A Vocation, Not a Job: A Model for Primary Care from the Abbott Northwestern General Medical Associates

What, exactly, is primary care? And what does it have the potential to be? In an age that is increasingly decentralized, specialized and efficient, how can primary care be relevant anymore? Surely, the notion of the general practitioner broadly-versed in medicine and familiar with the entire family is something out of heartwarming Norman Rockwell paintings. It is a role rooted in nostalgia: Endearing, quaint and impractical.

Or is it? How many times have we, in primary care (Internal Medicine, Pediatrics, Family Medicine, or Obstetrics/Gynecology), been told by our front desk that a patient called to see if we could add them to our schedule for a conversation? Why? Because they have seen a specialist or have a galling, unresolved problem or are trying to navigate their care, and they want us to help them understand, help them decide, or simply help them to be confident that the chosen course is the right one. While we may glory in the amazing tools and therapies at a physician’s disposal in the twenty-first century—whether PET/ CTs, angiograms, LVADs, targeted chemotherapies, antibiotics, or monoclonal antibody therapy—we can never forget what we all want for our parents, our children and ourselves: a physician who knows us, a physician we can trust. Notwithstanding the virtues found in specialization, there is something utterly refreshing and indispensable in someone who looks at the whole picture. The danger

in a specialization devoid of general considerations is an imbalanced reductionism. A patient is greater than the sum of their component parts. The tools of the primary care physician transcend their familiarity with the pathophysiology of each organ system, the selection of diagnostic modalities, or the choice of therapeutic options. As Sir William Osler would remind, “The good physician treats the disease; the great physician treats the patient who has the disease.” The primary care physician, especially, has to cultivate and rely on common sense, intuition and finesse that informs (and chastens) clunky technique, algorithm and efficiency. A primary care physician is not valuable simply because of his/her familiarity with the manifestations and management of multiple ongoing disease processes in their complex patient population. Even more, it is the primary care physician’s wise judgment that comes from knowing the patient—truly comprehending the patient’s many problems, level of understanding, and general philosophy of health—and integrating these variables into a sensible approach to care. To a primary care physician, context matters. And, we only understand context if we truly take time to understand the complicated patient who finds himself in a given medical circumstance. Here is an interesting fact: If we were to ask our patients why their primary care doctor matters, the answers would vary but follow a common theme: My primary knows me; is smart; listens; cares; goes the extra mile and takes care of my whole family. I trust my primary care physician. Our primary care practice is built around this fundamental truth: We want to be the physician for others that we would want for ourselves and our loved ones. Abbott Northwestern General Medical Associates (ANGMA) is a burgeoning west metro internal medicine clinic operating in Edina (Center for Outpatient Care), Plymouth (West Health), and Minneapolis (Medicine Clinic). The three pillars upon which ANGMA is built are: service, education and innovation. Service: ANGMA’s first calling is to serve the patient. Our clinic follows a traditional model where the majority of hours are spent in outpatient clinical care. A subset of our physicians rotate weekly on hospital call caring for any and all patients admitted from the clinic’s population. Both in and outside the hospital, we have cultivated a warm collegiality with our specialist partners. In building and enjoying these partnerships, we have crafted a more thoughtful and nuanced approach to each patient’s needs. From front desk staff, medical assistants, and licensed practical nurses to registered nurses, (Continued on page 22) Michael Cummings, MD Tod Worner, MD

physicians, and administration, a rich culture of respect and interdependence helps our efforts to be a collective calling. Our work is a vocation, not a job. Physicians know their patients and enjoy them. Whether it is scheduling or triaging, streamlining phone calls or medical messaging, administration and support staff do all in their power to ensure that the fundamental face-to-face meeting between physician and patient is available, amiable and efficacious. Our calling is to serve our patient’s healthcare needs. Education: ANGMA is passionate about forming future physicians. Our clinic offers a respected and award-winning preceptor experience for University of Minnesota medical students (part of the Primary Care and Beyond rotation) as well as a robust clinical mentorship for Abbott Northwestern Hospital Internal Medicine residents. In addition to clinical education, ANGMA has crafted a unique curriculum around critical reasoning and vocational understanding. Seeking to fill the widening void where common sense and deep purpose used to be, we offer lessons in heuristics and intuition, literature and philosophy. In sum, we seek to better answer practical (but philosophical) questions in an age of hyper-efficiency and burnout, namely “How do you think?” and “Why are you here?” Our Minneapolis branch (Medicine Clinic) especially works passionately on behalf of the underserved. Residents learn the vicissitudes of navigating the pressing social needs of patients that directly impact their health. Finally, ANGMA has a vigorous inpatient bedside, didactic and procedure-based curriculum that prepares internal medicine residents for the challenges of caring for a very ill patient population. Our whole approach to educating future physicians is formation. By moving beyond simple facts, we aim to cultivate a lens through which residents can truly see. We strive to be mentors in the art of medicine.

Innovation: Beyond their experience in residency, many physicians are interested in research and quality initiatives. As such, ANGMA has encouraged interested physicians to explore innovations in care.

At Minnesota Community Care, we believe in health for all.

That’s why we provide comprehensive primary health services to everyone - regardless of age, financial situation, access to insurance, language or immigration status. While our name has evolved, our purpose has remained the same over the past 50 years - to serve the health needs of our community.

Together, we are Minnesota Community Care.

The Automated Blood Pressure Monitor, twenty-four hour blood pressure cuff, program has brought better care to patients in discerning who truly has hypertension and the adequacy of their control. The Pre-Op Tool has streamlined pre-operative assessments by providing a thoughtful guide to evidence-based care. This tool has helped decrease needless testing, while leaving a physician’s decision-making autonomy intact. The Vascular Care Guide has provided evidence-based guidance to physicians (and patients) on the most pervasive maladies (diabetes, hypertension, coronary disease, obesity) to afford better care and less waste. Attending staff and residents conduct high-quality research which is presented frequently at local and national venues. ANGMA has also crafted a world-class bedside ultrasound program helping patients and training residents to bring this marvelous tool to their future corner of the world. It is time for us to remember an oft-forgotten truth about primary care: It is a vocation, not a job. It is a deeply human calling to treat an ailing brother or sister. It involves thinking, explaining, advocating, treating and caring. At ANGMA, we want to be the type of physician that we would like for ourselves and our loved ones. It is time for a renaissance in primary care. Along with our partners from different systems, we are proud to play our small part.

Tod Worner, MD is the Clinical Director of Outpatient Resident & Medical Student Education at ANGMA–Center for Outpatient Care/West Health for the Abbott Northwestern Hospital Internal Medicine Residency Program. In addition, he serves as Adjunct Clinical Assistant Professor of Medicine for the University of Minnesota Medical School and as Adjunct Assistant Professor, College of St. Benedict/St. John’s University where he teaches “The Art of Healing” to pre-professional students.

Michael Cummings, M.D. is the Co-Director of Abbott Northwestern General Medical Associates and has particular interests in clinical decision support tools, preoperative assessments, and twenty-four hour automated blood pressure monitoring. He further serves as Adjunct Clinical Assistant Professor of Medicine for the University of Minnesota Medical School.