Primary Care Potpourri AED November 1, 2006

1. Primary Care PotpourriAED November 1, 2006 Kurt B. Angstman, MS, MD Medical Director, Mayo Family Clinics Department of Family Medicine Mayo Graduate School of Medicine Mayo Clinic

2. Discussion topics • Primary Care • Rural vs.. Urban practice • Minnesota Lifeline October 2005- Katrina/Rita

3. PRIMARY CARE • Definition (mine): • Providers who assume the responsibility (with the patient and family members) to care for the patient and their family members; through a variety of medical conditions- over the course of their patient’s life. • Limited by training and scope of practice • Implies a relationship between the patient and the provider

4. PRIMARY CARE • Who are Primary Care Providers- • Pediatrics • Internal Medicine- general/ geriatric • Family Medicine • Pediatric/Internal Medicine combination • Nurse Practitioners • Pediatric (PNP), Family (FNP) or General (NP) • Obstetrics/GYN (?)

5. Pediatrics • Generally care for children from birth to 15-18 • Will care for siblings; longitudinal care • Training is a 3 year residency program following medical school • Consists of outpatient clinical expertise, along with hospitalized care of sicker children

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

7. Internal Medicine • Generally care for Adults- some will see patients > 15 or 16 of age • Will care for members of the same family • Longitudinal care, stressing preventative services, hospitalized care.

8. Internal Medicine • Three year residency training program after medical school • 1-2 year fellowships available for geriatrics, research, etc • Many residents will specialize in: • Cards/ GI/ Endo etc. • 48 % stay in Primary Care

9. Pediatric/Internal Medicine Combined training • Training is 4 years of residency after medical school • Board certified in both Peds and IM • Care of all except obstetrical care • Emphasis on hospitalized care, sicker adults and children • Popular on coasts, where OB care is routinely done by OB/GYN

10. Family Medicine • Three years of residency training after medical school • Training in broad range of medicine: • Peds; OB/GYN; Surg; ER; Ortho; Geriatric; IM; Neuro; etc. • Practice type depends on training- flexible and variable. • Approx. 50% are choosing not to provide OB care

11. Family Medicine • Specializing in outpatient management of a wide variety of medical illnesses • Coordinator of care with multiple specialists

12. Rural vs.. UrbanPrimary Care • Rural • Expectation for wider range of practice- OB/Peds to geriatric/NH • Care for “practice” rather than “patients” • ER/ Hospital/ On-call a given • Close relationship with patients • Involvement in practice management

13. Rural vs.. UrbanPrimary Care • Urban • More control over practice style • ER Coverage is assumed • After-hours care- usually arranged • More “shift” work • Less day to day management involvement • But… Patients are still Patients

14. Rural vs.. UrbanPrimary Care • Similarities • Can still maintain part-time practices (? Definition of part-time) • Provide educational experience to medical students; NP students etc • Both types of practices can be isolating/ overwhelming

15. Concern with Rural Practice • You know every one • BMP • Reality • How to survive

16. Rural vs.. UrbanPrimary Care • Best of times • Worst of times

17. Compensation • ALL PRIMARY CARE SPECIALTIES are in demand! • Recent data shows 25-50 offers to each resident • Starting salaries range: $120,000 to $220,000 • Signing bonuses range up to $30,000

18. Interested in Primary Care? • MAFP (www.mafp.org) • RPAP • MNAAP (www.mnaap.org) • www.sgim.org

19. Wave ThreeOperation Minnesota Lifeline OCTOBER 2005

20. Operation Minnesota Lifeline: Wave Three provided • Providers from the University of Minnesota, Mayo Clinic and Mayo Health System • Support staff for pharmacy, supplies, logistics and registering patients • RNs for assessing and triaging patients

21. FOUR WAVES • Wave One: Evaluation, start PHU’s, mass immunizations, “inpatient”, and RITA • Wave Two: Evaluation, staff PHU’s, mass immunizations, and wind down inpatient • Wave Three: Staff PHU’s, medical outreach, and immunizations • Wave Four: Staff PHU’s and coordinate departure

22. Public Health Units • Designed as a “core public health” facility • Not a primary medical clinic. Minimal physician involvement

23. Public Health Units • Have exam rooms for WIC, STD clinics • Minimal if any laboratory and x-ray equipment

24. Operation Minnesota Lifeline: Wave Three provided • Immunizations (given by RN’s, medical students, NP’s and yes –even MD’s)- 4965

25. Operation Minnesota Lifeline: Wave Three provided • Physician/NP visits - 1934 patients seen in ~15 days; • 4034 prescriptions or medications given out. • 251 mental health consultations- doesn’t count the untold “chats”

26. Outreach (aka: Road Trips) • Initially, sites in and around the Lafayette area where there were pockets of refugees • Most of the shelters were being “cleaned out” • Mission in evolution.

27. FEMA lines

28. Hotels

29. Churches

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

31. Even drive–by shootings!

32. Outreach to smaller communities

33. Gulf CoastPecan Island

37. New Orleans • A two hour trip from Lafayette • Clinic was from 9am – 5pm • At the site of the FEMA line in New Orleans • In four days- saw 434 patients and gave 683 people immunization with 59 mental health consultations.

39. Lessons learned in Louisiana • Disaster medicine vs.. triage medicine vs. primary care medicine • Physicians without logistic support and equipment are almost worthless • “Mayo Clinic gator survival course” • A good “hard freeze” keeps the bugs small • Blizzards melt- Hurricanes destroy

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