Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Welcome to Introduction to Health Care and Public Health in the U.S.: Delivering Health Care, Part 2. This is lecture b. The component, Introduction to Health Care and Public Health in the U.S., is a survey of how health care and public health are organized and how services are delivered in the U.S. It covers public policy, relevant organizations and their interrelationships, professional roles, legal and regulatory issues, and payment systems. It also addresses health reform initiatives in the U.S. Lecture b This material (Comp 1 Unit 3) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/. Health IT Workforce Curriculum Version 4.0

Delivering Health Care, Part 2 Learning Objectives Describe the organization of clinical health care delivery in the outpatient setting, and the organization of outpatient health care (Lectures a-c) Describe the organization of ancillary health care delivery in the outpatient setting (Lecture d) Discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting (Lecture e) The learning objectives for Delivering Health Care, Part 2 are to: Describe the organization of clinical health care delivery in the outpatient setting and the organization of outpatient health care Describe the organization of ancillary health care delivery in the outpatient setting And discuss the role of different health care providers, with an emphasis on the delivery of care in an interdisciplinary setting

Where Is Primary Care Delivered? Primary care clinic: Point of delivery A medical facility Usually, the conditions seen at a primary care clinic are not serious or life threatening “Gateway” to health care services This lecture will discuss outpatient primary care, outpatient specialty care, and types of disciplines involved in each, and the primary care crisis in the U.S. As reviewed in the previous lecture, primary care represents a category of health services. So where are these health services delivered? The usual point of delivery is a primary care clinic, where the medical conditions seen are not serious or life threatening. A primary care clinic may also be the gateway to other health care services. For example, after evaluation in a primary care clinic, the patient may be referred to a laboratory or diagnostic testing center, to an urgent care center, or even to an emergency room. The patient may also be referred to different clinical specialists.

Primary Care Medical Specialties Family Practice General Internal Medicine Pediatrics Obstetrics and Gynecology (OB/GYN) The medical specialties that make up primary care are family practice, general internal medicine, pediatrics, and obstetrics and gynecology, or OB/GYN. These medical specialties are discussed in greater detail in this unit.

Family Practice Defined by American Board of Family Practice Medical specialty that provides continuing and comprehensive health care for the individual and for the family in an outpatient setting. Integrates biological, clinical and behavioral sciences Encompasses all ages, both sexes, each organ system and every disease entity Family practice, or family medicine, is defined by the American Board of Family Practice as the medical specialty that provides continuing and comprehensive health care for the individual and for the family in an outpatient setting. It has a very broad spectrum of care, integrating the biological, clinical, and behavioral sciences. Its scope is also very large, encompassing all ages, both sexes, all organ systems, and every disease entity.

General Internal Medicine Doctors of internal medicine (also known as “internists”) Focus on adult medicine Special study and training focusing on the prevention and treatment of adult diseases. Can be called upon to act as consultants to other physicians Doctors of general internal medicine, another medical specialty, are known as internists. Internists focus on adult medicine, and after graduating from medical school, spend at least three more years in advanced training in how to prevent, diagnose, and treat diseases of adulthood. They also help to take care of patients with complex, multiple, or chronic issues. Internists are also referred to as the doctor’s doctor, because they can be called upon to act as consultants to other physicians to help solve puzzling diagnostic problems.

Pediatrics Medical care of: Focus: Infants Children Adolescents Diagnosing, treating and preventing diseases that affect children Pediatrics deals with the medical care of infants, children, and adolescents. Pediatricians are trained to diagnose, treat, and prevent diseases that affect children.

Obstetrics and Gynecology Obstetrics (OB) Care of women during pregnancy and immediately after childbirth Gynecology (GYN) Care of the female reproductive system Preventive care is an important facet of primary care Often same clinician provides both services Obstetrics is the care of women during pregnancy. Obstetricians also assist in childbirth and provide care in the postnatal period. Gynecology is the care of the female reproductive system. Both obstetrics and gynecology may involve surgery, in addition to the diagnosis and treatment of diseases. Women’s health and gynecologic preventive care are important facets of primary care. Often the same clinician provides both obstetric and gynecologic services.

Specialty Care A specialty is a branch of medicine Physicians train in specific field Ophthalmology Radiology Fellowship Additional training in more general field Example: Trained in General surgery, fellowship as cardiothoracic surgeon So far this lecture has examined primary care. Another type of health care practice is specialty care. A specialty is a branch of medicine. After completing medical school, physicians choose to train in a specific field, which is their specialty, such as ophthalmology or radiology. Some physicians undergo additional training, called a fellowship, after initial training in a more general field. For example, after medical school, a physician may train in general surgery and then receive fellowship training as a cardiothoracic surgeon.

Examples of Medical Specialties Dermatology Pathology Radiology Nuclear Medicine Psychiatry Emergency Medicine Preventive Medicine This slide gives a few examples of specialties. Specialties include: Dermatology, or the study of conditions of the skin; Pathology, or the study of the nature of disease and its causes; Radiology, or the use of imaging technology to diagnose and treat diseases; Nuclear medicine, or the use of radioactive substances to diagnose and treat diseases; Psychiatry, or the study of mental illnesses; Emergency medicine, or the care of patients who require emergency medical attention, usually in the emergency department of a hospital; and preventive medicine, which studies the methods of preventing illnesses.

Specialty clinics Medical specialties Surgical specialties Examples: Cardiology Immunology Gastroenterology Surgical specialties Examples: Orthopedic surgery Neurosurgery Plastic surgery Similar to primary care, specialty care also exists in the outpatient setting. Specialty clinics may focus on medical specialties such as cardiology, immunology, or gastroenterology; or surgical specialties such as orthopedic surgery, neurosurgery, or plastic surgery.

Delivery of Specialty Care Across Settings Surgical specialists See patients in outpatient clinics Perform surgeries in hospitals or in outpatient surgical centers Many surgical specialists see patients in outpatient clinics in addition to performing operations in hospitals and in outpatient surgical centers. For example, a patient with knee pain may be evaluated initially by an orthopedic surgeon in an outpatient specialty center. The patient may or may not have been referred by a primary care physician. After the evaluation, the patient may have knee surgery in a hospital and receive follow-up care in the orthopedic surgeon’s clinic.

Outpatient Surgical Centers Also known as ambulatory surgical centers Procedures performed in non-hospital location Patients go home after brief recovery period Surgical centers do not accommodate overnight or extended stays At times, surgery is performed in an outpatient surgery center instead of an inpatient hospital setting. In outpatient or ambulatory surgical centers, surgery or other procedures are performed in a non-hospital location and patients go home after a brief period of recovery, usually a few hours. Ambulatory surgical centers do not typically accommodate overnight or prolonged stays.

Primary Care In Crisis? Increasing number of older patients with complex medical issues Inadequate coverage of preventive care services Emphasis on documentation Complex billing and compensation system In the past few years, articles in the popular press and in the medical literature have warned that primary care appears to be in crisis. What does this mean? First, there seems to be an increasing number of older patients with complex medical issues and chronic illnesses, accompanied by inadequate coverage of preventive care services. There is also a growing emphasis on documentation and paperwork for clinicians, taking time away from direct patient care. Further demands include the complex billing and compensation system associated with the delivery of health care. All of these issues have contributed to a decrease in the amount of resources allocated to primary care and a consequent reduction in primary care services for the U.S. population.

Primary Care Crisis Contributing Factors - 1 Decreasing number of physicians practicing primary care Supply-demand imbalance Greater dependence on after-hours care Increased cost of health care delivery In addition, medical students may not consider primary care to be an attractive profession, which has led to a decreasing number of physicians who practice primary care. The growing number of patients with complex medical issues coupled with the decrease in the supply of providers has led to an imbalance. One result is a greater dependence on after-hours care in urgent care centers or emergency departments for primary care services as opposed to true emergencies, resulting in increased cost of health care delivery.

Primary Care Crisis Contributing Factors - 2 More than 80 percent of graduating medical students carry educational debt Specialists are better compensated than primary care physicians Fewer U.S. graduates enter family medicine Recent years have more positive statistics Some numbers help explain the crisis in primary care. More than eighty percent of graduating medical students carry an educational debt, and about five percent of all medical students graduate with a debt of more than two hundred thousand dollars. Given that specialists are better compensated than primary care physicians, it seems logical for graduating medical students to consider careers in medical specialties over primary care. The number of U.S. graduates entering a family residency program dropped by fifty percent between 1997 and 2005. Statistics in recent years are more positive. From 2009-2016, the American Academy of Family Physicians has seen a small but steady increase in the number of Family Practice residencies filled by medical students.

Solving The Primary Care Crisis Shift in training focus Increased funding International Medical Graduates Recruitment Loan forgiveness and other financial inducements The primary care crisis has several possible solutions. A shift in the focus of medical training from an emphasis on specialty care to an emphasis on primary care is needed. Increased funding for primary care education can increase the number of residency positions that are available to medical students. International medical graduates often fill primary care positions in underserved areas of the U.S., as these are positions that U.S. medical graduates are often unable or unwilling to fill. Financial incentives such as offering bonuses for choosing primary care, loan forgiveness, or other financial inducements may also help recruit more physicians into careers in primary care.

Delivering Health Care, Part 2 Summary – Lecture b Primary care locations Primary care specialties Outpatient specialty care The primary care crisis This completes lecture b of Delivering Health Care, Part 2. In summary, this lecture described outpatient primary care, outpatient specialty care, the types of disciplines involved in each, and the primary care crisis in the U.S.

Delivering Health Care, Part 2 References – Lecture b American Academy of Family Physicians at: http://www.aafp.org/medical-school-residency/program-directors/nrmp.html. Accessed January 20, 2017. American Board of Family Practice at https://www.theabfm.org/index.aspx. Accessed January 20, 2017. American College of Physicians at: http://www.acponline.org/patients_families/about_internal_medicine/ Association of American Medical Colleges at: www.aamc.org. Accessed January 20, 2017. Bodenheimer T. Primary Care -- Will It Survive? N Engl J Med 2006 355: 861-864 Karen E. Hauer, MD; Steven J. Durning, MD; et al., KE; Durning, SJ; Kernan, WN; Fagan, MJ; Mintz, M; O'Sullivan, PS; Battistone, M; Defer, T et al. Factors Associated With Medical Students' Career Choices Regarding Internal Medicine. JAMA 300(10):1154–1164 No audio Health IT Workforce Curriculum Version 4.0

Introduction to Health Care and Public Health in the U. S Introduction to Health Care and Public Health in the U.S. Delivering Health Care, Part 2 Lecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. No audio Health IT Workforce Curriculum Version 4.0