{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/mp4vh5fk65/manifest","type":"Manifest","label":{"en":["Dr. Michael Tuggy"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003eDr. Tuggy has a very diverse background that he speaks about in the interview. He is currently a rural Family Physician in Washington. But in the past, he was in the military, spent time abroad as a child, lived in Europe, and practiced sports medicine with soldiers which he talks about as great experiences in his life. He was fortunate enough to get on the Board of FMAH when the Affordable Care Act was passed and eventually, he was President of that organization. \u003c/p\u003e\r\n\u003cp\u003e \u003c/p\u003e (summary)"]}},{"label":{"en":["Date"]},"value":{"en":["2016-02-03 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["oral history"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Herbert Young (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["American Academy of Family Physicians","Family Medicine for America's Health","Family Physician","Family Medicine","Washington"]}},{"label":{"en":["Subject"]},"value":{"en":["Michael Tuggy, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}}],"summary":{"en":["\u003cp\u003eDr. Tuggy has a very diverse background that he speaks about in the interview. He is currently a rural Family Physician in Washington. But in the past, he was in the military, spent time abroad as a child, lived in Europe, and practiced sports medicine with soldiers which he talks about as great experiences in his life. He was fortunate enough to get on the Board of FMAH when the Affordable Care Act was passed and eventually, he was President of that organization.\u0026nbsp;\u003c/p\u003e\r\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064","type":"Canvas","label":{"en":["Media File 1 of 1 - TuggyMichael_01_Access.mp3"]},"duration":3512.4597,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/064/original/TuggyMichael_01_Access.mp3?1760557328","type":"Audio","format":"audio/mpeg","duration":3512.4597,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064/transcript/85360","type":"AnnotationPage","label":{"en":["Dr. Michael Tuggy interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064/transcript/85360/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"This is side one of tape one of my interview with Dr. Michael Tuggy, Vice Chair of the Board of Family Medicine for America’s Health. My name is Dr. Herbert Young and I’m conducting this interview on February 3, 2016. Dr. Tuggy is on the telephone. Welcome. And where is your current location, sir? \n\nI currently live in Winthrop, Washington.\n\nWonderful. And I’m at the Center for the History of Family Medicine in Leawood, Kansas. Dr. Tuggy, do we have your permission to record this oral history?\n\nYes, you do.\n\nIf you could start by giving us your name in full?\n\nMy name is Michael Leonard Tuggy.\n\nAnd what is your current title and positions?\n\nCurrently I’m the Vice Chair of Board for Family Medicine for America’s Health. I’m also a rural family physician working for Confluence Health out of Wenatchee, Washington.\n\nGive us a little understanding of your professional background.\n\nI started my initial training in medical school down in Baylor College of Medicine in Houston, Texas. And after that I joined the military because I had had a previous military commitment to do my residency at Madigan Army Medical Center in Tacoma, Washington. From there I moved to Europe to run a primary care clinic there for several years. And during my time in Europe, I was deployed with my unit to the Gulf War in 1991. After my three years in Europe were completed, I came back and finished my time in the military and then moved to Swedish Medical Center to join the faculty there and teach family medicine. And I was in that role for seven years before being asked to take the role of director of that program, which I ran for fourteen years. And just last year I handed over the reins to one of my successors and moved to a rural community to be able to focus more time on both direct patient care but also on spending more time with Family for America’s Health activities.\n\nA very varied background. How do you think your military experience has informed your later work?\n\nWell, one of the things, looking back on it, was the leadership experience in that setting. It was a pretty early stage of being asked to run and manage people and operations was something that I was kind of thrown into right after residency. I think that experience definitely gave me a chance to see a wide variety of leadership styles but also kind of learning to look at strategies, long term outcomes as you’re looking at how you’re executing out a plan. \n\nThinking back, what do you think drew you to family medicine within medicine?\n\nMy earliest contact with medicine was when I started shadowing a Filipino family physician in the rural Philippines when I was nine years old. And it was through that first, initial kind of encounter with a physician who was a community physician who did quite full spectrum family medicine, as a young person I was just really attracted to that. And as I got into medical training, initially I thought I wanted to do surgery because I loved the procedural aspects and things. But then I found that I really liked many aspects of medicine and wanted to be more connected to my patients. So family medicine was the big draw for me after my second year of medical school.\n\nAnd do I remember that you also have a sports medicine background?\n\nYeah, my sports medicine background is unfortunately not by formal training because at the time I was in the military I wasn’t able to take the time off for more training. But I did a lot of sports medicine with the troops because they exercise daily. And I also did some research in sports medicine as well.\n\nA really varied background. How did you get involved in Family Medicine for America’s Health?\n\nSo for me this was a really fortuitous thing. Being involved with the Association of Family Medicine Residency Directors I was asked to run for a position on the board and was elected to that position and was fortunate enough to be on the board right at the time when the ACA had passed. And within two years I was the incoming president of that organization. And it was at that Working Party of the meeting with the leadership of all of the family medicine organizations where the discussion started about how this politically was the right time for family medicine to take a stand on how we can improve our healthcare system in our country. And it was an amazing discussion to witness. Within the leadership of all the organizations of family medicine, there was such a coherent, clear vision about what was wrong with the system but also what we could do to improve it. So for me, the timing being in the leadership group of the AFMRD at the time of that meeting really helped me jump into the projects early on. \n\nAnd the ACA is the Affordable Care Act? The ACA is the Affordable Care Act and the Working Party – could you just describe that a moment?\n\nThe Working Party is the executive director and the acting president and incoming presidents and past presidents of every family medicine organization across the country. So that includes the Board of Family Medicine, the Academy, the academic organizations like the AFMRD and STFM as well as the NAPCRG and ADFM, the four. The AAFP Foundation also has representatives there as well. Also we added the leadership of the American College of Osteopathic Family Physicians to help formulate the strategic plan.\n\nAnd we’ll come back to their involvement a little bit later maybe as we compare Family Medicine for America’s Health to the prior effort in this area. You’ve talked about the Association of Family Medicine Residency Directors, AFMRD, or referenced them. Could you talk a little bit about that organization?\n\nYes, that organization was created around 1990. And it was really drawn from a need of directors and associate directors to have a forum in which they could actually have focused programming at an annual meeting but also to have a place where their interests could be represented formally at the organization, especially with respect to how training programs are run but also the requirements that were being handed down by the ACGME. And it really has met the huge need for having a leadership organization. Basically it’s all leaders. It’s the leaders of all the training programs in the country and it provides a place for good, safe discussions among those people who are in the same roles across organizations, but also support in education and it has a very strong membership and a very strong proportion of the programs are actually members of that organization, about 95% of residency directors.\n\nNinety-five percent of family medicine residencies?\n\nYes, are active members of that organization. A very high proportion.\n\nSo roughly how many members would that be – or residency programs?\n\nThere are 450 residency programs. And then including all the associate directors, there’s almost 600 members in the AFMRD.\n\nAnd they’re drawn from the various locations where family medicine has residency programs geographically and academically?\n\nRight, it spans the whole country. We even actually have international memberships now too.\n\nSo those based in medical schools and also in community hospitals and military?\n\nYes.\n\nSo talk a little bit more then about what knowledge and skills that you feel that you bring personally to this project. And I would say more broadly what does AFMRD bring to the project?\n\nThe thing that I’ve been most attuned with over the years has been residency training and getting residents prepared to practice in the communities that they serve. And one of the things that was pretty clear as we were sending residents out into our communities is that there was a wide range of skills they didn’t seem to have when they entered their practice and it depended tremendously on where they were located. But you couldn’t under-train somebody and have them be successful in a place of high demands for a broad skill set --. So I was fortunate to be in a program that had a very strong breadth of training. So we did the full spectrum of obstetrics including C-section training and inpatient medicine and all the things that a lot of primary care physicians need to do in their communities across our country. But seeing that it became pretty clear that across the country, as I got to talk to other program directors, that a lot of the programs didn’t have that latitude within their organizations to train that way or they didn’t have the cooperation from their specialty colleagues to allow them to get the spectrum of training that they wanted. And the next challenge was how do you teach an extensive curriculum within a three-year period. So one of the areas I was focused on early in my work was developing an online curriculum for family medicine. And we did that within our program and began to showcase that at some of our annual meetings and very quickly there was a groundswell from the other directors that said we should be doing this as an organization. And just last year we finally formally launched the Family Medicine Residency Curriculum Resource which is a joint project between AFMRD and STFM, the Society Teachers of Family Medicine, where we are basically building the teaching content for family medicine residencies to use across the country. So that curriculum component of work I was doing I thought was an outgrowth of my sense of what is it we’re trying to train and what are the types of physicians and skills that we need to bring to the public. And it was that interest … most of all, that is what got me into the role of being the president because there was a lot of support in the organization for that initiative and that helped move me into that role. But it was really that vision of this well-trained, broad-scope primary care physician that can work in the clinic, and the hospital, and the community- and understanding those relationships are a key component to what I was bringing to the discussion as we moved into the Family Medicine for America’s Health project. \n\nSo that’s part of the message brought by your membership in terms of what family medicine needs to do in the education arena to fulfill its function within the American healthcare system.\n\nYeah, that’s correct.\n\nThat is a challenge given the variety of places that family physicians practice from those that are incredibly resourced communities to those where you are the main provider of care. Can the discipline do that? Can it figure out how to train residents who then can go out and do that?\n\nYeah, I think the proof is in the pudding actually. We have a lot of residents who are doing that and a lot of our graduates do that very, very well and from a variety of programs around the country. So we clearly have the capability within a three year period to produce some really excellent graduates who can fulfill those roles and continue to grow their skills in practice. I think the challenge has been kind of the standardization piece and how can we make that happen through every program in the country. So that’s, I guess, knowing that it can be done that has driven a lot of our discussions in the whole training side about what are the tools that we can develop to help the programs be successful in their training - that and getting the right people into their training programs and recruiting really top people from medical schools who need to have a broad capacity in order to learn the material successfully and put it to use. So, yeah, I believe strongly that it can be done. It’s just a matter of whether can we support training programs properly so we get the faculty and the funding support to actually create those programs.\n\nAnd that’s what I think I hear you saying, it is being done in many places in the United States but the problems that are faced, some are national and some may be more local. Is that part of what Family Medicine for America’s Health is about, going after those barriers?\n\nYeah, definitely. One of the main focuses of the Workforce and Education Team is ensuring that the training system and even the postgraduate education system, the CME system, is actually providing the training tools and continuing education in order to make sure that all family physicians in practice have the capacity to learn and to deliver on the skills that our communities need them to have. That’s one of the first priorities of the Workforce Team. \n\nThinking of the sorts of barriers and thinking of the core teams that the Family Medicine for America’s Health has set forth, it would look like that some of the challenge is the economics.\n\nYes, definitely. So there are two pieces of that equation. One is the economics on the training side. Our country needs to prioritize medical education so that it is actually meeting the needs of the public. There is a lot of work being done on the advocacy side to help our congressional leaders to understand the need to invest in primary care education in order to develop the primary care workforce that we need to have. So there is that part of the equation and one of the areas of advocacy that we’re working on. And the second piece is also on the economic side and that is how do we make family medicine a specialty that can compete for students as well as other specialties, especially when we know we have to have many, many more of us and probably need quite a few subspecialists in certain areas. In order to draw people into our specialty, there has to be economic incentives for students to choose our specialty in order to attract good students into it.\n\nI suppose part of that is also, at least in some things being published now in 2016, the issue of burnout. Is that being addressed also?\n\nYeah. Well, really it’s all about the practice model. The issue of burnout occurs when you have a practice model that feels unsustainable and unrewarding. And the current model that we have of fee for service is the dominant model still. Even within organizations that have capitation fees for patients that they manage, they often still reward physicians for work units as opposed to patient outcomes or patient management. In that model burnout has a very high risk of developing over time. One of the major goals of Family Medicine for America’s Health is to move to a comprehensive primary care payment model where physicians are rewarded and paid for managing populations of patients and looking at outcomes as opposed to process – which has been, unfortunately, focused on profits and volume, not value and outcomes.\n\nHow do you compare that, or is it that same as a capitation approach?\n\nIn the 1990s -- capitation really fell apart primarily because we had a non-health system trying to execute on it and there was no real accountability for hospitals and secondary or tertiary care to the health system in managing patient costs. And at the same time, the burden was being placed on the primary care level. Physicians could try to manage those costs but they had no power to do so. So it was a setup for disaster. And what our payment model that we are promoting is, is that you carve out 10% of the healthcare dollar, which doesn’t sound like very much but it’s really what most countries have done across the western world, and if you commit that 10% to primary care in supporting it and funding it and allowing it to be functional then you actually dramatically reduce healthcare use and cost by doing that. And so that 10% carve out is the capitation fees for primary care and that allows, it changes the whole dynamics of the way the office can work when you don’t have to do fee for service billing and see patients face-to-face in order to actually deliver care to them. And it opens up a lot of possibilities of changing the way we practice. And we’re seeing numerous examples around the country now where this is really rapidly changing the face of both the cost of care but also the experience of the clinicians and the work teams - the teams that are working together in clinics and about how much they enjoy their work. \n\nYou’re mentioning teams. And so could you talk a little bit about how Family Medicine for America’s Health views the concept of a team and who are the players?\n\nYes, so the team that we envision in the future practice, a primary care practice, would be a pretty full scope of skill sets that you need in the primary care arena. So you have the clinician – you know, the physicians, the nurse practitioners and PAs working alongside them, the nursing staff, diabetic educators, pharmacists, I think we would all love to have physical therapists embedded in our clinics, and psychologists, social workers. That the set of skills which meets the common needs of our patients. Having those people embedded in the clinic as part of the team working together is a very different model than the old model of the physician with their nurse and maybe some support staff rendering care to one person at a time. Whereas the team-based approach allows different members of the team to interact with patients and problem-solve and provide care without having to have the physician do every single thing in order to get paid. And so the team approach already is driving significant change in other models of care delivery that we are seeing in primary care that are being developed. It holds great promise for actually meeting the needs of entire populations as opposed to just a practice itself. \n\nAre physicians other than family physicians considered part of primary care?\n\nYes, definitely. We see our pediatric colleagues and our internal medicine colleagues who are doing primary care internal medicine as key components of the primary care workforce. We also recognize that there are certainly other needs that a primary care level - needs, like psychiatry. Unfortunately, there’s not enough psychiatrists either. But, also, a lot of primary care, a lot of family physicians, especially, do a lot of psychiatry in their practice. And that, working along with psychologists that are part of your team could meet the needs of a significant number of those patients with psychiatric issues. \n\nHow about public health?\n\nSo the interaction with public health is a key part of what we would think about managing a population within a community. The challenge is that because we don’t really have a national organized healthcare structure, the integration of public health and private practices has been almost zero in most places in the country. But that needs to occur for us to really have a better sense of community health overall and improving the social determinants that impact healthcare delivery and healthcare utilization. \n\nSo is that saying that public health needs to outreach to primary care more within this model or that primary care needs to reach out towards public health or both?\n\nReally, the public health system is pretty strapped. They also are underfunded. And it’s really a matter of priority of our national health initiatives because we could prioritize primary care, which public health is a component of that, then having the funding resources to actually allow physicians the time to work with their public health counterparts would actually be one of the major steps that would need to occur to allow that to happen. But it’s obviously needed both ways – communication between family physicians and public health. But, interestingly, like in the small community I live in, we have about 4,000 people in the valley and the nearest public health department is forty miles away. So we are the public health system, the primary care clinics in this valley. There is no other place for people to seek out care or advice around health issues or to advise the community leaders on health issues really. So there are certainly places where primary care practices are the de facto public health officers for the region.\n\nSo either informally or formally they may play that role in various parts of the nation?\n\nYes, absolutely. \n\nWell, again, in 2016, in this month of February, there is news that the President is calling for a major almost moon shoot sort of approach to cancer, trying to prevent and cure it. Is this nation looking appropriately at primary care? And if not, what is Family Medicine for America’s Health going to do about it?\n\nOne of our major goals in the advocacy arena is to make sure that the healthcare system that we do have- which is primarily Medicare and Medicaid which covers half of our population in this country and is the biggest payer - and the big issue that they are continuing to move their focus to primary care support. Certainly it’s a great goal to try to treat cancer better. But at this point the system is so underfunded to prevent cancer and detect it early with a primarily care physician that can allow them to have the care that they need.  It’s almost like pouring your money into an endless bucket that will just consume tons of resources if we don’t actually build a primary care structure around an independent specialty initiative like cancer care. So we are in frequent conversations about this payment reform model with CMS to have the primary care support needed in order to allow primary care to function well. I think one of the biggest things that we could learn as a country, is that we look around us … you know, the Canadians, the Norwegians, the Danes, the Swedes, the British have very, very different healthcare system structures from us. But between them they have a strong similarity which is they focus much more effort and resources on primary care and the support of that yields much lower costs downstream. So, as you know, cancer care is extremely expensive and it’s going to be even more expensive as more specialized treatments are developed. But if we focus all of our energy on that and forget to build an infrastructure to prevent or screen for it, we’re going to have costs that are going to break the bank for the healthcare system in this country. \n\nThe leading causes of death in the United States, I understand, have been shifting in the percentages. Do you think primary care has shown its effectiveness in terms of cardiovascular disease?\n\nThat is certainly one of those areas where we think about population health. So if you look at health systems like Kaiser or Group health where they have implemented much more aggressive treatment guidelines that impact the primary care practices pretty effectively, you actually see decreases in heart disease in those populations and the statistics of cardiovascular death. But in other parts of the country where primary care is pretty weak and disabled, it’s really difficult to see those kinds of improvements at that level because there is no clear population impact, mostly because so much of the population doesn’t even have access to primary care. We’ve not seen the decrease in cardiovascular deaths over the years like they have overseas, despite of the use of good medications, except in those populations that have good primary care access. \n\nI was thinking also of non-pharmacologic approaches and the use of part of the team to help people eat better, exercise more – where that is available, of course.\n\nRight. You know, there are studies that show that even having a family physician or a primary care physician, no matter which specialty, talk to the person about exercise, that you have an impact on those people actually moving more and actually exercising. Even though they may not be exercising to the degree that you might want them to be, even that small incremental increase in activity can actually reduce mortality. \n\nYou mentioned within the model that it was not only face-to-face interaction but using other methods. Can you talk a little bit about that?\n\nYeah. So one of the beauties of the comprehensive payment model for primary care is that it allows patients and physicians to decide what kind of care is most appropriate in the moment. So if a patient is -- and wants to be seen in the clinic, they just come to the clinic and they are seen. However, probably at least 30% of our clinic visits that we do, some days when I’m at work, probably half of the patients I see, - they didn’t really need to see me per se or they didn’t need to see me face-to-face, but they needed to reach out to me. We needed to have some sort of interaction in order to help them answer their questions that they have. So a significant number of our patients that we currently are seeing could be managed by email or by telephone, perhaps by seeing my nurse educator for diabetes or maybe my psychologist for their mental health issues. The problem is we only get paid, as a clinic, if I physically see the patient. We have patients that come in for appointments that we know we could probably do it a different way if we didn’t have that payment model. In the pilots that have been done around the country where this new payment policy is in effect, we see very high patient satisfaction scores because they feel like they’re getting the care that they want and not being pushed into a care model that really just feeds the beast in order for them to be taken care of. \n\nSo what might have been viewed at one point as a cost to a practice that is providing care without a patient being present in the exam room for which you could charge, that goes away as a cost that prevented you from seeing another patient, let’s say, as just part of the package and maybe a more effective way of delivering that care. \n\nYeah. And I think the other thing you find with physicians who are working in those practices, it feels like the care makes sense to them. That what they’re able to do actually feels like it’s the right kind of care. A great example is your diabetic who is having trouble with their blood sugars, who has to work at an hourly wage job … Instead of having to leave their work, punch out on the clock, lose three hours of pay, park in your parking lot, wait to be seen, get their appointment done, then drive back and lose maybe a third of their day’s wage, instead we can set up a fifteen minute phone appointment at the office so they can call in to discuss their blood sugars and we can adjust their insulin. We had patients at one of our clinic sites where we were using the this new payment model who just absolutely loved that because they were working folks needed to work and to be able to get care without having to leave their workplace was really important to them. \n\nWe’ve been talking about what family Medicine for America’s Health has seen as barriers. What else, broadly or specifically, would you point to that this project is addressing?\n\nThe biggest barrier we see is this whole practice transformation that needs to occur, which has to occur by changing the incentives on the payment model. So those are probably the two biggest ones. The other big barrier, of course, is the pipeline. Can we recruit enough people into primary care as a whole and family medicine in particular? How do we expand that pipeline to bring in more students into primary care specialties? So that’s a major barrier. And, again, it’s tied to the first one which is the payment issues. Because if you can’t make a living or if their practice is distressing to do as a primary care clinician, that doesn’t attract that student away from the subspecialty that seems less constrained. Other barriers are research barriers. We have not done a great job as a nation in understanding the determinants of health care outcomes. And we need to invest a great deal in that to really provide the best advice to our patients and the most effective treatments to our patients. \n\nAnd is that both in how it’s delivered as well as what is delivered?\n\nAbsolutely, yeah, exactly. One of the great examples, this came up in our practice yesterday, where an email went out from one of our departments expressing how valuable mammography was in saving women’s lives from breast cancer. In fact, the research shows that it hasn’t saved women’s lives from breast cancer and there’s a lot of harm being done with the use of mammography but yet it was being promoting as if it was the truth. And so we, as family physicians, responded back and said, well, let’s not tell our patients that that’s actually true when it’s not true. We need to be cautious about what we are advocating for as far as treatment recommendations and screening guidelines until we really know if something really works or not. So that is one example, that we often promote things that we think are a good idea but we really don’t have the research and understanding to know that. \n\nSo is some of what’s going on maybe getting the participating organizations to change or become more aggressive in their messaging? The example for mammography – for example, the American Academy of Family Physicians for years has had a liaison to the U.S. Preventive Services Taskforce and has been instrumental in helping get appointed some of the members. And it is a battle with some of the other messages that are out there. And we’re going through that with a number of recommendations from the taskforce at this point in time across a number of conditions. How does a generalist, that is to say, in this case, primary care segment of the healthcare system take on the messaging from subspecialty organizations, from, in some cases, government units, other than those that are evidence-based, etc.?\n\nI think one of the biggest differences with this current initiative of Family Medicine for America’s Health is that a big part of our strategic plan is our Health Is Primary public outreach. So we’re spending a lot of money and resources on basically a public campaign for primary care. And that campaign is really kind of going around the traditional, you know, within medicine discussion. Because in the past we’ve often tried to approach other specialties directly and tried to get them to change what they were doing or to be more focused on more appropriate use of resources in taking care of patients. But that has really fallen on deaf ears in a lot of areas. But our real connection that we have is with our patients in our communities. So reaching out directly to them has been the strategy that we’re using now to basically bypass the medical politics and get into the public politics around what healthcare issues need to be addressed and getting the messaging out that way as opposed to trying to work through the AMA or other organizations that really have a lot of their special interests involved and not necessarily the interest of the public.\n\nIs there something about the American approach to health as a culture that embraces intervention and makes some of the arguments for more intelligent use of technology a challenge to sell?\n\nWell, I think we do have a culture that believes strongly in technology as a solution for many, many problems. And, indeed, technology is a great adjunct part of that solution. However, I guess I’ve always equated part of our problem as a country is that if we try to treat health care like we’re building a car in a factory and putting widgets together in order to build a particular product, the problem with that is that if you take that – analogy, imagine the car going through the assembly plant and disassembling itself on the way while people are trying to build it. And that’s basically what we do as humans, we break down in the process of time and we also do things to ourselves that are not healthy. So that analogy doesn’t really fit because we have to have a model where we think about the person and what drives that person, And because we’re dealing with people, we have to think about relationships. One of the biggest things in healthcare that we’re trying to actually do is we’re trying to change people’s behaviors and you can’t get behavior change from one person to another without a relationship. So the more technical our healthcare has become, the less relationship plays a part. Some aspects healthcare are very technical and they need to be. It’s great to have scopes to do surgeries with and things like that. Or other tools so we can use to do things technically better. However, if we don’t focus on the relationship piece as part of our healthcare working model as well, we’re not going to fix a lot at the primary level, which deals with changing behaviors much of the time.\n\nSo is it fair to say that one of the major themes of Family Medicine for America’s Health is to develop systems or enhance existing ones where the relationship building is maximized?\n\nYeah, definitely. If you look at our core strategies, one of the core strategies is basically that every American should have an opportunity to build a relationship with a primary care provider. And so that is one of the key features, is understanding that there must be some connection between that person and a real person within the healthcare system who cares about them and is managing their care and really wants the best for their health.\n\nAnd how is the provider defined?\n\nWe believe that primary care is going to have to be provided through a number of different professionals. But the primary person would be their family physician, the internist, or a pediatrician along with their ancillary clinicians that work with them. So the PAs and nurse practitioners may also be the primary care provider as well, especially in the areas where we have populations that you don’t have enough coverage to have a physician for every person. But those physician extenders do an excellent job when working together on a team with clinicians in providing primary care.\n\nSo is the relationship with an enhanced practice led by a family physician or other physician? \n\nYeah, in most cases that’s going to be the model. There will be a physician leader who is the primary person leading that team. However, one of the things we’ve also pointed out in discussions about this is that there are times when different people might be able to take the lead depending on what the patient needs. So sometimes it may be the diabetic educators taking the lead on a patient’s care. But the overall responsibilities of that care still rests in that of the physician that the person has identified as their primary care provider.\n\nWhat sort of reaction has the project gotten in terms of its relationship, it’s interaction with nurse practitioners, PAs and so forth?\n\nWe’ve had a couple engagements with their leadership at the national level. It’s been very positive. I think there are some political challenges, especially in the nurse practitioner community and the family medical community about what their scope should be. Our position is that they are excellent partners to work within our clinical teams and we would like to really enhance that working relationship. I think the challenge is that primary care is sometimes viewed as being simple and straightforward and therefore you may not have to have a tremendous amount of training to do it well. And those of us who are in it recognize that that’s absolutely not the case, that primary care is really complicated and requires extensive training and commitment over time. Many people can do that relationship building. You know, there are excellent nurse practitioners and PAs working alongside physicians who build great relationships with patients and can take care of patients very, very well. But as things become complicated, many times it goes well beyond their scope of training and that’s why we need to have a partnership that allows those practitioners to go to the physician within their office and say, hey, I’m having trouble managing this patient, can you help me sort through the best way to do that? \n\nDoes this call for different training approaches within family medicine residency? When I trained, we were the only learners in our model clinic. And in hospital settings I don’t think I encountered other health professionals in training. But you’re talking about a more integrated and complex office setting. Is family medicine education changing with this recognition?\n\nWell, it is in some programs. It’s not widespread enough yet, but it’s not uncommon to have a group of clinicians like pharmacy residents or psychology candidates for PhDs or masters of psychology folks training within a family medicine center now. In the training program that I was running for the last fifteen years, we actually had embedded pharmacy residents on our inpatient service. We had psychologists within our outpatient clinic that were in training. We had nurses that were in training there. We also had nurse practitioners who had come through as part of their training program to work in a clinic for six months at a time. So there was inner-professional training going on, but it needs to become much more widespread in order for those teams to learn how to work together well. \n\nAnd then, I guess, in the sort of parallel thought, is that how model clinics are now operating within residency programs in terms of their current staffing? Are those other types of members of the team part of a model clinic experience?\n\nYeah, it’s very patchy. It’s still not the standard way of doing it. And we’re certainly not being funded to do it that way either, unfortunately. It would be fantastic to have a GME (?) funding stream that allowed training of family medicine residents alongside either the practitioners who are training and having faculty and those other specialty areas working within your faculty structure within your training program. \n\nWe wanted to do a little comparison, if you don’t mind, to the Future of Family Medicine project. How is Family Medicine for America’s Health different from what was done with the Future of Family Medicine project?\n\nI think the biggest difference is the focus on implementation. Both projects did research work. In fact, the Future of Family Medicine did a lot of research into kind of what was wrong with the current model and what were the things that patients wanted. And then it published its findings and we learned a lot from that. But there was no follow-up activity, really. There was no real plan for implementation of how do you actually make change happen within healthcare. And, frankly, it being in 2004 when that was published, the healthcare system wasn’t in the mood to make big changes. I mean basically in that timeframe there was a lot of sub-specialization and focus on hospital-based care and funding those types of initiatives. Medicare was expanding its costs across the population that it manages with the complex older patients so they could grow in number. But with the ACA passing and the recognition that primary care needed to be a bigger part of the solution for reducing costs in this country, the timing of what we’re doing is quite different than it was in 2004 with the Future of Family Medicine politically. And then the focus of this effort really is on this five-year implementation plan, not really on repeating any research that we did before. And there was some market research done but it wasn’t to really look at some of the details around practice issues like what does the public want out of primary care and out of their physicians and how can we deliver on that?\n\nAnd as I remember the Future of Family Medicine, each organization stepped up to take one or more of the ten recommendations. What’s the model this time?\n\nSo this time we have a separate board which was built by all the organizations together and within that we have developed core teams that are working on various aspects of the strategic plan. And each of those core teams is populated by members of multiple organizations. So it’s not just one organization taking the reins for one particular area. We are definitely going to lean on some organizations more in some areas. Like the Academy is really involved in the payment reform work because they have the political connections in DC and the contacts within Medicare and CMS and Medicaid in order to actually do that work. And some of the academic organizations are stepping up for other aspects of it. But our core teams really are a blend of talent from across organizations to make sure that, first of all, we are using those organizations well, but, also, to make sure we’re not dropping the ball in a particular area that would impact another organization’s members if we didn’t focus on that in a balanced way.\n\nAnd this is a little more diverse group than what was in the Future of Family Medicine?\n\nI mean I guess diversity is an interesting term. I would say we are working on diversity within our core needs to make sure we have a good representation of our population there as well of physicians but also communities that we serve. But, yeah, we do have a broader input from … Every organization is invited in with these core teams, so they have representatives there that are impacting the way that we’re prioritizing the tactics that we’re delivering on and executing on. \n\nAnd I was actually also referencing the fact that I believe osteopathy is now represented firmly in the process?\n\nSure, yes. They joined in on the work in the strategic planning process with us. And since then they’ve been very involved. There’s a member of the board who’s an osteopath as well - Paul Martin, who is our treasurer. And they are at all the leadership meetings now, which is a big change from what it was ten years ago where often our DO colleagues were not invited to some of these meetings and sessions. And now they’re part of the group and that’s really excellent to have our DO colleagues working with us so closely now.\n\nI note that some outside expertise has been purchased. Can you talk about that?\n\nAre you referring to the PCPCC group, the primary care coalition?\n\nWell, that would be good to hear about as well. But I believe you mentioned an agency that determined what the public was interested in. \n\nRight. So we did work with a group called APCO, which is a marketing firm, and they did a good deal of market research the first year as we were putting together our strategic plan about what it is that patients and other physicians and policymakers, be it politicians, etc., what is it that they … How do they view family medicine and what do they view as the role of family medicine and what are the skills needed to make family medicine work. Because what they found was that family medicine was highly regarded among all the groups in general. And basically the lack of resourcing was kind of the biggest thing that came out of that. That people recognized that there were not enough resources being put into primary care, and especially in that policy. And so that firm really delivered us some really important data about where we should push on our strategic plan. And they have now joined us in our work. Actually, two people from the firm left their positions with that firm because they believed so strongly in what we were trying to do and they wanted to be really directly supporting it with their full efforts. So those two people basically are what makes up our, they’re our lead people for the marketing campaign for Health Is Primary.\n\nAnd do you anticipate that as the project goes forward that you all will contract with other organizations or individuals as needed?\n\nWell, we’re definitely going to be partnering with other organizations. We are partnering closely with the Patient Centered Primary Care Coalition because that organization, which is the national advocacy group, is supported by a lot of big businesses that have recognized that they would do far better for their employees if they had primary care for their employees that was well resourced. And that organization is working very closely with strategy and advocacy work at the national level. So those types of partnerships are ones that we’re looking for. We’re looking for other partnerships. We recently announced a partnership with CVS Pharmacy where that large corporation is supporting our project because they recognize that, for instance, pharmacies are a very important part of the medical neighborhood and that they need to work together closely with their family physicians around their local stores to be sure that they are supporting the practice of those physicians. Some of them have after hours clinics that the family physicians can’t afford to operate so the patients can go there after hours. But they also make sure that those patients who are seen there, that those go to their primary care clinician so that they know what happened after hours and they’re able to integrate their care better.\n\nAnd I believe some of the CVS facilities also operate during the day as well. Have you had any pushback at all from anyone saying, wait a minute, that’s a competition to a family medicine practice?\n\nYes, there are some physicians who are concerned about that – and those physicians are often booked up. So if a patient needs to be seen and they can’t work them in then where do they go? Well, it’s far better to have them go to another clinician who works within a system that actually believes in what you’re doing and will give you feedback and give you a report on that patient care, if you’re overloaded and can’t see that patient.\n\nSo there is a reporting out of whatever happened at the medical encounter in the CVS clinics?\n\nWell, that’s what we want to make sure is happening and that CVS leadership is committed to doing that. So that’s the part that we want to make sure in dealing with all the stores and with all the communities where family medicine practices and these pharmacies co-exist. They want to build those relationships with that. They’re part of the medical neighborhood, part of the medical team. Not just an isolated, free-standing urgent care clinic that doesn’t communicate with the local practices. That’s just not healthy for the patients in the community.\n\nAnd CVS, of course, is noted in this time period of 2015-2016 for having made the decision to stop the sale of all tobacco products. \n\nYes, which is one of the reasons why we partner with them because it shows a sincere effort to focus on patients and outcomes as opposed to profit.\n\nWhereas Walgreens, I noted in the paper within the last week, has announced that it intends to continue to sell tobacco products.\n\nYes, which is pretty distressing.\n\nWhat else would you like to share in this oral history?\n\nI hope that we look back on this ten years or twenty years from now as a time where we, as a specialty of family medicine, stood up for patients in our communities and said it is time that we look very hard at what our priorities are as a country and as communities and start putting the right emphasis on what’s most important to our patients - and that is they want to stay healthy and they don’t want to be in the doctor’s office all the time, they don’t want to have preventable illnesses cutting back on their lives. And the whole spirit of this project has been driven by family physicians at the leadership level who decided that really what’s more important is that we find a better way to deliver care to our communities. That’s the most important thing. And whatever that it does to our income or whatever it does to our practices we’re willing to do in order to make that happen. And history will determine whether or not we were successful in this. But I think the spirit is it’s really the care we have for our communities and our patients that’s driving this whole project. And I think our patients see that and I think a lot of policy leaders see that. And even insurance plan executives who look at what we’re trying to do, and when they take the steps to actually engage with their family physicians and their primary care physicians within their health systems, they will actually find that they will save money. It will save on cost and they will have better healthcare outcomes if we actually deliver on what primary care can actually do if we support it properly. \n\nAre there any other individuals that you think for sure, beyond the board itself and the leaders of each of the core teams, that we should interview? And feel free to send that as an email later, upon reflection.\n\nThere are so many people who are not on those teams, who are deeply engaged in their communities. And I know some of the local clinical leaders in Seattle were involved with the federally qualified healthcare centers. Some of those leaders are deeply involved in the community and have a similar passion for what primary care can do, so I can send you some of those names.  \n\nExcellent. We’re coming to the end of Side 1 of the cassette, so I’m going to pause the recording at this time.\n\n(Recorded conversation ends.)","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162276/file/295064#t=0.0,3512.4597"}]}]}]}