A popular video on social media lists 20 areas of improvement around the planet. It lists a 50% decrease in homeless veteran numbers. The rapid declines in Veteran homeless counts in metro areas are not necessarily a positive result. The media has a hard time understanding demographics and this makes it difficult when attempting to report on positive and negative areas.

Another popular poster notes that homeless veterans need attention before refugees. The fact of the matter is that many Americans are treated like refugees - as those who do well plan ways to do even better. Their designs continue to leave most Americans behind.

The relevant areas to consider for Veteran situations are not immigrants. The relevant areas are declines of veteran benefits, deteriorations involving lower income, disabled, fixed income, and less healthy populations of which Veterans are part. Most important is the consideration of available and affordable housing.

Factors Regarding Veteran Homeless Declines

It would be nice if all of these declines were about improved support for Veterans, but the fact is that Veteran benefits have been cut. Also, declines are explained by 

• Homeless counts are done in metro areas and may not reflect homelessness or housing in other parts of the nation
• Natural deaths - WWII to Vietnam Veterans age 64 - 98 years
• Deaths from Veteran System neglect - too little, too late
• Suicide - 22 per day all ages
• Forced migration from metro and higher concentration settings

Natural Deaths

The World War II veterans were 80% of the male population of the US for their age group. Few remain as illustrated. Korean veterans were 60% of the male population of the US and are about 8% of the Veterans.

Vietnam veterans are about age 64 to 74 - a longer time period and many are still around although their health care needs are increasing. Veterans that are younger are a smaller portion with somewhat less health care need.

Forced Migration

Places with concentrations have the lowest levels of 

Light green counties lack available housing in high amenity areas and high concentration settings (people, income, education, professionals). Blue and green counties are lower concentration counties and have higher levels of available housing. Many populations with less are forced to depart higher concentration counties because housing is less available, making it more costly.

Migrations of Veterans, poor, working poor, lesser employed, elderly, disabled, and fixed income populations continue as they are forced to move to places with lower cost of housing and lower cost of living. 

45 - 50% of living Veterans are concentrated in 2621 lowest physician concentration counties with 40% of Americans left behind in places with lowest concentrations of health dollars, health facilities, and health workforce.

Some places used to give bus tickets to dump unwanted people 

from their metro areas. The modern way to do this is to dump them 

via housing leaving them only the choice to be homeless or depart. 

By taking out affordable and available housing, highest concentration settings can accomplish many desirable goals for them while sending people elsewhere. They do this by intention (greed), lack of awareness, and by neglect. Alarms are sounded daily about the lack of affordable or available housing in metro concentration areas and yet there is little response.

Veterans Are Treated Poorly As Are Similar Types of Americans
 
Veterans have high rates of disability, mental health, and chronic conditions. They also have lower income, fixed income, and are older. People with these characteristics are not treated well. Veterans are forced to move with all of these populations to lower concentration settings because they have few options for affordable or available housing in higher concentration settings. 

Greed Drives Departures
 
High levels of available housing result in lower costs of homes and lower rental costs. It is best for those who own housing. It is worst for those who need housing, especially those that have less to spend on housing.

Greed is what drives homelessness, migration, and poor access to affordable housing, available housing, and available health care. Those who are greediest benefit the most with posters and postings that distract people from the real causes of most Americans behind by design.

Developers continue to convert low cost or public housing to high profit purposes. Government or government working with developers claim land by eminent domain for roads, facilities, health care, and other purposes. Government housing was often built poorly and fell apart - and the same mistake is being proposed again because as we would not want people too comfortable (Dr. Ben Carson, HUD). Suppression of government funding can make housing shortages worse and increase costs of housing. Homeless shelters on valuable land have been sold off. Even not for profits caring for the homeless caved for the greater good of others in need of food and services. 

Where Is the Anger Regarding Mental Health Neglect?

Mental health is a key factor in homelessness. Low income, lack of income, and mental health go together. We spend half enough for mental health, half of mental health services are provide by primary care which is also underfunded by half. The spending on mental health goes to places far away from where most Americans in need of mental health are found. Another way that insurance companies or health care systems can lower costs and improve outcomes is to drive off mentally ill patients and populations. 

Castaways By Design 

The cast off Veterans join cast off elderly and cast off poor and cast off disabled and cast off mentally ill and cast off indebted people (medical, business, or finance failure) in being forced into limited choices as concentrated places continue to concentrate more dollars and leave more people behind.


Greed and Concentrations of Health Care Dollars Compromising Others By Design
 
Also greed in health care consumes twice the dollars it should leaving little support for those in most need or those in lower concentration settings - as reflected in decades of state, federal, and local budgets increasingly impaired by health care costs.

As more people are sent into debt, they cannot afford to live in higher concentration settings and are forced to migrate to lower concentration places. The most complex situations, environments, and conditions are in lower concentration settings and those forced to migrate there bring higher complexity and strain the local resources - which are also least by design.

Lower concentration counties are predominantly Red Counties noted below plus some blue border counties in Texas and Black Belt counties in the southeast and Native Reservation counties. All share lowest concentration populations and situations. Metro Blue Counties have highest cost of land, housing, and living. Migrations are forced by housing design. 

More Cuts and Compromises


And cuts in support for Social Security, Disability, Veterans, and Food Stamps will hit these lowest concentration counties hardest because 42 - 45% of these dollars are sent to these counties with 40% of Americans. These are counties that lack economic contributions outside of health, education, and government spending. Frying Pan to Fire for Red Counties

As the United States continues to spend more on military and health care spending, there is little left. The least organized Americans suffer the most in their lower concentration settings. Budgets squeezed by military and health spending have less remaining for basic services - services most important for most Americans.  Two Forces Shaping Declines in Health and Other Outcomes - Austerity Focus Plus Runaway Health Care Costs

 

Eric Levi outlines the Dark Side of Doctoring in one of the most important health care topics of our time. He was led to this blog post after another physician took his own life. The words of the widow of the physician to trace the final steps leading to this tragic loss. These words have the power to help others to understand the process that leads to death for those pledged to life.

The following represent a number of resources for physicians and their families as they struggle with the Dark Side. Advice comes from the blog, the widow, 5 Regrets at the End of Life, The Antidotes of Stress, and what we should do as physicians and as a nation.

The formula is not difficult to understand - Too little sleep, too many life interruptions, too little time left for family or self, feeling too important, finances too complicated, feeling too inadequate, and eventually leaving too few indications of the final act to come. 

Exhaustion, interruption, marginalization, superhuman expectations of self and others, and neglect of the basics represent great challenges individually but are worse collectively.

The Big Three - Rapid Changes in Multiple Dimensions

• Loss of Control - too many bosses, including those that cannot be accessed. There are no negations with those who make policies, set contracts, and force behaviors. The recent changes in medicine make matters worse. Physicians are less and less independent and more likely to be employed. Graduation comes with much higher debt load. This debt will require years and will control job and other choices. More control comes in smaller or independent practices but these get paid less by design. Better payments go the the largest systems and practices, where individual physicians matter less. More will be part of large and impersonal and poorly responsive.
• Loss of Support - Support declines complicate the accelerations of too much to do. In previous generations of physicians, the spouse was able to be more supportive. Now physicians are more likely to marry a physician, a nurse, another person delivering health care, or another person with a career and a life of their own.
• Loss of Meaning - The physician pledge to put care of others before self comes with consequences when so much else is inserted. Menial tasks and numerous training modules are required, the same ones year after year. These are easily recognized by those experienced in health care delivery to be of little relevance to patient care. 

Physicians can be replaced by nurses, nurse practitioners, physician assistants, or other physicians. Loss of control, loss of meaning, and total loss of support are very real and very challenging to address.

Female and newer graduates have indicated that family and personal life is more important - making loss of control, lack of support, and loss of meaning more difficult.

Physician lives have always been divided into too many pieces. More pieces have been added and these pieces added have been replacing everything else.

Loss of Control

Policies and procedures required by government designers and insurance payers have been allowed to marginalize nurses, physicians, and all who deliver health care. Regulations have increased, approvals are required, data must be collected. Dollars distracted from those who deliver care takes time and energy away from patient care and from those who deliver patient care. 

It costs so much to do more that less time and energy is left to address patient needs or the needs of those delivering care. There is a reason why this is called meaningless change. It is meaningless except for those delivering care in which case the appropriate term is just plain being mean.

Anti-Support from Health Care Associations

Physician associations are failing in numbers of members and the support given associations by members. They fail to represent most of their members for good reason. They have failed in major areas important to physicians. They have failed to obstruct the efforts of those who have taken away the independence of physicians - most important for physicians to have some control over how they are treated and more importantly, how their patients are treated. 

Even worse, associations have added to certification burdens with meaningless Maintenance of Certification - evidence based only for more dollars in the hands of those that run associations.

• Depressing Theme in Health Care: We are health care designers and we are here to help you if you do not mind more micromanagement, less independence, more time before and after work to complete our tasks...

There is increasing recognition by those who deliver health care that they are  

Pawns of the For-Profit World and
Others Not Caring for Patients

Being Replaceable - A Constant Reminder That You Do Not Matter 

Physician expansions involving numerous sources mean more competition and less independence. You can be replaced. Someone else will put up with what you may not want to deal with. 

Initially nurse practitioners and physician assistants were seen as important team members in rural, underserved, and primary care practices. But they have long moved away from such practices to more specialties with more added to each new specialty. They work with physicians in offices, hospitals, procedural facilities, and other settings. Fewer physicians are needed of all specialties. Less costly clinicians can reduce the number of cardiologists or neurosurgeons needed by doing the non-procedural tasks. In turn, too many nurse practitioners impact upcoming NPs and their support, control, and meaning.

In some settings, the challenges are not about replacement. The challenges are about financial survival, annual raises, benefits, having enough team members, and other problems caused by the grossly inadequate payment designs across primary care, mental health, and basic services. The real problem in these practices is inadequate payment. MD DO NP and PA are marginalized in primary care and in other lowest paid basic services. 

Loss of control, loss of support, and loss of meaning are all facilitated by too many graduates regardless of payment for some while others struggle from insufficient payment.

Misguided Flawed Research

Many physicians still believe in the validity of today's research and what major journals publish. Their faith is misguided. The research errors are many and significant. Many are while male older physicians such as myself - all of these categories are blamed for problems by the research, especially BMJ publications. Almost daily one or more of my categories is blasted in the media. The following are constantly blamed for one ore more ills regarding health care. 

• Physician
• Older physician
• Male physician
• Lower volume
• Rural or lower concentration location
• "Medical" errors
• Too little time with patients
• Too slow in accepting technology, innovation, measurement focus, digitalization, mindless changes, heartless changes, or meaningless use and abuse

As I have outlined in numerous critiques of these articles, most of these studies should not see print or if they do, there should be more words about limitations than the rest of the article combined. Also there should be no speculation - the major fuel that gains promotion and distribution. 

Studies demonstrate that one of the worst sources of speculation involves the press releases of the institutions of the researchers. The press releases of associations are often not much better.

Not everyone has the ability to see through the research drama to the flawed techniques, the lack of hypothesis (witch hunt), the lack of specific data collection for the purpose of the hypothesis, the lack of exploring alternatives, the lack of limitations, the assumptions, the cherry-picking of findings or references, or the agendas of the journal or tendency for the dramatic or support of current bandwagons. 

There Are Research Findings That Are Important

Studies demonstrate more time required for EHR, too much cost of Primary Care Medical Home, more digital distractions, decreased morale, increased burnout, and decreased time with patients. But this fails to gain much print or promotion. 

It is not hard to see team members targeted by measurement focus, digitalization focus, quality improvement, cost cutting, higher complexity of patient, and higher complexity of health care. Why would a local practice hire a practice consultant to help them address quality - someone who does not understand local patients, populations, resources, situations, environments, behaviors that actually shape health outcomes? Why does it cost $80,000 to 100,000 more per primary care physician to be PCMH to improve process but not to be able to impact outcomes? Why focus team members upon measurement and protocol and away from working with the community and patient needs?

How hard is it to see that studies where there are comparisons with one cohort demonstrating better outcomes because their population has better health indicators (volume, rural vs urban, PCMH)?

Why is it so hard to see that studies with same or similar patient populations demonstrate little difference in outcomes (NP vs MD, Resident Work Hours Before and After, Pay for Performance)?

Why is it so hard to see why insurance companies, ACOs, large health systems, and others use strategies to cherry pick the patients with the best outcomes in ways that small and local practices cannot?

Triple Aim focus, Digital Focus, and the Perfect Storm of too little payment for too much required from too few are helping to make those who deliver health care sicker or dead - loss of control, loss of support, loss of meaning.

For those few such as myself that realize that health outcomes are mostly about people, populations, local situations, community, and other non-clinical factors - it is indeed a difficult time. The ways to improve people are about changes specific to people impacting them 24/7/365. It is not about those who spend a few minutes with people as residents, as physicians, as nurse practitioners, as physician assistants, or as nurses.

There is very little that can be done to improve health care outcomes from inside of health care. But there is Big Health Business demanding more to be done and more to be paid to corporations to do it.

The real changes have to occur in people, behaviors, environments, situations, relationships, loneliness, falls, impatience (driving too fast, running late), housing, nutrition, caregiver support, local resources, child development, and support for those under extremes of stress. 

Physicians and Patients - Sharing Loss of Control, Support, Meaning



It is not a surprise that physicians and their patients often share the same loss of control, decreasing support, and loss of meaning. As long as patients experience loss of control, declining support, and loss of meaning they will be failing - and often this is failure by design.

Patients and their physicians are experiencing post traumatic stressors - and neither have access to those who can identify, evaluate, or bring supportive resources.

I am pretty sure that one of my jobs came to a close because I was identifying too much with patients who were experiencing lack of control, support, and meaning. There was substantial impact upon me in ways difficult to understand. I learned much from the Balint support groups meant for residents, but helpful for faculty as well.

Physicians Observing Care of Family Members or Self
 
As a physician, it is difficult to see what has happened in health care - especially when you bring your father or children or other loved ones in for care. I understand why so little time is spent with my loved ones - but it makes me hate what has happened all the more.

The widow of the departed physician wanted to share the turmoil in the hope that some will avoid this in the future. 

She has already delivered on the promise of hope to come. The comments on the blog reveal the help already on the way.

• I struggled with the demands from the beginning. I always thought it would get better. It hasn't. 
• One female physician read the blog and widow's story aloud to her husband - who broke down in tears. None are doing poorly at what they are doing. They are all being asked to do too much with too little for too long.  
• Some related stories of being a physician and going through depression, postpartum depression, loss of relationships or family members.
• "Any kind of emotion other than pleasant subservience makes you a victim of gossip rumor and innuendo – particularly if you are new to a place, and then their is the added pressure of having enormous responsibility with zero familiarity with systems and no account taken for how much longer it will take you to perform and complete administrative tasks. I am battling depression for being vilified for doing my job extremely well and not caving to pressures to cut corners and compromise. Rashmi is right. One wrong event early on will set off a chain of events.
• Some were reminded of traumatic events in residency or in practice that led to career, family, and other changes - but the blog gave them a perspective that they did not have on what happened and why.
• Some noted the focus on best practices would be nice, it the time and resources were given for such a lofty goal.
• Some indicated patterns of abuse.
• Others watch as the help that they need is sent home or is not sent at all - due to cost cutting measures or policies that make sense only to those thinking about money and not about people, patients, or health care.
• Busier and busier, pushed and pushed, more done on unpaid time...
• "No one ever checks to see how ‘good’ you are at your job – which is caring for your patients and their being satisfied with the care that they are receiving."  C Card Frankly no one ever checks at all. There is little notice, other than perhaps a meeting to discuss occurrences which were largely outside of the control of anyone. 
• "All I ask is that people don’t play the world’s smallest violin to me when I whinge about little things in my life whilst I hide the dark side of doctoring behind my smile." - by SmallViolin

What Did the Widow Say About Her Physician Husband's Suicide, the Death of Dr. Andrew Bryant?

I apologise for the group email but I wanted to thank those of you who have been so kind with your messages and thoughts over the last three days.

Apologies also for the length of this email but it is important to me to let you know the circumstances of Andrew’s death. Some of you may not yet know that Andrew took his own life, in his office, on Thursday morning. Andrew had never before suffered from depression. He hadn’t been sleeping well since late February; but he was never a great sleeper. He was very busy with work; but had always been busy. Just before Easter he became anxious – about his private practice, about being behind in his office administration, about his practice finances, about some of his patients, about his competence. He seemed very dispirited and non-communicative. I did what I could to help where I could, but I was confused – he’d always been busy and the practice, as far as I could tell, was running just as it had for the last 20 years. He was flat all Easter and, the week after that, he was on call for the public hospitals. It was one of the worst on call weeks that he had ever had – he was called every night and some nights more than 3 or 4 times and during the day he had to see his own patients and do his endoscopy lists. He missed our sons birthday dinner and every other dinner at home that week.

By the end of the week he was exhausted, still could not sleep properly, and was just flat. I was very concerned about him, tried to talk to him about my concerns, but he was very unresponsive. I urged him to go and see someone about his sleeping but he was non-committal. He continued to see patients, do lists, go to work, get home late.  On Tuesday evening he was upset and teary because a patient had died. Andrew was always upset when any of his patients died, but his level of distress in this case was unusual.

In retrospect, the signs were all there. But I didn’t see it coming. He was a doctor; he was surrounded by health professionals every day; both  of his parentswere psychiatrists; two of his brothers are doctors; his sister is a psychiatric nurse – and none of them saw it coming either.

I don’t want it to be a secret that Andrew committed suicide. If more people talked about what leads to suicide, if people didn’t talk about it as if it was shameful, if people understood how easily and quickly depression can take over, then there might be fewer deaths. His four children and I are not ashamed of how he died.

So please, forward this email on to anyone in the Wilston community who has asked how he died, anyone at all that might want to know, or anyone you think it may help.

Support for Patients, But Not Team Members

The Geriatric Emergency Room and Hospital proposals were interesting. What they proposed for these places was better sound proofing, less interruption, and other environmental improvements.

These would be a great idea for the team members who are working there and need better environments all the time that they are working - and better support for what they do.

Above my work desk currently there is a sign offering me support regardless of where I work and at any time.It promises all the information and support that I would need – for EHR.

Signs of the Times - Today

AAFP Celebrates Family Doctors, but...

Celebrating you today (and every day)

Happy World Family Doctor Day! You are an inspiration to your patients and community today and every day. One of your most important skills is the ability to actively listen to each patient’s needs. For that, your patients trust you and turn to you for guidance. In honor of World Family Doctor Day, the World Organization of Family Doctors (WONCA) has named depression this year’s theme. To assist you in future conversations with patients, we’ve gathered a variety of depression and other mental health resources to access. We hope you take a moment today to reflect on how your work makes a difference. Again, thank you for all that you do for your patients—both body and mind.

Reflection is important, on what is going on in so many ways that indicate loss of control, loss of meaning, and loss of support. More than a card or web site is needed. AAFP also wants us to support new meaningless promotions and campaigns with interesting names such as Thunderbolt, generic support for primary care, and prevention campaigns. What about supporting us?

We need more support for nurses, teachers, police, and team members across primary care, public health, urgent, emergent care, and those stretched too far and too fast and too long. The jobs are getting more complex, the demands for time and additional efforts are increasing, the risks are greater, and the support is not sufficient to the challenges.

The Antidote to Stress is Structure From Travis Bradberry

Rule #1: Disconnect

Rule #2: Minimize Chores

Rule #3: Exercise

Rule #4: Pursue a Passion

Rule #5: Spend Quality Time with Family

Rule #6: Schedule Micro-Adventures

Rule #7: Wake Up at the Same Time

Rule #8: Reflect

Rule #9: Designate Mornings as Me Time

Rule#10: Prepare for the Upcoming Week

 

Five Choices You Will Regret Forever

The author continues the theme with this advice:

• Be aware of decision fatigue. Physicians often exceed levels of decisions that can be done without such fatigue.
• Situations without previous experience are more difficult to address. Physicians continue to face new situations as humans and their conditions are quite complex.
• Decision fatigue can involve situations at work or overlap into home life.
• Decisions should not be made based on what others think.
• Working too hard, failure to express feelings, losing touch with family or friends, and failing to allow yourself to be happy can result in regrets later in life.
• It is important to put yourself in a position to be able tomake the best decisions in work and in life. Best sleep, best time to reflect, being in a good position to

The Example of Too Many Graduates from Too Many Sources

The actual result of MD DO NP and PA expansions is entirely about non-primary care workforce contributions. NP and PA have established more new specialties with more added in each new specialty. This has not been difficult as the largest systems and practices have long seen value in this. The versatile NP and PA graduates have become important team members in specialty, subspecialty, office, and hospital settings. This results in fewer of the most costly physicians needed. This moves the subspecialty physicians to more of the highest paid procedures, but fewer are needed.

There are already too few physicians to be able to share call in subspecialty areas. With fewer needed, the call and the interruptions can be worse. Ideally there are 4 or more physicians of a specialty to share call. Perinatal specialists may have to cover 3 hospitals with only 3 physicians in some cities. Teams with 2 physicians, 2 nurse practitioners, nurses, and other team members are replacing 3 and 4 physician practices. Time on and off become more difficult.

There are many other problems arising from a rapid, massive expansion of workforce. Nurse practitioner expansionists have clearly not thought this through. Too many graduates 

• Will saturate the workforce and related workforce areas. Slow steady expansions are best for workforce. Each 1000 annual graduates results in 20,000 to 30,000 more in the workforce. This is a 20 - 30 times multiplier with full maturity at the new level and is substantially higher with continued expansion. 
• As the graduates age and long before they are ready to retire, there is no room for newer graduates. 
• The 20,000 a year for NP graduates if sustained will result in 400,000 to 500,000 who could be active NP workforce.  The PA graduates can have longer careers and 10,000 annual graduates results in 300,000 for a workforce - if there are no further expansions.

Expansions are not about solving workforce problems. Expansions have taken on a life of their own. Studies of future workforce and special centers have been proposed to address these areas. Unfortunately what is most important is an understanding of the consequences of rapid expansions and too many graduates. 

New announcements of new medical schools are not good. Those that promise more primary care are lying because the financial design prevents increases in primary care positions and team members. Such a new school or program may indeed produce more who train in primary and even more who enter primary care, but this may not result in more primary as they are forced to depart. The result within a state or nation may well be displacement of others from primary care for no net gain. 

Traditional medical school building should end. There should be reductions of international graduates as well as Caribbean graduates. The NP and PA expansions should also stop to address 

• loss of control, 
• loss of support, and 
• loss of meaning

Foundations Undermining Physicians, and Clinicians 

Assumptions guided the development of ACA and the resulting micromanagement and lack of help for lowest physician concentration counties. Assumptions guided managed care reforms. The same mistakes were made twice. 

Foundations who say that they are focused upon health access and better health care have funded new sources of workforce. There have been assumptions that physicians are replaceable while ignoring the fact that too many graduates makes all MD DO NP and PA replaceable. 

Government funding has been a major factor in the massive expansion of workforce. This supports those who profit from training, training that often is lacking in faculty (due to loss of control, support, meaning for faculty). This government expansion support undermines existing workforce and support for workforce. 

If this is not clear, examine the efforts of health insurance foundations such as United Healthcare to see the substantial support of alternatives to physicians. Sadly the massive increases of nurse practitioners from 1500 to over 20,000 annual graduates since 1980 has worked to marginalize nurse practitioners along with other sources. Physicians have been undermined. This is most obvious in the rural located major health systems such as Marshfield and Geisinger. There has been shrinkage of the physician workforce - replaced by massive additions of new team members following the dollars shaped by payment design. And the outcomes - well it turns out that these places had better populations - essential for better outcomes. Mayo was the first and the massive dollars entering Mayo changed the entire region, which already had better outcomes due to best child development and other factors impacting outcomes from birth to encounter.

 

Mental Health That Understands Toxic Situations and Relationships

One comment involved the TV show MASH. There are many times I would like to talk to Sydney the Psychiatrist - obviously another who was barely making it day to day as noted in the show. What set MASH apart was the physician and other advice that made the show real and relevant. 

What if we had the mental health that we needed when we needed it - 

• Major Sidney Freedman in MASH -
  Capt. Benjamin Franklin "Hawkeye" Pierce: So when do my nightmares end?
  Dr. Sidney Freedman: When this big one ends, most of the others should go away. But there's a lot of suffering going on here, Hawkeye, and you can't avoid it. You can't even dream it away. 
• Someone who listens, and probes, and cuts through the BS is necessary.

• Robin Williams in Good Will Hunting, Sean: "You think I know the first thing about how hard your life has been, how you feel, who you are, because I read Oliver Twist? Does that encapsulate you? Personally... I don't give a shit about all that, because you know what, I can't learn anything from you, I can't read in some fuckin' book. Unless you want to talk about you, who you are. Then I'm fascinated. I'm in. But you don't want to do that do you sport? You're terrified of what you might say. Your move, chief."
• Ultimately people, patients, and physicians have to make tough decisions. These decisions can involve the way that they relate to others, or choose not to do so.

• Dr. Dix is the policeman turned psychiatrist in the Jesse Stone series with Tom Selleck - Dr. Dix related the worst day of his life as a cop, and his last day as a cop - "Nobody knew what I did. I went home, pounded a fifth of scotch, passed out. I woke up with a hangover and a revelation; the job and the drinkin' feed each other... toxic. 
• Dr. Dix to Stone: You figure it out yet?
  Chief Jesse Stone: I don't think it's the kind of thing where a light-bulb goes on.
  Dr. Dix: Is it Jenn, or is it the work that makes ya' drink?
  Chief Jesse Stone: Hell I don't know, could be both, I'm not a shrink.
  Dr. Dix: I prefer 'therapist'. When you're on a case you don't drink.
  Chief Jesse Stone: I always drink; if I'm involved I don't like to drink a lot.
  Dr. Dix: You once told me you want to kill her boyfriend, did you mean that?
  Chief Jesse Stone: I was jealous.
  Dr. Dix: That's not much of an answer for a shrink.
  Chief Jesse Stone: Jealousy isn't a good enough reason?
  Dr. Dix: Jealousy's a powerful thing. What I want to know is, do you think you meant it?
  Chief Jesse Stone: I meant it.
  Dr. Dix: So if you could've gotten your hands on him...?
  Chief Jesse Stone: I'd've killed him.
  Dr. Dix: Jealousy's a powerful thing."
  Dr. Dix had a good understanding of the patient, his condition, his alcohol, and the toxicity of job and alcohol. We all have toxic areas to address.

Someone who understands what you do in your occupation, how you got there, how you could go too far, and is willing to work to help you not to go too far is important.

Mental health work is quite complex and poorly supported with lack of control and often meaning can also be lacking. We should appreciate the work and the workers more and demand more support for what they do. 

In family medicine we most need change agents and least need those who remain stagnant and unable to change the course of health access, of primary care, and of health outcomes for most Americans. We fail in training and in family medicine workforce because we fail in selection and preparation in ways that training cannot address.

The STFM blog highlighted the quality improvement potential of family medicine residents. There is so much more potential for those that begin efforts much earlier and work throughout their lives as change agents.

The Social Beginning Is the Beginning of Change Agents

Potential medical students and others preparing for health and education careers should spend age 14 to 30 years working in their communities improving health, education, and local resources in their communities. These important interactive life experiences should be the most important determinants for selection as nurses, public health officers, or family physicians. Selections should be based on the demonstrated ability to reshape lives toward better health, education, situations, environments, and relationships. 

 

Studies demonstrate difficulty if not impossibility with regard to training medical students in service orientation and empathy. These areas have been linked to primary care careers, but many still lack these important characteristics most important for changing people. It is likely that change agent characteristics are shaped long before medical training.

• Why do we still cling to medical training as able to shape these change agent areas?
• Why do we still believe that medical training can resolve deficits of workforce even with known deficits of the payments to support the workforce to address the deficits?
• We have far too many beliefs and assumptions that prevent needed changes.

As soon as humans become social and most interactive, their interactive abilities should be developed by opportunities to facilitate people change - starting age 14 for some and later in others. 

 

The Culture of Health Required to Change Outcomes Requires Change Agents

 

The Culture of Health that we most need to improve health outcomes, requires entirely different culture shaping the needed change agents.  

 

Why do experts discover this at the end of their careers, after watching another 300 million dollars in grants fail to improve much more than process? 

 

We have enough data to know much about disparities, but still lack the local focus to address them.

 

Just a few local projects include child development, facilitation of education, enhancements of parent involvement from the earliest years of life, development of community resources, projects mentoring youth, and Community Oriented Primary Care interventions working with local health care and local leaders on specific areas as guided by community needs, preferences, and readiness. Unless you experience the awesome power of community mentorship and community outreach, you will never understand the true assets and resources of even the most underserved and disadvantaged communities.

Our nation cannot be fixed from above.
It can only improve from the ground up.
Anyone who says they can fix America from above
is selling something Americans have bought too much of already.

 

Culture, Context, Continuity, and Commitment

 

Only preparation, selection, training, and payment design specific to health access within the context of local community, culture, and practice can address the basic needs of most Americans most behind as well as facilitating the higher primary care, community health, public health, child development, education, and similar functions.

When students are prepared and selected the ways that are best for most Americans, their thoughts and actions and reflections can reshape an entire nation. Lack of making a difference for decades indicates our continued failure by design.

 

We completely lack the focus on continuity at the highest levels and the focus on commitment at the highest levels for impact at the local level. 

Family Medicine Needs a New Beginning

Learning the Most from Those Most Different and Those Making a Difference

I have learned the most from those with different backgrounds and those who have experienced different training, often self-engineered (rural, accelerated FM residents, older students or FM grads, previous nursing or public health, activist students and residents, qualitative researchers, faculty that practiced where needed before becoming faculty). At STFM, these were generally seen in the 5 or 10 minute presentations - not the big ticket areas. Much learning occurs when you meet with these individuals and learn from them, between sessions or during sessions. As with curricula, it is the extracurricular that can be most enlightening.

Sadly our nation learns the least from most Americans most behind - and fails them most by designs shaped by those who know them least. They are damaged by lack of awareness to some degree, but mostly by those who focus on "their version" of quality efforts not realizing that what they do is most damaging where outcomes are already worst. The fact that we tolerate Pay for Performance designs is most revealing.

The P4P designs lack evidence basis for health outcomes and have evidence basis for discrimination against providers who care for those most complex with lesser health and most in need of care. Those with different backgrounds, preparation, selection, training, and careers would never tolerate this. Leading a nation to change requires us to change who we are in ways that can help our graduates change others and an entire nation. 

 

Shame on us for accepting the rescue plans of any political party and the sellout of American health care by corporate greed and the many misguided CMS designs. Shame on us for not addressing the substantial error in the literature - particularly regarding medical error and quality improvement.  Why do we tolerate the literature shaped by bandwagon assumptions and beliefs? Where is the critique and logical reasoning that should have protected us and most Americans?

 

Less Focus on Parties and More Focus on People

Political parties obviously have little focus on most Americans. Parties are most important to parties who have parted with people. 

 

Party atmospheres are also promoted by Family Medicine Party associations. I must admit enjoying family medicine parties, otherwise known as STFM Regional and Annual Meetings and Annual Meetings of the Students and Residents. But parties often distract from needed change.

 

One change that should have been done long ago is breaking up a very expensive Student Resident Faculty party in August in Kansas City. Students going to the meeting are already committed with few going that have yet to decide. There is great potential for intervention before medical school and at state or regional levels. 

 

Changes should include: 

• Making it regional or state
• Making it a celebration of Doctors Ought to Care or COPC projects involving age 14 up student projects.
• Making it a health career orientation for secondary education students. 

There is great power in Rural High School Career Fairs or matching up students to community mentors and projects. 

 

Even a focus of the Kansas City party on medical students just admitted to medical school would be better than those already committed to FM. Some of the best FM interventions were timed before medical school - timing prior to formal curricula that often retards the most important learning. 

 

The focus of early and often interventions would be attracting change agents to family medicine. The benefits at the community level would be enormous, and communities would learn to appreciate local students and their activities. They may also be more willing to support them as students, medical students, or local family physicians. 

Isn't it quite clear over 100 years that our nation 

• has moved away from the health care needs of most Americans, 
• has moved away from the health workforce needed by most Americans,  
• has moved away from the support of that workforce
• has moved away from the preparation and selection needed for that workforce
• has moved away from the specific training needed for that workforce
• has moved away from community level resources, projects, promotions, and performance.

Why not spread the focus on the Culture of Health and focus on the change agents to bring about such a culture?

 

Best Beginnings for Health Access Careers Are Quite Different. Medical Students Remain a Poor Choice for the Health Care Needs of Most Americans - too exclusive in origin, background, medical school, training, and distribution.

Are Departments of Family Medicine Necessary?

 

Rural Medical Education Rearrangements of the Deck Chairs

 

Why More Federal Dollars for Graduate Medical Education Still Not Able to Produce the Workforce Needed for Most Americans Now and Especially Not in the Future?

Annual graduates continue to increase at rates must faster than population growth or growth of the elderly, yet more sources all expanded have failed to address shortages. Where did the graduates go? Not surprisingly they follow the dollar directions shaped by health policy. GME training produces the wrong physicians for the wrong specialties and the wrong places.

Residency expansions could increase the physician workforce but will not address shortages of workforce, poor retention of graduates where needed, health outcomes improvements, or access to care for Medicaid and Medicare populations falling most behind. Residency expansions will worsen health care costs and will further marginalize physicians in their contracts with employers. New medical schools, residency programs, or nurse practitioner/physician assistant programs should not be promoted as a solution for health access woes. Only substantially more dollars to support more team members in lowest concentration settings will address health access deficits.

Graduate Expansions Fail for Relief of Shortages

• Residency expansions cannot address shortages. Too few dollars go to the places to allow adequate team members. Only payment changes can address shortages.
• Residency expansions cannot address poor retention and higher turnover where payments are least, support is least, and complexity is highest. Only payment changes can address these areas. 
• Residency training continues to produce the wrong specialties for the wrong places. The payment design prevents MD DO NP and PA from remaining within primary care careers and prevents residency graduates from staying within general specialties as taking a fellowship or two results in a great deal more support with less complexity and more team members to share the load.
• Uses of Medicare and Medicaid dollars for training are not specific to the needs of Medicare and Medicaid patients most left behind. The designs prevent graduates from going to places where such patients are concentrated and prevent the specialties that they most need.

Health Care Cost Acceleration

Expansions of residency positions are promoted by those who most benefit from such expansions. Fewer graduates can help to prevent runaway health care costs.  Nurse practitioners and physician assistants have long been promoted as excellent contributions for primary care, but do as well or better in subspecialty teams. More patients can be seen in more settings and the physicians can focus on the highest revenue areas.

Accelerations of health care costs are a primary mechanism resulting in across the board cuts - cuts that hurt the lowest margin practices. The lowest margins are seen in generalist and general specialty workforce.

Overproduction  

Too many MD DO NP and PA graduates are being produced. The growth far outstrips population growth and growth of the elderly. The result has been employer dominated workforce. This tips the balance greatly toward employers, particularly in areas with the least payment support. Various sources are played against one another and this prevents understanding of the damage done by too many graduates.

Inequities Contribute to Disparities and Poor Outcomes

Residency funding is distributed most inequitably, adding to disparities directly in dollar distributions with further contributions in the products produced. Only 6.5% of residency positions are found in lowest physician concentration counties with 40% of Americans and 43 - 47% of the elderly, poor, and others most left behind.

Residency training design is a great fit for the highest physician concentration places. These include 6 states, 100 counties, and 1100 zip codes that already have top concentrations of physicians. 

Residency is the dominant factor in practice location. About half of residency positions and 45% of physicians are found in 1% of the land area in 1100 zip codes that have the most lines of revenue and the highest reimbursements in each line. These are crafted by payment designs that leaders in top concentrations have largely shaped and protected.

Research has long established that physicians will crowd in to higher concentration places rather than to distribute to places of need.

Too Many Graduates Already

By the end of 1980 the US had 20000 physicians entering the workforce with 1500 for PA and 1500 for NP. Now 30,000 physicians enter the workforce with 20,000 for NP and 9000 for PA. In only a few years there will be more NP and PA than physicians. Each year brings a few thousand more NP graduates with no sign of slowing. New medical schools are being added and new PA programs as well.

The US will never resolve shortages by producing more graduates. Massive expansions have long failed as demonstrated with a 12 times increase in nurse practitioners since 1980 along with a 6 times increase in PA and two doublings of DO graduates plus 25% from international sources plus a 30% increase in MD graduates.

These increases have resulted in little or no increase in primary care and a massive increase in non-primary care workforce. 

Health care institutions, corporations, and businesses prefer to generate more revenue from services, tests, procedures, and evaluations that are paid at much higher rates. It is even better if this has lower overhead. Primary care and basic services are high in overhead and low in revenue. Businesses invest where profit is most likely and payment designs have take away the profit in primary care for decades.

Expansions Fail for Primary Care, Mental Health, and General Surgical Specialties

Despite recent expansions, the collapse of internal medicine primary care, family medicine down to 70% primary care result, and pediatrics down below 40% have resulted in less physician primary care. Each year the US gets less primary care result despite more graduates.

The last doublings of physician assistant and osteopathic graduates resulted in no net gain in primary care workforce. The entire expansion was devoted to non-primary care.

The last few decades of workforce expansion have entirely been in non-primary care highly specialized workforce areas in places with higher concentrations of workforce - where we already overutilize and have costs too high. Too Many and the Wrong Clinicians. The dollars expended follow the workforce to more spent for procedural, technical, hospital, and highly subspecialized leaving less for primary care and basic services.

Primary care spending and spending where people need care has remained stagnant for decades by design. NP and PA also add more specialties and more are added to each new specialty - leaving family practice positions behind - the predominant primary care form for NP PA and DO. 

Even family medicine is no longer immune to payment paucity with over 90% active in FM dropping to less than 70% in the last 15 class years. Family medicine may soon break the 50% mark with less than a majority remaining active and in primary care over their careers. This could begin in the next few class years due to insufficient primary care support, costly complications, and rapid increases in complexity. Burnout is at record high levels due to payment design. 

Primary care turnover costs are estimated to be over $300,000 per lost primary care physician or about twice the cost of loss of NP and PA clinicians, but clinicians turn over at twice the rate of primary care physicians. Worsening morale, productivity, burnout, and turnover result in negative margins.

Flexible workforce follows funding. Once primary care training physicians had no other options, but now they have many hospital, urgent, emergent, and specialty options. NP and PA graduates once had few options, but this is no longer the case. As with physicians, they have more support and more team members and more specialized roles with less complexity and higher salaries - all set up by payment design.

The Evidence All Points to Payment Failure

The evidence points to shortages as the result of payment design. Only the academic community clings to workforce as being shaped by training. Without the dollars injected into the services provided by basic specialties, there can be no resolution of shortages.

The nation needs generalists, mental health, and general surgical specialties now and for decades to come due to aging changes. This is even more important where most Americans are found with lowest concentrations of workforce as there are few other types of specialties. 

These basic services are lowest paid services and remain so by design. The MD DO NP and PA expansions do not reflect any movement toward addressing these workforce areas because of payment design. The failure of massive expansions should have long ago pointed to payment failure.

Payment Failure Fails Most Where Workforce is Most Needed.

Demand increases are greatest in 2621 lowest physician concentration counties that are growing the fastest

• In population (30% faster for decades)
• In elderly
• In chronic diseases
• In complexity

The Role of Affordable Housing

Americans in higher concentrations are being displaced by city, county, developer, and government designs. Land is most valuable in higher concentration settings. Converting areas of lowest value (affordable housing, older housing, public housing) to highest value is quite profitable. Many participate in these schemes. Articles indicate the worsening shortages of affordable housing across metro areas of the nation.

Destruction of affordable housing in higher concentration settings forces Americans who are older, less healthy, disabled, Veterans, Medicare, Medicaid, and Dual Eligible to go to lowest concentration counties - counties with the least resources and workforce. They bring their worst paying, least locally supportive insurance plans with them. These plans now exclude local providers, often pay less than cost of delivery, and require numerous hoops to jump through to address patient and payer needs. Those who do not want to take care of them include state, federal, and insurance payers. Providers caring for them get penalized by payment design because they care for them.

Concentrations of Patients with Lowest Paying Plans Shape Shortages of Workforce

The lowest concentration counties are shortest in workforce with 40% of the population and less than 13% of health spending. Only 22 - 26% of physicians, clinicians, internists, pediatricians, and general surgical specialties are found in this 40% segment.

In these counties about 46% of local workforce is primary care and 25% are found in general surgical specialties. Practices in these counties tend to have the oldest physicians - also an indication of lack of replacement. These counties have been hit hardest by recent designs that have compromised small practices - particularly the MD DO NP and PA that remain in family practice despite the design.

The specialties important for lowest concentration counties are in decline or are disappearing. In the following graphic the ratio of concentration is noted, followed by active physicians per 100,000, the proportion of the local workforce provided by the specialty, and expected changes.

Family medicine distributes most equitably at 1.18. Psychiatrists are 7 times more likely to be found in the 79 top physician concentration counties as compared to the 2621 lowest physician concentration counties. Family medicine remains at 26 to 32 active family physicians per 100,000 across the US and various divisions. In the very lowest concentration counties, only family practice is found. In top concentrations FM is only 3 - 5% of local workforce. Where policies are most shaped, family medicine is a small fraction. Where health access is most important, family medicine most matters. Family practice NP and PA have similar distribution, but only when staying in family practice positions. 

Only the general specialties provide much care in lowest concentration counties 

and only when they stay general and do not go on for one or more fellowships. 

Note that residents are 150 per 100,000 in the 79 top concentration counties - a level much higher than 115 active physicians per 100,000 from all specialties as found in the 2621 lowest physician concentration counties. It is a great advantage to design a new line of revenue specific to higher concentration settings.

General specialties are in decline and some are collapsing. In recent years, new specialties have replaced old as seen in pulmonary, oncology, and radiology. The new forms of oncology and pulmonary critical care and radiology do not distribute well at all and are replacing the older more general types. This is a reflection of differences in training and lack of distribution of those younger. 

Hospital closures are predominantly in these lowest concentration counties and the closures force the departure of 20 - 30% of local workforce. Care of challenging populations with lesser health results in more penalties - a known consequence of Pay for Performance. 

The loss of a hospital also forces delays in the care of urgent and emergent care needs such as involving trauma, falls, sepsis, acute vascular events, respiratory failure, asthma, allergic reactions, dehydration, burns, and other conditions.There are more ways for children, infants, new mothers, pregnant women, toddlers, teens, and older Americans to die - by design.

Demographics, Distributions, and Discriminations All Around

Poor Fit All Around

Resident training depends upon medical school selections. Medical schools select the wrong origins for these careers and locations. Medical schools train wrong for these careers and locations. An initial residency is just a stepping stone past these careers and locations. Payment design prevents these careers and locations. 

Just one fellowship that greatly benefits the teaching hospital allows the residency graduate to bypass what is needed to a place with better support, more team members, and less complexity along with higher salary and opportunities for income beyond salary.

The dollars flowing to these lower concentration places are too few to support the workforce - regardless of any training intervention. NO Training Intervention can help until payments are increased for generalist and general specialty services. Only then can more be hired and better supported along with the team members to address the massive and growing shortages.

Movement from 6% of health spending to 12% for primary care is required with nearly all of the additional dollars going to lower concentration counties - and without requirements for additional tasks that distract team members from restoring access.

Additional Funding Is Not Needed for Residency Positions

The last decades of residency expansion have been funded teaching hospitals and the VA.

Once again the most lines of revenue and the top reimbursement in each line goes to teaching hospitals. They have demonstrated the ability to create and sustain residency positions.

Teaching CHCs - Close But No Cigar for care where needed

What is Stunning About Primary Care Is No Change By Design