SPECIAL INTERESTS IN HIV AND HOSPITALIST
UCSD Healthcare/Family Medicine Clinic

San Diego, California
Primary Contact: Ralph A. (Tony) Brown, MD
Age: 47
Years in Practice: 15 years
Medical School: Boston University School of Medicine
Residency: Cook County Hospital, Chicago, Illinois

UCSD Healthcare, operated by University of California San Diego (UCSD), has provided leadership in patient care, biomedical research, education and community service for four decades. Physicians at UCSD account for 24 of the 29 San Diegans selected for "America's Top Doctors." The only university-based health care system in the region, the UCSD Healthcare system is vast, employing more than 4,000 staff at its two hospitals alone. In addition, the network includes a cancer center, an eye center, and six outpatient centers located within the San Diego community. One of these facilities is the Fourth and Lewis Medical Office, home to the Family Medicine Clinic, and one of the sites where UCSD residents have their continuity of care experience.

As a "full-scope" practice, the Family Medicine Clinic offers everything from obstetrics and pediatrics to sports medicine and geriatrics. Twenty physicians and a number of additional staff work together to provide personalized quality care to all of their patients. The Family Medicine Clinic is particularly proud of the role it plays in educating tomorrow's physicians, as is evidenced by the clinic's residency training program. For three years, nine family medicine residents work at the Lewis office as integral members of the health care team. In addition to this clinical experience, highlights of the residency program include a rotation at St. Vincent DePaul Village for the Homeless, OB clinics at the La Maestra Community Clinic, and work at the UCSD Student-Run Free Clinic Projects throughout San Diego County.

UCSD is an academic health care system with a family medicine department dedicated to teaching, research, clinical medicine, and serving the community. An important part of its family medicine philosophy is the team concept. Each team consists of three or four physicians or nurse practitioners and three family medicine residents. Team members are in close contact with one another and quickly become familiar with the more complicated patients who visit often. If the primary care physician is not available the patient will see another member of the continuity care team.

Dr. Tony Brown works at the Owen Clinic, a specialized HIV clinic with all integrated outpatient services on site. The Owen Clinic's mission is to provide state-of-the-art care to HIV patients. There is an emphasis on patient responsibility and accountability within a supportive and clinically-advanced environment.

"My interest in HIV is personal and professional. I lost two cousins and a nephew to HIV. The disease is growing among people of color. It has become a calling for me," explains Dr. Brown. He modestly adds, "It is a privilege to have the education and skills to serve the community. It is all about service."

Practicing family medicine has taken Dr. Brown to many locations. He practiced for six years among the Navajo and Ute Indians; he was the only physician on the island of Lanai in Hawaii; and had a "wonderful, rural practice" on the west side of Kauai, where he worked with Native Hawaiians from west Kauai and the island of Niihau. He recently returned from Haiti where he worked in the slums of Port au Prince. He plans to teach HIV care next summer at the Department of Family Medicine at the University of Transkei in South Africa. "Only family medicine can offer this degree of versatility," says Dr. Brown.

Serving others, especially those in need, is the hallmark of Dr. Brown's practice. "He is a doctor who absolutely relates to the African-American community and makes a commitment to people in need," explains Deenie Redmile, his former colleague at Lewis Clinic. "He works very hard, and is always willing to give his time, effort and energy where it is needed."

Dr. Brown has been on the UCSD staff for one year, having come to San Diego from North Carolina. He particularly enjoys his role as a hospitalist working with residents and his role at the Owen Clinic. He mentions that residents are sometimes surprised by the level of responsibility he takes with patients in a specialty-oriented hospital. Dr. Brown explains that when one is in Haiti or in a remote location, one quickly learns to do what is needed.

UCSD patients are very diverse, with a large gay and lesbian community residing around UCSD Hillcrest, one of the two hospitals. On a daily basis, Dr. Brown sees an ethnically diverse population. He particularly likes working with HIV patients and hopes to increase his clinic time at that particular clinic. The chair of the Family Medicine Department is also interested in starting a Gay and Lesbian Clinic at the Lewis Street Family Medicine facility, which is part of the UCSD health system. Dr. Brown has been discussing the possibility of launching that clinic and practicing there one day a week. Currently, he has a panel of approximately 2,000 patients in addition to his hospitalist responsibilities.

Dr. Brown finds his patients to be interesting, stimulating and appreciative. Many of his HIV patients are very knowledgeable about their conditions. Through his inpatient service Dr. Brown has the fulfilling opportunity of working with the same patients for their entire hospital stay. This daily continuity of care gives him a more complete understanding of his patients in the context of their visiting family and friends.

In this multi-specialty group practice, all UCSD physicians are board-certified and hold faculty positions at the University of California, San Diego School of Medicine. Two hundred physicians represent the full range of medical specialties at UCSD, with 20 specifically working in the family medicine practice.

As a "full scope" type of practice, the Family Medicine Clinic offers everything from obstetrics and pediatrics to sports medicine and geriatrics. There are two nurse practitioners working in the clinic. One mid-level's practice is predominately women's health, while the other provides diabetes education and management. Additional services provided by the Family Medicine Clinic include sigmoidoscopy, colposcopy, phlebotomy and diabetes education.

The clinic has a teaching inpatient service in which several faculty members work two blocks of time totaling four weeks per year. While Dr. Brown's inpatient time is currently 8-10 weeks per year his goal is to increase that number. As a "hospitalist," Dr. Brown is an acute-care specialist who focuses on a patient's hospital care from time of admission to discharge. He works in close consultation with other primary care physicians and referring physicians to manage the entire inpatient episode of care.

When not on the ward, Dr. Brown has a .5 FTE family medicine clinic and a .1 FTE HIV clinic-the Owen Clinic. Among America's top HIV care programs, the Owen Clinic incorporates the various disciplines that an AIDS patient may need into one outpatient clinic. An experienced team of physicians, physician assistants and nurse practitioners utilize 15 rooms for patient exams, and each patient is assigned a primary care practitioner based on his or her particular needs.

Hospitalists

As a "hospitalist," or specialist in inpatient care, Dr. Brown is part of a new and innovative way to practice family medicine. Hospitalists are often:

• Attracted to the complexities, variety, and rewards of working primarily with hospitalized patients;
• Comfortable building and nurturing collaborative working relationships with community physicians, peers, and hospital staff;
• Able to lead the entire care team in making decisions and taking actions that optimize a patient's care; and
• Self-starters who are active contributors to changes in hospital care. Although only a small percentage of family medicine specialists are full-time hospitalists, those who train residents agree that their graduates would be comfortable managing virtually all their own inpatient care, and most believe that their graduates would be comfortable functioning as full-time hospitalists.

Compensation and Benefits

UCSD offers a base pay with incentives based on relative value units or (RVUs). Family physicians' base pay is about $107,000, with the average salary coming to $130,000 - $140,000 after productivity bonuses. The University of California benefits are uniform throughout the system and include health insurance, four weeks of vacation, a week of CME and $1,500 stipend, and a retirement plan. The retirement plan is an independent benefit for all UC employees that begins five years after employment. Maximum retirement benefits are reached after 20 years.

Hours/Practice Flexibility

Among his hospitalist duties, clinics at both Lewis and Owen, and residency training, Dr. Brown routinely puts in 60-80 hours of work per week. Because of the needs of his patients and his wide range of expertise Dr. Brown finds that he is in high demand. Although some of his colleagues work part-time schedules, he does not. Dr. Brown particularly appreciates the vacation time because it gives him an opportunity to practice internationally, exemplified by his recent trip to Haiti.

Dr. Brown takes clinic call one day in eight. When he is on the hospital service, he covers the service 24/7 for 14 days.

Employees

The staff who work with Dr. Brown at the Lewis Street office, the Owen Clinic and the hospital are employees of the University of California, with benefits as indicated previously.

Balance

Between his practice, his volunteer work, and his community activities Dr. Brown says, "I am not the person to talk to about balance!" He adds, "Defining balance is a lifelong job that I am still working on." As one of his colleagues says, "Dr. Brown really engages with his patients. He really listens, and I hope that he can sustain that and still find time for himself. He sees people who have a lot of stress, yet he seems to transcend that stress when he is with them." As Dr. Brown puts it, "My patients know I am there for them and that I'll take the time needed for them."

As a divorced father of two children who live with their mother in northern California, Dr. Brown spends his valuable free weekends and down-time with his children. "There is never enough time to do all the things I want to do. I'd like to spend more time reading, traveling, perhaps even starting a business, but those things will have to wait for now," he explains.

When recruiting physicians the UCSD family medicine program looks for those who are interested in teaching and research, and who will contribute something extra to the practice. For example, right now they are looking for a physician who has a certificate of added qualification in geriatrics. Physicians who are experienced researchers are also in demand.

To keep up to date on a daily basis Dr. Brown attends grand rounds at UCSD and prepares carefully when working with residents, explaining: "Residents really demand evidence-based medicine." As part of his inpatient service responsibility Dr. Brown is always looking for "teachable moments" so residents get a thorough understanding of their hospitalist role.

For his own professional growth Dr. Brown would like to concentrate his efforts and learn even more about emerging AIDS research. He regularly attends HIV conferences to learn the latest research and treatments. Dr. Brown plans to continue his work in international medicine and will go to South Africa this summer. He sees family medicine as an exciting gateway to other cultures and people, whether in the U.S. or abroad. Closer to home, he wants to concentrate more on AIDS and meeting the "immense" health care needs of the underserved in southern California.

Dr. Brown is keenly interested in racial and ethnic disparities in health care. He is part of a group of physicians and community members of color who are working on gathering local data about this important issue. He cites "the huge San Diego problem of no public health clinics except for the one organized by students" as his primary motivation. He strongly believes that society will have to find a solution to the dramatic disparities in health care. He sees the Owen Clinic as a model, not only for HIV, but for all patients because it provides a collegial partnership with patients based on expertise. As one of the nurses describes, "The doctors who work here really know HIV and the latest research and treatments."

The practice's outpatient clinic performance indicators focus on patient satisfaction and financial markers, with results going to the division chair and the executive committee. While there are currently no clinical outcome measurements the family medicine inpatient service is beginning to work with the UCSD hospitalist team on this component. These inpatient measurements will then go to hospital administration. There is also a strong inpatient morbidity and mortality review process on a monthly basis.

The clinic does not participate in any disease registries; however, several members of the faculty are involved in clinical research.

Using a concept called Continuity Care Teams, physicians are able to provide strong continuity of care while simultaneously fulfilling other obligations at the medical school. Each team is made up of a patient's primary physician, one to two other physicians or nurse practitioners and three family medicine residents. Members of each team are in close contact with one another and become familiar with the patients, enabling them to step in and provide or coordinate care when the primary physician is unavailable.

Relationships with Other Specialists

The Family Medicine Clinic utilizes a very strong morbidity and mortality process to ensure that patients receive excellent care from other professionals with whom they work. Patients are normally referred to specialty departments within UCSD, and consultants' notes are available by computer to the referring physician.

Relationships with Other Health Providers

Dr. Brown currently works with nurse practitioners in the Owens clinic and at St. Vincent De Paul, the homeless clinic.

Hospital Relationships

UCSD Hillcrest, a university-based teaching hospital, and Thornton Hospital in nearby La Jolla, are the only hospitals with which the department is affiliated. UCSD Hillcrest, the main hospital for the UCSD School of Medicine, is the region's only academic medical center and offers both primary care and specialized services. The recently renovated 400-bed hospital is also the county's only Level I Trauma Center. Dr. Brown acts as the Family Medicine Inpatient Director at the hospital. He also serves on the Risk Management Committee.

Relationships with University/Other Educational Settings

At the clinic's affiliated university, UCSD, Dr. Brown is an Associate Professor of Family Medicine. Direct patient care, teaching residents, and research are all important parts of his role in this affiliation. Simply being around colleagues who have so much talent is the greatest benefit Dr. Brown receives from the relationship. He says, "There is so much intellectual cross-fertilization." One resulting disadvantage, however, is the continual tension between service (with revenue production) and academics.

Relationships with Medical Students and Residents

Devoting 0.3 FTE to teaching, Dr. Brown provides medical student education in the clinic and on the wards. Further work may include some direct teaching at the medical school on physical diagnosis. Additionally, he has .2 FTE committed to direct resident education, i.e., attending in the clinics, and also provides lectures. An important part of his responsibility as a hospitalist is to provide solid training to residents so they have the option of becoming hospitalists in the future.

Right now Dr. Brown is developing standardized oral exams to teach and assess the competencies of residents on the inpatient service at UCSD.

Patient Communication

The clinic has a website used primarily for residency education issues. E-mail is the principle means of communication between providers inside and outside the department and the clinic encourages patients to e-mail providers.

The family physicians at UCSD see the electronic health record as the wave of the future. Scheduled to go live in mid-2005, Lewis Family Medicine will be one of the pilot sites. Dr. Brown thinks, "it will be particularly valuable for those patients who take eight or 10 different medications." Dr. Carlos Rojas, another family physician at Lewis, is working with a team to help build the EHR template which he says, "will be an individualized template, but very intuitive and easy to use."

Practice Management Technology

The UCSD billing office handles all billing, with the attending physicians providing the ICD-9 and CPT codes on the billing form. Scheduling is done using an advanced access model of same-day appointments. With the exception of residency education purposes, Dr. Brown is not aware of any tracking procedures used by the clinic. The clinic currently outsources its billing however, this is changing.

Knowledge Management Technology

The clinic uses several medical search engines, including Medline and Pubmed, to access the latest clinical information at point of care.

Practice management is handled by UCSD with centralization of some services. The first floor of the Lewis Street building houses a registration center where all patients go prior to being seen by any of the physicians in the building and insurance coverage, copays and special circumstances are handled there. The university provides professional liability insurance and also offers a personal 'HMO type' of legal plan.

Marketing

At the Family Medicine Clinic, there is a clear effort to market to private insurers with higher reimbursement levels. Competition is intense within the clinic's geographical area, as many of the larger health care plans are targeting the same market. The clinic finds the most effective marketing to be the use of the UCSD name as a standard for excellence.

Coverage/Relations with Payers

The percentage of the practice covered by various payers can be broken down as follows: Medicare: 30-40%; Medi-Cal: 15% (and dropping); self pay: 2-3%. The remaining percentage is private. Sixty to 70% of each of the above categories are prepaid HMO, while the rest of the business is fee-for-service.

Nature of Contracts

The business office at UCSD negotiates contracts for the practice. The decision to enter, or not enter, into particular contracts is not in the hands of the physicians.

Reimbursement

Ninety-eight percent of patient visits at the Family Medicine Clinic are covered by insurance. Those who are uninsured are expected to pay a portion up front.

 

Primary Contact:	Ralph A. (Tony) Brown, MD
	Associate Professor, UCSD Healthcare/Family Medicine Clinic
	San Diego, California

Terri Allison, R.N., Manager, Lewis Family Medicine, UCSD Medical Group, San Diego, California

Roger Oen, MD, Third Year resident, UCSD Medical Group, San Diego, California

Carlos Rojas, MD, Associate Professor, Family Medicine, UCSD Medical Group, San Diego, California

Others contacted for this profile:

• Doris Gauff, RN, Clinical Supervisor, Owen Clinic, UCSD Medical Center, Hillcrest, San Diego, California
• Leonard J. LaRiccia, Patient, Family Medicine Clinic, UCSD Medical Group, San Diego, California
• Deenie Redmile, FNP, UCSD Antiviral Research Center, San Diego, California

Other Resources:

• www.health.ucsd.edu