Why More Assistant Physicians Should Be Utilized in Primary Care

Last month, I wrote about “What is an Assistant Physician?,” and also introduced you to Amber Milward, MD AP. It’s been three weeks since she started with us here at Direct Primary Care Clinics, LLC in Osage Beach, Missouri. So, what do I think?  I think I need to explain why Assistant Physicians should be utilized in Primary Care.

Dr. Milward’s knowledge is far superior to that of any nurse practitioner student that has previously rotated through my office. This is no surprise, since Dr. Milward matriculated from an accredited medical school. The healthcare industry is beginning to take notice of Assistant Physicians’ strength of education. According to the Primary Care Coalition Issue Brief: Collaboration Between Physicians and Nurses Work, the number of clinical hours (hands-on training seeing actual patients) for MDs is four times that of those getting a Doctorate of Nursing Practice (DNP).

So when it comes down to it, who would you prefer to be treated by if you’re sick – Someone with 500-1500 combined clinical hours, or someone with 6,000? Of course, there is another big difference in that certified physicians (like myself) have also completed at least three years of residency in primary care – including another 9,000-plus hours of intense, grueling training.

Of course, specialty residency training delivers a superior level of overall knowledge and expertise. I am not saying there is anything wrong with Nurse Practitioners, merely pointing out the vast difference in training and education. I have yet to work with or meet a Nurse Practitioner or PA (Physician Assistant) who does not acknowledge the extent of my education and training, as well as appreciating what they can learn from me. I believe they would each likewise feel there is something to learn from those MDs who have completed medical school, but have not completed residency training.

Imagine a practice consisting of a Family/Internal Medicine/Pediatrics physician, supported by an Assistant Physician (MD), a Nurse Practitioner (APRN or FNP) and a Physician Assistant (PA). Patients would have confidence that the care they receive from such a collaborating practice would be complete and thorough, as the definition of a collaborating practice is under the umbrella of supervision of the residency-completed overseeing physician.

To my fellow residency-completed primary care physicians: I suggest that you consider hiring an Assistant Physician as a mid-level provider in your practice. It would be a bit more like the “good ol’ days,” when physicians were trained as apprentices. The extent of their knowledge base is fantastic, and they are closer to medical school than you; they’ve more recently dissected the human cadaver. They have more recently practiced over and over the one-handed tie. And they are eager to work and to learn everything you can teach them about what you know best: how to deliver excellent individualized primary medical care. Feel free to contact me if you have any questions!

What is an Assistant Physician?

In 2014, then-Missouri Governor Jay Nixon signed the bill that created a new “mid-level” medical provider position, making Missouri the first state to license Assistant Physicians. But what is an Assistant Physician?

An Assistant Physician (NOT to be confused with a Physician Assistant!) is a graduate of a medical school, who therefore has a Doctorate in Medicine (MD), but has yet to complete a residency program. This medical school experience contains intense learning and skill development, covering ALL areas of medicine. For physicians, the residency that follows hones those skills into a particular specialty, such as Internal Medicine or General Surgery.

So why didn’t these medical school graduates get into residency? Is it really that difficult to get into a residency program?

Most folks don’t care if their physicians have an MD or a DO behind their name, which is good.  They are still “doctors.” There are differences in the methodology of the two schools, but overall competency is pretty much equivalent between the graduates who matriculate from medical schools or osteopathic schools.  Take a look at the chart below and note the 2016 percentages of MD and DO graduates in the U.S., as well as International Medical Graduates, who are degreed from non-U.S. medical schools.

Figure 1

Figure 1:Society of Teachers of Family Medicine

This gives you some idea of what the competition looks like, but not as clearly as this second graph I found:

FMpositionsfilled

When I graduated from my US medical school in 1999, it was so easy to get my first choice– notice the difference between number of available slots in Family Medicine residencies (blue line) and the number filled (red line). Nearly 600 residencies went unfilled in 1999, versus just over 100 empty spots this year. No wonder my second choice wanted to convince me to be their first choice – I was a U.S. medical school grad! Easy-peasy!!!

But take another look at that same graph – what happened around 2013? The number of residency positions in Family Medicine had decreased over the years, because they weren’t filling. Then in 2013 they started filling again. The number of available positions gradually increased, but the rate of filling those positions remains the same. In short, it has become a fierce competition to get into residency.

I know, I know – I’m throwing a lot of boring statistics at you. But the bottom line is this: getting into residency has become extremely competitive. Unfortunately, this leaves many competent doctors left behind in a cartoonish dust cloud. So they re-apply the next year. And the next. After a couple years out of medical school – with the medical school debt they can’t possibly pay back on a non-physician salary – it becomes harder and harder to get into residency.

Okay, this is all very well and good, but I have been speaking in a vague and abstract manner.  Let me put a face and a soul to this problem:

Meet Amber Milward M.D., AP. She received her Bachelors in Science from the American University of Antigua, St. Johns, then went on to earn an M.D. from their accredited medical school in 2013. While attending medical school, she also earned her online Masters in Healthcare Administration from Walden University in Minnesota, with the goal of gaining a competitive edge when applying to residency programs. Upon graduating in 2013, she applied for residency positions in multiple primary care specialties. And then again in 2014. And again in 2015. She was told by every residency program director that they “ranked” her as a potential candidate, but she had not matched – meaning, she had yet to get a foot in the door of a residency program.

Since then, she has done volunteer work to keep her skills up, and studies to stay up-to-date. But stuck in the limbo-land of Medical School/Residency purgatory, she could not get a paid position that allowed her to use the knowledge and skills she has obtained. Until Missouri’s Assistant physician program became reality. This program gives her –and the many other qualified medical professionals just like her– an opportunity to use their earned medical degrees to benefit patients in need of care.

Dr. Milward, Assistant Physician, will begin a collaborative practice agreement with me in April. Dr. Milward is originally from Arkansas and is no stranger to the Ozarks. She can learn a lot from our members and this experience will give her a lot of additional training.  I hope you will all welcome her and help her learn even more about Family Medicine. As I will attest, the ONLY excellent way to learn the practical side of family medicine is from listening to you – our patients.

Taking a stab at it

I’ve finally completed the Acupuncture Course for Physicians through The Academy of Pain Research in San Francisco! With my extensive hours of practice (especially body acupuncture), I am ready to apply all my knowledge for my members! We’ve already had some wonderful successes with it, from healing skin wounds, to treating wrist pain following a fracture, to helping with sleep, to helping with weight loss. Can I help you with your problem? I’ll take a stab at it!

Here’s what I’ve learned through the practice period: it takes commitment. There is no magic bullet, no super pill, no “single-acupuncture-treatment-and-I’m-healed.”  The more chronic and complex the problem(s), the longer it will take. But the commitment pays off, big time.

Here is the concept: we have energy pathways throughout our body that communicate with the brain. The brain is truly the engineer driving the complex train system. When there is pain, that means the energy has congested – has an obstruction over the tracks, so to speak. Until the obstruction is removed, the brain will continue to perceive the pain – even to the point that it becomes a habit. The brain is designed to learn, but not “un-learn.” It’s as if the brain gives up on that area, even after the obstruction is removed. Let’s say repetitive movements with one hand or one arm cause the muscles to cramp up. The brain perceives the blockage in the system caused by the repetitive strain on the musculature. If it goes on long enough, even when the muscles are no longer cramping up, the brain will believe there is still pain.

So, how long does it take to create a habit? Behavioral experts say it can be as little as 21 days for something simple, but more like 66 days for something more complex. This is why with longer-standing problems (the longer the obstruction has been on the tracks, so to speak) there is a higher likelihood that pain will continue to be perceived after the obstruction is removed. So is it any wonder – if acupuncture is “re-training” the brain – that in order to achieve true results it may require a couple months of treatment?

I’ve also learned that once a month is likely not often enough, and certainly once a week isn’t sufficient, at least not during the initial phase. The frequency should be at least twice-weekly treatment for 3-4 weeks, followed by a break and then another 3-4 weeks for chronic issues. I have not yet had anyone go for the 9-10 weeks that would encompass 66 days. But I have some dedicated souls who are working towards it.

The Bottom Line? Rome wasn’t built in a day.

Our body is designed to heal itself.  But in order to do so, it must have all the right tools. While duct tape and popsicle sticks came in handy for MacGyver, the body cannot effectively run on junk, much less heal itself. It needs good nutrition, sound sleep, and plenty of water – the three things in which I observe most patients to be deficient. If we are trying to heal using acupuncture, but are missing essential ingredients, all the acupuncture in the world will not be enough to get over the hurdle. This is why I recommend members add the Wellness Package to their membership. It helps get the body prepped and ready to address the needs of opening the energy system, in order to create the best environment for healing.

So – I’m ready to take a stab at it.  Are you?

It Takes Two to Trust

Our Mission at Direct Primary Care Clinics LLC is;

“To break down the barriers that currently exist in the patient-physician relationship, to restore mutual trust, and to provide excellent individualized primary health care.”

But how does one “restore mutual trust?”

First, the word “mutual” comes before “trust” in the sentence – not just because of standard English sentence structure, and not just because it is the describer of the noun. Mutual is defined by the Cambridge Dictionary as:

“(of two or more people or groups) feeling the same emotion,
or doing the same thing to or for each other.”

It can also mean holding something in common. This indicates that the trust I will have for the patient must by definition be shared by the patient with me as their physician, and most certainly vice-versa.  The patient’s trust in me must be shared by me, the physician.  This sounds very simple, since it is the basis for all relationships. But it is a rarity in today’s medical world.

Let’s start with the example of a medical problem, such as hypertension (high blood pressure). The patient often does not know they have hypertension, until their blood pressure is taken.  They may not even realize that their recent daily headaches, or the reoccurrence of nagging chest pressure, may both be signs of high blood pressure. But when discovered, it is – or rather, should be – a concern for the patient. It should also be a concern for the physician, and not simply because it falls in their area of expertise. It should create a MUTUAL concern. Now, within their relationship, the patient and physician have a mutual concern. The patient then should trust that the physician has the knowledge and means to help the patient with the problem. The physician should trust that they have the knowledge and motivation to help the patient with the medical concern. But that is not enough to truly constitute trust.

Since I’m into defining for you, let’s see how the Cambridge Dictionary defines Trust:

  • to have confidence in something, or to believe in someone, or
  • to hope and expect something is true.

In our above scenario, the patient should have confidence in the physician and believe the physician is working in their best interests. The patient HOPES and EXPECTS something from the physician. In Mutual Trust, the physician also has confidence – in the patient. The physician HOPES and EXPECTS something from the patient in return. I believe it boils down to this: the patient and physician will be on the same page regarding their hypertension, or whatever the real-world medical problem may be.

It is my belief that this mutual trust is absolutely essential to provide the “excellent individualized primary health care” we commit to in our DPC Clinics Mission.  If the trust is one-sided – either on the side of the patient, or the physician – and not mutual trust, the delivery of excellent care is impeded. If the patient has full trust and confidence in their physician, but the physician is suspicious of the patient and is confident in only their own medical ability, the physician does not – CANNOT – deliver truly excellent care. If the patient is suspicious of the physician and does not have confidence in the physician’s ability or motivation (even when the physician believes in the patient and their integrity), the delivery of care could well be “dead on arrival.” What is the saying? “You can lead a horse to water, but you can’t make it drink.”

This relationship-essential atmosphere of mutual trust has been assaulted by a number of outside sources, which I may touch on in a separate rambling. The concept of restoring this precious thing – mutual trust – is part of our Mission. The relationship has been broken, and building it back together like Humpty Dumpty is exacting and can be tiring. It takes effort, and must be done one person, one interaction at a time. Because it is time-consuming, it cannot be realistically accomplished in 10-15 minute intervals with 40 people a day. When you take into account time for administrative grunt work, not to mention the time required for personal relationship-building, you begin to see that time is the primary obstruction standing in the way of restored mutual trust. This is also why Direct Primary Care (DPC) is the best model for rebuilding that relationship – because we have adjusted our time around building relationships, instead of adjusting our relationship-building to fit the time.

By keeping our patient panel – the number of patients for whom we care – purposefully low, we can spend more time with each individual, provide better communication tools for our patients, and work on restoring mutual trust. Our Mission Statement posted in the DPC waiting room. It’s the first thing you see when you walk through the door and – hopefully – it will be the first thing you notice during your interactions with our DPC Clinics team.

1

 

Deer Me!

HALvsdeer

It was bound to happen sooner or later, with the abundant amount of deer roaming loose in the Ozarks.  These gals and guys don’t bother to look both ways when crossing a street, I’ve noted, and when you drive a quiet hybrid car, they must tend to think that the headlights are a large lightning bug approaching.

I was driving home one evening, just me and the little dog in her seatbelt-strapped-in carrier, minding my own business, on a winding wooded country road.  We were only going about 40-45 miles per hour, since we’d just turned left at a near 90-degree turn and were gathering up a little speed to head up a hill.  Out of Nowhere – which apparently is my name for the wooded area just at the bottom of the hill on the driver’s side heading home – out of my peripheral vision came barreling toward me the largest un-antlered deer I’ve ever seen. It may have been a small elk for all I know.  At any rate, no time to stop, I realized it was going to hit me. I instinctively swerved as I stomped on the brake pedal, and braced myself as the deer slammed into me.  “I am going into the ditch,” was my thought, and so I held on, steering the car so that the passenger side wheels would not go into the ravine part of the ditch.  I did not want to roll the car. Slowed to a crawl now, I drove forward for a few feet, thinking I might be able to drive out of the ditch, but as I heard the undercarriage of HAL (my Prius) being scraped and smelled a hot car I thought best to stop.  (Yes, I named my Prius after the computer on 2001: A Space Odyssey. http://www.imdb.com/title/tt0062622/ )

I sat for a moment, reasoning; I can’t drive this car out of this ditch, the ravine is too deep, and I can’t back up because there are large rocks in the ditch that have already scraped the undercarriage.  I looked at the space between my driver’s side door and the road.  I could probably open the door about 5 inches, and I’m no slender girl.  So I unbuckled myself, and my little dog’s carrier, put her in the back seat and crawled over to get out on the passenger side. I looked back down the road and, sure enough, there lay the deer – in the opposite lane of traffic, lying right across it like he/she was taking a nap and hogging the entire lane to him/herself. Along came a fella in a pickup truck who pulled over and got out to make sure I was okay.  I assured him I was fine, but I wasn’t so sure about either my car (I didn’t want to confuse him by referring to HAL) or the poor deer.  He looked back down the road and then offered to go move the deer.  I agreed that would be helpful for others who may be traversing the road that evening.

My Good Samaritan walked down to the deer and was standing near it, to judge – I suppose – how he was going to move this large animal.  Then, surprising both of us, it suddenly sprang up and ran back into the wooded area from whence it came.

The next day my right trapezius started to ache, like I’d lifted something heavy.  By the time I got to the office I considered either seeing if I could get a same-day massage from Infinite Touch Integrative Therapies (https://www.facebook.com/InfiniteTouchLLC/?fref=ts) or get trigger point injections into the shoulder.  But then Rebekah Anglin walked into our office.

 

Rebekah is the Wellness Coach who works out of our office on Thursdays and Fridays.  Her business is multi-faceted, but among other things, Rebekah uses essential oils and does auriculotherapy.  Now, I don’t know the physiology of essential oils, nor homeopathy, nor of acupuncture, reflexology or auriculotherapy.  But I know that if I can avoid leaving the office during a busy scheduled day, and I don’t have to have a needle shoved into my muscles, I am all for trying it.

First she concocted a muscle rub using a couple different essential oils mixed with carrier oil and it was rubbed into the aching muscle.  After about 15-20 minutes, I didn’t really notice the muscle as much.  A couple hours later I lay down on her table and she touched my ears.  Weird, but so cool.  There was one spot on the ear that – as soon as she touched it – I felt a lightning bolt go into my right shoulder.  There was another place that when she touched both ears, I felt an aching in my neck. Then, using a cotton-tipped applicator, she applied essential oil(s?) to those areas.  After asking my feet a couple of questions (don’t ask!), I got off the table and resumed work.  I felt terrific, until about 4:00 that afternoon when the aching in the shoulder resumed.  I took the oil combination she’d given me and rubbed more of it on the spot.  That night, before bed, I rubbed some more on, just for good measure, though I could longer feel the aching.

The next morning, it was as if the accident had never happened.

Now, I’m not about to stop taking Edarbi, which I take for my hypertension.  But if I have any further problems with this right shoulder, I’m making an appointment with Rebekah Anglin.  You can too, simply by calling her at (573)836-1197 or emailing: rebekah.a02@gmail.com.  She not only can work miracles (in my opinion) with essential oils and auriculotherapy, she can help you manage what ails you using nutrition.

I’m betting that deer could use her services!

Why I Am Firing My Family Medicine Board

I am firing my family medicine board, the American Board of Family Medicine, through which I have held certification for a long time.

First of all, some clarification: board certification is not required for state licensing. Once upon a time it was little more than a nice fancy title one could put after their name: “Diplomate, Board of Specialty Medicine.” It was a status symbol at one time, much like being named in “Who’s Who in America.”

Physician licensure is maintained by the State, and has nothing to do with board certification. All physicians must must renew their licenses yearly and attest that we have achieved a required amount of continuing medical education. Board certification is generally more related to what kind of original medical education a physician received: were they taught to research and study on their own, or just spoon-fed facts and taught to regurgitate them and take multiple choice exams? Can a physician think on their feet and outside the box?

The problem with many board certifications is that someone along the way decided they are schemes to remove physicians from their money.

Over the years, medicine boards have moved from a one-time passage of board exams to requiring reexamination every few years, and these exams are very costly. Many boards have implemented “maintenance of certification” programs with annual fees. Board exams have been made increasingly difficult in order to sell expensive Board Exam Review Courses prior to the exams themselves, and revenue from the study guides goes directly to the boards. Legislation has also been passed making it difficult, and potentially illegal, for physicians who have recently passed the exams to pass useful information to other physicians about to take them. And there is no recourse for addressing grievances.

In short, the board certification process has, in my opinion, become completely untenable. At least for the American Board of Family Medicine.

Back when my employer expected board certification, and when the insurance companies they billed required the same, I spent the money and was reimbursed at least a portion of it. But when I walked away from hospital employment and opened my own practice, I began working for patients. This forces me to look at those dollars quite differently. Is it truly a good investment for my patients to spend their money for my board examinations, or the costly yearly maintenance of certification programs? Sure, I get continuing medical education credit, but how much of what I am learning (i.e., to pass a multiple-choice exam) can be put into practice and actually benefit my patients?

As it turns out, I believe my patients—my employers—receive very little tangible result from my effort in maintaining that board certification. I can obtain just as much education and updates on treatment from far less expensive forums.

So, there you are: that’s why I am firing my family medicine board. The expense does not provide sufficient benefit for my patients. It is a bad investment. The return simply is not there.

I did get certification through the National Board of Physicians and Surgeons https://nbpas.org/. I did this mostly to support this board in hopes that it will be become recognized where board certification is required (primarily through hospitals and insurance programs, which I don’t play with anyway).

I just want everyone to understand that since I now work solely for my members—not a hospital system, not any insurance companies, not any governmental bodies—I have to consider every payment and every obligation, weighing whether it is worthwhile and beneficial for my “employers.” And I’m willing to bet not one of them cares at all whether I have that ongoing American Board of Family Medicine certification or not.

But they DO care whether I would end up having to increase my fees in order to continue to dance to that music.

So, you will no longer see the words “Diplomate, American Board of Family Medicine” below my name on my business cards. I will be taking down the framed paper that states I have re-certified through 2016. And I won’t have to increase membership fees.

I hope that you all, as my employers, agree with my decision