Dr. Blog

OMA Governance Change

By OMA President Carla McKelvey, MD

I had the pleasure of spending my 50^th birthday with a great group of people – the OMA’s Board of Trustees. As usual, Chef Ron prepared a wonderful dinner and a special dessert for me – crème brulee with a candle on top.

The burning issue at the meeting was an ongoing discussion regarding the elimination of the House of Delegates. Attendance has continued to decline over the years and, in fact, when the numbers were reviewed the majority of attendees at the House were actually Board of Trustees members; only an additional 10-15 delegates were not Trustees.

After an extensive discussion at that Board meeting on Oct. 21, it was decided that new bylaws would be drafted and brought back to the Board of Trustees in January. The bylaws would eliminate the House of Delegates, with the provision that the new bylaws be approved by the House at the meeting in April.

What would the OMA look like without a House? There would be an annual General Membership Meeting, which would include a keynote speaker, a State of the Organization presentation as well as more in-depth reports from our committees who are doing incredible work. There would also be time for members, any member, to present concerns or issues that they believe the OMA should address. As we have traveled around the state, we find that the House of Delegates system has served as a barrier for members. This is not only because 23 out of 36 counties no longer have county medical societies but also because they do not know how to become delegates.

The nominating committee would be selected by the Board of Trustees (although the next one will be selected at the House in April 2012) and part of their new responsibility would be to help find nominees for counties that do not have representation at the Trustee level. They would also consider resolutions and recommendations that came from the OMA sections as well as committees or individual members.

The OMA currently has four sections – IPAs, Resident Physicians, Physician Assistants and Medical Students. At the Oct. 21 Board meeting, we instructed the bylaws revision to include the addition of three more – rural physicians, hospital and health system employed physicians and the Alliance. We are in the process of organizing those sections. Sections will also meet at the annual meeting.

We are also committed to traveling around the state and meeting with members through “Day with the OMA” in which we will have a town hall meeting and also provide CME including our ever popular risk management program. These will start next year.

In addition to all of these items, the Board of Trustees felt it was time to review their structure. Are they a representative body? Should there be terms of service? What should the content of the meetings be? Once again, the President’s Task Force on Governance will take on this issue and hopefully, report back in 2012.

It is important that our organization remain relevant to its members, and that it becomes relevant to the physicians who are not members. Ensuring that we have an organization that is more open to its members’ concerns is an important step. That is not only changing from a structure that seems to be a barrier but also to one that utilizes the most up-to-date methods to communicate  including not only this blog but also social media such as Facebook and Twitter and our new website. I would love to hear from OMA members and stakeholders on these governance changes. Please email me at carlamckelvey@theOMA.org with your input. Related FAQs and an online comment form are available at www.theOMA.org/GovernanceChange.

Coos Bay

By OMA President Carla McKelvey, MD

I attended the Southwestern Oregon Medical Society Alliance Social at Steve and Eva Shimotakahara’s home. It was great fun with great food. The alliance does great work here with their internet safety program as well as their anti-bullying program.

In my opinion, Coos Bay is one of the most beautiful places in the state and I do not understand why anyone would visit and not want to move here. One of the challenges that many rural practices across the state face, though, is recruitment and retention. Some of this is related to the shortage of primary care physicians and some of this is related to lifestyle issues.

Communities are coming up with innovative ways to address these issues. Some rural hospitals have begun using hospitalists although they may tweak it to fit their challenges. Our hospital has utilized what they called a “nocturnalist” who is someone that covers from 11 pm to 7 am. The two physicians who work in this program are employed by the hospital. The slots they are not available to work are still covered by local physicians. It has proven to be a successful hybrid program.

Overall, though, the recruitment and retention of physicians is going to have to be solved by community efforts. Health care communities or private practices will not be able to do this alone. It is another area in which the involvement of the community through CCOs may enhance health care as a whole. Once local business owners see the importance or difficulty of recruiting and retaining physicians, there may be more effort and buy-in to assist. Continuity of care benefits everyone.

Bend

By OMA President Carla McKelvey, MD

I attended the Oregon Rural Health Association Conference. Though I was unable to attend the whole conference, the topics looked good and timely. It is a great networking event which gets different folks not only from different parts of the state together but also from different areas of health care, including clinics, hospitals, health departments and private practitioners.

I also wanted to let everyone know about the upcoming First National Rural Health Day – November  17. You can go to http://celebratepowerofrural.org for more information. The ORHA would be happy to help you publicize this in your community. You can contact them at www.orha.org.

It was an honor to speak at the conference. The following are some excerpts from my speech:

There is a lot of anxiety out there about what is occurring with health care transformation, and some physicians believe they may lose even more of their autonomy and their ability to care for patients effectively. I believe strongly that rural physicians do and can have a powerful voice in this discussion.

Approximately 37 percent of Oregonians live in a rural area and are cared for by 19 percent of the physicians in Oregon. Yes, our patient to physician ratio is higher than in the urban areas, but that is what makes our voice even more important. Our biggest weakness is that too often we are too busy and so do not take the time to make our voices heard. 

The rural population is an aging one with high rates of chronic disease. It would be easy for the state to forget about this population outside the boundaries of the I-5 cities.

 

What distresses me the most is probably what distresses you the most – the level of poverty and need, the lack of resources medically, economically and socially. When spending cuts are made the impact is felt greater in rural areas because there is little room to absorb cuts. I admit that at times I wonder if it is worth it and that maybe I should move to a bigger area where I can be more distanced from my community and its problems. But I know that my life would be less satisfying if I did.

I have come to realize that my role as a rural physician is not just to be a voice in health care issues but to also recognize the importance of the social determinants of health. I believe the most important of these is education. As we go through the current economic hard times, it is clear that the more education that one has, the better one is doing.

A well-educated person with a good job is going to be healthier and thus decrease our state’s health care costs. More research also seems to show that the stress of being poor sets off a physiological response which has a negative impact on one’s health.

 

Our current healthcare system though only focuses on health and not the social factors that contribute to it.

A physician from Corvallis said to me that he was tired of legislators not facing the reality of health care – that it was time for some to use the “R” word – rationing. I think we are privileged to live in a state that is willing to have those conversations. We have tackled the “R” word and have the Prioritized List as proof. We have dealt with End of Life issues. Our citizens and our legislators are willing to have those tough conversations.

Over the next several years, we as physicians have a tremendous opportunity to develop a health care system that works for us and our patients. We have taken the step of acknowledging that separating physical and mental health did not make sense and so will be rejoining them with this next step. We have an opportunity to say to our legislators and patients that social determinants of health may be just as important if not more important in addressing health care costs.

We may not agree on the solutions, but none of this will happen if we do not stand up and make our voices heard. That may be just a phone call or email to a legislator. I know the powers that be will listen if you will just take the time to make it happen.

Lebanon and Corvallis

By OMA President Carla McKelvey, MD

We left the Burpees with garlic, rhubarb and Jon’s legendary rock art – Jo with bookends and I with beautiful polished rocks, one of them from Whiskey Run Beach in my area. They were so gracious.

Our first stop was the new medical school in Lebanon, COMP-NW (College of Osteopathic Medicine of the Pacific). The school opened this year and is located across from Samaritan Hospital. The new building is amazing with the latest technology. It appears to be the campus of the future.

Jo and I visited the Gross Anatomy lab. That smell brings back memories of where a significant portion of your first year in medical school was spent. The lab is outfitted with monitors where x-rays and CT scans can be displayed so that radiographic findings can be matched.

Lunch was at The Corvallis Clinic. The concerns expressed mirrored what we had heard across the state, especially regarding the implementation of CCOs.

The day ended in Portland with more meetings. It was a whirlwind tour.

Once again, I am impressed with the diversity of situations across the state and thus the importance to keep sending the message of the need of flexibility and respect for local issues as health system transformation is created and implemented. Our physician communities will be able to continue to provide good patient care if they are given the leverage to do so and are not be hampered with regulations and rules that take their time away from their patients.

Grants Pass and Roseburg

By OMA President Carla McKelvey, MD

Jo and I drove from Klamath Falls to Grants Pass last night. We got here at 11 pm and went right to bed. It was a pleasure to wake up this morning and look outside to see the Rogue River off the hotel balcony.

Coos Bay and Grants Pass have much in common. Kim Kozak, DO, an ENT moved from Coos Bay to Grants Pass, and Laurie Hamilton, DO, an OB/Gyn moved from Grants Pass to Coos Bay. The CEO of Bay Area Hospital moved from Grants Pass to Coos Bay. Grants Pass has the amazing Rogue River and we have the powerful Pacific Ocean.

The morning was lovely and we walked along the river from the hotel to where the breakfast was. We had a good turnout of physicians and a good conversation primarily regarding the health transformation that is occurring in Oregon. As in most communities, there are many questions about how the process will work. The legislation that passed is a skeleton and the current workgroups are putting the meat on the bones. It won’t be until the final rules are passed in February that we will know the nuts and bolts of the transformation.

We also talked about the Patient Centered Primary Care Home (PCPCH). In general, the physicians are supportive of the PCPCH, but as one physician put it, “I am about initiatived out!” There are many concerns that while many of these items are well worth the change that it will require more paperwork and the amount of new documentation required will not be worth the financial incentives.

The physicians in Grants Pass seem confident about their ability to approach the future even though there is so little known. It is always great to see doctors who see opportunities in the challenges that we may face.

We moved on to Roseburg for lunch at DCIPA. Once again, there was a good turnout of physicians.

There seemed to be more of a focus on recruiting physicians. This has been a concern in most of the communities that we have visited. One physician stated, “Tell me who will take care of me when I retire.” They indicated that none of the physicians in Roseburg are currently taking new Medicare patients.

We had a good discussion about what motivates medical students to choose their future specialty. Is it the debt that makes them choose a higher paying specialty or is it lifestyle? Is there a belief that primary care has less respect or standing then a specialty field? There is no simple answer but we agree that mentoring and being role models for future doctors is important.

Our next meeting was at Marie Stoddard’s home with her and other Alliance members. The Alliance faces many of the same challenges that the OMA does – a changing demographic. Like the OMA, the Alliance is looking at how to update their structure to reflect their changing membership. The OMA and the OMAA are looking at ways to maintain relevance and vitality as well as reflect the needs of our members.

We spent a lovely evening with Jon and Jeannie Burpee. Jon is a retired ophthalmologist. For dinner we had fresh King Salmon, corn and broccoli from their garden. Fresh food tastes amazing, especially accompanied by the hospitality of the Burpees.

Klamath Falls Road Trip

By OMA President Carla McKelvey, MD

One of my first trips when my family and I moved to Oregon was to Crater Lake. Lodging was full in the park so we decided to stay at what sounded like a lovely place called The Sportsman’s Lodge in Chiloquin, which is near Klamath Falls. Let’s just say we got little sleep with the trucks whizzing by on one side and the trains going by on the other side. It was impossible to close the windows to drown the noise as it was a hot August and the lodge was not air-conditioned. Despite that rough start, I have always found the K Falls area beautiful. Driving in on 140 with the lake right by the road and watching all the waterfowl is inspiring. My family and I have returned to see the eagles in February and to play golf in the fall as well as to return to Crater Lake.

 

After a five hour drive from Coos Bay, I picked up Jo Bryson, the OMA’s CEO, at the K Falls airport. Klamath Falls has a National Guard unit and the jet planes were taking off as she was arriving. The power and speed of that aircraft is something to behold.

We had dinner with physicians from the Klamath County Medical Society, including Ralph Eccles, the OMA’s vice-speaker. Once again, it is always enlightening to hear what the concerns of physicians are. The conversation immediately launched into CCOs, or Coordinated Care Organizations. There is a sense that the CCO structure will be so complicated that a local group such as Cascade Comprehensive will not be able to achieve it. They have been very successful in managing the local Oregon Health Plan but this new “animal” may be beyond their abilities. They wonder if a larger organization will swoop in and take over and leave the good work they have done behind and they will become mute and just a cog in the wheel.

In addition, they struggle with maintaining collegial and good working relationships between primary care physicians and specialists as the pot of money gets smaller. They understand the importance of working together and that the pressures they feel are from the outside and not within the ranks, but it is hard to feel shared suffering when the roles of the two groups are different in their interactions with patients. They worry that if more funding cuts come down that they will have to bow out of the Oregon Health Plan and leave the patients that they have cared for without access to physicians – both primary care and specialty care. It is hard to provide care with funding cuts when 60% of your practice is Oregon Health Plan.

And finally they wondered if the OMA should help physicians unionize. This is not the first time that we have heard this in our conversations as we visit with physicians throughout the state. Physicians have always been an autonomous, independent minded group but they are feeling more and more that the system is controlling them to the point that they cannot do what they love the most – take care of patients. As newer structures with different names are imposed on them, they believe that, possibly, the only way to regain control is through a union. It is a conversation that I never thought I would hear from so many different physicians in different parts of the state.

We left K Falls at 9 pm to drive on to Grants Pass. I am confident that the physicians there with assistance will continue to be successful in providing care for their patients. They have good leaders who will be able to make the connections needed to create a local CCO. As an organization it continues to be important that we are there to provide the best information we can and the tools that are needed so that physicians can continue to do what they love the best.

OHSU Medical School Orientation

By OMA President Carla McKelvey, MD

Congratulations Class of 2015!

 
What do you remember about your first or second day of medical school? Do you remember being anxious, nervous about the road ahead or were you excited about what lay ahead?

I was thrilled to get into medical school. I had been put on a wait list, so when the news came less than a month before school started that I was officially accepted, it was a dream come true. As I told the students today, the best medical school is the one that accepts you because they have recognized your ability and potential. For me that was the University of Texas Health Science Center in San Antonio.

Standing before a group of medical students is a time of reflection. Why did you go into medicine? Why do you stay in medicine? Sometimes our daily grind overshadows the first question and we feel that we may not be able to have an impact on the system we work within. I hope that the OMA can show medical students how organized medicine can function as a voice for their concerns and issues whether that be related to medical school issues, legislative concerns including health reform, financial concerns, or community health. When we work together we have a much larger impact. They are often full of energy and optimism and can help re-energize those of us who have been in practice for a while.

This year, over 75% of the students are from Oregon. This is good news. The bad news is that they will graduate with over $150,000 in debt. As we continue to face shortages of primary care providers, we must be addressing this issue. It is unlikely that the State will contribute more to OHSU so that tuition can come down. One of the OMA’s goals for this year and moving forward is to more aggressively raise funds for the Oregon Medical Education Foundation in order to increase the number of scholarships that are provided to medical students within the State. I hope you will join us in that goal.

Heading Home

By OMA President Carla McKelvey, MD

It has been a whirlwind trip, and we have been running hard since Friday morning. We are headed back to Portland today but before we leave Ontario, we are going to have breakfast with Sandy Dunbrasky, a pediatrician – and in my opinion, a pediatrician extraordinaire.

I first met Sandy on “paper.” She and I participate in ORPRN (Oregon Rural Practice Research Network). Since we were the only pediatrics practices in the network, our practices were often paired. I was very impressed with what she had accomplished in Ontario and so was excited to be able to have a conversation with her. We had been at conferences together but had never had time just to sit down and talk.

Sandy came from a background where graduating from high school would have been a great accomplishment. Not only did she graduate from high school but she eventually received her nursing degree. She knew that she wanted to be a doctor when at age 12 a family member had a heart attack in front of her. While upset, she was also fascinated about how the human body could change so fast. It drove her to want to know more. As a nurse she would constantly ask questions of the pediatrician, who would tell her to become a doctor.

So at age 37, with the support of her husband and two teenage children, she entered medical school at OHSU. She said she never considered applying anywhere else because that is where she needed to go for her family. She would attend school during the week, drive back to Ontario on Friday night where her family lived, work in the hospital as a nurse on the weekend and be back in class on Monday. During her clinical years, she did the same thing every weekend she had available. It was not until she was a pediatrics resident at OHSU that she gave up her “part-time” job.

Upon completion of her residency, she returned to her hometown, Ontario, to start her own practice. Currently her practice covers 20,000 patients in Oregon and Idaho. Her practice was one of the pilot medical homes in Oregon. The two care coordinators at the practice have succeeded in making emergency room visits unusual for special needs kids. To advocate for the children, the coordinators attend medical visits to specialists along with parents and attend meetings at the school. The practice does this with two pediatricians and five nurse practitioners.

She would like to have more pediatricians and did at one time, but recruiting has been impossible. Like many of the physicians we spoke with, they are finding that new primary care physicians do not want to take call. They are also reluctant to care for patients in the hospital. Most think this is a reflection of the training that students are receiving with hospitalists being their role models and the restrictions placed on their work hours. They feel students do not always appreciate the relationship that can be developed between the physician, the patient and the family.

In these areas, having a hospitalist is not an option. Many times there are insufficient patient numbers to justify not only one hospitalist but the three that would be needed to have a feasible program. They are also finding that hospitals are unwilling to help solve these problems because there is no financial benefit to them. There is a significant level of pessimism as to what the future holds for their practices as well as rural health in general.

Although the sun was bright on the drive back to Portland, it felt much darker. The voices of these physicians had given me and the OMA much to think about. What was our role in these areas? Could we be a voice for physicians who are in conflict with hospitals? Was there a way for us to help them prepare for the upcoming changes that includes Coordinated Care Organizations, Patient Centered Primary Care Homes, and meaningful use demands? In some areas, physicians continued to be concerned about payment issues and in others these issues no longer mattered since they had become employed.

What left me feeling most hopeful were the words of one of the medical students who biked around Oregon to bring attention to the difficulties in rural areas. He said that having visited areas around the state had made him more likely to want to practice in a rural area. He talked of seeing the successes in many rural communities which had come together to solve problems. He told the story of Dr. Kim Montee in Union who flagged them down in the middle of the road to talk about his community and what they were doing.

It is also hopeful to hear the story of Dr. Lisa Dodson, who when told that the community clinic in Elgin was going to lose its provider, and thus close, she volunteered to staff the clinic until they found another provider. She drove from Portland to Elgin every week for nine months through all kinds of weather. She believes in the importance of rural health and so should we at the OMA.

Dr. Gus Tanaka

By OMA President Carla McKelvey, MD

Dr. Gus Tanaka celebrated his 88^th birthday this week. His life story is a remarkable one.

Dr. Gus Tanaka celebrated his 88^th birthday this week. His life story is a remarkable one.

His father, Ben, stowed away in a ship from Hawaii to Seattle. He eventually ended up in Portland and became the first graduate from OHSU of Japanese descent. He was a prominent family practice physician in Portland until the attack on Pearl Harbor. Unfortunately, he was arrested as a Japanese agitator and sent to a federal detention center and was there for six years. According to Gus, his father served as physician for the detention center. When he was finally released, all of his property had been seized so he decided to relocate to Ontario.

Gus was at Reed College but was told he had to leave so he transferred to an East coast “pacifist” college where he received his degree. He then joined the military and at one point was guarding a nuclear research lab, as he puts it, “to keep the Japs out.” He ended up in Japan and spent most of his time teaching illiterate American soldiers how to read. Returning to the United States, he went to medical school and, at the behest of his dad, joined him in Ontario where he was a practicing surgeon until he was 70 years old.

He met his wife, Teddy, in New York where she was a nurse. Teddy was from Ontario, which also played a part in his decision to return to Eastern Oregon.

Dr. Tanaka served as OMA president in the early 1970s. He was concerned by the distance from Ontario to Portland but he attributes his successful term to the outstanding staff led by Bob Dernedde and Jim Kronenberg, who he still remains close friends with to this day.

He is troubled by what he sees a decrease in professionalism by younger doctors. He states he does not understand how a surgeon can operate on a patient and then go home without checking on them because another physician is covering. He, too, is concerned about the difficulty in recruiting and retaining physicians. He says that as long as his life has purpose he wants to continue living, and so far people seem to still need him. Dr. Tanaka is truly a gem, and we expect to need him for many years to come.

Day 2: From Enterprise to Ontario

By OMA President Carla McKelvey, MD

Started the day with a tour of Wallowa Memorial Hospital in Enterprise where Dr. Liz Powers is head of the medical staff. Enterprise elected the Wallowa County Health Care District in 1992 to address the needs of an outdated hospital that was built in 1950. The current hospital, which is a critical access hospital, was built four years ago through a combination of private donations and funding with public grants. It is amazing! Very modern, airy and truly inviting. It is a great testament to the community that they were able to address the needs of their community.

 

Jo and I attended the Oregon Rural Health Association Board meeting at the hospital. Linda Lang from the Oregon Association of Hospitals and Health Systems is the current chairperson. The concerns expressed were those heard through the rest of our trip – can physicians survive in private practice? Will they be forced to become employees because of decreasing payment rates and increased costs, including liability costs? The critical access hospital system has allowed hospitals to go from running in the red to operating in the black. But unless a physician qualifies to become a rural health clinic they do not have the same benefit.

While the financial stability of these practices is a big issue, another looming problem in rural Oregon is the issue of recruiting and retention. Most agreed that lifestyle issues have become the major focus of many physicians. Many small towns cannot offer the amenities that are offered in the city. While J-1 visa physicians have helped take up some of the slack, there remains difficulty in retaining physicians. Issues such as good schools are becoming a bigger barrier in keeping doctors.

In Baker City, we had lunch with Doctors Nancy Hutnak and Steve DeLashmutt. Nancy was late because the cattle had gone through and ruptured an irrigation line and she had to repair it before joining us. Like Pendleton, there were concerns about how physicians were going to collaborate with the new hospital system. As employed physicians, they are not concerned about payment issues or liability reform. They are looking for assistance in how to evaluate and negotiate contracts. One health care system owns the hospital while another owns physicians’ practices. This situation adds to the complexity of other issues such as recruiting new physicians and creates questions as to how health reform will impact them.

As Jo and I turned the corner leaving the Geiser Hotel where we had lunch, I ran into two colleagues from my hospital, Bay Area Hospital. It is always a shock to run into people you know when you are from a small town especially when you run into them in another small town. Just a reminder that it is a small world.