TRAINING RESIDENTS IN FULL SPECTRUM FAMILY MEDICINE
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Medicine Residency Program
outpatient and inpatient, that it offers to the community. In addition to general office visits the practice has an array of outpatient services ranging from pre-natal care and pediatrics to sports and occupational medicine. If a service is not offered at MFA a patient will most likely be treated at the hospital, Mercy Medical Center Merced, located right across the street from the main office. The physicians at MFA are a key part of the hospital medical staff structure, keeping the relationship strong between the office and hospital.
| PRACTICE SUMMARY CHART | |
| Type of Practice | Multi-specialty/suburban |
| Physicians | 14 family physicians; 1 internist/gerontologist; 3 pediatricians; 2 OB/GYNs; 1 occupational medicine physician; 1 urgent care physician |
| Additional Providers | 8 mid-levels |
| Yearly Patient Visits | 87,980 outpatient and 14,460 inpatient visits through MFA |
| Yearly # of Deliveries Annually | 1,700 (through Mercy Medical Center Merced) |
| Additional Employees | 115 additional employees in 8 different facilities in the Merced area |
| Other Health Professionals | Dietician and counselor |
| Affiliations with Hospitals | Mercy Medical Center Merced (MMCM) |
| Residents | 21; 7 each year |
| Medical Students | Yes, through the Residency Program |
Compensation and Benefits
As is typical with most large multi-specialty groups MFA offers a full range of benefits to its employees. Dr. Johnston explains the five principles upon which the practice is based:
- Physicians are given autonomy in the way they practice.
- There is equity in that senior physicians and junior members of the practice are paid the same way: the more you work, the more you get paid.
- There are easy-in, easy-out provisions so that you can buy in after 18 months with $15,000; physicians get the same amount back if they leave.
- Don't sweat the small stuff.
- First year associates get paid an hourly rate.
MFA offers individuals the opportunity to contribute up to 15% to retirement, but the practice does not make a contribution. In the first year, as an employee physician, there is a guarantee of four weeks of vacation and CME time. In the second year and beyond, since all physicians are paid on a productivity basis, there is no paid vacation. Rather, physicians are paid only when they work. Malpractice insurance is also a covered benefit from MFA. The practice provides medical insurance for the physician and his/her family. Other employees receive the same coverage for themselves and an opportunity to add family members at their cost. Dr. Araujo reports that the salary of MFA faculty members ranges from $110,000 to $240,000 per year.
Hours/Practice Flexibility
MFA's main facility is open from 9 am to 8 pm most days and there are also Saturday hours. All MFA physicians are involved with the residency training program, ranging from Dr. Araujo, the Director, who spends approximately 80% of his time on residency matters, to the newest physicians who might spend a half-day a week with residents in clinic. Most physicians work at least 5 days a week in a combination of clinics and teaching.
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PRACTICE: WEEK-AT-A-GLANCE
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Call schedule is divided equally among the 11 faculty family medicine specialists. During the weekend, one physician covers ICU and another physician covers the medicine services, OB and phone calls from the practice; during the week, one physician covers all the services. During the course of the year, each physician has weekday call two to three times a month and weekend call eight to nine weekends a year.
Employees
When recruiting practice staff, the administrative manager looks for people who are responsible, trustworthy, willing to take the initiative and "street smart." During regular meetings with the staff, hands-on training is offered. When staff has the opportunity to take classes, they are asked to report back to the other staff.
Balance
Many physicians find support from their families, their partners and their churches. As Dr. Col says, "I am always trying to lead a selfless life, and sometimes I am more successful than other times." At a potluck dinner hosted by Dr. Araujo, some of the physicians talked about this quest for balance. Dr. Paik-Tesch says, "I am still learning how to balance my love of obstetrics with a balanced home life. It is a work in progress." Another physician says that the intimacy he has learned from his patients helps him in his role as dad and husband.
Dr. Perkinson advises, "It is important for spouses to be involved in the decision about where to practice because it "will never be a 9 to 5 job. If you are going to do OB, you will give up some lifestyle points; the tradeoff is being able to bring new miracles into the world."
As far as the residents are concerned, one woman offers, "I am waiting for a year after residency before we have our second child. If you can plan your family around training, it does make it easier."
Merced Faculty Associates offers a comprehensive financial package for its employed physicians. Typically, the practice gives an income guarantee for the first year of practice, which is based on either an hourly rate or a one-year salary guarantee. Moving expenses are negotiated by MFA, and medical insurance for the employee and his or her family is also covered. MFA pays for medical license renewal, as well as professional liability insurance. Out-of-pocket business expenses are reimbursed on a pre-tax basis.
According to Dr. Araujo, a physician joining the MFA team will be combining work in the practice with teaching in the residency program, and needs to be able to practice the full scope of family medicine (including hospital work and obstetrics). An ideal candidate for employment at MFA is willing to work hard, enjoys teaching and passing on his or her skills and knowledge to a younger generation of physicians, and places a high value on patient care.
To determine the need for additional physicians/providers, MFA analyzes:
- Its workload;
- The number of new patients coming to the practice;
- How busy current physicians and mid-level providers are; and,
- Whether new opportunities exist within the community.
The needs of the residency program are also considered, because there may be a need for more faculty physicians to cover teaching clinics.
Because MFA is located in a small town and medical community it is relatively easy to introduce a new physician into the practice and to promote his or her relationship with other physicians. In addition to introducing the new doctor in hospital department and staff meetings, a new physician is taken to informal physician get-togethers and the doctor's lounge. Advertisements announcing the new additions to the group are also posted in the local newspaper.
The MFA staff work hard to meet the needs of the community in the area of primary care. Physicians work as faculty of the Family Medicine Residency Program, and MFA makes every effort to keep at least one or two of the yearly graduating physicians in the community, either by hiring them or assisting them in joining other Merced-area practices. Dr. Araujo explains, "In this way, we have trained 35 to 40 family physicians in the Merced area, close to 75% of all the family physicians in Merced." These strong community ties were made especially apparent when the group won the "Practice of the Year" award last year. The award was based on a reader poll given out by a local paper.
MFA physicians contribute to the community in a number of ways. Some doctors serve as team physicians for the local high schools and junior colleges, and bring residents along to observe these athletic events. In addition, the group does free physical screenings for sports participation, either as a practice or through the residency program. Other involvement includes physician lectures at schools, as well as residents working in the Hmong and Latino community through the organization "Healthy House." Dr. Araujo personally serves as the medical director at a crisis pregnancy center and has served as a team physician for a local high school.
A large percentage of the Merced population is underserved, and it is the mission of the Family Medicine Residency Program to take care of the underserved and indigent of Merced County. As the attendings, physicians see all of these patients in the Emergency Department and hospital. "Our practice and physicians are the attending of record for all unassigned patients who present to the Emergency Department and then are admitted to the hospital," Dr. Araujo explains. Additionally MFA physicians are the attending teachers for all the patients seen in the Family Care Clinic, which is where the residents see their patients. Virtually 60-75% of these patients have no other access to health care.
MFA has some agreed-upon practices and guidelines that the partners have chosen to follow. Particularly for OB care, standards are discussed - such as Group B Strep screening - and implementation is then recommended for all of the physicians. Dr. Araujo notes, however, that the partners do not mandate compliance with practice guidelines.
Dr. Araujo is pleased to have many growth opportunities through the residency program. He keeps up to date on changes and new directions in residency education through national graduate medical education conferences. The University of California, Davis has a network of eight family medicine residency programs and these meet monthly to discuss issues of common interest such as recruiting, residency operations and communications.
Dr. Araujo and his colleagues also attend the meetings of the American Academy of Family Physicians, the California Academy of Family Physicians and the Association of Family Medicine Residency Directors.
Merced Faculty Associates reviews performance using a variety of means, including looking at the number of patients seen and the productivity measures for each physician. Additionally, the practice takes part in the Family Practice Liability Project which collects data on individual physicians' maternity care and their adherence to certain standards, in an effort to reduce the liability associated with maternity care. MFA sends annual data on the maternity care provided and outcomes of the pregnancies to NORCAL as part of this project.
In the past MFA has had some private insurance surveys of its performance on mammogram rates, Pap smear rates, vaccination rates, etc.; however, this has not been consistently measured. All performance indicator results are used internally and are discussed at the practice's partner and provider meetings.
All primary partners at MFA are teachers with the residency program, and as such hold clinical faculty appointments with UC Davis School of Medicine. Additionally, physicians have participated in some clinical trials through one of the cardiologists in the hospital when the practice has admitted patients who have been chosen to be part of the clinical trials.
A management team made up of a core of physician partners and the CFO, governs the practice and sets the tone for the group. Partner physicians meet on a monthly basis to discuss issues related to practice management, and one of these partners is also in attendance at the monthly nursing and front-office staff meetings.
Relationships with Other Specialists
MFA physicians consider their patients' insurance and then regularly refer to specialists in the community. Almost all major specialties are represented, although there are some shortages. Currently the practice's wish list includes more orthopedic surgeons and general surgeons, a rheumatologist, and a neurologist. The hospital has analyzed the physician workforce and is currently analyzing whether it can assist with income guarantees or other methods of recruiting for needed specialties. Because of its broad base of patients MFA has the advantage of being able to refer paying patients to specialists, and specialists can and do reciprocate.
Relationships with Other Health Providers
MFA and the residency program undertake special measures and training to make sure that all are providing culturally sensitive care. Hospital staff work with cross-cultural health care interpreters on a regular basis. In addition there are regular education programs that provide insight into traditional health and spiritual beliefs of the Southeast Asian community and Hmong Shamanism.
Hospital Relationships
Merced Faculty Associates has a close relationship with the 176-bed Mercy Medical Center Merced, the only hospital in town and the home to Family Medicine Residency Program. Most of the partners spend a large portion of their time at the hospital, either in direct inpatient care - particularly OB - or precepting and supervising residents.
Medical Faculty Associates are an integral part of the hospital medical staff structure, and admit all of the unassigned patients to the hospital. Dr. Araujo plays two important roles in the hospital, as both the Program Director of the Residency Program and as the Chairman of the ICU Committee. Other MFA partners regularly serve as chairs of hospital committees and Dr. Streeter is currently the Chief of Staff. "We deliver either by ourselves or through the residency program over 70% of all the deliveries in the hospital," Dr. Araujo states.
Relationships with University/Other Educational Settings
The partners of the group, who also serve as the faculty of the residency program, all have clinical faculty appointments at UC Davis School of Medicine. As program director Dr. Araujo attends monthly meetings at the university and is involved in negotiations with the university over its residency affiliation agreement. MFA receives a contracted payment from the hospital for running the residency program since the agreement is between the hospital and the university.
Relationships with Medical Students and Residents
As faculty for the residency program, teaching is a crucial part of a MFA physician's professional life. Merced Faculty Associates has a contract with the hospital giving the practice the responsibility for running the residency program, providing a director, and providing supervision for the 21 residents and mid-levels in the hospital and residency clinic. The amount of time each partner spends in teaching responsibilities varies, from 20% for those more focused on clinical activities in the main practice, to more than 80% for Dr. Araujo as the director.
Medical students are taught on a regular basis as they rotate through the residency program, they may also spend time in the MFA office in order to get a better feel for the practice.
Family Medicine Residency Program
The Family Medicine Residency Program was started in 1974 at the urging of the hospital medical staff because of a need for additional primary care physicians in the Merced area. It is the only residency program in the hospital. The residents function as primary physicians for a large number of inpatients. More than half of the active medical staff are involved in the residents' training. The Family Care Clinic is a licensed Rural Health Clinic and residents truly serve patients with unmet needs.
The Family Care Clinic is located next door to the hospital and contains 22 exam rooms, a conference room, a library, a minor surgery and procedure room, office laboratory and offices. There are three distinct nursing stations with residents working in teams at each station.
- First year residents spend one to two half-days a week in the clinic
- Second year residents spent three half-days a week in the clinic
- Third year residents spend four half-days a week in the clinic
Here residents seem to enjoy practicing the full spectrum of family medicine with a great diversity of patients from all walks of life and cultures. There are opportunities to learn many procedures including sigmoidoscopy, colposcopy, vasectomy and obstetrical ultrasound. There are also specialty clinics in dermatology, gynecology, geriatrics and behavioral medicine.
Jim McDiarmid, a clinical psychologist with the residency program explains, "As part of the residency training program each resident sees two patients every week for psychotherapy for 52 weeks. This gives them a real sensitivity to the cultural backgrounds of our patients."
Decisions for purchasing new equipment and technology are made by the MFA management team and are then discussed at the monthly partners' meetings. Recently the team considered purchasing a computer system to check all billing and charges for appropriateness and to flag billings where there may have been a mistake. The meeting provided a forum in which the team discussed the financial implications of the system, such as whether or not the new technology would be a net positive to the group's bottom line.
Patient Communication
The practice does not currently have a website but the possibility has been discussed many times. MFA's billing and registrations system contains e-mail, but e-mail contact is not routinely used with patients for clinical issues or questions. Most physicians have personal e-mail, which they use for residency business. MFA also links to the hospital to access electronic copies of x-rays and lab reports.
Knowledge Management Technology
The majority of physicians at MFA access the latest clinical information at point-of-care using handheld PDAs, with downloaded information such as Epocrates and UpToDate. The practice's computers have Internet capabilities and physicians can search databases while seeing patients.
Practice Management Technology
Merced Faculty Associates does not have an electronic health record but all agree that it is needed. PDAs are used widely among physicians to look up point-of-care information on drugs, current practices, etc. MEDIX is used to manage coding, scheduling, and billing. Fifteen employees staff a separate billing office and perform all practice management functions, as well as providing management services for several other practices in the geographic area. Staff can utilize the computerized billing system to track procedures and diagnoses. Several full-time employees manage the medical records, all of which are paper.
To ensure that MFA facilities are convenient, comfortable and efficient for both patients and physicians the practice employs a full-time staff of supervisors to oversee every main area, including nursing, registration and billing, as well as full-time supervisors at each of the practice's nine clinical sites.
Practice Management
The partners of the group are ultimately responsible for the financial health of the practice. A management team of approximately seven partners meets weekly to deal with the practice's financial issues and to make decisions regarding future direction. Supervisors report to the management team and a CFO oversees the financial picture of the practice.
Other Practice Resources
An attorney on retainer serves as the legal advisor for Merced Faculty Associates. The practice's CFO/Accountant prepares its taxes and sends them out to an independent accountant for review and audit. Several independent audits have been done over the years to ensure the practice is doing everything correctly. One employee handles all human resource functions and reports to the management team. The only service that is outsourced by MFA is the pension plan service.
Governance/Physician Leadership
Major decisions are made by a 2/3 vote of the partnership, and the management team (a group of seven partners) governs the group. There have been some difficult decisions made in the past, but most decisions are made by consensus. For example, several years ago the hospital wanted to buy the practice and the physicians were split on the issue, but eventually reached a decision not to sell. As Dr. Araujo says, "We typically make good decisions as a group because we put patients and the residency program first, and profits second."
Marketing
The practice's president, Dr. Johnston, spearheads and provides direction for MFA's long-term goals and business plans. These decisions are primarily determined in management team meetings and then ratified at partner meetings. In terms of marketing MFA tries to reach the community as a whole, not a specific market segment. However, the team continues to emphasize and recruit obstetrical patients. The most effective marketing efforts are participation in community activities and showing support for local groups such as theater and sports. Although MFA is the largest group practice of any type in town there is still some potential for competition. Dr. Araujo feels that Kaiser could be a competitor should it ever enter the Merced market.
Coverage/Relations with Payers
Payer breakdown is: Medi-Cal 24%; Medicare 10%; Medicare & Medi-Cal 5%; Blue Cross 14%; Blue Shield 8%; Capitated 8%; Private Pay 8%; Commercial insurance 23%; Medi-Cal 55%; Medicare 10%; Traditional insurance 10%; County assistance for medically indigent adults 25%.
Nature of Contracts
Contracts are negotiated by the President and the CFO. Before agreeing to any contracts, MFA always analyzes the potential effects of a contract on the group's bottom line. When looking at potential contracts, MFA also considers:
1) whether it will keep its patients with the practice;
2) whether it can get good rates for OB care; and,
3) whether it can get good rates for providing special services such as vasectomy, treadmills, ultrasounds, etc., that are above the usual primary care services.
| Primary Contact: | David Araujo, MD |
| Family Medicine Residency Program Mercy Hospital Center Merced |
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| Merced, California |
Isaac Kim, MD, Merced Faculty Associates, Merced, California
Timothy Johnston, MD, Merced Faculty Associates, Merced, California
Karen Carlquist-Hernandez, EdD, Family Medicine Residency Program, Merced, California
Al Col, MD, Merced Faculty Associates, Merced, California
John Paik-Tesch, MD, Merced Faculty Associates, Merced, California
Rob Streeter, MD, Chief of Staff, Mercy Medical Center Merced, Merced, California
Len Perkinson, MD, Merced Faculty Associates, Merced, California
Jim McDiarmid, PhD, Family Medicine Residency Program, Merced, California
Practice Staff:
Susan Harris, Billing Manager, Merced Faculty Associates, Merced, California
Others contacted for this profile:
- Annette Haugen, obstetrics patient, Mercy Medical Center Merced, Merced, California
- Michelle Holmes, 3rd year Resident, Family Medicine Residency Program, Merced, California
- Joe McCook, MD, 2nd year Resident, Family Medicine Residency Program, Merced, California
- Sarah Moriaty, 2nd year Resident, Family Medicine Residency Program, Merced, California
- Becky Shaw, CPA, Chief Financial Officer, Merced Faculty Associates Medical Group
- Yogini Shukla, 1st year Resident, Family Medicine Residency Program, Merced, California
- Michael Snyder, 2nd year Resident, Family Medicine Residency Program, Merced, California
- Gail Tuck-Guerrero, MD, 3rd year Resident, Family Medicine Residency Program, Merced, California
Other Resources:
- http://fpnetwork.ucdavis.edu/merced/intro.htm
- www.mercymercedcares.org
- "Cultural Positivity: Connecting Cultures through Responsive Health Care," brochure about symposium, September, 2004
- Anne Fadiman, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of
- Two Cultures, Farrar, Straus and Giroux: New York, 1997