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--> 8 Training and Utilization of Generalists and Subspecialists at the University of California, Los Angeles
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--> Introduction William R. Hazzard The environment that dictates reappraisal of the management of rheumatic disease is changing rapidly and is the principal force behind the present study. Nowhere are these forces of change felt more acutely than in the academic health center wherein advances in the diagnosis and treatment of rheumatic disorders have been concentrated in recent decades of major biomedical research. In no rheumatic disorders more than rheumatoid arthritis and systemic lupus erythematosus have the coincidence of biomedical research and highly focused, subspecialized diagnosis been more concentrated than in these academic health centers. Thus, it is important to examine the approach of one major academic health center to the reorientation and reorganization necessary to survive the whirlwind changes in health care delivery and financing so as to permit its continued focus on excellence in fulfilling its historical tripartite mission of research, teaching, and clinical care. A particularly instructive and reassuring example is the leadership of the University of California, Los Angeles (UCLA) Medical Center in reorganizing to address the forces of managed care market domination in a manner so as to preserve its commitment to academic excellence. Thus, the report by Alan Fogelman, chairman of the Department of Medicine at UCLA, presents an approach that appears promising, logical, well designed, and rational. It is also useful to examine this approach in the context of a previously articulated plan to reorganize the department in a manner that preserves its historical excellence in biomedical research and the training of both future physician scientists and an even greater number of primary care internists at the medical student and resident levels. Thus, UCLA Internal Medicine under Alan Fogelman appears likely to survive—indeed flourish—through a rational,
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--> enlightened process of planning and commitment to change (with considerable shared sacrifice), allowing transition to a model of prosperity in the most demanding environment of competitive managed care. Biomedical scientists, academic physicians, administrators, and planners at the local and national level have much to learn from Dr. Fogelman's thoughtful, scholarly, and clearly articulated approach to the challenge faced by all academic health centers.
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--> Invited Address Alan M. Fogelman A central theme of our system at UCLA is that it is based on the education of physicians, of patients, and of the staff that participate. With this in mind, I am going to tell you how the Department of Medicine component of our UCLA health system is approaching some of the problems you are grappling with today. In response to economic pressures, as we have all heard, health care delivery has shifted significantly toward primary care. By July 1992, when I became department chair, our department had only four full-time practicing primary care physicians. These full-time physicians spent fewer than 20 hours a week on direct patient contact. As the future importance of primary care became evident, we developed a strategy to create a positive environment for primary care, and to recruit a sufficient number of primary care physicians on the Westwood campus to care for the number of lives necessary to compete for contracts and preserve both our teaching mission and our subspecialty practices. This strategy is described in detail in an article published in the Annals of Internal Medicine,116 and I will not repeat the details here. Our initial goals have largely been met. We successfully persuaded the university to eliminate the requirement for regional and national recognition as prerequisites for advancement and promotion of these clinician educators. They are now judged on their achievements and creative contributions to local education and patient care. We have established productivity standards that are similar to those of a staff model HMO. That is, the clinician educators that 116 Fogelman, AM (1994). Strategies for training generalists and subspecialists. Annals of Internal Medicine, 120: 579–583.
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--> are primary care doctors, as well as our subspecialist clinician educators, are scheduled to spend 32 hours each week in direct outpatient contact when not assigned to an inpatient service. One result has been a dramatic increase in patient visits to our primary care clinician educators since initiation of the program. As a result of this tremendous increase in primary care, our subspecialty practice has also grown, although at a slower rate, 10 percent per year. This modest growth in subspecialty practice needs to be taken in the context of the West Los Angeles market, where subspecialty activity and incomes have declined on the order of 25–50 percent in the past two years. In contrast, our net cash continues to grow and our faculty has received, on average, a 5 percent increase in salary this year. A major principle of primary care is that it is provided in the neighborhoods where people live. Having largely met our goals for primary care on the Westwood campus, we have begun to establish neighborhood facilities. We have opened three community sites already: in Marina Del Rey, in Culver City, and at our Eichenbohm site in the Fairfax district, which is a geriatrics facility. We have negotiated leases on three additional sites, one of which, in Manhattan Beach, is almost ready to open. We are renovating or negotiating for facilities in four other sites, including two in Beverly Hills and one in the Valley in Sherman Oaks. The area west of UCLA in Santa Monica is being developed with the Huntington Provider Group and the Santa Monica independent practice associations (IPAs), an affiliation established by UCLA. We anticipate having five neighborhood satellites open before the end of this academic year and 10 open by July 1, 1997. The goal of the department is to open 20 neighborhood satellites. All of the offices are in small buildings. This is not UCLA Medical Center. These are simply offices. To accomplish our goals we have established the following principles and infrastructure; they are the backbone of a primary care strategy for transitioning to all-payer capitation. Our mission statement is to develop a high-quality patient-focused system for providing primary care in geographic proximity to the neighborhoods where people live, but with the capability of providing state-of-the-art, world-class knowledge and technology for those individuals with conditions warranting such resources, that is, the infrastructure and support systems to provide care in the most appropriate and cost-effective setting in an all-payer capitated system. As I have indicated, our outpatient sites are stand-alone buildings with easy parking. We find that former bank buildings are particularly good, and there are a lot of those in southern California; we are making them small, dedicated medical buildings. Our sites are of sufficient size to accommodate two to five physicians, one to two medical residents, and one to two visiting subspecialists accompanied by a trainee. Inpatient treatment for patients outside the catchment area of UCLA
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--> Medical Center is done at local hospitals for low-acuity conditions, unless the patient requests otherwise. Patients are admitted to UCLA for higher-acuity conditions or are transferred to UCLA Medical Center if appropriate facilities do not exist at the local hospital. Primary Care Physicians Primary care physicians are general internists or subspecialists with heavy general internal medicine practices—that is, greater than 50 percent. All internist physicians are full-time faculty in the Department of Medicine in the clinical compensated series, and they are expected to spend a minimum of 32 hours each week in direct patient contact. Physicians recruited with existent practices are paired with recent graduates who have been trained in general internal medicine in a managed care environment. An inpatient team of general internists has been created, which is responsible for caring for hospitalized patients at local hospitals. The community subspecialists and specialists on staff at these hospitals are utilized. Our team of internists is also responsible for arranging for transfer of patients to UCLA Medical Center when this is appropriate. Subspecialty and Specialty Consultation The subspecialty divisions provide regular consultative services on-site in neighborhood facilities one-half day per week for the more common disorders requiring consultation. This has allowed the establishment of relationships with primary care physicians so that urgent consultation can be provided in Westwood on nonscheduled days. Communication systems have been established so that the primary care physicians can request a consultation by E-mail or pager from a consultant who has been designated as being on call. E-mail is, in many ways, preferable to the phone, because you don't have to make the connection at the same time. Consultants outside the Department of Medicine are chosen in consultation with the medical group. Often, immediate consultations are not required for patient treatment, but an extended E-mail dialogue will result. We are encouraging this system, even though capitation is only about 8 percent of our business. We are trying to prepare for the future. Even though we are not reimbursed, we are encouraging our faculty to communicate and to seek consultation in easy ways that present no barriers, without regard to compensation. A visit may be scheduled for the regular day on which the consultant visits the neighborhood facility. However, if the consultant or the primary care physician feels that urgent consultation is required, this is
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--> arranged, together with transportation to bring the patient to Westwood for the consultation. To facilitate these matters and to keep the system focused on the patient, the Department of Medicine has hired personnel who are responsible for seeing that the physicians have communicated—and that is the key word—prior to the patient's visit. They see to it that appointments have been made, that transportation has been arranged, that the patient has been contacted prior to the visit, that the patient is greeted on arrival at UCLA and transported back after the visit, that the consultant communicates with the primary care physician after the consult, and that the patient is also contacted by phone after the visit to be sure that all went well and that the patient understands what has been recommended and what the next steps in treatment will be. It is expensive to have these patient facilitators, but it has made all the difference in the world in terms of both the perceived and what we think is the real quality of care that is provided. These personnel also work with the inpatient team to facilitate notification of the team and arrange admission to the local hospital, track patients in local hospitals, and participate in discharge planning and organizing return visits to the primary care physician and subsequent consultation with UCLA subspecialists and specialists. A system is being devised to increase the efficiency of ambulatory care and to track electronically the medical problems of all patients in the system. It will include allergy and drug information referrals and key process variables that will allow a continuous quality assessment and improvement process. This is being undertaken as a joint venture among our department, our medical group, and our medical center. Transportation Systems An important component of our system, transportation, has been developed as a joint venture with UCLA Medical Group and Medical Center and includes the transport of patients for routine, subacute, and emergent care from neighborhood facilities or local hospitals to UCLA Medical Center. We find that senior patients like to be able to drive to the neighborhood office, get out, go in and talk to the staff, and have a van pick them up there to take them up to UCLA. They are greeted by one of our greeters, walked to their consultation, and walked back to the van. They come back to the office, walk in and talk to the staff, and perhaps see the doctor briefly. We have found that this has made an enormous difference in the ability of patients to participate in a system as complex as ours.
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--> Education Systems Subspecialty divisions have been charged with developing programs for educating patients and primary care physicians in new developments related to practice in their particular subspecialty areas. These education modules are being developed in conjunction with the Division of General Internal Medicine and focus on improved outcomes from processes that can be delivered at the primary care provider or patient level. A new position, director of communications, has been posted for the Department of Medicine. We are interviewing right now. Among the duties of this individual will be responsibility for developing patient education materials, which we think are critical to enable us to provide high quality care. Graduate Medical Education General internal medicine residents rotate to neighborhood facilities as part of their ambulatory medicine experience and ultimately have continuity of care clinics at a neighborhood facility. A new track for training general internists in critical care is being incorporated into the inpatient team. Integrating Subspecialty Medicine Into General Internal Medicine The challenge to fee-for-service medicine has been to prevent overutilization. The challenge to capitation is not to provide incentives for underutilization. A health system such as ours, based on primary care, must learn how to include subspecialty and specialty care in an appropriate balance. Starting with the curriculum issue of how best to teach general internal medicine, the department has embarked on an expanded role as the integrator of subspecialty science and practice. Our department has created a series of small working groups composed of general internists and representatives from each of the subspecialty divisions charged with designing the subspecialty content of the general internal medicine curriculum. These working groups include both clinician educators and health services researchers. In addition to designing the curriculum, they will also be charged with designing and implementing clinical guidelines, deciding on medications for our formulary, determining measures of quality indicators and outcomes, and designing patient education modules. Thus, the department has assumed the task of integrating the talents of the faculty in general internal medicine and in medical subspecialties to create a new paradigm for a primary care based health system for adults.
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--> Continuing Medical Education Building on our approach to the residency curriculum, we have committed to a new program in continuing medical education. We have asked Dr. Roy Young to develop a new system of continuing medical education for our clinician educators. To this end, we are establishing an educational center where Roy, who is a general internist, will bring our clinician educators for seminars in continuing medical education on a variety of topics related to practice. For example, Roy may decide to present a diabetes module. A group of our primary care clinician educators, perhaps from one of our neighborhood offices or from one of the Westwood firms (we use a firm system) will be invited to provide a list of their diabetic patients. Prior to the seminar, Roy's staff will collect the hemoglobin A1c levels on these patients. At the seminar, Roy will review the treatment approach utilizing a diabetes specialist and will outline appropriate follow-up reading materials. Subsequently, this group's hemoglobin A1c levels will be sampled again, and when the group reconvenes, the data will be reviewed as a positive reinforcement to better practice. Our goal is to develop a system in which we practice what we preach and teach. To accomplish this, we feel we must incorporate continuing medical education into the work week, realizing that a primary care practice cannot fit into a 40-hour work week. In preparation for this workshop, I met with members of our primary care group and with David Klashman, a rheumatologist clinician educator who works in Bevra Hahn's Division of Rheumatology. I asked them to tell me how they would approach the two diseases that you are considering. For early rheumatoid arthritis (RA), the consensus was that a patient with symptoms compatible with early mild RA without erosions would likely be started on nonsteroidal anti-inflammatory drugs (NSAIDs) by our general internist. If the symptoms disappeared completely within two to eight weeks and the RA factor was negative, a referral to a rheumatologist was unlikely. If the symptoms did not resolve or if the serology was positive, a referral would likely result. Parenthetically, our general internists are comfortable aspirating knees, and some will aspirate an ankle, but none will aspirate a shoulder or wrist. Our general internists are comfortable injecting bursa in some joints, but not others. What about advanced RA? If a patient has advanced RA upon presentation to one of our internists, is on a disease modifier other than an NSAID, or has marked deformities, a referral is likely to be made to a rheumatologist. If a patient has nonactive RA and is not on chloroquine, methotrexate or gold, and there is no question of the need for surgery, a rheumatologist is not likely to be consulted. When consultation is made, the follow-up is decided by discussions between the general internist and the consulting rheumatologist. Rheumatologists often act as the principal care
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--> givers for patients with active RA when the patient is on methotrexate or gold. The key principle, however, is co-management. What appears to have changed in the past few years is that subspecialist-to-subspecialist referrals have been replaced by a co-management approach between the principal subspecialist and the general internist. What about sytemic lupus erythematosus (SLE)? The diagnosis of SLE or suspected SLE is usually carried out by a general internist who orders the appropriate serologies. If the diagnosis is entertained seriously, a rheumatology consultation is usually obtained. Definite SLE is almost always referred to a rheumatologist before treatment is started. The treatment of active SLE is almost always managed by a rheumatologist in our practice. If the disease progresses to renal failure, the nephrologist usually becomes the principal caregiver. If the disease burns out without the need for dialysis, care is returned to the general internist. From my discussions with our generalists and rheumatologic consultants, I believe that a system that fosters regular communication between the general internist and the subspecialist is more important than trying to establish who is a primary care giver and who is a principal care giver.
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--> Invited Reaction Jerome H. Grossman I have just come from a meeting of the executive committee of the National Alliance of Business, and I am struck by the fact that Dr. Fogelman's presentation could have been a description of the new paradigm for running any industry: team-based and quality-based—in a constantly changing environment. I would like to make three points. First, I will go back to what Al Tarlov was commenting about. That is, although we have captured, I believe, the issue of cost, we have not matched it at all with what in other market environments is called the quality or value trade-off. He mentioned that this was beginning but was only very modestly process related. Al Tarlov also made the comment that he worries a little bit about how managed care will work out. I guess the second point I would make is that, although we have been talking about full capitation risk and co-management and no specific limit on visits to specialists, those are, I think, critical, really forward-thinking views about co-management. However, let me tell you, I have now looked at four companies in California that are subspecialty and specialty carve-outs. The specialists don't want to leave the work to primary care. They don't want primary care people making decisions about when they get used and who gets to keep the benefit of not using them. As a result, they are now arguing for a carve-out capitation, saying they are better at diagnosing and better at treating. So, we are not done with this issue yet. My final comment relates to the fact that we have been talking about economics, about medical science and technical medicine, and about medical care giving. What is missing so far, but very relevant to today's discussion, is some recognition of the importance of relationships: medical caring is often
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--> dependent on a quality relationship between two individuals. It is not at all clear that this must involve one sort of physician or another, but knowing a patient as a human being is a critical part of success in managing these chronic relapsing diseases. A successful medical outcome is quite often a function of the quality of that relationship. What we are discovering in an Institute of Medicine (IOM) committee that I chair, which is looking at managed care of mental illness and substance abuse, and I am sure it is true here as well, is that the social infrastructure that supports a patient with a chronic, declining, or relapsing disease is critical to that person and his or her family's ability to cope with those diseases. Thus, when we think about capitation, we need to be thinking not only about the medical and the caring part of it, but about the wrap-around social infrastructure that is so important.
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--> Invited Reaction William Arnold I have several remarks, the first of which is a follow-up on Jerry Grossman's point about the societal infrastructure. I work in, and am on the board of directors, of an integrated delivery system (Advocate Health Care System) that is faith based. We are a product of the Evangelical Lutheran Church and the United Church of Christ. In the true tradition of faith beliefs, we believe that faith-based care has a place and adds value, particularly to the care of patients with chronic illness, because we go into the community where these patients live. One of the things we are currently about is trying to quantify that value, which is, as you can imagine, a daunting task. The second area I would like to cover is a lesson I learned 25 years ago in my first days as a consulting rheumatologist in the hospital where I now practice. I learned it from an experienced consultant who taught me as a medical student when he was a resident. He said, ''Billy, if you want to be a successful consultant, remember the three A's. You must be available, you must be able, and most important, you must be affable. You must be able to talk to your doctors and your patients; you have got to be there for them; and you have got to be able.'' I have remembered that, but I would submit to you that, after this morning, particularly after Alan's talk, it should be the six A's. The new six A's of being a rheumatologist and a consultant in this era of managed care could guide us as we seek to optimize the care of the patient with rheumatic disease in an integrated delivery system by optimizing at least one member of the caregiver team, the rheumatologist. The first of the new A's—adaptability—is a prime requirement in this era of rapid change. Rheumatologists must be willing to change continuously during their careers to better serve the needs of their patients with arthritis.
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--> Whether these changes involve going directly to the offices of internists to provide services, as in Dr. Fogelman's construct, or being able to function as a consulting specialist, a principal care physician, or a combination of the above, rheumatologists must adapt to the changing environment. In fact, I would have said that rheumatologists should check all four options on Dr. Eisenberg's choices, even the one that includes driving a taxi, particularly if the taxi is bringing a patient with arthritis to a needed service! In addition, our curriculum and fellowship training programs must produce rheumatologists who are adaptable and comfortable with the experience of lifelong learning. In my own situation, long after my rheumatology fellowship experience I acquired the skills to provide diagnostic and therapeutic arthroscopic services for patients with arthritis. I'm pleased to say that I've also had an opportunity to train rheumatologists who are now providing similar services at several centers. Both Drs. Hahn and Rothfield now have rheumatologists on their faculties who provide diagnostic and therapeutic arthroscopy services. Other examples of the continued learning and incorporation into practice that are necessary include the management of patients with rehabilitation needs and the diagnosis and management of osteoporosis. Even the most adaptable rheumatologist, however, will not be allowed to care for patients unless she or he is "aligned." The second A—alignment—refers to both financial and clinical alignment. Financial alignment is most simply understood as becoming a member of as many provider panels as possible for insurance and managed care products. Since this often involves considerable administrative burden, many rheumatologists find it easier to simply become aligned with a group, either a rheumatology practice group or a multispecialty group. In this setting, the administrative aspects of alignment generally are handled by the management of the group or organization. Clinical alignment comes through participating in devising and implementing clinical care pathways for patients with arthritis. Together with internists and other allied health professionals, rheumatologists need to understand and help direct the overall care of the patient with rheumatic disease in a setting where the paradigm is value added, not quantity equals quality. The third A—accountability—makes explicit what all rheumatologists have done implicitly for years (i.e., accept responsibility for the care of patients with arthritis). Its explicit nature means that we must be accountable in a quantitative fashion for outcomes, both financial and clinical. Financial outcomes, of course, include cost of care and must fit within reasonable parameters. Clinical outcomes are easy to talk about and difficult to determine or measure. Nonetheless, our patients, insurers, employers, and the government are demanding that we provide explicit outcome measures to illustrate the quality of our care, and we must do this. If rheumatologists do achieve better outcomes than generalists, we must document this, not merely claim it.
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--> Finally, I don't know if women physicians make a difference, but I do know that in the care of my patients with rheumatic diseases, the characteristics that are most notably associated with being female definitely make a difference. Males can have these characteristics too, but the so-called female characteristics that, in my opinion, predict success in the management of chronic disease include the ability to share one's feelings in an open manner, often with multiple people. I continue to be impressed with the fact that I can sit in a room and talk with a good male friend for an hour, and we will share less about what is really important about our families than our wives will do in five minutes. The female side of us is also used to working in groups, has high levels of compassion, and—I think very importantly in chronic illness—uses a very spiritual approach.
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--> Discussion RICHARD FINKBINER: The Health Plan Employer Data and Information Set (HEDIS) has been mentioned a couple of times, and I wanted to make a comment. HEDIS is not a static process. It is ongoing, and we staff at the National Committee for Quality Assurance are very sympathetic to the perception that process measures dominated earlier versions. I am now project director for a Robert Wood Johnson chronic disease initiative to develop quality indicators. This is an enormously complicated area. You have different model types within managed care trying to achieve uniformity there. You have the issue of the ebb and flow of chronic disease, as has been mentioned. For rheumatic disease, I am aware of nothing that has come forward from the call for measures for the next versions of HEDIS. However, those of us working with HEDIS are very interested in processes and dialogues like these. BEVRA HAHN: I want to ask Dr. Grossman two questions. The more important one is what you think that salarying physicians would give them incentives to communicate. How likely do you think it is that physicians would be salaried under some of these coming health programs? Second, what is the content of your software in terms of how you are going to evaluate quality? JEROME GROSSMAN: In answer to your question about salaried positions, let me just give you the latest example. In Boston last week, Harvard Pilgrim Health Plan announced that its health centers with salaried positions would be spun off into group practices. Kaiser in California, the largest salaried
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--> practice, is having a very complicated, difficult time making the transition to being adaptable. Frankly, I don't think salary is the issue. The issue is whether you want to be at risk, be fully capitated, or be a carve out. We will be testing a thousand different strategies, because we don't know what the answer is yet. They will keep evolving, but I do not think that straight salary is going to turn out to be the dominant model. To answer your question about quality measures, I am very much interested in making patient-based assessments, which A1 Tarlov alluded to—quality of functioning and satisfaction, as well as the technical, disease-specific measures of well-being. I have a strong belief that such assessments can make a large contribution to the quality of the relationship between caretaker and patient, if those measures are included in the day-to-day care of patients. THEODORE FIELDS: I have a question related to the co-management of patients with rheumatic disease. Where does patient preference fit into that? Two speakers with rheumatoid arthritis described very different feelings about how often they wanted to see their rheumatologist. Where does the factor of patient preference fit? I see it as a factor in different patient payment systems. ALAN FOGELMAN: For us patient preference is always an important component. It really becomes known when the patient communicates either to the primary care physician or to the consultant. If the consultant and the primary care doctor are talking to each other, this is one of the things they will discuss, and it has worked out. We don't have complete control over this, because of the multiplicity of plans that we must work with. In some plans we don't have absolute control over access to some of the diagnostic modalities without preapproved authorization. However, in terms of flow between the doctors, at least for us, that is pretty easy. THEODORE FIELDS: You wonder if some of the incentives that may be set up over time may influence the ability to carry out the patient's preference. ALAN FOGELMAN: We are trying to find the right incentives. For our primary care doctors, incentives are going to include three components: availability, productivity, and patient satisfaction. We just hired somebody for our small group—actually, more than one person—whose full-time job is to sample patient satisfaction. We are trying to develop a component of salary for our primary care doctors that is incentive based. I happen to agree with Dr. Grossman that incentives have to be there. The key is to find the right incentives.
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--> CAROLYN CLANCY: I wanted to reinforce a point that Dr. Grossman made about who is in charge, whether it is the specialist or the primary care physician. I think an open question now for many kinds of chronic disease is the extent to which the carve-outs we have seen for mental health will be extended to other conditions as well. On the one hand, you can make a very appealing case for doing so. After all, if you have a constellation of services organized tightly for patients with rheumatic disease, who would not like that? What is there not to like? On the other hand, there are patients who, of course, don't have just one condition. I think the other benchmark is how well services are coordinated, because the more doctors a patient sees, the more opportunities there are for error. WILLIAM HAZZARD: First of all, you said that these activities cannot fit into a 40-hour week. How long is the week for a full time equivalent in your model? A second question stems from what must be a continuing need for capital to develop your system. Where is that capital coming from? ALAN FOGELMAN: The answer to the first question is that it is probably on the order of 50 to 55 hours a week. The incentive is the educational component of practicing with us and the requirement for doing creative work. We find that helps to make that long work week as enjoyable as it can be. In terms of capital, we decided as a faculty—a collection of people committed to scholarship, research, and education—that we would take a portion of our income, a significant portion, and reinvest it in developing this primary care system. We are putting about $3 million a year of faculty money into this system right now. The vast majority comes from the fact that we are still largely in a fee-for-service market, and that, instead of the subspecialists taking the money home, we are reinvesting it in the system.
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Representative terms from entire chapter: