The Seven Pillars of High Performing Primary Care Practices – Part One

In a previous post titled, “Is Making Primary Care More Professionally Satisfying as Simple as Lowering Panel Size” I observed that lowering panel size and implementation of an electronic medical record did not change how doctors worked. Those doctors who stayed late continued to stay late. Those who left earlier tended to continue to leave earlier. Within a health care organization often touted by many to be an example of how health care should be delivered in the country, this phenomenon existed. Why?

Was making primary care more professionally satisfying and more attractive to future doctors simply more than lowering panel size? Doctors at the Permanente Medical Group, where I practice, do not have many of the frustrations of other primary care doctors. Doctors are salaried. There is no perverse incentive of doing more tests or more procedures when there is no medical benefit. Doing more is a common pressure for doctors in the fee for service world as if they do less they do not get reimbursed and will lose income. Our doctors work in a very large multispecialty group practice where we use a common electronic medical record. Doctors in both primary care and specialty care can discuss cases, review information, and determine together with the patient the best course of action. Our primary care doctors have lower panel sizes than a decade earlier. This panel size is adjusted and normalized for patient age, medical problems, and other factors so each primary care doctor has similar clinical responsibilities. Our doctors have clinical autonomy. There is no prior authorization needed for specialty care referral or prescription medication which can also occur in a fee for service setting. With that autonomy, there also is responsibility that our doctors provide the best care. This was most recently recognized by the American Medical Group Association (AMGA) Acclaim Award which noted:

• “the physicians of TPMG have
• Reduced patients’ cardiovascular mortality 30% below the surrounding community;
• Achieved nation-leading success in hypertension control;
• Decreased colon cancer mortality through effective screening; and
• Earned the trust and confidence of their patients by providing rapid access to care in person, by phone, or through advanced information technology tools.
• As a result of these and other initiatives, hospital mortality has declined dramatically and member satisfaction in the TPMG health plan is the highest in Northern California. In addition, TPMG is viewed as a highly desirable place to practice medicine, as evidenced by the fact that the number of new physician applicants for positions in TPMG is now ten times the number of available positions.”

After observing colleagues in their practices and then collaborating and coaching them, I created a framework on how physician leaders might help improve the lives of primary care doctors. There are seven pillars of high performing primary care practices. Within the seven pillars are three areas of focus. They are: (1) individual doctor, (2) primary care module, and (3) outside the primary care module.

Individual Doctor

For each doctor, there are 4 skills or pillars that a doctor can work on. They are in no particular order: mastery of the electronic medical record, patient-doctor communications, clinical expertise / judgment and time management. Doctors who work on all four skills will have effectively done everything possible within their individual control to make their lives better.

1) Mastery of the electronic medical record.

Until recently, the vast majority of my colleagues did not use an electronic medical record (EMR) in their training. Unlike writing with a pen on paper, which we have all done since elementary school, using computers and finding data quickly and easily is a skill. Though electronic medical records should be even more intuitive than the current generation, physician leaders cannot wait. Much like any new skill, like playing golf, there is value in attending an introductory class where everyone signs up and then later when one hires a golf pro to work one on one. Having doctors coach others one on one was inspired by the writings by Atul Gawande around coaching. 

In our group, our training began with large classroom settings and then later in the offices real-time with non-clinical EMR experts and support.  Even afterwards, there would be periodic updates informing all of us of the latest upgrades. Despite this approach, I and other doctors discovered that some doctors never got better beyond the basic skills demonstrated in our training session and others maximized use of the EMR. The latter group appeared to experiment and keep tweaking their workflow. They never stopped asking questions or learning.

To close the gap so all colleagues benefited, we created a program where primary care doctors coached colleagues one on one on how best to use the EMR in their practice. Only doctors watching other doctors can intuitively ask and anticipate what a colleague is looking for. Non-clinical EMR experts are very helpful in training and onboarding new hires as well as updating doctors on system upgrades. Organizations that stop there, however, will be missing opportunities to help their doctors master the EMR further. It was this program which generated conversations “I didn’t know you could do that” and learnings. Physician leaders should be aware that doctors don’t like to be coached.

2) Patient-doctor communications.

Patients contact doctors for essentially two reasons – when they have symptoms or when they are worried. Building trust and rapport with a patient, whether a first visit or a return visit, is incredibly important. The vital skill of active listening is incredibly important. This is a challenge when most doctors have very high volume practices and interrupt patients within 23 seconds of the visit. With listening and understanding, doctors may make snap judgements and order unnecessary tests or treatments.

Truly listening, addressing a patient’s concern, and having a candid conversation about the limitations of testing (or conversely a different approach that does address the true nature of the concern) can result in fewer unnecessary testing, treatments, and referrals. Not only can this improve a doctor’s professional satisfaction (fewer tests and referrals to track), but also decrease a patient’s frustration by paying more and spending more time for more tests and referrals without a satisfying answer.

Dr. Jerome Groopman, author of How Doctors Think (one of four books I recommend for medical students, interns, and residents) provided an excellent example of this in a November 2008 ACP Internist blog post:

• “80-year-old man who required knee surgery for arthritis that severely limited his ability to walk. After surgery and rehabilitation, the patient was able to walk and ventured out on the golf course for the first time in several years. However, he reported that he was “fatigued” and had “no stamina.” The orthopedic surgeon referred him to his internist who sent him to a cardiologist.”
• An extensive evaluation showed normal pulmonary and cardiac function. The patient, having seen advertisements for testosterone therapy, said to his internist, “I hear testosterone can help your stamina,” and asked that he check his testosterone level. The internist complied and found a level of 242 ng/dL (where 240 was the lower limit of normal) and referred him for an endocrine evaluation.
• Dr. Chernoff [an endocrinologist] questioned the patient regarding libido and sexual function, and was told, “In this area, things are great.” Dr. Chernoff then said to the patient, “I want to hear in your words about the problem.” The patient replied as he had done before, “I have fatigue and lose stamina.” At this point, Dr. Chernoff said, “What do you mean by fatigue and lose stamina?” The man replied, “Whenever I walk, I lose stamina,” pointing to his calf. “When I stop walking, the stamina comes back and I can walk again.”
• Dr. Chernoff told us, “It was a classic description of intermittent claudication.” On physical examination, a loud right femoral bruit was easily heard. Dr. Chernoff referred the patient to a vascular surgeon, and a successful angioplasty was performed. “The man is now back on the golf course,” Dr. Chernoff reported.
• Commentary
• It is easy to see how a physician could be misled by the words this patient used to describe his symptoms. It took an extra step to determine exactly what the patient meant by “fatigue” and “stamina.” Part of being an effective physician involves functioning as a translator of the patient’s symptoms, converting the patient’s words into human biology. Mutual understanding between doctor and patient is essential to ensure accurate diagnosis and appropriate medical care.
• Dr. Chernoff concluded his description of the case as follows: “The reimbursement for the correct diagnosis: $. The reimbursements for all the unnecessary testing prior to the correct diagnosis: $$$$. The satisfaction in getting it right … priceless.”

Had this patient’s internist asked the simple questions offered by Dr. Chernoff, he would have solved the patient’s problem the first time, avoided a follow-up visit requesting testosterone evaluation, and avoiding setting up a referral to an endocrinologist after seeing the low lab result in his EMR. The patient would have avoided all of the time and costs to see a cardiologist, endocrinologist, and all of the testing done prior to the definitive treatment, a referral to a vascular surgeon for angioplasty. For both doctor and patient,  these take time and energy. Mastery of communication skills is better for the patient and better for the doctor.

In part two, I will cover the other two skills individual doctors should master.