Defining a pathway toward leadership
in patient-centered care
With all the discoveries and advances that have remarkably enhanced medical care, we have a delivery system characterized by a shortage of primary care physicians, high expenditures on chronic disease and pressure to improve efficiencies and access. Out of the ashes of this “old system” of health care, these authors assert, will rise the “Phoenix Physician”: a nimble leader able to employ health care teams, utilize population data and new technologies, and apply heightened chronic disease management skills to provide top-quality care.
Robert G. Good, D.O.’77, FACOI; John B. Bulger, D.O.; Robert T. Hasty, D.O.; Kevin P. Hubbard, D.O.; Elliott R. Schwartz, D.O.’73, FACOI; John R. Sutton, D.O.; Monte E. Troutman, D.O.; and Donald S. Nelinson, Ph.D.
Editor’s note: This article appeared in the Journal of the American Osteopathic Association (JAOA), Volume 112, No. 8, August 2012. JAOA reprinted it with permission from the American College of Osteopathic Internists (ACOI); it originally was a position paper on the ACOI website.
The health care delivery system is in a state of constant transition. During the past 100 years, the patient-physician relationship has changed as a result of the outbreak of an influenza epidemic; the onset of two world wars; the invention of penicillin, which is associated with the knowledge of infectious organisms; the development of imaging and diagnostic testing; the development of Medicare; the expansion of insurance; and the invention of the computer. At each of these intervals, physicians have adapted to new concepts of health care delivery. However, the medical community has sometimes resisted change.1
Participants in the health care system are growing increasingly concerned with the health care delivery system. Patients and employers are growing concerned with access to affordable care. Physicians are growing concerned with being able to provide the quality care that their patients need. Payers are growing concerned with the need for increased efficiencies. Despite these different concerns, all of these participants have at least one thing in common – a desire to improve quality.2
Evolution in the delivery of health care services is driven by scientific and technological discoveries, emergent patient needs, and market forces. The patient-physician relationship, however, is a constant and must remain at the core of any health care quality improvement initiative. The American College of Osteopathic Internists, which sought to provide a tool to enhance professional competence in and adaptability to the changing health care delivery system, has developed the Phoenix Physician training program to better prepare residents in training and practicing physicians for the changes yet to come.
Included in the Phoenix Physician training program are a curriculum that will be initiated nationwide in internal medicine residency programs and a year-long Physician Leadership Certificate Course that launched at the American College of Osteopathic Internists’ 2012 Annual Convention and Scientific Sessions in October.
Changes in health care delivery
The delivery of health care services for much of the past century has focused on the development of medical schools, research centers, and large hospitals and the science of patient care. An emphasis in recent years has been placed on the development of an infrastructure that houses the technological needs of the U.S. health care system.3 The societal value placed on developing the current medical system has resulted in the use of vast financial resources.
The financial assets used to develop science and technology are more limited now, as society’s focus shifts toward individual, patient-centered care. Excellence is defined by clinical outcomes, interpersonal relationships, teamwork in a multidisciplinary system, and patient satisfaction. This approach represents a fundamental shift from episodic acute care models and has become an integral part of the federal Patient Protection and Affordable Care Act.4 Several provisions in the health care reform law seek to strengthen the primary care system and encourage the widespread adoption of patient-centered medical home models of care. Central attributes of patient-centered medical homes include enhanced patient access to a regular source of primary care, stable and ongoing relationships with a personal clinician who directs a care team, and health services that emphasize prevention and chronic care management.5
A substantial portion of health care dollars is spent on chronic disease management.6 Ferrer et.al.7 found that evidence-based studies have demonstrated improved outcomes and decreased costs in systems led by primary care physicians. An adequate supply of primary care physicians is associated with better health outcomes, such as lower mortality, higher life expectancy, and better self-rated health status.8 Other factors such as financial incentives, however, have led to the growth of specialists in various fields. Reimbursement disparities favoring specialists at a time of escalating medical education costs devalue medical generalists and primary care physicians.9 The result has been an increasing shortfall in the number of primary care physicians available to meet growing needs. This shortfall has occurred at a time during which cultural shifts toward patient-centered care are increasing the importance of patient-physician relationships.10 Unfortunately, at least a quarter of the Medicare population has difficulty finding a primary care physician.11
The primary care physician as Phoenix Physician
Reliance on other members of the health care team has increased to meet the growing demands of our society. Primary care physicians, however, have the unique education and training needed to coordinate care with specialty physicians and manage complicated, multi-organ-compromised conditions.
Meanwhile, the emerging patient-centered health care system will likely be more outreach-directed, focusing not only on patients with appointments but also on others in the system.12 Coordination of care will include patients who are empowered, educated, and more involved in their care. Operational changes, data management skills, and team leadership skills will be needed.13 The health care system will have to reallocate resources to meet the needs for improved access, quality, and efficiency. As a result, the medical generalist of the future, the Phoenix Physician in our concept, will have to develop a new skill set to assume leadership of the health care team. These skills include the following:
- The ability to provide open-access health care to meet patient needs. Patients expect to access care when it is needed.14 A team approach allows physicians to make the best use of their time and provides patients the security of timely evaluation and treatment.
- The ability to understand the strengths of allied health professionals in the overall care of a patient or group of patients. Other professionals have the potential to augment the care provided in a patient-centered medical home. Empowering others to follow appropriate medical protocols and guidelines will be an important means to provide necessary services.
- A better understanding and working knowledge of population medicine. Although immediate patient satisfaction for medical care is important, the ability to compare actual mass data with national benchmarks also will be critical. As a consequence, future compensation methods likely will be made on the basis of performance outcomes.15
- Additional education in the practical uses of medical databases and information technology. The implementation of transformative new technologies is under way globally. These new technologies will constitute essential tools to improve overall care and understanding in a value-based reimbursement system.16
- Chronic disease management skills. Shared medical appointments, outreach services, patient education, and team building around groups of people with similar conditions will enrich overall outcomes.6
- The development of personal leadership and communication skills. The training of most physicians has centered on science and diagnostic criteria. The mature physician must become a leader of a team, and aptitudes can be developed to prepare for this role.17
A number of challenges confront our current health care system. It will take a nimble physician to adapt to the changes needed to provide high-quality, cost-efficient care.
These changes will take time to develop and implement. The American College of Osteopathic Internists has developed a training process to meet these challenges. Out of the ashes of the old system will rise the Phoenix Physician – a new physician leader of a patient-centered system that will maximize available resources to provide high-quality care while respecting the patient-physician relationship.
The authors of this article include DMU alumni Robert G. Good, D.O.’77, and Elliott R. Schwartz, D.O.’73, both fellows of the American College of Osteopathic Internists (ACOI). Good is ACOI president and a board-certified general internist practicing in Mattoon, IL. He also is medical director of Carle Foundation Physician Services, a large multi-specialty group in southern Illinois. Schwartz, a fellow of both the American Board of Sleep Medicine and the American College of Chest Physicians, is board-certified in internal medicine, pulmonary disease, critical care medicine and sleep disorders medicine. He is co-medical director of the Sleep Disorders Center of Oklahoma, Southwest Medical Center, and clinical assistant professor at the Oklahoma State University College of Osteopathic Medicine.
- Timmermans, S., Oh, H. The continued social transformation of the medical profession. Journal of Health and Social Behavior, 2010; 51 (suppl.): S94-S106.
- Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Improving Health Care Quality: Fact Sheet. Rockville, MD: Agency for Healthcare Research and Quality; 2002. AHRQ Publication No. 02-P032.
- Jacobs, L.R. Politics of America’s supply state: health reform and technology. Health Affairs, 1995; 14(2): 149-163.
- Henry J. Kaiser Family Foundation. Summary of new health reform law. Kaiser Family Foundation website, www.kff.org/healthreform/upload/8061.pdf. Accessed July 10, 2012.
- Finkelstein, J., Barr, M.S., Kothari, P.P., Nace, D.K., Quinn, M. Patient-centered medical home cyberinfrastructure current and future landscape. American Journal of Preventive Medicine, 2011; 40 (5 suppl. 2): S225-S233.
- Bodenheimer, T., Wagner, E.H., Grumbach, K. Improving primary care for patients with chronic illness: the chronic care model, part 2. Journal of the American Medical Association, 2002; 288(15): 1909-1914.
- Ferrer, R.L., Hambidge, S.J., Maly, R.C. The essential role of generalists in health care systems. Annals of Internal Medicine, 2005; 142(8): 691-699.
- Macinko, J., Starfield, B., Shi, L. Quantifying the health benefits of primary care physician supply in the United States. International Journal of Health Services, 2007; 37(1): 111-126.
- Bhatia, N., Meredith, D., Riahi, F. Managing the clinical workforce. McKinsey Quarterly, 2009; www.mckinseyquarterly.com/Managing_the_clinical_workforce_2467. Accessed July 10, 2012.
- Levinson, W., Pizzo, P.A. Patient-physician communication: it’s about time. Journal of the American Medical Association, 2011; 305(17): 1802-1803.
- Medicare Payment Advisory Commission, U.S. Department of Health and Human Services. Medicare Payment Advisory Commission report to Congress, March 2010. Journal of Pain and Palliative Care Pharmacotherapy, 2010; 24(3): 302-305.
- Margolius, D., Bodenheimer, T. Transforming primary care: from past practice to the practice of the future. Health Affairs (Millwood), 2010; 29(5): 779-784.
- Bohmer, R.M. Managing the new primary care: the new skills that will be needed. Health Affairs (Millwood), 2010; 29(5): 1010-1014.
- Task Force 1 Writing Group; Green, L.A., Graham, R., Bagley, B., et.al. Report of the task force on patient expectations, core values, reintegration and the new model of family medicine. The Annals of Family Medicine, 2004; 2 (suppl. 1): S533-S550.
- Rosenthal, M.B., Dudley, R.A. Pay-for-performance: will the latest payment trend improve care? Journal of the American Medical Association, 2007; 297(7): 740-744.
- Davis, K., Doty, M.M., Shea, K., Stremikis, K. Health information technology and physician perceptions of quality of care and satisfaction. Health Policy, 2009; 90 (2-3): 239-246.
- Page, D.W. Professionalism and team care in the clinical setting. Clinical Anatomy, 2006; 19(5): 468-472.