Dean's Newsletter
Archive of previous newsletters
Highland Family Health Center
March 16, 2005
On February 11, 2005, we cut the ribbon to celebrate the opening of the Highland Family Health Center, home of the Department of Family Medicine at the University of Rochester School of Medicine and Dentistry and at Highland Hospital.
This beautiful and functionally state-of-the-art facility, located at 777 S. Clinton in the South Wedge section of the city, will enable a new model of care to upwards of ¬10,000 families at a rate of about 70,000 patient visits a year. The story of the driving forces behind this building is inexorably linked to the story of the Department of Family Medicine. In turn, the Department's history is linked not only to local circumstances but to the history of the field nationally.
When I was a kid, my doctor was also my family's doctor. He was in the neighborhood, in easy walking distance. He not only prescribed antibiotics for my ear and throat infections, and tended to my sports injuries, but diagnosed and successfully treated my father's hypertension and made an early diagnosis of my grandmother's breast cancer (she was a long-term survivor.) It is interesting that, looking back, I thought of my early medical-school interest in internal medicine as being influenced by him, but didn't think of family practice as a career. From the little that I gleaned in my first couple of years of medical school, I thought it would be hard enough to grasp the enormous breadth of internal medicine, never mind pediatrics, orthopaedics, etc. My mindset--in part influenced by my medical school which didn't have a Department of Family Medicine, but also, in part, a reflection of my own hard-wiring--was "specialty".
Can there be a "specialty" of family medicine? Is this an oxymoron? I have come to believe that, while family physicians share important commonalities with other primary-care physicians, their unique philosophy of practice and training marks them as belonging to a distinct specialty. Although all physicians like to think of themselves as broadly based, family practitioners in particular travel through multidisciplinary continuums like no others--vertically from biochemistry to sociology, horizontally from pathology to psychiatry, and temporally from infant to aged.
The history of family practice as a specialty indeed has its roots in "general practice" The number of general practitioners in the United States, which had begun to decline in the 1930s, showed an accelerated decline after WWII with the burgeoning of medical specialties. Amidst this decline came the formation of the American Academy of General Practice in 1947. In 1966, three influential commissions ("Folsom," "Millis" and "Willard") issued reports that addressed the decline of general practice as a health policy concern and gave legitimacy to the recently incorporated American Board of Family Practice. A new specialty was recognized in 1969 and given the name "Family Medicine." The practitioner of the specialty was deemed a "family physician." Family medicine was defined as the academic discipline that lies at the heart of the practice philosophy, clinical values, and core content of the specialty. In 1970, the American Academy of General Practice changed its name to the American Academy of Family Physicians.
In 1969, there were 15 residency programs in family medicine. By 1979, the year I graduated from medical school, the number of residency programs in family medicine had grown to more than 300. It is important to remember the political and cultural atmosphere of the late '60s and '70s. Who were the medical students, on the vanguard of the field, who chose to enter the new family medicine residencies? Although my medical school (NYU) did not have a Department of Family Medicine, 7 students (of 140) entered family medicine residencies. They were among the smartest students in the class; they were also the most likely to volunteer at the free clinics, rail against the drug companies for providing stethoscopes and pens, and participate in, or organize, political protests. At a time when many medical students were torn between the intellectual and emotional draw of the "counterculture" and the mainstream pull of the medical profession, there was little question that the family-practitioners-to-be were part of the counterculture. (An interesting commentary on this issue was written by Gayle Stephens: "Family medicine as counterculture" Fam Med 1989; 21:103-9.) Imagine the nonconformity and rebellion that would have been required of the medical students who chose to enter family medicine in this era. The Chair of Family Medicine, Tom Campbell (a 1979 graduate of Harvard Medical School, which also did not have a Department of Family Medicine) puts it this way: "My classmates who went into Family Medicine, three of whom came to Rochester (Richard Rockefeller who now chairs the Board of Directors of US Doctors without Borders, Bill Bayer who has practiced in the inner city of Rochester since residency, and myself) all received tremendous pressure from our professors not to 'waste' a Harvard education. None of us have had any regrets." These were the students who now fill the faculty ranks of family medicine programs around the country.
The attraction for these students was clear. Family practice was viewed as the quintessential application of the art and science of primary medical care, through all of the multidisciplinary continuums noted above. Like other primary care fields, it was a way to practice relationship-based health care with a personal commitment to continuity and coordination of care, and apply comprehensive clinical reasoning when faced with undifferentiated problems. It also brought focus, however, on problems of living as a health care concern, and to a systems approach to primary health care, including social systems such as family and community. What an exciting career for smart medical students with community commitment and a social conscience!
This was the world into which family medicine in Rochester was born. The University of Rochester's Family Medicine Residency Program is the second oldest family medicine residency in the country. It was developed jointly in 1967 by Bob Berg (then Chair of Preventive Medicine), John Romano (Chair of Psychiatry), Robert Haggerty (Chair of Pediatrics), and Larry Young (Chair of Medicine). Gene Farley was the first program director and established a model family practice center by remodeling an old Loblaw's grocery store on South Ave, just down the street from Highland Hospital. At the time, it was a very innovative practice that attracted the best applicants for its family practice residency from around the country.
More recently, the specialty of family medicine nationally (along with primary care generally) has suffered from declining morale as the financial pressure to see more patients in less time has driven a dagger into the very heart of what was originally attractive about the field. It's hard to practice relationship-based care with a personal commitment to continuity at 10 minutes per patient. The handwriting was on the wall. Indeed, in 2003, U.S. medical school graduates filled only 42% of family practice residency positions, the lowest percentage in the specialty's history.
As you can imagine, national trends have also been reflected in the Department here. Across time, it became more difficult to attract and retain the most talented residents and faculty. Limited financial gain from a poorly-compensated field, and inherent inefficiencies in an old facility, left little in the way of funds to upgrade the building or the practice. A vicious circle had been created.
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In 2003, at a time when the Chair of Family Medicine was open, an opportunity presented itself to create a fresh approach that would have the chance to create a new future for Family Medicine in Rochester. Several steps were taken: First, we had two consultant visits. One was from Frank deGruy, MD, Chair of Family Medicine at the University of Colorado. Another was a joint visit from Jim Herman, MD, MSPH, Chair of Family Medicine at Penn State and Director of their Center for Primary Care, and Jack Colwill, MD, former Chair of Family Medicine at the University of Missouri at Columbia and head of the RWJ General Physicians Initiative. Among the key recommendations were to integrate more fully the Department of Family Medicine into the Medical Center and to create a Primary Care Center in which Family Medicine would play a key role. Second, Dr. Mac Evarts, who was only recently named CEO of URMC at the time, had created the Primary Care Center model at Penn State and knew how well it worked. He committed to establishing such a model here. Third, and most important for Family Medicine, was appointment of a Chair who had the respect of the faculty and the qualities needed to lead a transformation of the practice, including its coordination with the Primary Care Center. There is no more important job as Dean than to appoint the right Chairs. In the case of Dr. Tom Campbell, as has become evident since his appointment as Chair in February, 2004, we have just that leader.
In Tom's words: "We knew we wanted to improve and reengineer our practice; the clinical mission had to be the department's top priority. We want to create an excellent, high quality clinical practice to educate residents and students and conduct practice-based research. Our faculty are first and foremost excellent clinicians, as well as outstanding educators and/or researchers. We want to transform our clinical practice into a practice for the future."
As the blueprint for this transformation, Tom and his faculty turned to a report from the Institute of Medicine, entitled "Crossing the Quality Chasm: A New Health System for the 21st Century." The IOM criticized the quality of American health care and called for a transformation of the American health care system. The report stated "The current system cannot do the job. Trying harder will not work. Changing the system of care will." The IOM challenged the health-care system to adopt six aims:
Safe--Avoid injuries to patients from the care that is intended to help them.
Effective--Provide services based upon scientific knowledge to all who could benefit and refrain from providing services to those not likely to benefit.
Patient-Centered--Provide care that is respectful of and responsive to individual patient preferences, needs, and values, and ensure that patient values guide all clinical decisions.
Timely--Reduce waits and sometimes harmful delays for those who receive and those who give care.
Efficient--Avoid waste, including waste of equipment, supplies, ideas and energy.
Equitable--Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.
At the same time, several family medicine specialty organizations commissioned the Future of Family Medicine project, which applied the IOM aims to Family Medicine and proposed a New Model of Family Medicine. The Department of Family Medicine is using IOM aims, many of the components of the New Model of Family Medicine, and innovations from the Institute for Healthcare Improvement (IHI) to transform its clinical practice into a practice for the future. They designed their new building to have six small clinical units or suites that operate as independent teams or practices. In addition to implementing a team-based approach, they have redesigned patient and work flow and have rewritten the roles of all team members so that responsibilities are consistent with level of training. Waiting times have been reduced and efficiency has been improved.
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Patient-centered care is an IOM aim and has long been a strength of the Department. Ron Epstein, MD, and others in the Department have conducted nationally recognized research on the patient centered method, and our residents have been taught this approach for decades. We are making changes in our clinical practice so that it is more patient-friendly and patients can take a more active role in their care.
Electronic Health Records (EHR) is the nervous system of the practice and addresses the IOM aims of safety, effectiveness and efficiency. The department will implement Touchworks (the Allscripts product adopted by URMC) within the next year. This information system will more easily incorporate preventive health and chronic disease management into the practice by tracking whether patients have received recommended preventive and chronic disease care. It will also allow clinicians to integrate clinical practice guidelines with individualized, patient-centered care at the point of contact. Finally, electronic prescribing will improve the safety and efficiency of our prescription refills and medication management
Under a special project with RIPA and the Monroe Plan, medical group visits (an IHI innovation) are being conducted for our diabetic patients. This model will be expanded to include other conditions (CHF, depression, obesity). A physician facilitates these group visits, with the assistance of a nurse, medical assistant and behavioral health clinician. Patients learn about their illness and how to manage it from other patients and family members. Research has demonstrated that medical group visits significantly improve health outcomes and are more cost-effective than usual care.
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Later this year, Family Medicine will implement open scheduling (another IHI innovation), a method of scheduling in which up to one half of all appointment slots are left open until 24 hours before the visit. Patients are encouraged to make same day appointments for routine as well as acute visits. This approach in other URMC primary care practices has dramatically reduced no-shows and improved patient satisfaction.
On the list of planned innovations is a practice Web site that will allow electronic appointment scheduling, e-mail communication with clinicians and patients' health care team (e-visits), which will provide information about the practice to patients and link them to reliable health information on the web.
The sixth aim of the Quality Chasm report is equity: to provide the highest quality care to all individuals, regardless of insurance or income status and reduce health care disparities. The Department of Family Medicine has a long commitment to caring for underserved and underinsured populations and reducing health care disparities. Kevin Fiscella, MD, MPH, Associate Professor of Family Medicine and Community and Preventive Medicine, has become a nationally recognized expert on health care disparities. Moreover, the residency program has implemented an extensive curriculum, supported by a $500,000 Title VII HRSA Training Grant, to teach cultural competency to all of our residents and faculty.
The biggest challenge we have faced in providing care for uninsured and underserved populations in Rochester has been financial. It is a challenge that will grow if the Governor's proposed cuts in Medicaid and Family Health Plus are enacted. To address this problem, Dr. Campbell is applying to become certified as a Federally Qualified Health Center, which would bring much-needed funding for expanded social work services, outreach workers, and case managers.
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In addition, the practice will house Strong Behavioral Health at Family Medicine, a satellite of the Department of Psychiatry, developed by Susan H. McDaniel, PhD. This satellite will provide behavioral health care that is closely integrated with the rest of a patient's primary care, an important part of the team approach to primary care advocated by the Future of Family Medicine model.
To conclude in Dr. Campbell's words: "We believe that this transformation of our clinical practice will not only improve the quality of care for our patients and their families, but will enhance our ability to conduct cutting-edge clinical research and provide innovative and exciting medical student and resident education. This, in turn, will attract the top medical students to our residency and be a model for other practices and departments around the country."
The excitement is palpable on S. Clinton Avenue. You can feel that the pendulum for Family Medicine has begun to swing back in its favor.
David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
