Tom Bodenheimer – Building Blocks of High-Performing Primary Care and the Quadruple Aim

Play

Dr. Tom Bodenheimer is one of the world’s foremost experts in primary care re-design, having recently written about high-performing primary care clinics and the Quadruple Aim, which are articles consistently in the most-read list for the Annals of Family Medicine and among his most cited work.  We focused much of our conversation on his work visiting 23 high-performing primary care practices, what he and co-authors learned, how resident teaching sites can also be high-performing, and why we should be seeking a fourth aim in addition to IHI’s famed Triple Aim.

A general internist who received his medical degree at Harvard and completed his residency at the University of California-San Francisco, Dr. Tom Bodenheimer spent 32 years in primary care practice in San Francisco’s Mission District, a primarily low-income, Latino community—ten years in community health centers and 22 years in private practice.  He is currently Professor of Family and Community Medicine at UCSF and Founder and Co-Director of the Center for Excellence in Primary Care.  He has written extensively in journals such as the New England Journal of Medicine, JAMA, Annals of Family Medicine, and Health Affairs, on health policy and health care delivery for chronic disease management, including patient self-management, health coaching, and team-based care. He is also co-author of the books Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy text book Understanding Health Policy.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

How does architectural design impact c-section rates? Mass Design & Ariadne Labs

Play

This episode starts with a question: “what if the architectural design of an obstetric unit influenced the c-section rate in that unit?”

That question occurred to obstetrician/gynecologist Neel Shah when he attended a presentation by Michael Murphy, the co-founder and executive director of Mass Design, an architectural design and research firm that focuses particularly on healthcare architecture. Neel thinks about c-section rates all the time and is a leading researcher in the field of maternal health. C-section rates vary widely throughout the US – from 7 to 70%, and where a woman delivers better predicts whether she will get a c-section than her own personal risk factors. So, Michael Murphy’s contention that “Architecture is never neutral. It either heals or hurts” stayed with Neel and inspired him to pursue a research initiative between Mass Design and his research group, Ariadne Labs.

Neel Shah and two of his collaborators, Amie Shao and Deb Rosenberg, researchers and architects with Mass Design, join us to talk about their collaboration and the report they produced.

Amie Shao is a director with MASS Design Group, where she oversees research focusing on health infrastructure planning and evaluation. In addition to guiding impact research for MASS built projects, she coordinated the production of National Health Infrastructure Standards for the Liberian Ministry of Health and has been involved in the design and evaluation of healthcare facilities in Haiti, Africa, and the United States. Deb Rosenberg joined MASS in 2015, with a unique background in healthcare and architecture. Throughout her career in nursing and architecture is a common ambition to promote health and well-being, and she believes that the spaces where people live, work and heal have the capacity to greatly support or restrict our human potential. Neel Shah, MD, MPP, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and director of the Delivery Decisions Initiative at Ariadne Labs. His team is currently collaborating with hospitals across the United States, and using methods from design, systems engineering, and management to reduce the epidemic of avoidable c-sections.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Frederick Chen – Teaching Health Centers

Play

Teaching health centers (THCs) are primary care residency training sites in community-based organizations, often in federally qualified health centers (FQHCs), in contrast to traditional tertiary care hospital-based training. Federal funding for the THC program, created by the ACA in 2010 and renewed through MACRA in 2015, is set to expire on September 30, 2017.

THCs may be a key part in solving the primary care workforce shortage, so we talked with Dr. Frederick Chen, Professor of Family Medicine at the University of Washington and a recent senior advisor to HRSA’s Bureau of Health Professions for the Teaching Health Center program.

We review flaws in traditional methods of funding graduate medical education in the US (2:50) then discuss Freddy’s research (8:15) showing that residents trained in FQHCs are 3-4 times more likely to go work in underserved settings. He also describes the key factors in creating community health center-family medicine residency partnership (12:20). Freddy’s work led to the THC graduate medical education program, an innovative federal policy that aims to increase access to primary care where it is needed the most, and we talk about some of the early lessons since its inception (18:50). You can also find the controversial 2014 Institute of Medicine report mentioned by Freddy in our conversation here.  Finally, Freddy shares about how his academic career led him to help shape national health policy (23:07).

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Journal Club – Association Between Process Measures & Mortality in Individuals with Opioid Use Disorders

Play

This week, we are discussing a recent article from the journal Drug and Alcohol Dependence, entitled: Association between process measures and mortality in individuals with opioid use disorders, by Katherine Watkins and colleagues: Susan Paddock, Teresa Hudson, Songthip Ounpraseuth, Amy Schrader, Kimberly Hepner, and Bradley Stein. We are also joined by a guest discussant, Gabriel Wishik. Gabriel Wishik is a clinician educator in general and addiction medicine, and is an instructor at Boston University and Boston Medical Center. He is the clinic medical director at Boston’s Healthcare for the Homeless Program’s largest clinical site and practices harm reduction in primary care with a population at the front lines of the current opioid epidemic. You can find the obituary we shared on the show here.

If you like the show, please rate and review us on itunes, google play, stitcher or your favorite podcasting app, which makes the show easier for others to find; and share us on social media. We tweet at @RoSpodcastand are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Dave Chokshi – Population Health Management

Play

This week, we are joined by Dave Chokshi. Dave is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest public health care system in the U.S. He practices primary care at Bellevue Hospital and is a Clinical Associate Professor of Population Health and Medicine at the NYU School of Medicine.

We talk about what population health is, how it is distinct from public health, and what value it adds to our healthcare system. We also talk about how in some ways it might contribute to the erosion of relationships between primary care providers and patients, how that can be remedied, and how the small 1 or 2 doctor practice may fit into a population health management vision. We talk about a piece he wrote with Neil Calman and Diane Hauser about what they call the “expanded denominator,” and how that may further goals of public health and accountable care. Lastly, we talk about population health approaches in urban and rural settings, and how we should think about the opioid epidemic from a population health vantage point.

We reference a few articles throughout our conversation: Christine Sinsky’s already classic Annals paper detailing that physicians spend two hours on administrative tasks for every hour they see patients, and our journal club on that paper. Robin Williams’ and colleagues Health Affairs blog on utilizing the HIV cascade of care to battle the opioid epidemic, and Lawrence Casalino and colleagues work calculating what we spend measuring the care we provide. In addition, we reference the Surgeon General Vivek Murthy’s landmark report on addiction.

A quick note about a word we use frequently but didn’t pause to define for listeners – attribution. Attribution is the assignment of a specific patient to a specific primary care physician in a health system. Once a patient is attributed to a PCP or health system, that PCP and health system is held accountable for the patient’s quality measures and healthcare costs within ACOs or other alternative payment contracts. This still applies patients who do not frequently access the healthcare system through traditional channels or most frequently see specialists, who perhaps have never seen the assigned PCP, and is therefore at times controversial.

A little more background on Dr. Dave Chokshi: He was Assistant Vice President of Ambulatory Care Transformation at NYC Health + Hospitals and director of Population Health Improvement at NYU School of Medicine. In 2012-13, he served as a White House Fellow at the U.S. Dept. of Veterans Affairs, where he was the principal health advisor in the Office of the Secretary. His prior work experience spans the public, private, and nonprofit sectors, including positions with the New York City and State Departments of Health, the Louisiana Department of Health, a startup clinical software company, and the nonprofit Universities Allied for Essential Medicines, where he was a founding member of the Board of Directors.

If you enjoy the show, please rate and review us wherever you listen, and share us on social media. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Danielle Ofri – Communication Between Patients & Doctors

Play

This week, we are joined by Danielle Ofri. Danielle is a primary care physician at Bellevue Hospital and a prolific essayist and author. We start out talking about her most recent book, What Patients Say, What Doctors Hear. We talk about communication between patients and doctors and why it can be so challenging, and how physician communication can be evaluated and more effectively taught to trainees. Danielle talks about the power dynamics of the medical interview and how it can be uncomfortable for us as physicians to have the tables turned when the patient is more empowered in the conversation. We also talk about the campaign that Danielle has spearheaded to get physicians and other medical professionals involved in the health care reform efforts of the last few months in Washington DC with her House Calls Campaign.

Danielle is a physician at Bellevue Hospital and associate professor of medicine at NYU. She writes about medicine and the doctor-patient connection for the New York TimesSlate Magazine, and other publications. Danielle is co-founder and Editor-in-Chief of the Bellevue Literary Review, the first literary journal to arise from a medical setting. She is the author of a collection of books about the world of medicine. She’s given TED Talks on Deconstructing Perfection and  When Doctors Face Fear, and has performed at The Moth.

If you enjoy the show, please rate and review us wherever you listen, and share us on social media. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at contact@rospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for clarity.

Joshua Freeman – Designing a Fair & Equitable Healthcare System

Play

Dr. Joshua Freeman is a family physician, health policy researcher, social justice activist, and writer.  He publishes a widely-read blog, “Medicine and Social Justice”, and in 2015 published a book, Health, Medicine and Justice: Designing a fair and equitable healthcare system (Copernicus Healthcare press), which is available on Amazon and other sites, in both softcover and electronic versions.

This week, Thomas Kim chats with Dr. Freeman about some of the major themes of the book: why the US health care system fails to produce a healthy population, the role of profit in American medicine, why he uses social justice to frame his analyses and commentary, and how the American health care system could become more primary care-centered.

Dr. Freeman is Professor Emeritus at the University of Kansas Medical Center in Kansas City, where he served as the Alice M. Patterson MD and Harold L. Patterson MD Professor and Chair of the Department of Family Medicine from 2002-2016, and was also Professor in the Departments of Preventive Medicine and Public Health and of Health Policy and Management. He was a Fulbright Scholar in São Paulo, Brazil in 2003 and served nationally as Treasurer of the Society of Teachers of Family Medicine and the Association of Departments of Family Medicine. He received STFM’s highest honor, the Recognition Award, in 2006. He served as a member of the board of trustees of Roosevelt University in Chicago, as assistant editor of the journal Family Medicine, and also on the board of Southwest Boulevard Family Health Center in Kansas City, KS.

Dr. Freeman is a graduate of the Loyola-Stritch School of Medicine, family medicine residency at Cook County Hospital in Chicago, and faculty development fellowship and Preventive Medicine residency at the University of Arizona.

This interview was lightly edited for clarity.

Journal Club – Exploring the Patient and Staff Experience with the Process of Primary Care

Play

This week, we bring you a journal club on the manuscript: Exploring the Patient and Staff Experience with the Process of Primary Care, which was published in Annals of Family Medicine in the July/August 2015 issue by Elizabeth J Brown, Shreya Kangovi, Christopher Sha, Sarah Johnson, Casey Chanton, Tamala Carter, and David Grande.

If you like the show, please rate and review us on itunes, google play, stitcher or your favorite podcasting app, which makes the show easier for others to find; and share us on social media. We tweet at @RoSpodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

How to Prevent Burnout with Diane Shannon & Paul DeChant

Play

This week, in the second of our series about physician burnout, our guests focus on solutions. Diane Shannon and Paul DeChant, both physicians, join us to talk about their recent book Preventing Physician Burnout, Curing the Chaos and Returning Joy to the Practice of Medicine.

Diane and Paul talk about their experiences with burnout and how they came to work on this project together, how they contend that organizational and structural factors are more important than individual factors in driving burnout, how compensation and intangible rewards can reduce burnout, how leadership in healthcare can address the epidemic of burnout. We also talk about how they have come to believe that the LEAN principles, most especially the pillar of respect for people, is key in transforming healthcare organizations into places where primary care physicians can thrive, why change is so difficult, and some other resources that can help.

Diane Shannon is a general internist who left clinical medicine due to burnout and turned to a career in medical writing and public health. Paul DeChant is a family physician and experienced healthcare executive who has previously worked in organizations such as The Paulo Alto Medical Foundation, Sutter Gould Medical Foundation, and is now a senior advisor with Simpler Healthcare.

If you’ve missed it, have a listen to the first in our burnout series with Colin West, researcher at Mayo Clinic who has done foundational research on burnout and physician well-being. Please rate and review us on itunes, google play, or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you, and thanks for listening.

Colin West – The Evidence Behind Burnout

Play

This week, we are joined by Colin West, professor of Medicine, Biostatistics and Medical Education at Mayo Clinic. Colin’s research focuses primarily on physician well-being, evidence based medicine and medical education. We talk today about his extensive research in the area of physician well-being and burnout.

We talk about what researchers mean precisely by burnout and how it is measured, what the implications are for patient care and quality of care that the primary care workforce is increasingly burdened with burnout, and his findings in an important 2016 study that physicians with significant burnout scores cut back on patient care over time. We also talk about the EMR, and what specific features of EMR most correlate with user dissatisfaction. Lastly, we talk about what questions he most wants to answer in his field. This is part 1 of a 2-part series on burnout. Today we focus on the evidence behind burnout, and in part 2 we will talk about what can be done to alleviate the problem.

If you like the show, please rate and review us on itunes, google play, or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you, and thanks for listening.