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This public health manager turned family doc explains why students and residents in primary care must learn about billing and coding and what he is doing to help.

By Raymond Tsai, M.D.

For three years before I applied to medical school, I worked in post-Katrina New Orleans helping to rebuild school-based health centers. One of the main challenges, however, was how to create a sustainable safety net for at-risk youth to whom we were hoping to provide much needed health services – key word being “sustainable.” All too often, there isn't funding to carry out primary care’s mission of improving the health of communities and underserved populations. At the time, I was a public health manager, and I often felt frustrated at physicians who couldn't optimize their coding and billing. Not only were they leaving money on the table for the much-needed services they were providing, but they also made my job of trying to advocate for them near impossible. One of the avenues we tried to pursue was state funds to support the school-based health centers, but without proper coding, we never had accurate data to show exactly the needs we were addressing. In addition, when we asked state legislators for increased funding, we were easily countered with, "But you don't use the money we're giving you now through Medicaid..." The only thing I could do was stare back like a greedy kid who asks for seconds before I’ve finished what’s already on my plate.

Posted by Sonya Collins on Jul 31, 2014 12:41 PM EDT
Many members of the PCP community recently attended the Direct Primary Care Summit in Arlington, VA. We'll be sharing their perspectives here over the coming weeks. Today a family medicine resident with a background in business makes "cents" of the model. 

By Sahil Jain, M.D.

“What is the value of the service I am providing you?” Dr. Brown used this question in a story that he told at the Direct Primary Care Summit in Washington, D.C., this June, about a $1,200 bill for a plumbing job that saved him a night’s sleep. It highlighted an important aspect of direct primary care that I have often been attracted to — creating value and capturing value.  Based on my knowledge from business school, it makes the most sense to me as a practice model in the outpatient medicine world.

Posted by Sonya Collins on Jul 29, 2014 10:17 AM EDT
In response to a JAMA editorial, this family doc says there's no paradox in family physicians leading health reform. He attests that he and his colleagues have what it takes to take the lead.

By Kenny Lin, M.D.

The subtitle of a JAMA editorial on accountable care recently caught my attention: "The paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."

Posted by Sonya Collins on Jul 24, 2014 10:10 AM EDT
Many members of the PCP community recently attended the Direct Primary Care Summit in Arlington, VA. We'll be sharing their perspectives here over the coming weeks. Today a family medicine faculty physician weighs in. 

By James Breen, M.D.

The discipline of family medicine was founded on the idea – contrarian at its inception – that a generalist physician who knew his/her patients across the life cycle could serve as the cornerstone of the medical system and counter the reductionist approach of the burgeoning medical specialties of the time.  In the years after World War II, the rapid growth in medical knowledge and the return of physicians from the service heralded an “Age of Specialization” and a precipitous drop in the number of generalists.  The specialists of the mid-twentieth century underwent expanded postgraduate training that distinguished them from general practitioners, who lacked a structured residency preparation. 

Posted by Sonya Collins on Jul 22, 2014 10:43 AM EDT
Jessie Gruman, founder of the Center for Advancing Health, died Monday. Her mission at the center for 20 years was to increase patients' engagement in their own health care.  She encouraged this engagement in her regular posts on The Prepared Patient blog. She shared one of those posts with Progress Notes earlier this year.

By Jessie C. Gruman, Ph.D.

Having cancer has infected me and many others with the irritating tendency to view any persistent, troubling symptom through the lens of a recurrence or a diagnosis of a new primary cancer. A friend of mine who is nearly five years post-kidney cancer treatment casually remarked the other day that he needed to see a doctor about his sore ankle: It could be arthritis, but it might be cancer, of course. Someone I interviewed recently commented that despite the ten years since her treatment for breast cancer, she frequently has to convince herself that each new symptom that crops up is not evidence of another catastrophic cancer diagnosis about which she panics.

Posted by Sonya Collins on Jul 17, 2014 11:02 AM EDT
Practicing low-resource family medicine in developing countries revitalizes this family doc's love of his specialty. He encourages other family docs and trainees to take part in international medical trips because of their close alignment with the scope and values of family medicine.

By Mark Ryan, M.D.

I was born in the Dominican Republic, but only lived there for a few months. As a child, I lived ten of my first 16 years in Latin America: four in Venezuela, four in Argentina, and two in Panama. After graduating from VCU School of Medicine in 2000 and completing my family medicine residency in Blackstone, VA, in 2003, I joined my first international medical trip. From my experiences growing up and my interest in returning to Latin America as an adult, the opportunity to work overseas as a physician—in a profession focused on service and on providing care for those in need—was exciting, and the experience was fulfilling. 

Posted by Sonya Collins on Jul 15, 2014 9:47 AM EDT
In his third post for Progress Notes, Dr. Selinger explains that good communication -- which is the key to a high functioning health care system -- extends far beyond just doctor and patient and must be maintained across all touch points in the health care system.

By H. Andrew Selinger, M.D.

When I get sick, I want to know what’s wrong, how I can get better and all the details in between. If I need to get tests, why? What medicine do I need to take? If I don’t need to take medicine, why not?  How long until I get better and what can I expect along the way? In sickness, education is just as important as treatment. Education and dialogue reduce stress and promote healing.

Likewise, when a patient comes to me for an employer/Medicaid/Medicare-encouraged “wellness examination,” I want them to know what tests they need and, just as important, what tests they don’t need. My job is to tell my patients what problems I identify and what they need to do to successfully address them. Nowadays, we use “teach back” and motivational interviewing to be sure our patients understand our instructions and to alert us when they are ready to make a behavior change.

Posted by Sonya Collins on Jul 10, 2014 12:36 PM EDT
By Matthew Mintz, M.D.

Most articles about why medical students don’t choose primary care will say that a career in primary care simply won’t pay off the enormous debt accrued in medical school. Indeed, the average 2010 graduate came away $157,944 in debt. And primary care salaries are in fact far lower than those of other specialties, a disparity that is increasing. However, I repeatedly ask medical students if they would choose a career in primary care if it would completely erase their student loan debt. A few hands go up, but not many. In fact, for a while now, the federal government has dedicated millions of dollars to repaying loans for students who choose primary care. Yet residency match numbers show that the percentage of students choosing primary care is not increasing.  Though loan forgiveness is a step in the right direction, medical students realize that by choosing a more lucrative specialty, they can pay off their loans just fine.
Posted by Catherine Rizos on Jul 8, 2014 9:55 AM EDT
In today's Progress Notes, leaders of PCP's UCSF chapter write about the storytelling event they held last month. What if every PCP chapter hosted an event like this?

By Anna Chodos, M.D. (top L); Nathan Cade (top R); Brittany Sprigg (bottom L); and Faby Molina (not pictured)

Last month, about 70 people got together in an old fraternity house, now the Faculty-Alumni House, on the UCSF campus. Medical students, residents, sociologists, family physicians, internists, nurses and pharmacists settled into chairs and couches to hear six storytellers take the mic to tell stories about practicing primary care. 

Our PCP chapter began planning this event, called Social Histories, months ago as a way to harness the abundance of stories that pervade and define the practice of primary care.  We took inspiration from current radio programming and podcasts built around stories: This American Life, The Moth, RadioLab, and Story Corps, to name a few. It felt like the right time for us to hold a public storytelling event focused on primary care and capitalize on the power that stories have to bring us together.  We called the event Social Histories not just because it sounded better than “Assessment and Plan,” but to emphasize what we hoped would be a central part of the evening: community. 

Posted by Sonya Collins on Jul 3, 2014 10:19 AM EDT
On an ER rotation -- which she thought should have been the most exciting rotation of all --  this med student knew more than ever that she wanted to form long-term relationships with patients through the practice of primary care.

By Jennifer Stella, M.D.

As a third-year med student, I was doing an ER shift when the call came through our dispatch: 56-year-old man, status epilepticus, being flown in from Yosemite, 10 minutes out. I watched the residents snap into a semi-ordered chaos. Ten crucial minutes. Prepping the trauma bay. Anticipating acute management, who was going to do it, half-tying the yellow paper gowns. Anyone who had looked tired didn’t anymore.

Posted by Jenette Restivo on Jul 1, 2014 10:59 AM EDT
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Most Recent Comments

Raymond!!! Thank you for highlighting this critical point. Primary care providers are leaving way too much money o...
Great post and much food for thought! I completely agree with Ryan above that getting patients, especially the youn...
Great post. I too am very excited for this move and feel it will empower both physicians and patients. The greatest ba...
I have had many students rotate in my DPC clinic in the past 2 years. Most of already been interested in primary care or...
Great post Dr. Jain. It can be difficult for people to understand the real value of excellent primary care, includin...


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