Embracing the Many “Cs” of Family Medicine

PRESIDENT’S MESSAGE to Members

By Dr. David Rinehart 2019–2020 NCAFP President

~ THE 2019 INAUGURAL ADDRESS ~

On Saturday, December 7, 2019, Dr. David Rinehart of Belmont, North Carolina, was installed as President of the North Carolina Academy of Family Physicians. His inaugural remarks to members appear below.

Thank you so much for welcoming me as your new President of the North Carolina Academy of Family Physicians. It is truly a great honor and privilege to be elected to this position. I have been involved in the leadership of this Academy for eight years and I will tell you that this has been a wonderful experience, meeting and getting to know so many highly skilled and committed family physicians over this time and working with a top notch Academy staff. We are a specialty that cares deeply about what happens in health care, about disparities that exist in health care, about access and quality and affordability of care.

1969, 50 Years Ago

Fifty years ago, our country experienced many seminal events. We saw the liberation of a generation in the experience of Woodstock. We marked the turning point in the gay rights movement at Stonewall. The country had a feel-good moment of technological breakthrough putting a man on the moon. And, as many of you know, in response to our forebear’s vision, and the recognition of the need for comprehensive, patient and family-centered, high Continues on next page

Executive Officers President David R. Rinehart, MD President-Elect Jessica Triche, MD Secretary/Treasurer Dimitrios “Takie” P. Hondros, MD Immediate Past President Alisa C. Nance, MD, RPh Executive Vice President Gregory K. Griggs, MPA, CAE

At-Large Directors

Talia M. Aron, MD

Elizabeth B. Baltaro, MD

Jewell P. Carr, MD

Garett R. Franklin, MD

Shauna L. Guthrie, MD, MPH

Brian McCollough, MD

Mark McNeill, MD

Ying Vang, MD

Academic Position Mark L. Higdon, DO (Novant FMR)

Resident Director Elizabeth Ferruzzi, MD (Novant)

Resident Director-Elect Clayton Cooper, MD, MBA (Duke)

Student Director Katelyn Turlington (WFSOM)

Student Director-Elect Hannah Smith (ECU)

AAFP Delegates & Alternates

AAFP Delegate Michelle F. Jones, MD AAFP Delegate Karen L. Smith, MD AAFP Alternate Richard W. Lord, Jr., MD, MA AAFP Alternate Robert L. Rich, Jr., MD

quality primary medical care -- and importantly for us here today -- was the creation of the new medical specialty of Family Medicine.

A little about me...

Also, about 50 years ago, there was this 14-year-old boy who became very interested in biology, physiology, diseases, and medical care. That was me. I had the good sense to be born into a wonderfully supportive family that valued education as well as emphasized the importance of family relationships. I decided I wanted to be a doctor.

I found myself at the University of Virginia (UVA) for college, then four more years as a Cavalier for medical school. At UVA, I was greatly influenced by Dr. Lewis Barnett who was a wonderful advocate and thought leader and pioneer for Family Medicine in those years. Probably like many of you, I was fascinated by all the different specialties in medical school, and I decided I wanted to specialize in Family Medicine.

I came to North Carolina now more than 37 years ago, to Carolinas Medical Center for Family Medicine residency, drawn by another great intellect and visionary, Dr David Citron. I developed many wonderful friendships in Charlotte, and I had an excellent residency experience there, and I have not left. When I precept medical students, I have always encouraged them to take away the best ideas and characteristics of each of the physicians that they encounter along their professional path. I have tried to do that with each of my physician mentors, and others, who have contributed to my professional path, and I am thankful for each of them.

From my Charlotte Family Medicine residency, I moved about 10 miles west to Belmont, to a small community, where I joined two other family physicians who had graduated from my residency a few years earlier, and we have

been South Point Family Practice ever since, now 34 years for me there. We grew quickly and practiced independently as a single specialty family practice group for more than 20 years, including a very busy hospital practice, then changed to outpatient Family Medicine and ownership by our local hospital system. I have been practicing most of the breadth of Family Medicine (except obstetrics) throughout my career.

It has been a great ride for me and my colleagues, with so many wonderful patient relationships developed over the decades of time. I treat several generations of patients now and I’ve seen so many grow up as successful adults and parents and built so many caring relationships over the years.

I met my wife, Lucille, as an undergraduate student at UVA. We have been married for more than 40 years now and have three wonderful children who are here tonight, and two grandchildren.

That is a little bit of history about my journey over the past 50 years.

Our founding 50 years ago

So now I want to spend a few minutes reflecting on the founding ideals and precepts of Family Medicine and think about how those ideals, those principles, live on with us today. How have those founding ideas held up over time? Let’s go back 50 years; what were the attributes of quality Family Medicine 50 years ago?

I reviewed some of the original documents from our founding and found discussion about the need for primary care physicians with the qualities we now might call “the many Cs of Family Medicine:” Contact (first contact), Caring, Comprehensiveness, Continuity, Community-oriented, Competent, Coordination, Cost Effective. Here, then, lie our roots, our core, our wonderful heritage. These “Cs” defined the quality of Family Medicine 50 years ago, and I believe also define quality Family Medicine today.

Our current “quality metrics”

I want to spend a few minutes talking about today’s ideas of quality measures.

We are all used to grappling with our EMRs and quality metrics every day. The fall risk assessment, the PHQ 2s and 9s, the A1Cs, and colonoscopy, all of that necessary stuff that we need to keep track of in order to be sure our patients get proper care, good preventive care. But these are narrowly focused measures, mostly disease specific, and I think most of us would agree that they do not really tell the story about the breadth and essence of what we do in Family Medicine. They just don’t seem to me to be at the core of what we do, at the center of our founding principles. Sometimes we get caught up with the box-clicking that we might miss our core.

I recently came across an article published earlier this year in the Annals of Family Medicine by RS Etz, et al*, that I think is very well done. The article tried to answer the question, “what really matters when we talk about quality in Family Medicine?” I know we struggle with these metrics and numbers every day, but at the core, what really matters? What is real quality? Is it any different than it was 50 years ago?

Let us look at some other patient-centered practice quality metrics mentioned in this paper that I think we should be asking. Questions that we could ask of our patients to see if we are really following the principles set out for our specialty 50 years ago.

There are many different practice types represented in our specialty: traditional office practice, hospitalists, skilled nursing facility physicians, academic physicians, urgent care, direct primary care; all sorts. But whatever your practice type, see if you agree that these are useful measures for your practices today.

My practice makes it easy for me to get care CONTACT (FIRST CONTACT)

We must be available to our patients. This may involve ease of appointments in the traditional office, or access through patient portals, telemedicine, or after-hours care. Patient access is our priority.

My practice is able to provide most of my care COMPREHENSIVENESS

We know that physicians who practice the full spectrum of Family Medicine tend to be happier and their patients tend to be happier as well. They feel more fulfilled in their work and their patients are not running all over the place

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In caring for me, my doctor considers all of the factors that affect my health COMPREHENSIVENESS

We know that only a small part of a person’s health is affected by what we can provide in a medical office setting. We have long understood that health involves more than the absence of disease and that there are numerous social determinants of health and we take them into consideration in our treatment plans.

My practice coordinates the care I get from multiple places. COORDINATION

I have a patient who regularly sees 11 different subspecialists. Do we keep careful track of our subspecialty consultants, do we have the analytics to understand where our patients are getting their care outside of our offices, particularly when they have multiple chronic conditions that require careful coordination?

My doctor or practice knows me as a person CARING

I have an elderly man who used to tell me a different golf joke at each visit for many years, until he eventually became too demented and started telling me the same golf joke every time. Still funny. I have a 97-year-old man who writes a daily blog that I read. We get to know our patients.

My doctor and I have been through a lot together CONTINUITY

We have the rare opportunity and privilege to have patients share with us some of the most difficult times of their lives, the deep feelings of grief and depression and life-threatening illness, as well as the sharing their joys of health and comfort and healing.

My doctor or practice stands up for me COORDINATION

Do we power through those prior authorizations, those endless forms and questions and qualifications necessary for our patients to get the care they need, and do we keep trying to make the system work better for our patients? Your Academy is trying to help with this.

The care I get takes into account knowledge of my family COMPREHENSIVENESS

How many times has a child’s stomachache reflected a family’s discord, or the cause of a person’s fatigue be understood when we know the challenges they face as the sole caregiver of a demented family member?

The care I get in this practice is informed by the knowledge of my community COMMUNITY ORIENTED

Do we keep track of the resources available in our communities, the mental health resources, the food banks and

social services organizations and cost-effective medical services available to our patients?

Over time, my practice helps me stay healthy COMPETENT, COMPREHENSIVENESS, CONTINUITY, CARING

A large body of research proves that establishing an ongoing relationship with a primary care physician is one of the most reliable determinants of better health outcomes.

Over time, this practice helps me to meet my goals CONTINUITY AND COMPREHENSIVENESS

These are patient-centered goals. Our patients often have goals very different from the boxes in our EMRs. They may want to be able to have their arthritis controlled enough to dance at their daughter’s wedding or be healthy enough to attend the grandson’s graduation.

Patient-centered quality metrics for 50 years of Family Medicine

You will not find these metrics in a check box in your EMR, but you will find them in the minds and in the hearts of family physicians throughout North Carolina and indeed the world. Our core mission, our core quality as reflected in these metrics, has endured over the last 50 years.

We have a great tradition of patient-centered care that I believe will carry us forward for another 50 years.

Thank you.

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*Etz RS et al. New Comprehensive Measure of High-Value Aspects of Primary Care. Annals of Family Medicine, May/June 2019

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