Thursday, July 18, 2013

Residency takes a big picture approach

Family medicine physicians are key to integrating care, helping patients manage their health. 

As best as she can remember, Dr. Stephanie Pendergrass has always wanted to be a physician. She doesn’t recall what sparked her interest in medicine, but she remembers a story she wrote in the first grade about being a doctor. She followed the path she set early in life and years later, after she graduated from medical school, she returned home to Springfield to attend the Cox Family Medicine Residency. 

Like her original pursuit of medicine, her choice of family medicine was based on instinct. “I knew I wanted to do family medicine,” Dr. Pendergrass says. Like many family medicine physicians, she was drawn to the appeal of caring for a patient over the years and seeing many members of the same family.

“We’re treating people, not just a medical problem. I’ve been able to tell a woman she is pregnant, then taken her through pre-natal care, then delivery, and now I see her and her son. That’s very exciting to me – I love that.”

After completing her residency early this summer, Dr. Pendergrass has joined the ranks of more than 150 physicians who have graduated from the program since its inception 25 years ago. As the program completes its first quarter-century, leaders say the comprehensive training the Cox Family Medicine Residency provides is more vital than ever – for CoxHealth, for the region and for the future of patient care in a shifting health care climate. 

Those are big claims, but spend a little time with residency leaders, such as Dr. Larry Halverson, founder and senior faculty physician, and Dr. Tim Fursa, residency director, and they make it clear that seeing the big picture is at the heart of family medicine.

They’re quick to point out that family medicine is set to play a key role in addressing our national health care crisis. Across the country, health care costs are going up, but the outcomes aren’t always getting better. The question becomes: How do we get more value out of the system? What skill set does a physician need to make a difference for patients?

“We have to look at individuals and their needs – not just acute needs, but ongoing needs,” Dr. Fursa says. “How can we change their behaviors and their habits to support a healthy lifestyle? We have to understand the whole person and how to engage them with specialized care.”

Because of the relationships they build with patients and families over time, family medicine physicians are in a unique position to provide comprehensive care and improve community health. 

It was the need for more family medicine physicians in a growing region that led Dr. Halverson to leave his practice in Aurora to help found the residency. At the time, the average age of a family medicine physician in southwest Missouri was 62. Dr. Halverson and the early residency leaders knew that with the region’s growth, there would be a real need for more family physicians. Over the last 25 years, the residency has helped meet that need: 92 of the residency’s graduates are practicing within 100 miles of Springfield.

Dr. Fursa says that from the beginning, the mission of the residency has been to train doctors that can go out, anywhere, and provide care in any environment: from the hospital setting to rural practice to international medicine. The full-scope training is especially important for physicians who may practice in rural or remote areas, where there may not be another physician within 100 miles.

“Not all of our physicians do those things, but the training to do so enhances their skills,” Dr. Fursa says. Leaders point out that many residencies don’t do obstetrics, an important skill set for physicians who are the primary doctor for a community. Here, the residents enjoy support from CoxHealth hospitals, where they are able to work directly with expectant mothers. 

Dr. Stephanie Pendergrass visits with patient Angela Hall of Springfield during a visit at the Family Medical Care Center at Cox North. 

When the residency began, Dr. Halverson envisioned a program that focused on providing prenatal care and delivering babies. While that’s still a large part of the residency, much of the focus now is on helping patients manage chronic conditions. 

Dr. Halverson points out that nationally, about 1 percent of patients consume almost 30 percent of health care dollars, while 5 percent consume about 50 percent of the total.

“With more than 90 percent of people, we’re doing fine, so we focus on those 10 percenters. Focusing on that group is what primary care does,” he says.

There are few family medicine providers on the north side of Springfield, so the Family Medical Care Center at Cox North serves a valuable community purpose.

“Many people in that 1 percent of the population that consumes 30 percent of health care costs live right here,” Dr. Halverson says. Providing primary care for patients with limited resources can head off the need for more expensive care later. And, it’s simply the right thing to do.

In addition to meeting a community need, the residency serves as a laboratory for innovative ways to provide care. Halverson and Fursa both note that electronic medical records at CoxHealth were piloted first at the residency in the mid-1990s before their use became the standard system-wide. Now, they believe the residency’s new approaches to managing chronic conditions could become the standard for patient care in the future. They may even offer the key to a health care holy grail: improving outcomes while reducing costs. 

Among the innovations going on at the residency:

Providing a medical home: In 2010, the National Committee for Quality Assurance (NCQA) certified the Family Medical Care Center as a level three patient-centered medical home, the first such clinic in southwest Missouri and only the second in the state. The patient-centered medical home model is designed to strengthen physician-patient relationships and better integrate a patient’s care. 

Dr. Fursa says that when practices pursue medical home status, they sometimes choose easy things to focus on. But FMCC picked three chronic conditions that affected most of their patients: diabetes, depression and pain management. If they could affect those three things, they could make a difference in patients’ lives.

Pioneering group visits: The residency is exploring new ways to serve patients beyond the traditional one-on-one between a patient and a doctor. Now, patients with conditions such as diabetes are seen in a group setting. They are still able to get prescriptions, tests and referrals just like in a regular visit, but they all receive education on diabetes during the session. The group environment gives patients more access to their physician, while the physician saves time by providing the education once, rather than in individual sessions. 

Support groups: FMCC is currently hosting “Healthier Together,” a support group for patients that provides education and encourages healthy lifestyles. “Patients can influence each other and people change in groups better than individually,” Dr. Halverson says.

Drs. Halverson and Fursa say that as they work with patients over time, family medicine physicians are in the best position to see the entire scope of a patient’s situation. Whereas much of medicine is focused on specific interventions to fix a problem, the overall view a family medicine physician provides can be key to improved outcomes. 

Dr. Halverson cites an anecdotal example from another health system: A patient receiving dialysis comes in for treatment, only to remove his IVs early and leave. A few days later, he lands in the ER, suffering from renal failure. The ER solves the immediate problem, but they’re not in a position to look into the overall case. 

A social worker who was part of a patient-centered medical home team was able to do an in-home visit, a service that the residency also provides for its patients. At the home, she noticed that the patient had trouble sitting still. He told her he was restless and it was always hard for him to be calm – especially in a stressful situation such as receiving dialysis. Only one thing kept him calm: painting. The social worker suggested that he be allowed to paint while receiving dialysis. The strategy worked and he returned to his regular course of dialysis. Because the social worker on the family medicine team was able to look at the entirety of the patient’s situation, a simple change was able to head off a complex, expensive intervention down the line.

Dr. Halverson says that’s the power of family medicine. Skilled physicians like those the residency trains are able to coordinate a patient’s overall wellness, which produces benefits that reverberate throughout the health care system. 

“The data shows that if you have more primary care doctors in a population, you have lower costs and better outcomes,” Dr. Halverson says. “The solution to overcrowded ERs isn’t just to provide more ERs. Part of it is to get more family medicine physicians on the front lines to provide ongoing care that can help people manage their health.”

Dr. Pendergrass says the residency has given her the chance to oversee the full range of care for her patients – being on the front lines for everything from the birth of a child to end-of-life care. It’s simultaneously challenging and rewarding, but she says that seeing her regular patients make positive lifestyle changes is one of the best parts of working in family medicine. 

“You work a lot in any residency, but here you really take ownership of your patients. On day one, patients look at you as ‘my new doctor,’” she says. “That’s a lot of pressure, but it’s good pressure – you’re not an observer of the situation, you’re the doctor managing the situation.” 

With her training complete, Dr. Pendergrass and two of her fellow residents are joining CoxHealth full-time this summer in the Diagnostic Clinic, where they will be providing inpatient, outpatient and prenatal care.

This summer, eight new residents will be joining the Cox Family Medicine Residency, beginning their journey from medical school graduates to primary care physicians trained in the full scope of patient care. Dr. Fursa says the field of family medicine draws a special kind of physician, one who is eager to take on the wide variety of challenges and issues patients may present with in the primary care setting. 

“For the family medicine physician, some uncertainty is part of the territory,” he says. 

A big part of the skill set for new physicians is being able to navigate uncertainty and help patients find the correct solutions. “We’re often faced with situations where we can’t know all the answers, but we train to know the pathway to get the right answer.” 

Leaders say that flexible approach is valuable both on the small scale with individual patients and on a larger scale as we evolve to provide patient-centered care in a changing environment.

“The people who choose this program are purpose-based and value-based,” Dr. Fursa says. “Their heads and hearts are in the right place to take care of patients.”