Nov 6, 2015 — The United States needs more primary care physicians and team-based medical care to better serve patients. Primary Care Progress is a group that promotes the need for primary care teams of doctors, nurses and pharmacists and educates medical students on their benefits. Karen Gunning holds a doctorate of pharmacy (Pharm.D.) and is supervisor of the PCP chapter at the University of Utah School of Medicine. In this podcast, she and family physician Dr. Kyle Bradford Jones talk about how learning about the benefits of team-based care in med school can prepare students for success in practice and treating their patients for their whole careers.

Interview

Dr. Jones: The structure of primary medical care is progressing increasingly to the use of multidisciplinary teams in the care of patients. So what are some ways the medical profession students can learn the importance of team care? I'm Dr. Kyle Bradford Jones, family physician at the University of Utah School of Medicine, and we're talking about this next coming up on The Scope.

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Dr. Jones: Now we all know in the United States our health care system is broken. It costs too much, it doesn't provide great outcomes, and it's not structured in a way that's beneficial to the patient. Now research shows that an optimal health care system provides the most value when it has one-half of its physicians in primary care, the other half in specialty care. And the United States currently has only one-third of its physicians in primary care, which means we as a nation are underperforming at an optimal level, and that means that the patient gets lost in the middle.
So one of the solutions to overcome this primary care shortage, and improve the value of health care is a move towards multidisciplinary care teams. There's a national group called Primary Care Progress, which is helping to train students in multiple different disciplines in this model.
I'm joined by Dr. Karen Gunning, who's a doctor of pharmacy, professor, and interim chair of the Department of Pharmacotherapy at the College of Pharmacy at the University of Utah. She's also an adjunct professor in family and preventive medicine, and she acts as one of the faculty supervisors for the Primary Care Progress chapter at the University of Utah.
So Dr. Gunning, tell us a little bit more. What is Primary Care Progress?

Dr. Gunning: Primary Care Progress is an organization that was really designed to promote primary care as both a specialty that medical students would want to go into, but also as an organization that promotes the need for primary care.
So to really cause people and students to think about what are the reasons we need primary care, and what are the reasons they might want to go into it. So initially it was a medical student organization, and really through the efforts of people across the country, really became a driving force for integrating teams. And so it's one of the first organizations in the country that really has embraced having multiple health professional students be involved in the organization.

Dr. Jones: And so how does this help students and residents in multiple different disciplines learn how to practice in different care teams for when they enter their practice?

Dr. Gunning: I think it's giving them exposure earlier, and more intensely in terms of what other health care professionals can do. Interprofessional education is nothing new. We've been doing interprofessional education, demonstrations here at the University of Utah for several years. But where Primary Care Progress has really been successful is in getting these professional students to work together.
So working together at our Maliheh Free Clinic, working together on sessions to advance their leadership skills, or their career skills, and really just getting in a room and talking to each other, which I think is at the core of what we need to do as professionals to begin to grow our team.

Dr. Jones: Now, how have the students responded to that?

Dr. Gunning: The students have been amazing. The first year that we really started this chapter we had a pharmacy student and a medical student that were co-leaders of the chapter and they both are now in leadership positions in pharmacy residencies, and family medicine residencies across the country.
Now each year we'll have different professions that stand up and become the leaders. So this year we have nurse practitioner students that are effectively leading the group, and we really have broadened over time in terms of the professions that we are able to engage in our group.

Dr. Jones: And in general with health care teams and there being so many different disciplines, how do we decide who should be on that health care team to help benefit our patients?

Dr. Gunning: Well I think the first thing we need to do is look at who our patients are. Different communities have different needs, and so when we have a geriatric population for example, we might need to have a different mix of professionals than we might need for a pediatric population.
So I think it comes from doing a needs assessment of the population and really looking at what are the needs in that population.
The other thing that I really think about as professional and try to teach all of our health professional students is how do we work at the top of our license? What are the activities that only a physician can do? Or only a pharmacist can do? Or only a nurse has the unique skills to do? And how can we work together by doing those things that really define our profession? And I think in doing that we'll provide the best health care for our patients.

Dr. Jones: I know obviously as I mentioned you're a doctor of pharmacy so a lot of patients don't necessarily see pharmacists as part of the clinical team. So what role do pharmacists play in this?

Dr. Gunning: Well, pharmacists are the direct experts. And so in terms of the amount of new medications and the complexity of new medications over the past 15 to 20 years, it is no longer possible for any one person to be able to be in control of both diagnosis and treatment. And so we really help to compliment the providers, the nurse practitioners, the PAs and the physicians who are doing diagnosing, and we can step in and assist, and be a part of the team with treatment decisions, and in educating patients about medications.

Dr. Jones: Now with the Primary Care Progress training many of these students to practice in team settings we don't necessarily see that in a lot of clinics. What are some of the barriers to implementing this?

Dr. Gunning: So if we're paying providers on a fee-for-service basis where we're paying them for the specific activities that they are doing and we're paying them for more for activities that are procedurally based, but not more for activities that are maybe educational, or providing non-procedural things to patients. So in that world it is very difficult to pay for a team of providers that are providing things like care management through nursing, or medication management through pharmacy because those are not fee-for-service reimbursable services.
As we move more towards the capitated payment model were we're getting a set fee for the care of a patient, it makes more sense to have however on that team has provided the care the patient needs to step into that role. And as we have that more available, and in some parts of our country it is more available, we be begin to see more pharmacists in clinic, more care managers, more social workers, more community health workers as we have the means to provide that through paying for it.

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