My Story, the First 40 Years
Larry Shore, MD, FAAFP
I graduated from Mount Sinai School of Medicine in 1978, having been told that I had done well there and, “Didn’t have to go into Family Medicine”, which was a left handed complement, I guess. I found my happy place at MSSM in the Community Medicine Department. As an expatriate Californian, I did as many electives in the Bay Area as I could. My spouse was a grad student at Stanford, so it was nice to be together a bit more.
I got fired up about Family Medicine after spending time at the Santa Rosa program. I matched to the San Jose (now O’Connor Hospital) program as part of their first match group. San Jose was a practical location, with my wife still at Stanford. As a new program, there was plenty of opportunity to try new things, which I found I liked a lot.
My first job was as a Medical Director at Telegraph Hill Family Practice in 1981, an historical free clinic in North Beach in San Francisco. It was an interesting partnership between the Telegraph Hill Neighborhood Center and a local hospital. It was community-based, had a diverse clientele and provided services for seniors, teens and preschoolers. Sadly, the hospital and the neighborhood center had a falling out and my dream job lasted only 18 months.
At that point, Kaiser was not as attractive for Family Medicine and I believed I could continue to serve my patient population from North Beach in a new location, which was partially true. I made ends meet by moonlighting at employee health, an after hours clinic, and doing executive physicals in downtown SF. I was still doing full spectrum Family Medicine, including OB, and it was an exciting challenge.
The mid 80s brought on many changes, including PPOs, struggles for political legitimacy for Family Medicine in local hospitals and the AIDS epidemic. All of these forces would shape my career path in significant ways.
I left a small group of Family Physicians on Fillmore Street to start a solo practice as part of establishing a Department of Family Medicine at the former Children’s Hospital of San Francisco (now a part of Sutter). I served as Department Chair from 1985 to 2004, through various hospital mergers. Although it was important to have a full department at that time, the advent of Hospitalists and discontinuing OB made many of the struggles around hospital privileges moot.
In the early 90s, HMOs were a big force in the Bay Area. Our local medical staffs came together to form two organizations to help physicians cope with PPO and HMO contracting. The PPO side was addressed by a messenger model physician association that could advise, but not negotiate, contracts for physicians. The HMO side was addressed by the formation of the California Pacific Medical Group IPA (now known as Brown & Toland Physicians). I was Founding Board Member and Officer of CPMG and enjoyed working on several projects and committees for several years.
The AIDS epidemic affected our practice profoundly, as it did most PCPs in San Francisco. Our nights and weekends were dominated by managing several very sick hospitalized patients. Even with house staff and high quality ID consultants, it was a difficult time. Continuing OB became impractical and I delivered my last baby in 1989.
By 1997, the clinical practice, the department chair responsibilities, multiple projects with the IPA and being the parent of two small children required a reevaluation. As much as I liked the work at the IPA, it was more of an avocation and mostly uncompensated work. I left the board of CPMG and focused on building my practice to a two-provider (MD/FNP) office, which worked very well for several years. When my FNP left, I was able to take on a new Family Physician, which was very fortunate indeed. Almost impossible to do that these days!
Then came the HiTech Act and the EMR. Being an early adopter had benefits and risks to be sure. No need to tell any physician about this experience.
In 2007, I became curious about the Patient Centered Medical Home. After attending a PCPCC conference in Philadelphia, and hearing Dr. Paul Grundy and others speak, I became convinced that this was the model of the future and completely in sync with Family Medicine Values. After making some changes in my own practice, it became clear that there were aspects of the model that could not be implemented or afforded by a small practice.
It was my belief that the PCMH model could dovetail with Brown & Toland’s desire to replenish the ranks of our PCPs. It seems logical that the Triple Aim driven PCMH model would perfectly suit the needs of a managed care organization. B&T had always been a progressive organization. I was re-elected to the Board and made the PCMH proposal soon after.
I was chosen to be the Lead Physician of our medical home project (My Health Medical Group), which became the first NCQA recognized Level 3 PCMH in the Bay Area in 2013. To this project, I brought my previous independent practice and staff, as well as a patient base of 5,500 patients. It was a very professionally rewarding experience, again with a lot of opportunity to try new things, especially in Care Management and Population Health.
Sadly, the business plan for MHMG did not work out and the practice closed in late
2016, at which point I found myself looking for a job… at age 65.
I feel fortunate to have joined a well respected group of Family Doctors with an established practice and am comfortable doing primarily clinical medicine. For the first time in 35 years, I am nobody’s boss. Sort of liberating.
A part of me is still highly attracted to opportunities for change, both small and large, that align with PCMH principles and embrace the Quadruple Aim (a la Sinsky and Bodenheimer). Along those lines, my partners and I will be piloting a scribing solution provided by Augmedix in the next few weeks to see if we can reverse the clinical:clerical ratio of time spent.
I also am pleased to be serving as the Chair of the Medical Practice Affairs Committee of the CAFP. Last year we focused on MACRA and MIPS (happy to say my practice completed that submission a few days ago!) and now will be focusing on the shifting landscape of practice models where Family Physicians provide care. I remain very interested in newer technologies that offer the promise of providing better care at a better price, and hope to try out a few more before I hang it up.