Valley. There they perform bone scans with a bone denistometer, colonoscopies and all sorts of diagnostic ultrasound, including echocardiograms. They use one of their two ultrasound machines in concert with a treadmill to perform stress echocardiograms. They do their own X-rays and most of their lab work in house, and of course the patients love it. They make fewer trips to the doctor’s office and spend less time awaiting results.
The doctors brought on David Champion, M.D., a few years ago to share the load and now each physician takes off four months a year. Sure, they take great vacations, but they also use that time to attend CME conferences, hone their skills and learn new techniques to bring back to the clinic.
Dr. Schneider told the attendees at the Family Medicine Leadership Conference that the Raymondville practice meets the FFM recommendation to embrace lifelong learning and it challenges the misperception that family physicians are old-fashioned technophobes, meeting another of the recommendations. “It’s time to broaden the scope of what we do in terms of the tools we use,” Schneider said.
Drs. Kristensen and Smith will be the first to say that their practice is not the new model and certainly not for everyone. “This isn’t a franchise possibility,” Kristensen says. “This practice can’t be duplicated in every county and every state. You have to decide what your interests are.”
Kristensen is Canadian and began his practice in the remote Northern Territories, where access to care is virtually nonexistent. Out of necessity, his scope of practice included whatever the situation demanded. After five years, he says he burned out. He took a job as an occupational doctor with the government of British Columbia. There he experienced a number of innovative practices.
After a while, he wanted to live where the sun shines regularly and with no particular attraction to Florida or California, Kristensen decided to set up shop near the Gulf Coast. Soon Smith joined him and the practice took shape. In 1989, Kristensen began to read a lot about cardiology and started taking courses in echocardiography. Around a year later, they bought their first cardiac ultrasound machine. Kristensen says the year that followed was a watershed time for the practice. “Suddenly, we had a window to cardiac care that I’d never realized.” Within a year, Smith, who had been unsure about the appropriateness of their venture, began taking courses.
Smith and Kristensen say they maintain a great relationship with the cardiologists in the area. Their work is respected. That’s not to say there haven’t been challenges along the way.
In 1996, Medicare sent the practice a certified letter saying some studies the doctors had ordered were not appropriate and they would be required to return a substantial sum of money. Kristensen says they asked for and received a fair hearing, which included submitting videos of tests to a cardiologist Medicare had designated. Long story short, Medicare rescinded its challenge and recommended that the practice be paid in full.
Kristensen says they have also been challenged by Blue Cross/Blue Shield and by Medicaid, but each time they’ve proven their case. “All I know is that since we got this equipment in our office, we’ve become superior doctors, not because we’re smarter but because we have superior technology,” Kristensen says.
For Smith, their ability to incorporate these diagnostic procedures into their practice is part of what makes practicing medicine as a family physician so exciting. “[Family medicine] really should be attracting the brightest and the best because it is by far the most broad of all the specialties of medicine and it offers the most opportunity for a person to find their own niche.”
Interest has been growing among the TAFP leadership in determining how the Academy can help its members explore new procedures. At this year’s TAFP Annual Session, the Academy created the Task Force on Procedural Skills and appointed Grant Fowler, M.D., as the chair. Fowler is the vice chair of the Department of Family Practice and Community Medicine at the University of Texas Medical School at Houston, and he is also the co-editor of the textbook, “Procedures for Primary Care.” He says the purpose of the task force is to identify what kind of procedures should be within the reach of family doctors in Texas and what role the Academy can play in providing adequate training for those.
“We’re kind of charged as a primary care specialty with managing the preventive care of patients, and it’s very simple to look at the top killers — cardiovascular disease, colon cancer, breast cancer, prostate cancer. What can be done to improve our skills at diagnosing them earlier and preventing them?” Fowler says. Two procedures stand out as areas family physicians should explore, he says: colon procedures including colonoscopy and cardiovascular screening procedures. “We need to do a better job of that, for sure treadmills, which have been in our repertoire since we became a specialty, but maybe we need to be looking farther beyond treadmills for screening cardiovascular disease.”
Some of the other procedures Fowler sees as possibilities worth exploring are joint injections, IUD implantation, colposcopy for abnormal pap smears, obstetrical and gynecological ultrasound, skin biopsies and vasectomies. Fowler likes to use the experience of surgeons when the laparoscope came into use in general surgery as an example of lifelong learning. “The practicing surgeons did not go back and redo residencies, they learned it on the job,” he says. “They went to weekend workshops and they learned new skills.”
While procedures tend to augment a physician’s revenue, Fowler and others stress that the goal of doing procedures is not to make more money. “It’s to improve patient care and perhaps to decrease liability,” he says.
As the chair of FFM’s Task Force Six, a group charged with developing a viable financial model for the new model of family medicine, Steve Spann, M.D., agrees. “We would hope we would not be dependent on adding new procedures to get the reimbursement up,” Spann says, adding that in certain places, the practice may work, but in urban and metropolitan areas, family doctors will have trouble getting managed care organizations to pay for certain procedures and lab work done in the office.
“Historically, I think primary care docs have sort of been forced to do a bunch of procedural stuff to keep up their incomes,” Spann says. “What we’re saying in Task Force Six is, ‘Look, we need to be paid adequately for doing the things we do mainstream, the cognitive stuff.” That doesn’t mean that family doctors should avoid procedures, though, Spann says, but he warns of a slippery slope where physicians might be tempted to perform procedures whether the patients need them or not.
Spann does think there is a role for certain procedures in the new model’s basket of services, listing diagnostic ultrasound as worthy of adoption. “Some say that the ultrasound machine is going to become the new stethoscope.”
The chair of the AAFP Board of Directors, James Martin, M.D., says that to decide what procedures family medicine should pursue, physicians need to ask whether they are aligned with the core definition of primary care. He agrees that colposcopy, cardiac treadmills, diagnostic ultrasound and endoscopy are some procedural areas that family medicine should consider.
“If we find that there are technologies, new devices that can be helpful,” Martin says, “I think the [Texas] Academy, particularly at its Annual Session, can have programs available for people to … learn these new processes and procedures and that could be extremely helpful.”
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