Primary Care PotpourriPrimary Care PotpourriAED November 1, 2006AED November 1, 2006

Kurt B. Angstman, MS, MDKurt B. Angstman, MS, MD

Medical Director, Mayo Family ClinicsMedical Director, Mayo Family Clinics

Department of Family MedicineDepartment of Family Medicine

Mayo Graduate School of MedicineMayo Graduate School of Medicine

Mayo ClinicMayo Clinic

Discussion topicsDiscussion topics

• Primary CarePrimary Care

• Rural vs.. Urban practiceRural vs.. Urban practice

• Minnesota Lifeline October 2005- Minnesota Lifeline October 2005- Katrina/RitaKatrina/Rita

PRIMARY CAREPRIMARY CARE

• Definition (mine):Definition (mine):• Providers who assume the Providers who assume the

responsibility (with the patient and responsibility (with the patient and family members) to care for the patient family members) to care for the patient and their family members; through a and their family members; through a variety of medical conditions- over the variety of medical conditions- over the course of their patient’s life.course of their patient’s life.• Limited by training and scope of Limited by training and scope of

practicepractice• Implies a relationship between the Implies a relationship between the

patient and the providerpatient and the provider

PRIMARY CAREPRIMARY CARE

• Who are Primary Care Providers- Who are Primary Care Providers- • PediatricsPediatrics• Internal Medicine- general/ geriatricInternal Medicine- general/ geriatric• Family MedicineFamily Medicine• Pediatric/Internal Medicine combinationPediatric/Internal Medicine combination• Nurse PractitionersNurse Practitioners• Pediatric (PNP), Family (FNP) or Pediatric (PNP), Family (FNP) or

General (NP)General (NP)• Obstetrics/GYN (?)Obstetrics/GYN (?)

PediatricsPediatrics

• Generally care for children from birth Generally care for children from birth to 15-18to 15-18

• Will care for siblings; longitudinal Will care for siblings; longitudinal carecare

• Training is a 3 year residency Training is a 3 year residency program following medical schoolprogram following medical school• Consists of outpatient clinical Consists of outpatient clinical

expertise, along with hospitalized expertise, along with hospitalized care of sicker childrencare of sicker children

PediatricsPediatrics

• Some pediatricians will specialize Some pediatricians will specialize and do further residency training and do further residency training in: ID; Cards; GI; Neph, etc.- in: ID; Cards; GI; Neph, etc.- Currently 66% nationally go into Currently 66% nationally go into Primary CarePrimary Care

Internal MedicineInternal Medicine

• Generally care for Adults- some will Generally care for Adults- some will see patients > 15 or 16 of agesee patients > 15 or 16 of age

• Will care for members of the same Will care for members of the same familyfamily

• Longitudinal care, stressing Longitudinal care, stressing preventative services, hospitalized preventative services, hospitalized care.care.

Internal MedicineInternal Medicine

• Three year residency training Three year residency training program after medical schoolprogram after medical school• 1-2 year fellowships available for 1-2 year fellowships available for

geriatrics, research, etcgeriatrics, research, etc

• Many residents will specialize in:Many residents will specialize in:• Cards/ GI/ Endo etc.Cards/ GI/ Endo etc.• 48 % stay in Primary Care48 % stay in Primary Care

Pediatric/Internal Medicine Pediatric/Internal Medicine Combined trainingCombined training

• Training is 4 years of residency after Training is 4 years of residency after medical schoolmedical school

• Board certified in both Peds and IMBoard certified in both Peds and IM

• Care of all except obstetrical careCare of all except obstetrical care

• Emphasis on hospitalized care, Emphasis on hospitalized care, sicker adults and childrensicker adults and children

• Popular on coasts, where OB care is Popular on coasts, where OB care is routinely done by OB/GYNroutinely done by OB/GYN

Family MedicineFamily Medicine

• Three years of residency training after Three years of residency training after medical schoolmedical school

• Training in broad range of medicine:Training in broad range of medicine:• Peds; OB/GYN; Surg; ER; Ortho; Peds; OB/GYN; Surg; ER; Ortho;

Geriatric; IM; Neuro; etc.Geriatric; IM; Neuro; etc.

• Practice type depends on training- Practice type depends on training- flexible and variable.flexible and variable.

• Approx. 50% are choosing not to Approx. 50% are choosing not to provide OB careprovide OB care

Family MedicineFamily Medicine

• Specializing in outpatient Specializing in outpatient management of a wide variety of management of a wide variety of medical illnessesmedical illnesses

• Coordinator of care with multiple Coordinator of care with multiple specialistsspecialists

Rural vs.. UrbanRural vs.. UrbanPrimary CarePrimary Care

• RuralRural• Expectation for wider range of Expectation for wider range of

practice- OB/Peds to geriatric/NHpractice- OB/Peds to geriatric/NH• Care for “practice” rather than Care for “practice” rather than

“patients”“patients”• ER/ Hospital/ On-call a givenER/ Hospital/ On-call a given• Close relationship with patientsClose relationship with patients• Involvement in practice Involvement in practice

managementmanagement

Rural vs.. UrbanRural vs.. UrbanPrimary CarePrimary Care

• UrbanUrban• More control over practice styleMore control over practice style• ER Coverage is assumedER Coverage is assumed• After-hours care- usually arrangedAfter-hours care- usually arranged• More “shift” workMore “shift” work• Less day to day management Less day to day management

involvement involvement

• But… Patients are still PatientsBut… Patients are still Patients

Rural vs.. UrbanRural vs.. UrbanPrimary CarePrimary Care

• SimilaritiesSimilarities• Can still maintain part-time Can still maintain part-time

practices (? Definition of part-practices (? Definition of part-time)time)• Provide educational experience to Provide educational experience to

medical students; NP students etcmedical students; NP students etc• Both types of practices can be Both types of practices can be

isolating/ overwhelmingisolating/ overwhelming

Concern with Rural PracticeConcern with Rural Practice

• You know every oneYou know every one• BMPBMP• RealityReality• How to surviveHow to survive

Rural vs.. UrbanRural vs.. UrbanPrimary CarePrimary Care

• Best of timesBest of times

• Worst of timesWorst of times

CompensationCompensation

• ALL PRIMARY CARE SPECIALTIES ALL PRIMARY CARE SPECIALTIES are in demand!are in demand!• Recent data shows 25-50 offers to Recent data shows 25-50 offers to

each residenteach resident

• Starting salaries range: $120,000 to Starting salaries range: $120,000 to $220,000$220,000

• Signing bonuses range up to $30,000Signing bonuses range up to $30,000

Interested in Interested in Primary Care?Primary Care?

• MAFP (MAFP (www.mafp.orgwww.mafp.org))

• RPAPRPAP

• MNAAP (MNAAP (www.mnaap.orgwww.mnaap.org))

• www.sgim.orgwww.sgim.org

Wave ThreeWave ThreeOperation Minnesota LifelineOperation Minnesota Lifeline

OCTOBER 2005OCTOBER 2005

Operation Minnesota Lifeline: Wave Operation Minnesota Lifeline: Wave Three provided Three provided

• Providers from the University of Providers from the University of Minnesota, Mayo Clinic and Mayo Minnesota, Mayo Clinic and Mayo Health SystemHealth System

• Support staff for pharmacy, supplies, Support staff for pharmacy, supplies, logistics and registering patients logistics and registering patients

• RNs for assessing and triaging RNs for assessing and triaging patients patients

FOUR WAVESFOUR WAVES

• Wave One: Evaluation, start PHU’s, mass Wave One: Evaluation, start PHU’s, mass immunizations, “inpatient”, and RITAimmunizations, “inpatient”, and RITA

• Wave Two: Evaluation, staff PHU’s, mass Wave Two: Evaluation, staff PHU’s, mass immunizations, and wind down inpatient immunizations, and wind down inpatient

• Wave Three: Staff PHU’s, medical outreach, and immunizations

• Wave Four: Staff PHU’s and coordinate Wave Four: Staff PHU’s and coordinate departure departure

Public Health UnitsPublic Health Units

• Designed as a Designed as a “core public “core public health” facilityhealth” facility

• Not a primary Not a primary medical clinic. medical clinic. Minimal physician Minimal physician involvementinvolvement

Public Health UnitsPublic Health Units

• Have exam rooms Have exam rooms for WIC, STD for WIC, STD clinicsclinics

• Minimal if any Minimal if any laboratory and x-laboratory and x-ray equipment ray equipment

Operation Minnesota Lifeline: Wave Operation Minnesota Lifeline: Wave Three providedThree provided

• Immunizations Immunizations (given by RN’s, (given by RN’s, medical students, medical students, NP’s and yes –even NP’s and yes –even MD’s)- 4965MD’s)- 4965

Operation Minnesota Lifeline: Wave Operation Minnesota Lifeline: Wave Three providedThree provided

• Physician/NP visits Physician/NP visits - 1934 patients - 1934 patients seen in ~15 days;seen in ~15 days;

• 4034 prescriptions 4034 prescriptions or medications or medications given out. given out.

• 251 mental health 251 mental health consultations- consultations- doesn’t count the doesn’t count the untold “chats”untold “chats”

OutreachOutreach (aka: Road Trips) (aka: Road Trips)

• Initially, sites in and around the Initially, sites in and around the Lafayette area where there were Lafayette area where there were pockets of refugees pockets of refugees

• Most of the shelters were being Most of the shelters were being “cleaned out” “cleaned out”

• Mission in evolution.Mission in evolution.

FEMA linesFEMA lines

HotelsHotels

ChurchesChurches

Parking lots- most of the time working Parking lots- most of the time working out of back of the van out of back of the van

Even drive–by shootings! Even drive–by shootings!

Outreach to smaller communitiesOutreach to smaller communities

Gulf CoastGulf CoastPecan IslandPecan Island

New OrleansNew Orleans

• A two hour trip from LafayetteA two hour trip from Lafayette

• Clinic was from 9am – 5pmClinic was from 9am – 5pm

• At the site of the FEMA line in New At the site of the FEMA line in New OrleansOrleans

• In four days- saw 434 patients and In four days- saw 434 patients and gave 683 people immunization with gave 683 people immunization with 59 mental health consultations.59 mental health consultations.

Lessons learned in LouisianaLessons learned in Louisiana

• Disaster medicine vs.. triage Disaster medicine vs.. triage medicine vs. primary care medicinemedicine vs. primary care medicine

• Physicians without logistic support Physicians without logistic support and equipment are almost worthlessand equipment are almost worthless

• ““Mayo Clinic gator survival course”Mayo Clinic gator survival course”

• A good “hard freeze” keeps the bugs A good “hard freeze” keeps the bugs smallsmall

• Blizzards melt- Hurricanes destroyBlizzards melt- Hurricanes destroy

How to say “boudin”How to say “boudin” and then how to eat it and then how to eat it