Proceedings of the 25th National Conference; April 14, 2014 (First Plenary Session, WIlke et al. Questions and Comments)

This session immediately follows: Proceedings of the 25th National Conference – First Plenary Session, Part 2 (Pugno)

We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine (Dayton, Ohio) for funding the transcription and editing of this section of the Proceedings of the Twenty-Fifth National Conference:

 

Allan Wilke, MD; Western Michigan University
Allan Wilke, MD; Western Michigan University

The designated lead questioner for the morning’s First Plenary Session is Doctor Allan Wilke of Western Michigan University Homer Stryker School of Medicine, Kalamazoo. [Doctor Wilke is a Senior Fellow of the National Conferences on Primary Health Care Access]:

Dr Wilke: First of all, you two guys [Doctors Norman Kahn and Perry Pugno] are amazing and I have the most respect and affection for the both of you. What I wanted to ask Perry is, WTF? But I don’t think that’s an answerable question.

Dr Pugno: WTF stands for “Where’s The Focus?”

Dr Wilke: Perry, because there was an overlap between Norm heading up the Future of Family Medicine version 1 and you heading up version 2; to me that would seem like a really difficult job, so my question to the two of you, is: what was it like? What was the most difficult task that you had heading up the Version 1 and th Version 2?

Norman B. Kahn, MD;  Council of Medical Specialty Societies, Chicago
Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

Dr Kahn: I don’t remember Version 1 being all that difficult. It was busy. It was a lot of hard work.

I hate to say this, but the first thing I recall is that raising sufficient money for the project created controversies.

For example, we had to work to get people to agree that we could take money from the Eli Lilly Foundation, because it was an entity distinct  from the pharmaceutical firm, the Eli Lilly Corporation.That was the issue then.

We had a lot of folks from other disciplines that participated in Future of Family Medicine 1.0 who were very engaged. It seemed very visionary, like the right thing to do.

It has been 10 years, I’ve been away, but just don’t remember it as being that difficult, although I think we’re genetically programmed to forget things like that. It was kind of like having babies. After having the first one, you’d never have another one if you didn’t forget what’s involved.

Perry A. Pugno, MD, MPH; American Academy of Family Physicians Vice President for Education
Perry A. Pugno, MD, MPH; American Academy of Family Physicians Vice President for Education

Dr Pugno: Norm, how would you know?

I have a real time perspective of the Future of Family Medicine 2.0, so I haven’t forgotten.

Money hasn’t really been that much of an issue. We are cautiously optimistic that the “family of family medicine organizations” are going to step up to the plate with money.

There is increasing optimism that there may be additional external money.

Doctor Paul Grundy (the physician who directs IBM’s Global Healthcare Project and founded the Patient-Centered Primary Care Collaborative) has been preaching on our behalf.

I fully intend to squeeze Dr Grundy and say to him, “Let’s have IBM® step up to the table and throw a few dollars at this project that will advance the objectives that Paul Grundy’s been talking about.”

Even our certifying boards have agreed that there may be some industry money – non-pharma, non-alcohol, non-tobacco companies – that would be willing to donate some money, given the value set that we’re putting forward.

Johnson & Johnson gave 50 million to nursing to develop their communication campaign. A few dollars our direction would be a welcome contribution.

But to answer the question directly, the biggest challenge in this project has been for the family organizations to all agree on what are going to be the strategic planks, how are we going to go forward, what are going to be the priorities.

There has been some interesting tension among the various generational communities about how we get there. It has been an interesting, respectful debate. But we are now at the point of consensus and are ready to move forward.

Senior Fellow Charles Q. North, MD, MS; University of New Mexico School of Medicine; Albuquerque
Charles Q. North, MD, MS; University of New Mexico School of Medicine; Albuquerque

Charles Q North, MD, MS, University of New Mexico [Doctor North is a Senior Fellow of the National Conferences on Primary Health Care Access]: First, I’d like to ask Norm this question, because I’m in a position now where I work with the orthopedic surgeons a lot and because I have actually seen orthopedic surgeons more than family physicians as a patient (because as you know my lifestyle is one that requires their services): Why don’t they participate in the societies?

Then I’d like to ask Perry, what are the brands that are more popular than IBM®, Nike® and family physicians, and does that include orthopedic surgeons, and should we ask them for money to fund our organization?

Dr Kahn: The answer from me is quick, so I’ll let Perry answer the rest.

Most of the societies are organized to protect and advocate for their own and it takes a lot of convincing for the societies.

You know what the answers are when you try to create a big movement for something: you have to have one of two options, you have to have a common enemy or a common vision. It’s a lot easier with a common enemy.

The orthopedic surgeons don’t perceive that they need to come together with another organization to which they would pay dues twhen they are doing fine all by themselves.

That was also true to some other organizations who have been convinced to participate because of a common vision. But it’s a lot harder to motivate people with a common vision than with a common enemy.

Dr Pugno: To answer your brand threshold question, there’s no question that primary care is what’s on the tip of everyone’s tongue. We have heard at the AMA meetings the neurosurgeons say that they should be the primary care home for the central nervous system. So that’s clearly the case.

When we talk about primary care, there is good data, repeated data, that there are plenty of pediatric providers out there. That’s not where the shortage is. The shortage is in the physicians serving the aging adults.

Let’s be candid. General internal medicine has abdicated primary care. We’re talking single digits of internal medicine graduates directed toward primary care. For all practical purposes, the brand, so to speak, that’s on top for the future delivery system, is going to be family medicine. That’s the reality of it.

We have been our own worst enemy . . . our modesty, and our unwillingness to ring our own bell, to say, “ey we’re pretty good.”

Our unwillingness to do that has been our biggest shortcoming going forward, and it’s time that we got over this inferiority complex, and step forward and say we are what America needs. We can deliver better, more effective care, more cost effectively, with better outcomes. Get out of the way and let us do it.

Samuel C. Matheny, MD, MPH, University of Kentucky, Lexington
Samuel C. Matheny, MD, MPH, University of Kentucky, Lexington

Samuel C. Matheny, MD, MPH, University of Kentucky, Lexington [Dr Matheny is a Fellow of the National Conferences on Primary Health Care Access]: I have a couple of comments about the last Future of Family Medicine project and then a couple of questions for you all.

One of the things that appears different is that this time, as opposed to last time, is that you do see that there’s a lot of public recognition of family medicine. That certainly wasn’t what we perceived when we did our first focus group studies ten years ago.

There was a lot more debate ten years ago about what is a family physician – people identifying that it was more the focus of the activities rather than the person called a family physician. At least that’s my memory of it. This new recognition appears to be a real plus for us.

A second issue that you just brought up Perry, is the changing role of primary care in the specialty of internal medicine. That sub-specialization of internal medicine wasn’t really as apparent ten years ago as it is now.

The question that I have is the political dance that may have to occur with this report. We’re in the middle of a major Congressional election year, to be folloed by a very important 2016 election. For better or worse, the American Academy of Family Physicians (AAFP) really sided with one political party.

How do we walk through that with the Future of Family Medicine (2.0), knowing that in many cases we have many friends on one side of the aisle, and a lot fewer on the other?

Dr Pugno: Boy, that’s a fair question.

Perry A. Pugno, MD, MPH; American Academy of Family Physicians Vice President for Education
Perry A. Pugno, MD, MPH; American Academy of Family Physicians Vice President for Education

The answer is, we walk that carefully. But we have a strong basis for doing so, and that is (as with Family in Family Medicine 1.0), we have the advantage of the values that underpin our discipline.

It is those values with which the public resonates. To be fair to both sides of the aisle, they are not quite that far apart. There are legislators in both parties who resonate with many of the values that we espouse.

The debate is how to get there. And the challenge right now is that we are paralyzed by partisan politics. There’s nobody in the middle right now.

Everybody is an extremist. We need to find some people willing to move toward the middle to say we need to get back to core values, and make those a priority and move beyond the politics.

It doesn’t matter what political party you are if we can agree on three core values. Can we agree that we need better patient outcomes? Can we agree that we need to provide more cost-effective care? Can we agree that people need a better healthcare experience?

If we can agree on that Triple Aim that could be the “touch-point” that will allow us to navigate the politics.

I don’t think we need Congress for that.

The best thing Congress did was set up this Center for Medicare and Medicaid Innovation and fund it for ten years for $10 billion and authorize it so that anything that works can be scaled without Congressional approval. That’s where the demonstration projects are. We don’t really need Congress in this case. We have to demonstrate the value of meeting the Triple Aim.

Donald Frey, MD; Creighton University, Omaha, Nebraska
Donald Frey, MD; Creighton University, Omaha, Nebraska

Donald Frey, MD, Creighton University, Omaha [Dr Frey is a Fellow of the National Conference on Primary Health Care Access]:

Norm, you prefaced couple of your questions with: “Hey now, don’t throw anything at me.”

Now I preface what I’m about to say kind of with the same thing. Now don’t throw anything with these questions, but a couple of questions that are in response to what you spoke of one particularly in regards to the makeup of the professional societies, the motivation of members and so forth.

One of the things I do is give a lecture on professionalism to first year medical students and one of the thought provoking questions I pose of them is what’s the difference between a labor union and a professional organization?

And the answer, obviously, is that a professional organization holds itself out to be something that promotes a profession for the good of those that they are engaged with; whereas a labor union is an entity that looks out first and foremost and solely for the welfare of its members.

And as I tell the students, I have no problem with that if I worked for Wal-Mart I’d want to join a labor union. Of course I couldn’t because they’d fire me, but that’s a separate issue.

At any case the way you’ve described the behavior, the attitudes, the makeup, the focus of many of our professional organizations they really sound more like labor unions than professional organizations. So I guess the question of one is, is that the case? Number two, if it is how do we get beyond that? Because we cannot do that.

Many of the things that you described here as being fundamental to changing healthcare are not going to be addressed if we cannot do that; unless we’re able to get beyond that; so thoughts from both of you on that.

Norman B. Kahn, MD;  Council of Medical Specialty Societies, Chicago
Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

Dr Kahn: Sure. There is tension. The answer to that question is the same as to the question I asked my specialty society CEOs: “What is the greatest tension that you feel in your job?”

The answer is dealing with the tension between the “trade union” on the one hand and the “professional organization”. The front line physicians really perceive they need a trade union and the national leaders really perceive that they need to be a professional organization.

At the Council of Medical Specialty Societies when we did our strategic planning process in 2008-2009 (and then revisited it and reaffirmed it in 2012), we adopted a specific definition of professionalism as having three attributes.

The first attribute is altruism, which is assuring that the needs of patients come first. There’s another big organization of physicians that has a reputation for putting the needs of physicians first. We’re going to assure that altruism is our first part of professionalism.

The second is self-regulation which means, not only teaching and educating ourselves, but also regulating ourselves. We have some organizations, notably the American College of Surgeons, that are so ethical, that if a surgeon violates their ethical standards, they kick them out of their organization and they publish their name in their monthly journal. This is about self-regulation.

And the third is transparency. Which is disclosure to peers but also open to patients and the public. Right now we’ve got a big issue because Medicare is disclosing the Medicare payments to physicians and people are in the reactive mode because there’s so many fears out there, what’s going to happen and so on.

And I commented to my president and my president-elect who are in the reactive mode right now; I said “Let’s go back to our strategic priorities. Isn’t disclosure of payments in the public sector transparency?”

Dr Pugno: My comment is, today we are blessed to have somebody like Norm Kahn as the CEO of an organization like CMSS. Norm’s very modest, but he has been facilitating conversations among specialties that never happened before. Yes, the orthopedists don’t want to play. Well, they can sit on the sidelines and watch.

The fact is that we’re having conversations we never have before. To suggest a really good example of this: about a year ago CMSS, with Norm’s help, facilitated a statement on GME funding, that all of the specialties bought into.

I will admit it’s a “motherhood and apple pie” document. There was not much controversy there, but the fact that we even had the conversation is historic. The reason these conversations are happening is because a diverse organization like CMSS is being led by someone with the vision that understands that we all need to come together.

We all need to talk together. We all went into healthcare because we wanted to make a difference. By hanging onto that core value, that organization, CMSS, I think, is moving forward. And I believe that CMSS, more than the other professional organization that I won’t name, will in the future be speaking on behalf of the medical community in ways that the medical community has never spoken before.

Associate Dean Michael Prislin; University of California, Irvine School of Medicine
Associate Dean Michael Prislin; University of California, Irvine School of Medicine

Michael D. Prislin, MD, MPH, University of California, Irvine [Dr Prislin is a Fellow of the National Conferences on Primary Health Care Access]:

Norm and Perry, two terrific presentations.

Norm, first I’m going to take your post-test. The answer is no.

Perry, we’re so busy training people to be pluripotential stem cells that we don’t have time to do some of the things that are really important, so whatever direction we go, I would say that the training model is not adequate to get the job done.

Maybe we look at Oregon Health and Sciences University. What they have developed there is a different pathway. I thought the interesting point of intersection of your two presentations has to do with payment.

We all agree that when we say that the payment system needs to change, we mean that family physicians need to be in control of the healthcare dollar allocation.

That seems to be something that there might be a little bit of potential for disagreement in terms of Norm’s organization. I see that as a point of terrific conflict and I’d be interested in your comments on that.

Dr Kahn: This question came up at breakfast and I would say that the ACO model as it’s being implemented right now with hospital-based and system-based ACOs is probably not going to last very long, because it’s too expensive. There are all of the extra expenses in the hospital and in the emergency room, so that if you run a hospital, you have perverse incentives.

To the degree that we could have physician-based ACOs – whether its family physician based or not doesn’t really matter I don’t think – then those ACOs will probably work. Look at Community Care of North Carolina and its history, where you can mix part A and part B from Medicare like you do with Medicaid and you can save money out of part A by investing money in part B.

That has real potential but you have to have huge deep pockets to be able to take risks like that. So those incentives are there, it’s just going to be a real challenge for the physician community to take on that kind of risk and assume that kind of leadership.

Dr Pugno: I agree 100%. The answer to the question is ithat it’s time physicians retook control of the healthcare system. We’ve abdicated control of the healthcare system to the bean counters and the lawyers and they’ve screwed it up. They have to get together to do it and I don’t see that happening yet.

They’ve sucked a lot of money out of the healthcare system that used to go to patient care. As physicians retake control of the system there will be more there for their patients. And I really think that’s the direction we need to go.

Dr Kahn: I have a question for Bill Burnett. This plenary session has stimulated a lot of questions for me, and I have some issues, and we all saw the new FFM for the first time here this morning. And it’s a great tribute to Perry to be able to time it so that this is the first group that gets to hear about the future of family medicine two.

I’ve got some reactions. So I’m hoping that somewhere in this meeting without taking any more time from your program that we’ll have a little more time to talk about our reactions to FFM two. I’d like to be able to share them with this group and stimulate some discussion. I know I’ll share them with Perry.

Dr Pugno: I’m confident I’ll hear from several of you after having disclosed this information. Thank you.

This section is followed by: Proceedings of the 25th National Conference: April 14, 2014 – Second Plenary Session, Part 1 (Allen)