4th Natl Workshop Internet Dialogues: Zervanos, Elison, et al.

Internet Dialogues:  Responses to the Theme Presentation, Fourth National Workshop on the Community Benefits of Family Medicine Residency Programs

The following responses have been received to the posting of the Annals of the 4th National Workshop: Background of Natl Project:

Editor: William H. Burnett, MA

The response of Nikitas J. Zervanos, MD; Director Emeritus, Family Medicine Residency Program; Lancaster General Hospital Lancaster, Pennsylvania

Dear Bill,

Thanks for providing me the opportunity to comment on as I found the dialogue most informative and telling. I must admit when I get immersed in these issues, I feel a great deal of nostalgia and wish that I was still directly involved in these matters.  I guess I retired too soon.

Doctor Peter Nalin, as you may know, is a graduate of our Lancaster family medicine residency program and I am not at all surprised that he has surfaced as a leader in our specialty.  He is one of the young Turks and he will continue to make great contributions in family medicine in its many different arenas.

I believe our program, as I think is true for so many programs, has offered many unique responses to the care of underserved people in our country. When the Lancaster program began in 1969, it was two years after the Medicaid legislation (1967) and 4 years after Medicare.  It is not a coincidence that our specialty commenced around the same time of Johnson’s “Great Society” program. It was intended to defeat poverty including many initiatives to improve the delivery of medical care, especially for those living in underserved areas of America.  Although we have made much progress on many fronts, I am afraid poverty can never be totally defeated as it is inherent in the human condition.

When the Lancaster program was initiated in 1969 we proposed two family practice centers, one that satisfied the RRC requirements for a model family practice center, and one we argued was going to be part of our “community medicine” curriculum.  We considered in effect two “models of practice.” The RRC model family practice center was to service a patient population representative of a wide socio-economic mix, and was aimed to be more typical of the private practices in our community. We wanted to place it however in the most underserved area of Lancaster. This meant southern Lancaster County, but unfortunately that was farther from the hospital than the RRC would accept. The other family practice center was to be placed in the new hospital wing where it would have its own identity, etc, but it was to serve our city’s medically indigent population.

Despite the distance of 15 miles from the hospital, we argued successively for a rural-based model family medicine center in the borough of Quarryville, a town of only 1800 people in the center of the 300 square mile area of rural Southern Lancaster County (Amish Country). Tom Johnson, MD, the field secretary working in the Division of Education of the AAFP was impressed with the idea, and encouraged us to proceed.  He said it was “worth the try.”  If it did not work, the RRC would tell us so after our provisional review. Well, it did work, and to this day we operate these two “model” family medicine centers. They continue to grow and “prosper”.

All 39 residents, 13 in each of the three years, participate in both FPCs.  Each resident spends one and occasionally two half days per week, throughout the three years in the hospital-based facility known as the Family Health Service (FHS). This is where they also acquire most of their maternity care patients, and for that matter, much of their pediatric experience as well. They do not go to our rural unit, known as the Walter L. Aument Family Health Center (WLAFHC), until their second year.

In the second and third years they spend 2 to 4 half days per week in this practice following their patients. Some of their patients are upper middle income and some indigent, but most are in between, including many farmers and Amish. The vast majority are intact family units. They also provide a fair degree of maternity and child health care to this population group as well.

The program has been fortunate to have developed an excellent reputation in the community in providing high quality care, including maternity care among its indigent; hence a large obstetrical practice. Most of the 800 deliveries performed each year come from the FHS; the rest mostly from the Quarryville site. They are supervised by family practice faculty and the program’s own four ob-gyn faculty who also provide the residents’ rich gynecologic experience.

Furthermore, to enhance the program’s community medicine experience the residents are required to complete a “community medicine” project before they graduate. This could include participation in some activity, preferably a research project, with one of Lancaster’s many community agencies. That could mean working with the Lung Association to curb tobacco consumption; with the Bethany Program to curb teen-age pregnancy; with one of the Mennonite Church groups to assist single mothers in raising their children; with one of several Drug and Alcohol agencies to assist in the care of people afflicted with addiction disorders; with one of the HIV groups to care for people suffering from AIDS; or work with the community’s free clinic to help care for the homeless.

The free clinic is housed in a homeless shelter founded by several of the program’s graduates who now practice in another outlying borough of the county. The residents are also required to write a paper before graduation. This might include any other research project that the residents have engaged in, but regardless it must be of publishable quality on either a clinical or public health topic, many of which have been published in refereed journals. To date the program has averaged about one paper a year since its inception. In the meantime the program’s research endeavors have expanded and now boasts its own medical director of research and a PhD researcher.

In summary, we met the challenge! And I believe we continue to do so. Family practice more than any other specialty has contributed considerably towards alleviating the physician maldistribution problem. The Lancaster program instituted innovations that did much to address the challenge of underserved populations in Lancaster County. It has remained a constant part of the solution as it continues to reach out to meet some of Lancaster’s most pressing public and community health issues. We believe the program’s innovations in public health education in the context of the academic setting of “Family Medicine” improved the communitys health, while enhancing the quality of the residents’ education and training.

I can’t say enough good things about our program and the gratitude I feel on how our hospital has supported our endeavors throughout these many years.

Nik

The response of Gar Elison, MD, Utah Rural Health Board, Salt Lake City, Utah

Bill,

I just completed reading the presentations you reference in your  e-mail.  I have only one comment.  One of the early evolutions for providing care to the Uninsured was the Health Cooperative.  In a sense it was a prepaid plan since families pledged a certain amount and care was available. They operated beginning in the 1920’s and had pretty much disappeared by 1940.  A cooperative was composed of 300-500 families. There were 87 cooperatives with 97 physicians.  We had one in Utah in the Community of Tremonton where a number of poor farm families and government and business people joined together to hire a physician.  If you or Dr. Rodos are interested some of the pictures still exist .

Sincerely,

Gar

The response of and follow-up communication with Thomas Brown, Ph.D., Retired Faculty, University of California, Davis Network of Affiliated Residency Programs:

Thanks for the update.  My grapes, which I planted as my  retirement activity, have consumed most of my time so I am really out of date, now.  I did talk to Doctor John Geyman and he was really impressed by what you guys are doing.

You may remember that Doctor Bruce Nickols (former director of the family medicine residency program at San Joaquin General Hospital in Stockton, California) and I spent some time trying to define the research base of Family Medicine.  Our final thoughts were that the “research basis of family medicine is the fact that it is a health care delivery system”.  That is, the practicing family physician defines the scope of resources his/her patients need and orchestrates how patients flow through that system (referrals, etc.).  From what I gathered from you remarks after Jerry’s talk, you have stepped this up to defining the “practice” a family physician (or resident)is associated with as the core unit of study.  That, I believe, is a masterful stroke! . . .

Tom Brown

Thomas C. Brown, Ph.D.

Hi Tom –

Your remarks are appreciated. Your reference to Doctor Bruce Nickols’ belief that the research base of family medicine is health care delivery system stimulated some thought on my part.

I think Dr Nickols’ statement, in itself, would not be controversial in most family medicine circles.  However, your reference to it in the context of the presentation that Doctor Jerry Rodos and I made at the Fourth National Workshop in Indianapolis leads me to take it a step further.

One of the working hypotheses of the National Benefits study is that both family medicine centers and a family medicine residency program’s community sites constitute “systems of care” for various populations, including such populations as those whose care is publicly financed and such vulnerable populations as “the homeless” etc.

The exposition of this working hypothesis has revived the “service” vs “education” debate in some quarters.  I think your e-mail illuminates an area where there might be some reconciliation between the two sides in this debate.

The family medicine community is currently spending a great deal of time in discussing (even debating) the concept of the “basket of services” provided by the family physician.

I think if one extends Doctor Nickols’ observations about the province of family medicine research to the family medicine residency program curriculum, it is only an additional step to say that the residency is teaching “systems of care” for defined population groups.

Obviously, one could remark that these are simply the “comprehensiveness” and “continuity” elements of family medicine that derive out of the sum of the individual patient encounters a family medicine resident will experience through the residency program curriculum.

Furthermore, one can say that the resident gets a smattering of “defined population medicine”, although not necessarily in any context of the resident’s own patients. Similarly family systems theory is applied (more in some places than other), but it is often considered a distinct part of the curriculum, if it is there at all.

But I think there may be something more.  As the National Project begins to focus on these populations seen by the residents, it could provide some insights into areas where the curriculum itself can be expanded to understand the impact of the totality of the residency program’s services to a particular population group.  Such a group could be the medically indigent, or the families of diabetic patients, or Russian-speaking families, or any such group. If taken seriously, a whole new area of family medicine residency program curriculum development could be established.

Let me know what you think.  I plan to share your observations and my response with the Policy Analysis Committee people who are overseeing the National Project.

Cordially,

Bill

William H. Burnett, MA

Hi, again, Bill;

As usual, you have taken a few random comments of mine and  expanded the ideas to encompass a much larger content.  And I like it!  I have several thoughts.  First, my initial work before entering the field of medical education was system theory and application.  I worked with guys like Bob Mager (he “invented” the behavioral objective), Roger Kaufman and others.  While at Chapman University, we developed a statewide program called Operation PEP (Preparing Educational Planners).  We got all of the county Superintendents of Schools together at monthly meetings and taught them Instructional System Technology.

From this and other experiences, I developed a pretty good understanding of systems theory.  Therefore, when I refer to family practice as a health care delivery system, I am defining all of medicine in that system.  While no practitioner or resident can access all components of the total system, they can access most of those that can benefit their patients.  Often, especially with uninsured patients, they cannot get many portions of the system to respond and must make do with care practices that are not as effective as others.  We have all seen that.

John Geyman and I did a study of practicing family physicians to study trier referral patterns.  We found that:

1. With patients to whom they planned to continue providing services, they worked alongside the consultant, not only to help the patient, but to learn from the consultant as a form of self-study to keep themselves current.

2. With patient so ill that they felt the patients would die, they made referrals, often to larger cities with larger facilities.  These patients rarely came back, expiring at the larger facility.

I always found it fascinating to watch our “star” residents and or “really great preceptors” manipulate the system to benefit the patient.  They were experts in getting services and procedures for patients that were generally not available to them.  I think that is why Bruce loved medicine so much as he could play that game better than just about anyone else.  No one was more of a patient advocate than he was.

I am not sure residents are taught much about “how to beat the system”.  I believe that the best family physicians are the ones most  expert and getting resources/ services to patients that are not available to them, generally because of a lack of insurance and/or money.

The response of Edward Rylander, MD, “In His Image” Family Medicine Residency Program, Hillcrest Medical Center, Tulsa, Oklahoma

Dear Bill,

I have been interested and involved in both Family Medicine education and health care for the underserved since graduating from the Oral Roberts School of Medicine in 1985 and the residency program at ORU in 1988. I am board-certified in both Family Medicine and Palliative Medicine and have been active in the Hospice community for many years here in Oklahoma. Additionally I have been part if the “Beck Fellowship program in Health care for the Underserved” out of the USCSD Family Medicine Department for the last 5 or 6 years, and have helped run a maternity clinic for undocumented/uninsured mothers in association with the local health department here in Tulsa for the last 18 years.

I am very interested in the work you are accomplishing and found the paper you referenced insightful and very interesting. My personal outlook is that there is a greater cost to any community in not providing care to the members of the community when it is appropriate (early) and that cost increases the longer you wait to provide the care. One of our responsibilities is to help others see the true cost of limiting care across the spectrum of the community, that can only happen with projects like yours and others that will help identify and quantify the hidden costs involved.

Ed Rylander, MD

Last Updated (10 November 2005 10:54)

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