Starting or Improving your Primary Care Track: What you need to know

Transcription

1 Starting or Improving your Primary Care Track: What you need to know UW Madison: Joan Addington-White MD Vidthya Abraham MD UM Michigan: Kristin Collier MD Jennifer Lukela MD AAIM 3/2017

2 Objectives 1) Describe the development, maintenance, and growth of Primary care at UM and UW. 2) Compare differences between programs. 3) Collaborate to address challenges in your own institution. 4) Review specific innovations that could be used to make GIM training more robust and engaging. 5) Recognize strategies to inspire your institution.

3 Medically Medically Underserved underserved areas Areas/Populations and populations 03/2017 Legend

4 Projected Shortages Association of American Medical Colleges Shortage of 12,500 primary care physicians currently Projected to increase to 31,100 by 2025 Key Factors: 1)Increase in medical education debt $176,348 avg. 2)Decreased income potential for PC MDs vs specialists -Gap between median incomes $135,000 -Difference of $3.5 million over year career -Decreases odds of choosing PC by nearly 50% 3)Increased administrative requirements causing great dissatisfaction Financing U.S. Graduate Medical Education: A Policy Paper of the AAIM and the ACP. May 3, 2016

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7 Transparency vs Inspiration The New Yorker, 1/23/2017

8 We all love a novel winner/problem SARS vs Malaria In July cases world wide and 813 deaths. Malaria 400 million worldwide/2 million deaths How do we raise interest in GIM? Be role models for diagnosis, collaboration, success that is intellectual and personally meaningful in the long run. How do we get what we need for PC tracks? Going to my chair, Dr. Rick Page

9 Objectives 1) Describe the development, maintenance, and growth of Primary care at UM and UW. 2) Compare differences between programs. 3) Collaborate to address challenges in your own institution. 4) Review specific innovations that could be used to make GIM training more robust and engaging. 5) Recognize strategies to inspire your institution.

10 Primary Care Track Overview

11 Timeline: Development, vmaintenance and growth Draft proposal to GME 2012 Dr. Collier brought on as APD to start the track Fall 2014 Curriculum and design of the track developed real time along with recruitment Approved for 2 FTE slots/year 2013 One HO1 joins track Winter residents currently in the track General Medicine

12 Proposal to GME v Formal proposal written up. Background Current State Goals/Objectives of Proposal Plan Follow up General Medicine

13 Basics of the Track v Open to all categorical residents. Idea of same + extra. Currently seven residents, all women. Goal of career exploration + selfish goal of easing local shortage of PCPs. Recruitment before and during residency. General Medicine

14 Continuity Clinic v UM has three types of sites for resident CC. UM has a hybrid model. Historically, more residents go into PC from our community based sites. RRC says you cannot switch sites. 3 PCT residents have two continuity clinic sites. All sites are PCMHs. Same attendings over three years. General Medicine

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16 Continuity Clinic specifics v Interns have 60 min appointments for the first 2-3 months. After initial ramp up, they can have up to 6 patients per half day. Continuity Clinic service documents Expectation that resident is PCP. Goal panel of ~ 100 patients. General Medicine

17 Continuity Clinic Service v Documents Sister documents for inpatient service documents Requirements of CC Experience Expectations of Residents Managing patient care issues that arise outside of direct clinic time Monthly Teaching Sessions Feedback and Performance Evaluation General Medicine

18 Curriculum v Blocked off time monthly for teaching (all). Tracked on professionalism report. PCT residents included in Gen Med Faculty Clinical Conference. Iron sharpens iron. General Medicine

19 Professionalism Report v General Medicine

20 Block time for PCT residents v PCT residents have two week blocks of PC time plus one month Ambulatory blocks. Year one: Care of the Patient (2) two week PCT blocks, but (2) ambulatory blocks. Year two: Care of the Panel (1) two week PCT block + (2) ambulatory blocks. Year three: Care of Population (1) two week PCT block +(2) ambulatory blocks. Individualized based on career interests. Ambulatory blocks (all) have daily AMR, themed curriculum and focus on PC year one. General Medicine

21 Sample HO3 PCT Block v Mon Tues Wed Thurs Fri AM CC (GMCC) Hope Clinic PM CC Hope Clinic (CBT PM) Admin Teaching Time CC CC Lecture / Reading Injections Clinic Derm General Medicine

22 Curriculum during PCT vblocks Learning objectives and readings based on theme. Dropbox with shared articles. AMA Steps forward modules assigned. Special talks/lectures/meetings around the theme. Residents can t be pulled for jeopardy coverage. General Medicine

23 Core rotations for the track v Outpatient endocrinology Outpatient nephrology Outpatient rheumatology Women s Health Sport Medicine Chronic Pain Lean Thinking (H03s as a cohort) General Medicine

24 Other aspects of the track v Ability to customize blocks. HO3s join faculty rotation in Journal Club. Regular get togethers as a track. Funding for extra education (MOOCs, local CME) Goal of coaching/increased Direct Observation All residents complete scholarly project and QI project. PCT residents also complete mini-qi. General Medicine

25 Massive open online course v General Medicine

26 University of Wisconsin Primary Care

27 Timeline- development, maintenance, growth Began with 2 residents Spring 2008 Second continuity clinic and blocks added Winter residents match per year 12 total in track 2012 Chief resident for primary care track 2015 Fall 2008 Central clinic site established 2010 Blocks Individualized 2013 Block time protected, cannot be pulled Panel size applicants for 4 spots Support for scholarly activity increases

28 Creating a community

29 Continuity clinic- University Clinic Begin with Yale See 4-6 patients per ½ day Diverse population base See patients in the hospital and recruit from the hospital Function as true PCP Name in EMR as PCP Expected to cover In-basket daily with back up if needed

30 Keeping it strong Meet every 6 months with continuity clinic attendings Cases for teaching and mentoring New learning venues-njm interactive cases, ACP high value care during Yale curriculum. Problem learners Feed back 360 evaluation

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32 Primary Care Track Block PK Monday Tuesday Wednesday Thursday Friday Primary Care Ambulatory Blocks - PGY-1 8 weeks AM Cardiology Endocrine Neurology U-Station Grand Rounds AM Report PM U-Station CC Infectious Disease Sports Med Women s Health U-Station Primary Care Ambulatory Blocks - PGY-2 12 weeks Monday Tuesday Wednesday Thursday Friday AM Rheumatology Hepatology Pulmonary Oncology Clinic Preventative Cardiology PM Spine Clinic Continuity Clinic Reading 2 nd Continuity Clinic Dermatology Primary Care Ambulatory Blocks - PGY-3 12 weeks Monday Tuesday Wednesday Thursday Friday AM Nephrology Addition Med Urology Hematology Psychiatry Grand Rounds AM Report PM Research/ QI meeting U-Station Cont. Clinic Gyn 2 nd continuity clinic Health service

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36 Primary Care Ambulatory Blocks - PGY-1 Monday Tuesday Wednesday Thursday Friday CA AM Cardiology Reading Neurology U-Station Endocrinology PM U-Station Continuity Clinic Infectious Disease Sports Med Women s Health U-Station Primary Care Ambulatory Blocks - PGY-2 Monday Tuesday Wednesday Thursday Friday AM Spine High Risk OB Pulmonary Gastroenterology Rheumatology PM U-Station Continuity Clinic Reading Congenital Heart Disease Clinic 2 nd Continuity Clinic Dermatology Primary Care Ambulatory Blocks - PGY-3 AM PM Monday Tuesday Wednesday Thursday Friday Transplant Nephrology U-Station Continuity Clinic Hematology High Risk Breast Clinic STI Clinic Gynecology Reading Sports Medicine 2 nd continuity clinic Research Women s Health

37 Monday Tuesday Wednesday Thursday Friday Rheumatology Jon Arnason Endocrine Vanessa Rein Dermatology Justin Endo Neurology Susanne Seeger Rheum Jon Arnason AM Hepatology John Rice Geriatrics Alexis Eastman Transplant Nephrology Laura Maursetter CKD: Prison Telemedicine Laura Maursetter Headache clinic Susanne Seeger High risk Breast Clinic Kari Wisinski Hepatology Michael Lucey Preventative Cardiology Patrick McBride Hematology Ryan Mattison Urology Dan Williams Headache clinic Susanne Seeger Gynecology Mary Landry Addiction Medicine Randy Brown Neurology Susanne Seeger Infectious Disease Andrew Urban Pulmonary William Ehlenbach Allergy Sujani Kakumanu Hematology Ryan Mattison Preventative Cardiology Patrick McBride Gynecology Mary Landry Gastroenterology high risk Jenn Weiss Allergy Sujani Kakumanu Oncology Kari Wisinski Geriatrics Alexis Eastman Psychiatry Karen Milner Urogynecology Sarah McAchran Geriatrics Alexis Eastman HIV/prison Jim Sosman Faculty available Spine James Leonard Pituitary Diane Elson Palliative Care Toby Campbell Breast Cancer Kari Wisinski Geriatrics Alexis Eastman PM Geriatrics Alexis Eastman Endocrine Diane Elson Psychiatry Eric Heilingstein Infectious disease Bennett Vogelman Geriatrics Alexis Eastman Hematology Ryan Mattison Headache clinic Susanne Seeger Sports Medicine Katie Miller Hematology Ryan Mattison Preventative Cardiology Patrick McBride Psychiatry Karen Milner Geriatric Psychiatry Art Walaszek Geriatrics Alexis Eastman Women s Health Shobina Chheda Dermatology Justin Endo Women s Health Annie Wilson University Health Allan Rifkin Psychiatry Eric Heilingstein Gynecology Mary Landry

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40 Subspecialists training for GIM Send survey and interview all residents after block. Question your graduates-what was really helpful in block experience. Make sure attendings know who they are teaching to. Cardiology for GIM Post grad evals- procedure competency Speak directly to those whose message is- Don t go in to GIM

41 Curriculum Monday AM report outpatient cases by PC chief for all residents. Procedural competency IUD conference and supervision in clinic Joint clinic Skin biopsies in Derm clinic Transgender conference and clinic Domestic violence Service project Dinners with recent graduates Scholarship- All PGY-2s submit abstracts for presentation at national conference

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43 Objectives 1) Describe the development, maintenance, and growth of Primary care at UM and UW. 2) Compare differences between programs. 3) Collaborate to address challenges in your own institution. 4) Review specific innovations that could be used to make GIM training more robust and engaging. 5) Recognize strategies to inspire your institution.

44 Break Out Session #1 Think about your local environment What do you identify as barriers to continued growth in training options for GIM and primary care? What possible solutions can you envision to overcome these barriers?

45 Objectives 1) Describe the development, maintenance, and growth of Primary care at UM and UW. 2) Compare differences between programs. 3) Collaborate to address challenges in your own institution. 4) Review specific innovations that could be used to make GIM training more robust and engaging. 5) Recognize strategies to inspire your institution.

46 Innovations v Two rotations that were developed with the PCT in mind. #1. OP Pain rotation. Developed in collaboration with colleague in Department of Anesthesiology. Two week rotation in General Medicine Pain, Pain psychology, PMR, Anesthesiology, Acupuncture. Opportunity to bring patient to Chronic Pain workshop and have 1:1 consultation with CP expert faculty. General Medicine

47 Innovations v #2. Lean Thinking elective. Two week rotation designed by leader in the field at UM. Done as cohort for the HO3s. 4 days of didactic lean curriculum/education. Go on Huddle Rounds in various departments. Work on mini-qi project using A3 process. Present work at end of rotation at meeting. General Medicine

48 A3 Process Map v General Medicine

49 Innovations: Transition to Practice Aim: Develop strategies and skills to address practical aspects of transitioning to a full time staff physician by pairing PGY-3s with early career GIM faculty 2 week individualized rotation in GIM clinic and urgent care Objectives: -Develop strategies to optimize efficiency -Understand how to lead a clinic team -Develop in basket management strategies for full panel -Review panel management techniques -Review financial aspects of practice- coding/billing

50 Innovation: Home visits Establish a home based primary care curriculum for healthcare providers at UW/VA Goals ID patients who would benefit vs. standard office visit Perform function assessment/pe in the home Function as part of interdisciplinary team Evaluate DM care and outcomes office vs home

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52 Objectives 1) Describe the development, maintenance, and growth of Primary care at UM and UW. 2) Compare differences between programs. 3) Collaborate to address challenges in your own institution. 4) Review specific innovations that could be used to make GIM training more robust and engaging. 5) Recognize strategies to inspire your institution.

53 Break out session #2

54 Different solutions to the same problem University of Michigan Track within a categorical program to provide flexibility/support for residents who identify primary care as a career later in training, emphasis on same + extra to avoid image as primary care as less than categorical training University of Wisconsin Independent match, emphasis on well established relationships with specialists who have respect for GIM careers, long blocks in ambulatory settings

55 Common Tools/Strategies Have a vision/be passionate about your goals Recognize the needs of your institutional/challenges in your local environment Collaborate Create a culture supportive of GIM careers Innovate Think about sustainability Don t be afraid to individualize

56 Everybody Loves a Winner..

57 What is your definition of success?

58 Thank you!