Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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8: Training and Utilization of Generalists and Subspecialists at the University of California, Los Angeles
8: Training and Utilization of Generalists and Subspecialists at the University of California, Los Angeles
Pages 147-168
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From page 147... ...
8 Training and Utilization of Generalists and Subspecialists at the University of California, Los Angeles 147
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From page 149... ...
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.
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From page 150... ...
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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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,i'6 and I will not repeat the details here.
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From page 152... ...
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.
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From page 153... ...
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.
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From page 154... ...
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.
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From page 155... ...
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.
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From page 156... ...
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 40hour work week.
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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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From page 159... ...
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 159
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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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From page 161... ...
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.
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From page 162... ...
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.
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From page 163... ...
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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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 165
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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.
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From page 167... ...
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?
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