient to another facility or responding to ambulance calls in the community. The best part of the job is that each day is different, but the same. I can respond to two chest pain calls and the symptoms for each person, the heart rhythm, and history for each are different.

I initially started college to be an ER nurse, but met a paramedic who told me to become an EMT to see if I liked that type of work. After less than a year of being a paramedic I knew that I loved EMS and would be in it for a long time. After being an EMT for nine years I went to paramedic school at South Central College in Mankato. I was fortunate to be able to continue to work with Willmar Ambulance after graduation. I have been with Willmar Ambulance now for 14 years.

Being a paramedic requires you to think on your feet. For example, when you are treating a patient and the heart rhythm changes, you need to be able to change your thinking and “go down another path” to treat the patient appropriately. Another way you have to think on your feet is to change what you think might be wrong with the patient. For example, if we respond to a car accident we need to determine if the patient had an underlying condition that might have caused the accident – for example, a heart attack or chest pain, or did the car accident cause the heart attack/chest pain.

There are days that we don’t have calls during our shift. On those days we have projects that we do in the office. Some of the projects that I work on are bike helmet safety, CPR classes, Sonshine First Aid tent volunteers, maintenance/coordination of patient care reports for the ambulance and maintaining supplies, handouts for community events as well as setting up staff to attend community events and community education such as taping a segment for the WRAC-8 show, “Willmar 911.”

The hospital has CPR classes once a month for their employees. I coordinate the instructors for teaching. Also if a business, church or community organization needs a CPR class, we work with them to set up a class. Along with CPR, I am part of the AED coalition of Kandiyohi County which helps place AEDs in the community at businesses and churches.

Sonshine Music Festival arrives in Willmar every July. Willmar Ambulance maintains the tent with volunteers from Kandiyohi County and throughout the state of Minnesota. We have over 150 volunteers who take time to help in the first aid tent. We use all types of medically trained staff, from paramedics, EMTs, RNs, LPNs and CNAs. There also are doctors and non-medically trained staff that volunteer.

All of our patient charting is now done on computers. We have a specially designed report that we use to document everything from the ambulance call. Part of my job is to make sure these reports make it to the patient medical chart at Rice Hospital. Also to make sure the reports get sent to the Emergency Services Regulatory Board.

Community education and events are also part of the job. We attend events such as National Night Out, Healthy Kids Day, and Family Fun Night and Safety Days. We give tours of the ambulance to Boy/Girl Scouts, daycare centers and preschools.

If it’s not ambulance calls keeping us busy, it’s the boss!!

1 p.m.: Just got a 911 call to a local restaurant, working with the crews right now.

1:25 p.m.: A large percentage of Willmar Ambulance calls are cardiac-related. Signs and symptoms of cardiac events can vary from males to females, but some typical clues are pain or heaviness in the chest that lasts longer than five minutes, pain radiating into arms and/or jaw. Other signs and symptoms can include unexplained shortness of breath, unexplained sweating and nausea.

Willmar Ambulance, along with the other services in Kandiyohi County, has the ability to detect significant cardiac events by being able to perform a 12-lead EKG and transmit the data directly to a physician in the emergency room. Having EMS involved early in a cardiac event has shown up to a 45-minute decrease in time when a person needs to be taken to a higher level of care like a catheterization lab in St. Cloud or the metro.

How 12-lead EKGs came to Kandiyohi County

2:18 p.m.: Our work today continues as we prepare for our open house events tomorrow. Sounds like the weather is going to be great! We hope to see a lot of families come out and enjoy the evening with us!

Oh, and since it’s going to be soooo nice, we will even cook for you!

So reminder, Wednesday 4-7 p.m. at the Willmar Ambulance garage. See more at http://www.willmarambulance.com/.

3:14 p.m.: Hello, my name is Dr. Scott Abrams, emergency physician at Rice Memorial Hospital.

For the last couple of years, I have provided medical direction for the Willmar Ambulance Service. I basically help with the medical decision-making process or “protocol” that we follow in providing care to the community.

I have come to greatly appreciate the level of care provided by Willmar’s emergency medical technicians and paramedics. They consistently provide excellent care to the community and are always working and training to become better. As medical director and as someone who calls Willmar home, I want to know that when I call 911, I’ll be getting rapid, appropriate care. I can say that we absolutely have that kind of care here in Willmar, thanks to everyone who works with the Willmar Ambulance Service.

I’ve also had the privilege of providing medical direction for several of Willmar’s surrounding communities (Sunburg, Kerkhoven, Atwater, Lake Lillian and Raymond). While Willmar has a professional or “paid” service, these communities rely on volunteers to staff their ambulance services. I have been consistently amazed by the number of people that volunteer their time and efforts to be trained and to work on their local ambulance service. It is a credit to them and to their community that these towns have such excellent services. They truly are wonderful people volunteering to do a tough job and I’ve been fortunate to work with them.

3:36 p.m.: Hi, I’m Jim Kroona and the reason the surprise breakfast wasn’t a surprise. Sorry about that, boss, and congrats on 14 years.

I’ve been an EMT with Willmar Ambulance for 13 years and on the County Rescue Squad for 16 years so the pager is always on. A shift for me is on call from 7 a.m. to 7 p.m. and on duty from 7 p.m. to 7 a.m. Twenty-four hours can go so fast and yet seem so long.

My partner Keith and I started last night with a transfer to Hutch and ended it with a transfer to St. Cloud (which went about 10 minutes before our shift was to end). We had a call where the police assisted us with a patient and did an intercept with Atwater Ambulance. So hardly time to take a lunch break. You learn early on to eat and sleep when you can because you might not have the chance if you wait.

For me it’s about giving back to my home town. Born and raised here and enjoy the sacrifice we make to help those in need.

I have had the joy/terror of delivering a baby in the front seat of a car and the sadness of extricating a relative from his truck as he died.

Please be safe in your day and with what you do. Finally off to bed!! Hope I can fall asleep.

3:51 p.m.: With over 2,600 calls per year, our crews have days of what feels like controlled chaos and some days where it feels like we are just working in the office or the garage.

It typically takes our crews one hour to respond to, transport and do the paperwork on a routine ambulance call. Our service covers 137 square miles within the county and has a response time standard of having to be enroute to calls once dispatched within 90 seconds 90 percent of the time and to be on scene within 10 minutes 90 percent of the time as well.

We use electronic patient care reports so our information about a patient is recorded and uploaded via a secure system where our records are stored and accessible to our hospital health information department as well as our quality control staff. Having the ability to do electronic reports has tremendously helped our service see and respond to our data, from staffing levels to quality assurance.

I tend to still write information on my gloves; old habits are hard to break. Oh, I still enter the data into the electronic system, but other staff members are way better at it than me.

4:33 p.m.: Being paged to a local clinic where someone has fallen, crew responding code 3 now!

4:39 p.m.: Sometimes, depending on the situation, we need to ask for a second ambulance to help on a call. This could be a need for lifting assistance, or because the patient is severely injured and extra hands are required to take care of the patient safely and without causing more harm. We are very fortunate to have backup when we need it to better take care of our patients and help prevent staff injuries when lifting or moving patients in difficult situations.

We communicate with our emergency department nurses and physicians via radio when we are on scene to give them a heads up of what we are dealing with so they can better prepare for the patient coming in. We use portable radios or mobile units within the ambulances. Cell phones are also sometimes used, but radios are simple and are quick access to medical control when needed.

Our reports are quick, with basic important information relayed to the ED about the situation, background and treatments given, as well as asking for any further questions or orders from the doctor in the ESD. We always assess our patient’s vital signs, and depending on the call, may use our cardiac monitor, oxygen, medications or other equipment as needed to make our patient as comfortable as possible and to help ease any pain they have.

4:47 p.m.: Well, as of this posting we have had six calls since midnight, with four of the calls before 7 a.m. It is typical that we have streaks where our main volume of calls comes in on the night shift and some where they come on the day shift.

Our data tells us our busiest times are M-F from 0900-1700 but calls are not always predictable, so to have 24/7 coverage is a must for a town our size.

I will keep you posted until 7 p.m. on what is yet to come. Hope you’re enjoying the weather and the day with the great crews of Willmar Ambulance.

5:41 p.m.: Hello, my name is Jim Bode and I have worked for Willmar Ambulance Service since 1998. I am currently employed as a casual paramedic and also have critical care certification.

Today was kind of a quiet day around here for an ambulance service. When we got to work at 7 a.m. we checked over all the trucks to make sure everything is stocked and ready to go for the day (and night). After truck checks it was time to get something to eat from the cafeteria. Sometimes this does not go as planned; today we got to sit down and enjoy our meal.

After breakfast we went to the garage again and started cleaning it up for the upcoming event tomorrow (come get some hot dogs and see some really cool stuff). After cleaning the garage and running errands around the hospital, we finally decided on lunch, a local pizza joint that is very understanding when we gotta run out the door.

At last we get a call, problem unknown at another restaurant in Willmar. After the run it’s time to restock supplies and clean up the truck for our next run. This usually takes about 15 minutes to get everything in order.

This afternoon was more prep time for tomorrow and enjoying the sunshine which has been missing for some time now. We got a call from the primary crew that they could use some help with a patient they had, so we assisted them on the scene with their requests.

At this time there is nothing more to report on, so everybody stay safe and come see us tomorrow at the ambulance garage.

6:53 p.m.: Well, everyone, not a crazy day and that’s OK! Thanks for hanging out with us and stay safe! This is Brad Hanson signing off for the day.

Thanks to Rice Memorial Hospital for agreeing to participate in a live blog; to Sandra Schlagel, communications coordinator at Rice Hospital, for facilitating this project and providing photos; and most of all to Brad Hanson and the rest of the Willmar Ambulance Service for making it all happen.

Primary care’s image problem

From the doctor’s point of view, is primary care rewarding or is it just plain boring?

Medical student Suchita Shah spent five weeks awhile back doing a clinical rotation at a primary care and general internal medicine clinic.

She blogged about the experience a few months ago. Then her blog entry was picked up at Kevin, MD, one of the leading voices in the medblogging world, which is where I discovered it. It seems to sum up many of the issues ailing primary care these days: namely, that many (maybe even most) medical students no longer seem to find it worth their while.

Shah writes:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.”

Medical students and doctors like to be challenged and this wasn’t challenging, she writes. “And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.”

Houston, I think we have an image problem.

To be sure, there’s a lot that’s frustrating these days for primary care physicians. There’s the paperwork, the crummy reimbursement, the pressure to churn patients through the exam room. But are these reasons to disdain the entire field of family medicine or general internal medicine?

The responses to Shah’s guest blog were interesting. “ALL of medicine is boring. And/or frustrating, time-consuming, aggravating or headache-inducing. Welcome to the real world,” one physician wrote.

From another doctor:

really? as a med student, u really feel like u have mastered primary care medicine? as a professor of medicine, i have a reference point, and i can assure u that u have not.

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

It’s true that primary care doesn’t pay as well as most of the specialties. For medical students lumbered with enormous educational loans, career decisions often come down to the financial realities. It doesn’t seem to be only about the money, though; there also seems to be a perception that primary care itself isn’t interesting enough or worthwhile enough to be the focus of one’s career.

An article published a couple of years ago by the Association of American Medical Colleges reflects on why this is so. The devaluing of primary care isn’t new, and it often starts in medical school with a so-called hidden curriculum that devotes fewer resources to learning primary care, fewer good opportunities for students to experience primary care firsthand, and often even subtle discouragement or disdain by medical school faculty, the article explains.

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

Primary care obviously isn’t suited for everyone. In the final analysis, students need to choose a specialty that’s a good fit for them, and the American health care system needs a good supply of specialists as well as primary care doctors.

But it would be too bad if students wrote off primary care on the basis of a limited experience that may not have been representative.

It looks as if Shah may have completely missed what makes primary care interesting and challenging, a physician commenter wrote: “Every patient encounter is an opportunity to discover something and someone new. I chose primary care partly because I didn’t want every patient of the day to be a life and death situation. I am happy to be brilliant once or twice a day and very much enjoy discovering what makes each of my patients tick, what they love and hate and why they make the health choices they do. I love to hear about their jobs and hobbies and families, their grief and their joy. I can always find a way to plant a small seed of better health in each of their lives. I love my job!”

Update: Results from Match Day on Mar. 17 show an uptick in the number of medical students obtaining residencies in primary care. The National Resident Matching Program reports that the number of U.S. medical school seniors matched to a residency in family medicine rose by 11 percent this year. There was an 8 percent increase in the number of matches to internal medicine and a 3 percent increase in pediatric matches.

The numbers are a little bit misleading because the overall number of residency training slots in primary care has been increased. Family medicine programs, for instance, are offering 100 more positions this year. The number of Match Day applicants for all specialties also is up overall.

According to this year’s Match Day statistics, dermatology, orthopedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery and vascular surgery remain the most competitive specialties for applicants.

Match Day helps determine where fourth-year medical students will spend the next three to five years completing their residency training. It’s usually predictive of the student’s ultimate choice of specialty.

Photo: Wikimedia Commons

Rx for primary care

When primary care doctors openly admit they wouldn’t advise medical students to follow in their footsteps, it does not bode well for the future of patient care.

A couple of weeks ago I attended a local meeting on the future of primary care. It was one of several that were hosted around Minnesota this past month to gather ideas and perspectives on the issues surrounding primary care.

On many levels, the discussion was truly depressing. Among the concerns I heard: There’s too much paperwork. Aging and chronic disease have made patient care much more complicated. Doctors are overburdened and dissatisfied. The primary care workforce is shrinking.

There was some talk of potential solutions, such as bringing in scribes to reduce the burden of medical charting or finding ways for physicians’ work time to be more flexible.

But what I didn’t hear was where patients might fit into all of this.

For better or worse, there’s a lot of frustration in health care these days. Consumer Reports recently published the results of an online survey of 660 doctors and the findings are revealing:

- 70 percent of the respondents said they were getting less respect and appreciation from their patients.

- The top complaint was failure by patients to follow advice or treatment recommendations.

- The volume of insurance paperwork was the No. 1 barrier to providing optimal care, followed by financial pressures that force doctors to see more patients for shorter visits.

If health care providers are frustrated, so are patients. Consumer Reports also surveyed 49,000 of its subscribers and found that although the majority were very satisfied with their doctor, they were less so if they felt their doctor rushed them through a visit, dismissed their symptoms or were too quick to whip out the prescription pad.

By now you’ve probably connected some of the dots. No one’s happy with short visits, unappreciative patients, harried doctors or tons of paperwork. Whether we realize it or not, patients are deeply enmeshed in what ails primary care, and if the ship is going down, patients are going down with it.

It’s all the more unfortunate, then, that many of the so-called solutions to primary care often are formulated and implemented with little, if any, input from patients. Take medical scribes. On the surface, it sounds like a great idea: someone who can take over the burden of charting and documentation so the doctor can concentrate his or her attention on the patient. But how do patients feel about this? Will it change the dynamics of the encounter? It’s one thing, after all, to have someone transcribe the doctor’s notes after the visit; it’s quite another thing to have a third person in the room, during real time, taking notes on the visit.

Evaluations of demonstration projects to implement the medical home concept found that patient satisfaction actually eroded. Assumptions that patients don’t mind having their care turned over to mid-level professionals also can be mistaken.

For what it’s worth, I think patients and doctors still value the relationship-building that lies at the heart of primary care. In fact, when the Consumer Reports survey asked doctors what patients could do to obtain better medical care, establishing an ongoing relationship with a primary care doctor was at the top of the list.

Unfortunately the ability to form and sustain those relationships is being seriously fractured by multiple pressures from the outside. There’s a very real danger that in the rush to come up with solutions, we overlook or devalue what makes primary care unique, what draws physicians to primary care in the first place. Who benefits from that? Not physicians, and certainly not patients.

This is a discussion in which patients need to participate. I hope someone out there is listening.

Photo: Wikimedia Commons

The efficiency factor: One visit or five?

It’s game show time: Behind Door No. 1 is a 30-minute visit with the doctor during which you’ll be allowed to address multiple issues. Behind the other door is a series of three 10-minute visits addressing one issue apiece.

You chose the 30-minute visit? Bzzzt! Wrong answer.

It’s an unfortunate reality that most doctor visits are short, and patients who want to bring up more than one concern will likely be asked to make another appointment.

The issue came up awhile back in a guest column by Dr. Danielle Ofri which appeared in the New York Times health section, lamenting an encounter with a patient who arrived with a long laundry list of problems. How do you sort through them all without becoming overwhelmed – or, as in this patient’s case, possibly missing something critical? Dr. Ofri says she learned a lesson:

When a patient presents with so many complaints that it’s not possible to cover them all in depth, I openly acknowledge the limits and say, “Today, we are going to review three of your concerns: you pick two and I pick one.” This allows the patient to select the two most concerning issues, and allows me to home in on the one I think might conceal a serious illness.

If there are other issues that haven’t been addressed or resolved, the patient presumably would be told to make another appointment.

On many levels this is a reasonable course of action. After all, doctors have other patients who need to see them too. And patient volume, rather than time spent with individual patients, essentially is what supports the practice’s overhead costs.

Is this really better, though, for overall patient care? Dr. Ofri’s column was picked up this week at Kevin, MD, where the online discussion quickly grew interesting. The comment that most caught my attention came from a medical office practice manager who wrote, “Patients… resist numerous shorter appointments as they feel they are getting less for their co-pay, and want the most bang for their buck.”

Whoa… what?

Money certainly enters into the equation. There’s no getting around the fact that two office visits and two co-pays are more expensive for patients, especially if they’re uninsured or underinsured or have a large deductible. Sometimes this is the main reason patients show up with a long, and frustrating, list of issues that need addressing: They save up all their concerns and bring them to one visit because they can’t afford to come in more often.

But I can think of many other reasons why patients wouldn’t be thrilled with a system that requires them to make multiple appointments to get all their issues addressed. For working-age adults, it means taking more time off work. For adults who are caregivers or who have small children, it means making arrangements each time to reorganize their personal responsibilities. What about older people who no longer drive and must find transportation for each of those additional doctor visits? What about people who are frail or not very mobile, for whom a trip to the doctor can be an exhausting logistical challenge?

There are many times when a face-to-face visit is necessary, regardless of the hassles it might entail. Nor is it reasonable for patients to expect unlimited time with their doctor. But from the patient’s point of view, being asked to restrict their visit to one or two issues and make additional appointments to deal with the rest is a fragmented and inefficient way of doing business – and providers should not be surprised that patients sometimes “resist.”

It would be interesting to speculate on how this practice might be contributing to the escalating cost of health care in the United States and the increasing burden on the health care system. Ten-minute visits can help churn patients through the process more quickly, but if many of those patients have to keep coming back, what has been gained? How does it save money or help the system operate more efficiently?

Much of this goes back to how doctors, particularly in primary care, are paid. They’re rewarded for volume and procedures, not for diagnosing, problem-solving, coordinating and managing. There’ll be little progress until this changes.

In the meantime, how about a little more mutual understanding? Patients aren’t villains for resisting multiple short appointments when a single longer appointment would do, any more than doctors are villains for asking patients to keep it short and come back another day.