Understanding how to return joy to practice with Christine Sinsky

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In order to make primary care better, we have to understand what is working and what isn’t – and not just in broad strokes, but in granular detail. Dr. Christine Sinsky is on the cutting edge of this type of research, and publishes prolifically on what is driving burnout in primary care, what specific steps we can take to fix it, and how to return joy to practice. Dr. Sinsky is the VP of Professional Satisfaction at the AMA and has practiced as a general internist for 30 years in Dubuque, Iowa. We talk about her landmark work with Tom Bodenheimer, which introduced the idea of the quadruple aim in 2013, how new EHR metrics can improve how we deliver care and improve the experience of caregivers and patients, and the extent of the burnout crisis in medicine at large, not just primary care. You can find the call for research that Dr. Sinksy referenced and collaborated on with Dr. Lotte Dyrbye and other leaders in this field here. We previously featured one of Dr. Sinksy’s publications, which showed that physicians spend about 2 hours doing clerical work for every 1 hour they see patients in a journal club, which you can find here.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity. Photo courtesy of Christine Sinsky.

Reprise – Journal Club: Sinsky et al, Allocation of Physician Time in Ambulatory Practice

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David Rosenthal, Thomas Kim, and Audrey Provenzano discuss the landmark study published in Annals of Internal Medicine by Sinsky and colleagues, Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.

Have you ever wondered how much time you spend each month fighting with technology or filling out VNA forms? Well, Christine Sinsky and her colleagues studied this and have some answers for us…all of which raise more fascinating questions about how we practice medicine.

Tweet us your thoughts @RoSpodcast, and send us feedback at audrey@rospod.org!

Integrating Primary Care & Behavioral Health at Lynn CHC: Kiame Mahaniah & Mark Alexakos

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Primary care models integrating behavioral health services are being adopted across the country. This week, we talked with two leaders at the Lynn Community Health Center (LCHC), Dr. Mark Alexakos and Dr. Kiame Mahaniah, about their experience with integration.

LCHC is unique among community health centers in that it started out as a mental health counseling center, and now has the largest community health center-based behavioral health program in Massachusetts. In this conversation, we talk about what it means to integrate behavioral health services with primary care clinical services – how it can reduce the fragmentation of services to better meet the needs of patients and the demand for mental health care (2:40), why it may better position clinics participating in accountable care (7:40), what successes they’ve seen (8:45), and the resources it has required (12:28). Along the way, our guests make it clear that the staff at LCHC love working in integrated teams. You can learn more about various other models of integrated behavioral health here.

Mark Alexakos MD, MPP, is the chief behavioral health officer of LCHC. He has a joint degree in medicine and public policy and developed an early interest in the interface between policy, research, and service delivery as they relate to access barriers, health disparities, and community health. Before working at LCHC, he spent seven years developing intensive, school-based mental health services that combined health promotion and prevention with quick access to behavioral health treatment in five Boston Public Schools.

Kiame Mahaniah, MD, is the chief executive officer of LCHC, though at the time of this interview, he served as the chief medical officer. His passion resolves around social and restorative justice, in the context of healthcare.   His twin clinical interests are teaching—he holds an appointment at the Tufts University School of Medicine—and integrating opioid addiction treatment into the primary care/behavioral health matrix.

This interview was edited lightly for length and clarity.

photo credit: Lynn Community Health Center

How do we improve the value of care delivered in primary care? with John Mafi

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All of us like to think that we provide high-value care for our patients; but the truth is, just like the rest of the health care system, primary care provides a lot of low value care too – and we drive a lot of overuse. John Mafi joins us this week to talk about his leading research into these thorny, complex issues.

We talk about the definitions of high-value and low value care, his 2016 study in Annals of Internal Medicine examining rates of high and low value care among physicians, NPs, and PAs in the primary care setting, how practice setting may affect the delivery of high and low value care, and the essential truth that there is no free lunch in trying to solve some of the challenges in fixing primary care in the US. You can find Shah et al, which John referenced here; a recent study relevant to our conversation by Hong et al looking at clinician characteristics and frequent ordering of low-value imaging studies; and an extremely important new paper that John published recently in Health Affairs looking at the the impact of low-cost, high-volume studies on unnecessary health spending.

A little bit more about our guest:  John N. Mafi, MD, MPH is an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA where he also practices and teaches. He also serves as an Affiliated Natural Scientist in Health Policy at RAND Corporation. Dr. Mafi trained in internal medicine at Beth Israel Deaconess Medical Center in 2012, where he also served as Chief Medical Resident and completed the Harvard Medical School Fellowship in General Internal Medicine and Primary Care in 2015. Dr. Mafi’s research focuses on quality and value measurement and how electronic health records can improve the value of care.

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

 This interview has been lightly edited for length and clarity.

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

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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.

Joshua Freeman – Designing a Fair & Equitable Healthcare System

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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

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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

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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

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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.

Journal Club – Do On-Site Mental Health Professionals Change Pediatricians’ Responses to Children’s Mental Health Problems?

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On our journal club this week, we talk about an article published in September 2016 in the journal Academic Pediatrics: Do On-Site Mental Health Professionals Change Pediatricians’ Responses to Children’s Mental Health Problems? By Sarah McCue Horwitz and colleagues.

If you like the show, please rate and review us on itunes 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.