During my initial years as Chair in Memphis, I developed and implemented a time/productivity data base in which faculty time was described as a resource with finite limits. Faculty were asked and agreed to see their own patients 30-40 % time. To my surprise, year after year even the most productive faculty member rarely saw more than 1000 visits per year Discussions followed. No-shows were called, problem patients were identified, walk-ins were encouraged, and office hours were extended to Mon eve/Sat
Then we hit the brick wall. We discovered that our MSO [aka the faculty practice plan] was a human resources revolving door which trained potentially competent staff who departed when they became competent, and the university retained those unlikely to find employment elsewhere.
In a "hall of fame" management moment, the Medical Group managers actually assigned a deaf person to answer the phones. Apparently she was quite adept at reading lips and otherwise extremely acquiescent. She sat at the phones for 2 days before our clinic manager noticed the problem.
I diplomatically suggested that these infrastructure problems were the rate limiting step in an article published in Family Medicine Dec 1998. To my surprise, several in the Med School tried to stop publication of the study. One faculty actually wrote and called Barry Weiss requesting that publication be blocked. Well the rest is history. By 2002, the Department was deeply in debt, a third of the residency positions were lost, several replacement chairs had resigned, and the University faculty practice had severed ties with FP declaring it to be a "money loser"...............Rather than believe the message, the university shot the messengers. What had been a profitable and excellent education site in rural Tennessee became a "money loser" and was closed in 2005.
Those faculty who were clinically capable became demoralized by the steady stream of nonsupport. Adverse selection ran rampant. Acute patients seeking care for workplace injuries, possible fractures, and skin biopsies were turned away. Office radiographs were unavailable for lack of an "x-ray technician". The percentage of children seen in the practices dropped to less than 8%. The "model" Family practice Center became a recruitment disincentive.
The progress made 1991-1998 [JABFP June 2002 and Fam Med Dec 1998] started with an attempt to allow sick patients the opportunity to walk in without an appointment i.e. OPEN ACCESS. Similarly to Carter's recently published study by the AAFP, we increased the scope of service in the office and hospital. The volume of cases increased, but the increase was not viewed negatively because there was a broad mix of cases varying from easy to difficult.
In my next practice, started in the year 2000, priority # 1 was for a practicing physician to head the hiring and evaluation of support staff such that we did not unintentionally create institutional barriers to OPEN ACCESS for sick patients. This was a labor intensive and emotionally challenging responsibility. Although lip service was given to the idea, even in private practice, there was constant resistance to seeing patients who arrived at times inconvenient to staff.
One physician developed counter productive loyalties to enhanced continuity and suggested that problems with patients could be avoided if we ".......saw patients by appointment only". After all, isn't this what continuity is all about? This one physician spread a virus that infected almost 80 % of the entire office environment.
With her departure, policies, procedures, and job descriptions were rewritten and discussed. Most of the original staff & nbsp left within 12 months. A new core staff was developed and they remain in place 56 months later. In recognition of the role played by staff who maintain our productivity, we now pay salaries at 125-150% of the local average.
After 3 years, the pilot project in an over-doctored urban area became successful, and another practice was established in Nashville 2004.This is private practice with weekly hands on involvement of the [now former} Chair and the practicing physicians who all share night call and weekends. There is no doubt that staff development resting on the principles of OPEN ACCESS make it possible for faculty to reach MGMA productivity standards of 5000 visits per year while teaching.[in addition to 40 deliveries per FTE/yr]. Despite a case mix which is 85% Medicaid and uninsured, there is financial viability supporting full scale salaries for family physicians.
In 2000, as a comparison group, I tested this hypothesis at another university. Phase one [2002-2003[24 months] demonstrated that OPEN ACCESS could establish, from scratch, a vibrant teaching practice in an over-doctored urban environment. But, after rapidly climbing to 600 patients a month, the project stalled out when University governance failed to pay vendors, collected less than 35 cents on the dollar, and set employment scales for support staff at a non-competitive level [Been there, done that, got the T-shirt, etc.]
Interesting to see the point-counterpoint between DR Scherger's address at the 2005 STFM meeting [no need to see so many patient, do away with minimum numbers of patients for accreditation] Fam Med July 2005 and Joe Carter's study about what makes a high earning family physician. Family physicians should not teach the illusion of endless financial abundance while ignoring accountability. Funding is always linked to productivity
This is a large part of what has killed the viability of family medicine as a career choice among medical students. Our model units, where students are likely to witness family medicine, are no longer accountable to the core principles of the specialty. In response there is a move to change the core principles.
Stay tuned for late breaking developments. At any time, fecal debris can occur spontaneously.
Wm MacMillan Rodney MD
Adjunct Professor of Family Medicine
Adjunct Professor Surgery/Emergency Medicine
Meharry/Vanderbilt School of Medicine
Medicos para la Familia
Memphis and Nashville, Tn.
www.psot.com
