The Phoenix Physician
Prepared by the American College of Osteopathic Internists
Phoenix Physician Task Force
Robert G. Good, DO, FACOI, Chairman
August 17, 2011

The healthcare delivery system is in a state of constant transition. Over the last 100 years, the physician-patient relationship has changed as a result of an influenza epidemic, two world wars, the invention of penicillin associated with the knowledge of infectious organisms, the development of imaging and diagnostic testing, the development of Medicare and the expansion of insurance and the invention of the computer. At each of these intervals physicians have adapted to new concepts of healthcare delivery. At each of these milestones, the medical community has sometimes resisted change1.

Patients and employers increasingly are growing concerned with access to affordable care. Physicians increasingly are concerned with being able to provide the quality care their patients need. Payers are concerned with the need for increased efficiencies. All of these participants in the healthcare system have at least one thing in common – – a desire to improve quality2. Evolution in the delivery of health care services is driven by scientific and technological discovery, emergent patient needs and market forces. The physician-patient relationship, however, is a constant and must remain at the core of any healthcare quality improvement initiative. The American College of Osteopathic Internists (ACOI), which seeks to provide a tool to enhance professional competence and adaptability to the changing healthcare delivery system, has developed the “Phoenix Physician” concept to better prepare residents in training and practicing physicians for the changes yet to come.

The delivery of healthcare services for much of the last century has been focused on the development of medical schools, research centers, large hospitals and the science of patient care. An emphasis in recent years has been placed on the development of an infrastructure that houses the technological needs of the U.S. healthcare system3.The societal value placed on developing the current medical system has resulted in the use of vast financial resources.

The financial assets used to develop science and technologies are more limited now, as society's focus is shifted toward individual, patient-centered value. Excellence is defined by clinical outcomes, interpersonal relationships, teamwork in a multidisciplinary system and patient satisfaction. This approach represents a fundamental shift from episodic acute care models and has become an integral part of the federal Patient Protection and Affordable Care Act (ACA)4. Several provisions in the new healthcare reform law seek to strengthen the primary care system and encourage the widespread adoption of patient-centered medical home (PCMH) models of care.

Central attributes of PCMHs include enhanced patient access to a regular source of primary care, stable and ongoing relationships with a personal clinician who directs a care team, and health services that emphasize prevention and chronic care management5.

A significant portion of the health care dollar is spent on chronic disease management6. Evidencebased studies have demonstrated improved outcomes and decreased costs in systems led by primary care physicians7. An adequate supply of primary care providers is associated with better health outcomes, such us lower mortality, higher life expectancy and better self-rated health status8. Among other factors, however, financial incentives have led to the growth of specialists in various fields of expertise. Reimbursement disparities favoring specialists at a time of escalating medical education costs devalue the medical generalist or primary care physician9. The result has been an increasing shortfall in the number of primary care physicians available to meet growing needs. This has occurred at the same time in which cultural shifts are increasing the value of patient relationships10. Unfortunately, at least a quarter of the Medicare population has difficulty finding a primary-care physician11.

Reliance on other members of the healthcare team has increased in order to meet the growing demands of our society. Primary care physicians, however, have the unique education and training needed to coordinate care with specialty medicine and manage complicated, multi-organ compromised conditions.

Meanwhile, the emerging patient-centered healthcare system likely will be more outreachdirected, focusing not only on the patient with the appointment but also on others in the system12. Coordination of care will include patients who are empowered, educated, and more involved in their care. This will require operational changes, data management skills and team leadership skills13. The healthcare system will have to reallocate resources to meet the needs for improved access, quality and efficiency. As a result, the internal medicine physician of the future, the Phoenix Physician in our concept, will have to develop a new skill set to assume leadership of the healthcare team. These skills include:

• The ability to provide open access healthcare to meet patient needs. Patient expectations are to access care when it is needed14. A team approach allows physicians to make the best use of their time and provides patients the security of timely evaluation and treatment.
• The ability to understand the strengths of allied health professionals in the overall care of a patient or groups of patients. Other professionals have potential to augment the care provided in a patient-centered medical home. Empowering others to follow appropriate medical protocols and guidelines will be an important means to provide necessary services.
• A better understanding and working knowledge of population medicine. While immediate patient satisfaction for medical care is important, the ability to compare actual mass data against national benchmarks also will be critical. Future compensation methods likely will be based on performance outcomes15.
• Additional education in the practical uses of medical databases and information technology. The implementation of transformative new technologies is underway globally. They will constitute essential tools to improve overall care and understanding in a value based reimbursement system16.
• Chronic disease management skills. Shared medical appointments, outreach services, patient education and team building around groups of people with similar conditions to improve outcomes will enrich overall outcomes6.
• The development of personal leadership and communication skills. The training of most physicians has centered on science and diagnostic criteria. The mature physician must become a leader of a team and aptitudes can be developed to prepare for this role17.

There are a number of challenges that confront our current healthcare system. It will take a nimble physician to adapt to the changes needed to provide high-quality, cost-efficient care. These changes will take time to develop and implement. The ACOI has developed a training process to meet these challenges. Out of the ashes of the old system will rise a new physician leader of a patient-centered system that will maximize available resources to provide high-quality care while respecting the physician-patient relationship --The Phoenix Physician.

1. Timmermans, S. and H. Oh, The continued social transformation of the medical profession. J Health Soc Behav, 2010. 51 Suppl: p. S94-106.
2. Agency for Healthcare Research and Quality, U.S.Department of Health and Human Services Public Health Service, Improving Health Care Quality, , Pub. No. 02-P032, 2002.
3. Jacobs, L.R., Politics of America's Supply State: Health Reform and Technology. Health Affairs, 1995. 14: p. 149-163.
4. Kaisser Foundation, Summary of New Health Reform Law. Pub. No. 806, 2010.
5. Finkelstein, J., et al., Patient-centered medical home cyberinfrastructure current and future landscape. Am J Prev Med, 2011. 40(5 Suppl 2): p. S225-33.
6. Bodenheimer, T., E.H. Wagner, and K. Grumbach, Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA, 2002. 288(15): p. 1909-14.
7. Ferrer, R.L., S.J. Hambidge, and R.C. Maly, The essential role of generalists in health care systems. Ann Intern Med, 2005. 142(8): p. 691-9.
8. Macinko, J., B. Starfield, and L. Shi, Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv, 2007. 37(1): p. 111-26.
9. Bhatia, N., D. David Meredith, and F. Riahi, Managing the clinical workforce. McKinsey Health Care Payors & Providers, 2009.
10. Levinson, W. and P.A. Pizzo, Patient-physician communication: it's about time. JAMA, 2011. 305(17): p. 1802-3.
11. Medicare Payment Advisory Commission report to the Congress, March 2010. J Pain Palliat Care Pharmacother, 2010. 24(3): p. 302-5.
12. Margolius, D. and T. Bodenheimer, Transforming primary care: from past practice to the practice of the future. Health Aff (Millwood), 2010. 29(5): p. 779-84.
13. Bohmer, R.M., Managing the new primary care: the new skills that will be needed. Health Aff (Millwood), 2010. 29(5): p. 1010-4.
14. Green, L., et al., Report of the Task Force on Patient Expectations. Core values, reintegration, and the new model of family medicine. Ann Fam Med, 2004. 2 (1): p. 533-550.
15. Rosenthal, M.B. and R.A. Dudley, Pay-for-performance: will the latest payment trend improve care? JAMA, 2007. 297(7): p. 740-4.
16. Davis, K., et al., Health information technology and physician perceptions of quality of care and satisfaction. Health Policy, 2009. 90(2-3): p. 239-46.
17. Page, D.W., Professionalism and team care in the clinical setting. Clin Anat, 2006. 19(5): p. 468-72.