Partnering Primary Care & Public Health — Lloyd Michener

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Can we solve chronic disease using a medical model? In this episode, the first in a series with speakers from the 2017 second Starfield Summit, we talked with Dr. Lloyd Michener – the principal investigator of the Practical Playbook, which facilitates the integration of primary care and public health – about why primary care clinicians need to collaborate with public health agencies to tackle chronic disease, how to look at data differently to identify what’s really happening in our communities, and how primary care can be a better partner in community collaborations.

Lloyd Michener is a professor of Community and Family Medicine at Duke, the department’s former chair, and one of the country’s pre-eminent authorities on reducing health disparities through community health, community engagement, and practice redesign. Lloyd also leads the technical support service of the BUILD Health Challenge (bold, upstream, integrated, local, and data-driven), a national competitive award program aimed at improving hospital, community, and public health collaborations that improve health. He has also served as President of the Association for Prevention Teaching & Research, Chair of the Council of Academic Societies and as a member of the Board of the Association of Academic Medical Colleges. You can also learn more about his personal and professional journey here.

The Starfield Summit brought together leaders in primary care, clinicians, experts, advocates, patients, and community members – this year in order to collaborate in paving paths towards health equity and social accountability. The Summit was primarily sponsored by Family Medicine for America’s Health, Oregon Health & Science University, and OCHIN.  Stay tuned in upcoming weeks for more speakers from the Starfield Summit.

This interview was edited lightly for clarity.

Photo credit: Duke

Reprise: Integration of Healthcare & Social Services with Lauren Taylor

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Today we’re joined by Lauren Taylor, a health services researcher based at Harvard Business School, where is she is earning her doctorate in health policy and management. Prior to joining HBS, Lauren co-authored The American Health Care Paradox, which has become required reading at a variety of medical and public health schools across the country. Our discussion spans a range of topics and should excite clinician and policymaker listeners alike, especially those interested in addressing upstream factors that affect health in our American society.

We start with reviewing the initial research paper that lay the groundwork for her book and what other countries show us about how government spending on social services can affect health outcomes, as well as what she learned interviewing caregivers and social services workers in the US.  We also talk on how American sociopolitical factors influence our discourse on the distribution and allocation of resources as well as how research is done in her field. We discuss whether health systems are moving in the right direction addressing social determinants of health through ACOs, why management gets overlooked and undervalued as a key ingredient in healthcare delivery, and why it’s just so hard to get all of this right.

Lauren’s work focuses on organizational theory and strategy in health care, with a particular emphasis on the integration of health and social services. She holds a BA in the History of Medicine and a Master in Public Health from Yale University. She has also worked as a health care chaplain and studied ethics as a Presidential Scholar at Harvard’s Divinity School.

If you like the show, please subscribe on our website www.rospod.org, and rate us on iTunes and Stitcher and share us on social media. Get in touch via twitter @RoSpodcast or drop us a line at contact@rospod.org. Thanks for listening!

This interview has been lightly edited for length and clarity.

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.

Lori Tishler of Commonwealth Care Alliance – Caring for the Most Vulnerable Patients

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Have you ever felt lonely and overwhelmed in a clinic room with a patient whose needs are far beyond your skills and ability to meet? I have, many times, and so has our guest this week, Dr. Lori Tishler. Dr. Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, duals, or individuals who have both Medicare and Medicaid.

We talk about how CCA’s member-centered approach (as opposed to a physician-centered approach) has helped her feel more effective in caring for these vulnerable patients. We talk about the range of services that CCA offers, the role of their care partners, and the freedom that their financial model permits – for example, they provide 90% of care to patients in their homes.

You can find the Atlantic Magazine article we referenced featuring CCA here, and find a few Health Affairs blogs featuring CCA here, and a blog post focusing on building the business case for a community paramedicine program here.

A bit more about our guest: Lori Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, people who have both Medicare and Medicaid.  She oversees CCA’s physicians and is involved with clinical aspects of quality, utilization, and pharmacy.  In addition, she is an Assistant Professor at Harvard Medical School and an active member of the General Medicine Faculty at Brigham and Women’s Hospital, As a caring and connected physician leader, mentor, and educator, Dr. Tishler’s passion has been providing care for the medically and socially vulnerable and making a difference in health systems for all.   Tishler has found that the most rewarding way to help change and grow our health care systems is to mentor learners who are interested in clinical care, leadership, and innovation.

Her leadership roles have extended outside of the clinic and outside of primary care.  She served on the Partners Healthcare Board of Directors, the Board of Directors for the Office for Women’s Careers, and the Board of the Schwartz Rounds while at the Brigham.  At Commonwealth Care Alliance, she teaches and presents nationally about our care model and innovations.

In addition to her leadership work, she continues to provide clinical care  Tishler feels that working as a clinician informs her choices and decisions as a leader.  Outside of work, Dr. Tishler loves to spend time with her husband and teenaged daughter, to travel, read, and knit.  She is honored to have been interviewed on Review of Systems.

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.

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.

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.

David Himmelstein – Blending Research & Advocacy

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Our guest this week is David Himmelstein. He is a distinguished professor of public health and health policy in the CUNY School of Public Health at Hunter College, adjunct clinical professor at Albert Einstein College of Medicine, and lecturer in medicine at Harvard Medical School. He has served as chief of the division of social and community medicine at Cambridge Hospital.

David has authored or co-authored more than 100 journal articles and three books, including widely cited studies of medical bankruptcy and the high administrative costs of the U.S. health care system. His 1984 study of patient dumping led to the enactment of EMTALA, the law that banned that practice. He is also a co-founder of Physicians for a National Health Program and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. Steffie Woolhandler.

We talk about how he got his start in research by looking at patient dumping practices as a trainee, and how he views advocacy as a natural outgrowth of his research findings. We also talk about his work as a leader in advocacy for a national health insurance program and talk about a few common arguments against such policy changes. Lastly, he gives some advice for folks early in their career who would like to follow his model of research blended with advocacy.

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.

Reprise – David Buck, Caring for High-Need, High-Cost Patients

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This week, Thomas Kim hosts the show and interviews Dr. David Buck, a family physician and professor of family and community medicine at the Baylor College of Medicine.  He is the founder and president of Patient Care Intervention Center (PCIC), an organization that uses advanced population health methods to target super-utilization of the health care system and intervenes through intensive care coordination and case management. It’s based in Houston, Texas and recently opened a branch in Dallas, and they were recently featured on PBS NewsHour. Prior to Dr. Buck’s work at PCIC, he founded Healthcare for the Homeless – Houston (HHH), now a federally qualified health center for over 7,000 homeless in Harris County, as well as the associated Houston Outreach Medicine Education and Social Services (HOMES) clinic, a student-managed clinic at HHH in conjunction with BCM and the University of Texas Health Science Center. He is a co-founder of the Houston-based physician advocacy group Doctors for Change, and founded the Houston-Galveston Albert Schweitzer Fellowship. He helped found the international street medicine institute, and was appointed to the 15-member Consumer Operated and Oriented Plan Program advisory board created as part of the Patient Protection and Affordable Care Act in 2012.

You can find some CDC resources about Adverse Childhood Experiences, or ACEs here, and a New Yorker article about the effects of ACEs on health here.
Dr. Buck is a graduate of the Baylor College of Medicine and the University of Texas School of Public Health, as well as family medicine residency at the University of Rochester.