Primary Care Models: Not One Size Fits All

A Perspective From Reid Blackwelder, MD, Board Chair, AAFP

Laurie Scudder, DNP, NP; Reid Blackwelder, MD


March 31, 2015

Editor's Note: A two-part documentary, Rx: The Quiet Revolution, will air on PBS on April 2. Reflecting on his physician father's practice and the move away from hands-on care in contemporary medicine, the documentary's award-winning director, David Grubin, highlights a range of innovative practice models from Maine to Alaska. Medscape asked a number of our experts to preview the film and offer us their reactions and opinions about how well the documentary depicts the healthcare system as they know it and live it.

In this commentary, Reid Blackwelder, a family physician in practice in rural Tennessee and board chair of the American Academy of Family Physicians, offers us his perspective.

Medscape: Do the primary care models depicted in the documentary resonate with you and reflect the world of primary care as you know it?

Dr Blackwelder: The two models—one in rural Maine and one in Alaska—focused on different things, and I think that's important to show. In Maine, I very much loved David Loxterkamp, the physician. He is obviously compassionate, caring, well-rounded. He played guitar; he went running; he knew his patients; he made house calls. This was a powerful individual who personally transformed a practice and created a team. I think he is symbolic of why most people go into healthcare, which is—we all say this— to help people. We also know clinicians who demonstrate it better than others. This physician is a charismatic, dynamic person who transformed his practice and, therefore, the care of the community.

In comparison, the transformative figure in the Southcentral Foundation in Alaska was actually Katherine Gottlieb, a member of the community who started as a receptionist and eventually became the CEO. She was the powerful transformative individual in that model, not a specific physician. She was somebody who had the organizational structure and vision—plus, obviously, a strong cultural background that fit with the community. That community-based practice model required many other people. You saw the faces of the team, and that's another powerful message. I don't think you could identify a clinician that necessarily stood out as being the real mover and shaker. That's not a good or bad thing; it's just an interesting comparison.

I think depicting these successful models is important and provides hope. We need to have clinicians and practices that show that it can be done, even in the damaged system we have.

This is the powerful message—that these stories are coming out of a fee-for-service, siloed, fragmented healthcare system that is much maligned. These people are succeeding despite those challenges, and they can show the way for the rest of us as we are in the process of transformation. You can make it happen.

I like that the documentary will allow a physician who is in solo practice to watch the segment filmed at Seaport Community Health Center in Maine and be able to say, "He did it. Maybe the first step I should do is maybe make a home visit once a month."

Or the provider in a larger community practice, such as Southcentral Foundation in Alaska, who may be feeling disconnected, could watch that practice and say, "Well, I wonder who the champion is in this setting who is able to help this system do a better job for this community?"

I like that breadth of opportunity shown in the documentary. That was one of the things that was most notable to me. The practice in Maine had a very visible face; you knew it was that physician. The second in Alaska had a system, rather than a single individual, that had become part of the community in a very important way.

Medscape: Is it an aspirational and achievable model?

Dr Blackwelder: It has to be. To those who say, "We can't do this," the film answers, "Well, they did." That doesn't mean it wasn't without sacrifice, and we don't know what their bottom-line numbers are. I'm sure there'll be folks that will note that Dr Loxterkamp in Maine is probably not earning the salary he should. One of the responses I would have is that he's not doing this for the salary; he's doing it because it's exactly what he loves to do and is right for him.

Not that the financial questions are not important ones. But one of the biggest frustrations that I think people have in primary care, regardless of money and payment reform, is barriers to achieving the satisfaction of being a healer.

For me, that's one of the more powerful messages of this documentary, in terms of its depiction of a model that is achievable. Here are people demonstrating a way to reclaim, or perhaps not ever lose, the joy of what took them into healthcare in the first place. It is very much achievable. That doesn't mean it won't be hard, but it certainly looks like its well worth doing in whatever way your community most needs.

Medscape: In your view, what are the lessons to be learned from these models?

Dr Blackwelder: These two separate models emphasize two different but important things: the importance of teams, and the importance of patient-centeredness. I'm speaking to your from a conference sponsored by the American Pharmacist Association. I and a colleague, a clinical pharmacist who works in my practice, are providing the keynote address at this meeting. Our message is about the need for critical members of the healthcare team to come together and act as a team in the setting of the community.

These two practice models really reinforce how important it is for those of us who believe in team-based care to spread this message.

The other key lesson is about patient-centered care. I've been talking about patient-centeredness for a long time. I'm afraid it's become a bit of a catchphrase and it's lost the meaning, but I've got two comments. The first, and I am not the first person to emphasize this, is to remember: It's not patient-centered until the patient says it's patient-centered. I'm afraid a lot of folks who create teams begin by emphasizing that their practice is going to be patient-centered. But the team members then get together and make decisions and sort of forget to see what it is the patients in the community need.

My second comment is that I'm really beginning to believe that the goal must be not only patient-centered, but also community-centered.

The more correct way of really exploring or implementing the patient-centered medical home is to envision it as a community-based medical home. Both of the practices—especially the one in Alaska, because of how wide-ranging that delivery system was—really point out the importance of community-based care that is also culturally based care. That's why each community really has to find what it needs most. When the stakeholders found that the model that they had in Alaska was not working for their culture, they changed it to find a way to make it happen—by, for example, incorporating community health aides, most of whom are members of the community who were selected and trained to fill a critical role. But their most important role is in saying to the people served: These are my people; these are my family. That's such a powerful message.

Medscape: In your opinion, is the transformation healthcare is undergoing as the result of the continuing roll-out of the Affordable Care Act (ACA) going to help or hinder the creation of true community-centered practice models? Or is the jury still out on that?

Dr Blackwelder: Right now, as we are in the process of transformation, some of these changes are probably a little easier because people don't yet know "the rules" (a term that I put in quotes). When you're an early adopter, you find—and I don't want this to sound negative—ways of doing maybe a little more than people might have expected because there wasn't a rule that said you couldn't. Or there was a rule, but it was a rule that still had holes, and you filled in the dots.

Early on in this process of transformation post-ACA, people are making it work. But what happens in systems is that there is often an expiration date, if you will, to that period where change can be accomplished ad hoc. The people affected by the system recognize loopholes or places where there is too much leeway. Eventually, rules are tightened either by Congress or through insurance plans that limit things, and then it can become more difficult to be creative.

I think we're going to watch this go back and forth. My hope is—and this reflects my personal approach—that we will put in place some guidelines but recognize that it really is about the individual patient and the community.

I'll give one very practical example. We all read any number of guidelines that refer to use of a screening test that, in general and when applied to a population, has good evidence to say it can help pick up a specific cancer early and make a difference. That's wonderful, but I don't treat average patients. When I see my individual patient, I have to take in consideration all the variables that are part of that patient's life and philosophy, their fears, and their context. I have to answer their questions, I have to be able to say that this test looks appropriate for them.

But, if that person tells me that he or she really does not want the test, and does not want any of the treatments that may be called for by the results, why should I do the test? When the patient makes that decision—because it's about shared decision-making—I as the provider have to have the necessary comfort level to allow the patient to make that decision knowing that it will not affect how the system evaluates me as a physician. In the system now, the insurance company could review my chart, conclude that I have not performed appropriate screening, and determine that I'm not a good doctor. And yet when you see what happened in the room, I am actually being a very patient-centered physician and supporting the right decision for my patient..

I worry that we restrict ourselves in order to be standardized. When, in actuality, we are taking care of a lot of individual patients and individual communities, and we need to have some flexibility to allow those individuals and those communities to have an opportunity to decide what they need to be community-centered, what resources they have, what they need, and how they all interact to make it work.

Medscape: What are your final messages for primary care clinicians?

Dr Blackwelder: There are a couple. First, I was struck by the analogy referred to early on that people are not birds. It's easy to hit a fixed target when you're throwing rocks. That's why we have numerical targets, such as A1c for diabetes. You can get to that number in anybody. You may hurt the patient; you may even kill the patient. But you can get to that number one way or another if you're just throwing rocks. But if you recognize that people are more like birds—that they move rather than stand in one place—then you have to be creative. You have to make the target attractive so that the birds will come to it. I thought that was a great analogy for the challenges we face taking care of patients.

I also was struck—and this comes through very clearly in the documentary—by the power of caring, not just on a personal basis but also in the larger community and with the team members. You have to have good communication, trust, and respect. You've got to have all of those things, and I think that was demonstrated though not overtly discussed.

A third takeaway is the huge difference that seeing a patient in their natural environment with a home visit provides. It is a totally different vision. As was demonstrated in the community in Alaska, however, that perspective can also be provided by seeing people in their broader community. In the very remote settings shown where there was not a physician, the community-based provider brought that perspective back to the team.

And a final comment is to contrast the care depicted in these models with what too often happens in our current healthcare model. Before the Southcentral Foundation's development, the one that existed in Alaska especially was the patient got the wrong care at the wrong time in the wrong place from the wrong person. They all went to the emergency department—the worst possible scenario. Our advocacy always has to be toward ensuring right care, right place, right time, right person. That really does embody the importance of primary care; it embodies the recognition that we have to have teams to be able to do this, because every team member brings a unique set of skills and is critical to the function, although we're not interchangeable.

So, how do we find a way to make that work? This documentary demonstrated two different but effective models, and those are really important messages.


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