Individuals like you now more than any point in the past have the power to “empower” oneself not only in their own health and wellness but also in the understanding and definition of health care providers and entities that provide health care.  The empowerment comes from knowledge one can access from things like word of mouth to searching on the web.  There is so much free, professional, detailed information right at ones fingertips.  This section will help define some commonly asked questions that I have experienced throughout my health care career and ones I have answered pertaining to my said responsibilities within the health care arena.  This by no means is advice on medical treatment, just educational definitions, descriptions, examples, etc, to help you understand and empower yourself to take charge of your health and wellness

Doctors, Pharmacies, Insurance Companies, Hospitals, etc, also are realizing this and some are taking steps to build personalized relationships with their patients/customers.  They are accepting things such as education, preventative medicine and resources as part of their overall care with their patients/customers.  This only benefits you more along with you continuing your health and wellness knowledge.

The following in the section are a start to your empowerment of your health and wellness.  Ask questions, research the web, go to the library, spend a day at the bookstore, most of this cost little to nothing in return for the knowledge you will receive.  Your health and wellness is your “Return on Investment”.

Who are the health and wellness providers?

The beginning point of entry into health care is normally with a primary care provider.  In a matter of fact, Primary Care is the foundation of managed care systems.  They are the “gatekeeper”.  Of all the questions, I have been asked, have heard and continue to hear as a Health care Executive, is around Primary Care.  I believe that this section be more detailed as much as possible to help one understand the meaning of Primary Care, their specialties, their credentials and the other staff they may have carrying out some of your care.

The best definitions I liked were from the Institute of Medicine and the American Academy of Family Doctors.  The Institute of Medicine defines Primary Care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained relationship with patients and practicing in the context of family and community.”  In addition, the American Academy of Family Doctors describes that “Primary Care is an inclusive discipline that covers health promotion and maintenance, disease prevention, counseling, patient education and treatment of acute and chronic illnesses in a variety of settings.”

Primary Care Doctors

The Primary Care Doctors currently of today are viewed as the traditional family doctor of the past who treated everything.  While a Primary Care Doctor is trained in a broad variety of needs, he or she is not like “Doc Baker from Little House on the Prairie, who traveled to your house or out in the field, to treat you for everything”.  They have specialized training in at least one of the following specialties:


• Family Practice - Generalist by training, who can provide comprehensive care for anyone without regards to gender, age or health issue.  Family Practice is now a specialty within its’ self that includes a three year residency program, accreditation and certification.  Being comprehensive, he or she will perform the basic functions of an internist, pediatrician and gynecologist.  Thus saying this, they normally do not dive in too deeply therefore referring the patient on to the said specialists.
• Internal Medicine – Specializing in a wide range of non-surgical medical problems of adults and trained to look at the whole person with special emphasis on clinical skills, diagnostics and problem solving.  Internists are Board Certified by the American Board of Internal Medicine following completion of a three-year residency and passing an examination.  Many further into subspecialties such as Cardiology, Endocrinology, Hematology, Infectious Disease and Oncology, to name a few.
• Pediatrics – Specialize in the care for children and teenagers in every stage from infancy to adulthood.  They are often involved with behavioral and social as well as strictly medical issues.  A residency in General Pediatrics lasts three years.
• Obstetrics/Gynecology – specializing in medical and surgical care to women and has particular expertise in pregnancy, childbirth, and disorders of the reproductive system. This includes preventative care, prenatal care, detection of sexually transmitted diseases, Pap test screening, and family planning.
  
  An obstetrician is a physician who has successfully completed specialized education and training in the management of pregnancy, labor, and puerperium (the time-period directly following childbirth).
  
  A gynecologist is a physician who has a successfully completed specialized education and training in the health of the female reproductive system, including the diagnosis and treatment of disorders and diseases.

Doctors of Medicine and Doctor of Osteopathic Medicine

Doctors of Medicine (M.D.s) is defined by John Hopkins University School of Medicine as follows:  “Medical Doctors who receive an intensive medical education that begins with an undergraduate college degree in a subject that lays groundwork for medicine.  This is followed by four years of medical education at a university-based medical school.  The medical school provides a scientific and clinical orientation to health care.  Doctors are taught to prevent, diagnose and treat disease and to promote overall health for their patients.  Medical education emphasizes the interrelation between, teaching, research and health care.  For most M.D.s, graduation from medical school marks just the halfway point of their professional education.  M.D.s continue their education in residency programs, usually in hospitals, where they get hands-on training in the specialty they have chosen.  Residency programs usually last from three to seven years depending on the specialty and even more years for sub-specialties.

Doctors of Osteopathic Medicine (D.O.s) is defined by the American Osteopathic Association as follows: “They work in partnership with their patients considering the impact that lifestyle and community have on the health of each individual, and they work to erase barriers to good health. D.O.s are trained to look at the whole person from their first days of medical school, which means they see each person as more than a collection of body parts that may become injured or diseased. D.O.s are taught that the whole person is greater than the sum of the parts. This means that osteopathic medical students learn to integrate the patient into the health care process as a partner. They are trained to communicate with people from diverse backgrounds and they get the opportunity to practice these skills in the classroom with simulated patients.  Because of this whole-person approach to medicine, approximately 60 percent of all D.O.s choose to practice in the primary care disciplines of family practice, general internal medicine, and pediatrics.  Osteopathic medical students also learn the art of osteopathic manipulative medicine, a system of hands-on techniques that help alleviate pain, restore motion and influence the body’s structure to help it function more efficiently. One key concept osteopathic medical students learn is that structure influences function. Thus, if there is a problem in one part of the body’s structure, then function in that area will also be affected.  Another integral tenet of osteopathic medicine is the body’s innate ability to heal itself. Many of osteopathic medicine’s manipulative techniques are aimed at reducing or eliminating the impediments to proper structure and function so the self-healing mechanism can assume its role in restoring the person to health.

The fact is that both D.O.s and M.D.s are fully qualified physicians licensed to prescribe medication and perform surgery. Is there any difference between these two kinds of physicians? Yes and no.
Students entering both D.O. and M.D. medical colleges typically have already completed four-year bachelor’s degrees with an emphasis on scientific courses.
Both D.O.s and M.D.s complete four years of basic medical education. After medical school, both D.O.s and M.D.s obtain graduate medical education through internships, residencies and fellowships. This training lasts three to eight years and prepares D.O.s and M.D.s to practice a specialty. Both D.O.s and M.D.s can choose to practice in any specialty of medicine—such as pediatrics, family medicine, psychiatry, surgery or ophthalmology. D.O.s and M.D.s must pass comparable examinations to obtain state licenses.

D.O.s and M.D.s both practice in accredited and licensed health care facilities. Together, D.O.s and M.D.s enhance the state of health care available in the U.S. D.O.s, however, belong to a separate yet equal branch of American medical care.

It is the ways that D.O.s and M.D.s are different that can bring an extra dimension to your health care.”

Board Certified vs. Non-Board Certified

The American Board of Medical Specialties (ABMS) is an organization comprised of 24 approved medical specialty boards. ABMS exists to assist the activities of its member boards and to provide information to the public, government and medical profession concerning issues involving specialization and verification of medical specialists’ board certification.  ABMS, recognized as the “gold standard” in physician certification, believes “higher standards for physicians means better care for patients”.  ABMS describes being Board Certified as “An added measure of expertise, Board Certification granted by an ABMS Member Board provides assurance of a physician’s expertise in a particular specialty and/or subspecialty of medical practice.  They also add, “Since there is no requirement or need for a certified physician in a recognized specialty to hold special certification in a subspecialty of that field, the lack of a subspecialty certification does not indicate that a physician is unqualified to practice in the subspecialty.”  The twenty four recognized ABMS Board Specialties are:  Allergy and Immunology (1971), Anesthesiology (1941), Colon and Rectal Surgery (1949), Dermatology (ABMS Founding Member), Emergency Medicine (1979), Family Medicine (1969), Internal Medicine (1936), Medical Genetics (1991), Neurological Surgery (1940), Nuclear Medicine (1971), Obstetrics and Gynecology (ABMS Founding Member), Ophthalmology (ABMS Founding Member), Orthopedic Surgery (1935), Otolaryngology (ABMS Founding Member), Pathology (1936), Pediatrics (1935), Physical Medicine and Rehabilitation (1947), Plastic Surgery (1941), Preventive Medicine (1949), Psychiatry and Neurology (1935), Radiology (1935), Surgery (1937), Thoracic Surgery (1971), Urology (1935) and within these are more than 120 subspecialties.  

American Osteopathic Association (AOA) is a member association representing more than 67,000 osteopathic physicians (D.O.s). The AOA serves as the primary certifying body for D.O.s, and is the accrediting agency for all osteopathic medical colleges and health care facilities.  The AOA’s mission is to advance the philosophy and practice of osteopathic medicine by promoting excellence in education, research, and the delivery of quality, cost-effective health care within a distinct, unified profession.  AOA has eighteen Approved Specialty Boards that a D.O. has achieved expertise in a medical specialty or subspecialty.* Certification by an AOA Approved Board is not a requirement to practice in a medical specialty.  Doctors of Osteopathic Medicine can become AOA certified in the following areas:  Anesthesiology, Dermatology, Emergency Medicine, Family Practice, Internal Medicine, Neurology & Psychiatry, Neuromuskuloskeletal Medicine, Nuclear Medicine, Obstetrics & Gynecology, Ophthalmology, Otolaryngology, Orthopedic Surgery, Pathology, Pediatrics, Physical Medicine & Rehabilitation, Preventive Medicine, Proctology, Radiology and Surgery.

Why is a physician not board certified?

Certifacts On-line, an on-line resource for verifications of Physician’s Board Certifications and their explanation is the following; “Physician board certification is a voluntary process that approximately 80 percent of doctors in the U.S. obtain. A physician is licensed by the state to “practice medicine and surgery,” and medical board certification is not a requirement for licensure. Licensed physicians may practice in whatever medical disciplines interest them and can legally practice in that field of interest without obtaining a medical residency or fellowship. Board certification, however, means that a physician’s skills and knowledge in the specialty/subspecialty has been examined and meets standardized requirements by an ABMS Member Board. Additionally, some of the surgical specialties require one or more years of experience before physicians can take their board-certifying exams (the number of years varies according to each board). The physician in question may fit that category and may be working to satisfy the requirements for medical board certification. Most international medical graduates need to complete some required training in this country before they are able to take a particular board’s exam (if the entire postgraduate training is completed in another country). Exceptions are made and vary with each board. (Some boards may accept Canadian and/or United Kingdom residencies.”

What does “Board Eligible” mean?

There is only Board Certified or Non-Board Certified, in the past doctors used the term “Board Eligible” to signify their progress to obtaining Board Certification.  Some physicians used it so regularly with no intentions of becoming Board Certified that its’ meaning became useless and misleading.  Thus, prompting American Board of Medical Specialties (ABMS) to have the term “Board Eligible” disavowed.  Now if one inquires about a particular doctor, the Board will only state one’s precise position in the certification process.

Physician Assistants (P.A.s)

Physician Assistants (P.A.s) practice medicine under the supervision of physicians and surgeons. They should not be confused with medical assistants, who perform routine clinical and clerical tasks P.A.s are formally trained to provide diagnostic, therapeutic, and preventive health care services, as delegated by a physician. Working as members of a health care team, they take medical histories, examine and treat patients, order and interpret laboratory tests and x-rays, and make diagnoses. They also treat minor injuries by suturing, splinting, and casting. P.A.s record progress notes, instruct and counsel patients, and order or carry out therapy. P.A.s also may prescribe certain medications. In some establishments, a P.A. is responsible for managerial duties, such as ordering medical supplies or equipment and supervising medical technicians and assistants.

Physician Assistants work under the supervision of a physician. However, P.A.s may be the principal care providers in rural or inner city clinics where a physician is present for only 1 or 2 days each week. In such cases, the P.A. confers with the supervising physician and other medical professionals as needed and as required by law. P.A.s also may make house calls or go to hospitals and nursing care facilities to check on patients, after which they report to the physician.

Physician Assistant educational programs usually take at least 2 years to complete for full-time students. Most programs are at schools of allied health, academic health centers, medical schools, or 4-year colleges; a few are at community colleges, are part of the military, or are at hospitals. Many accredited P.A. programs have clinical teaching affiliations with medical schools.

In 2008, 142 education programs for Physician Assistants were accredited or provisionally accredited by the Accreditation Review Commission on Education for the Physician Assistant. Eighty percent, or 113, of these programs offered the option of a master’s degree, 21 of them offered a bachelor’s degree, 3 awarded associate degrees, and 5 awarded a certificate.  Most applicants to P.A. educational programs already have a college degree and some health-related work experience; however, admissions requirements vary from program to program. Many P.A.s have prior experience as registered nurses, emergency medical technicians, and paramedics.  P.A. education includes classroom and laboratory instruction in subjects like biochemistry, pathology, human anatomy, physiology, clinical pharmacology, clinical medicine, physical diagnosis, and medical ethics. P.A. programs also include supervised clinical training in several areas, including family medicine, internal medicine, surgery, prenatal care and gynecology, geriatrics, emergency medicine, and pediatrics. Sometimes, P.A. students serve in one or more of these areas under the supervision of a physician who are seeking to hire a P.A.

Nurse Practitioners

More than ever are nurses are coming to the forefront of health care and the delivering of health care.  Under the collaboration of a doctor, nurse practitioners have taken on many of the duties traditionally performed by doctors that includes but not limited to taking health history, performing physical exams, ordering/performing diagnostic tests and determining & evaluating care. Depending on their collaborative doctor and the state they are practicing in, nurse practitioners can prescribe routine medications; the only exceptions may be narcotics.

Nurse practitioners have master’s or post master’s degrees and many have further specialty training in fields such as adult medicine, pediatrics, family medicine, emergency medicine and or OB/GYN.

Doctors, Medical Groups, Hospitals, etc, have all recognized the value of these nurse practitioners for the achieving their goals of quality and cost effective health care delivery.  With being a health care CEO, some of my best achievements were accomplished with nurse practitioners.  The return on investment was so great that at one particular entity, it allowed me to transform an age-old mentality that would not even recognize nurse practitioners to them leading the way in overall health care delivery and patient satisfaction.

Most of us use to understand that when we went to the doctor, if our illness warranted it, we would be admitted to the “hospital”.  Additionally, if we needed lab work, radiology, surgery, and any other specialized testing, we would also be sent to the hospital.  Now we all know that some of the doctors have some of these services inside their practices.  The mentality of “one stop shop” has furthered itself outside the walls of an all-encompassing “hospital”.  Putting it plainly, you the patient/customer are demanding for better, more efficient, cost effective, accessible, health care delivery. Even doctors, laboratory companies, pharmacies, radiology/imaging centers, surgery centers, etc, are listening to lead the way in catering to your needs.  This is a great step but it is highly recommended that one have an understanding of some of these entities.

Who are the Health & Wellness Entities?

Hospitals

In the United States alone, there are over 6,500 hospitals with more than one million beds and like everything else in modern medicine, America’s hospital system in is a drastic state of change.  Many are down sizing, merging, affiliating, integrating services and most noticeably, diversifying.  They are attempting to move into a future that demands medical institutions redefine themselves.  A great tool to use to determine the quality of a hospital is their accreditation by the Joint Commission on Accreditation of Health Care Organization.  Though not required by some hospitals, it is the standard on how a hospital whether large or small, for profit or non-profit and Critical Access Hospitals, deliver health care.  State and Federal inspections of hospitals are made public and they make them available free of charge on their websites. 

• For Profit Hospitals - are investor-owned hospitals that were established particularly in the United States during the late twentieth century. In contrast to the traditional and more common non-profit hospitals, they attempt to gain a profit for their shareholders.
• Non-Profit Hospitals - are hospitals that organizes as a non-profit corporation. Based on their charitable purpose and most often affiliated with a religious denomination they are a traditional means of delivering medical care in the United States. Non-profit hospitals are distinct from government owned public hospitals and privately owned for-profit hospitals.
• Critical Access Hospitals - a hospital located in a remote rural area; provides 24-hour emergency services; have an average length-of-stay for its patients of 96 hours or less; be located more than 35 miles (or more than 15 miles in areas with mountainous terrain) from the nearest hospital or be designated by its State as a “necessary provider”. Hospitals may have no more than 25 beds.  Federal law with special payments under the Medicare program established the designation. The majority were built in the 1950s by the funding of the Hill-Burton Act.  In addition, most are government owned county facilities that are governed and operated by elected officials within its’ county.
• Hospitalist – I have included this definition under this hospital section because it is so important.  Most likely, when you are admitted to a hospital, you will be admitted to a hospitalist and not your primary care doctor.  Hospitalists are employed by the hospital.  Some primary care doctors do not even admit their own patients any longer.  This is something you should consider when seeking a new doctor or ask your current doctor if he or she provides continuity of care for you once you are admitted to a hospital as an inpatient.  As defined by the Society of Hospital Medicine, “Hospitalists are physicians who specialize in the practice of hospital medicine.  Following medical school, hospitalists typically undergo residency training in general internal medicine, general pediatrics, or family practice, but may also receive training in other medical disciplines.  Some hospitalists undergo additional post residency training specifically focused on hospital medicine, or acquire other indicators of expertise in the field, such as the Society of Hospital Medicine’s Fellowship in Hospital Medicine (FHM) or the American Board of Internal Medicine’s Recognition of Focused Practice in Hospital Medicine.”
  
  If you know you are going to be admitted, ask the hospitals who are their hospitalist and their credentials and remember that hospitalist can be Physician Assistants and or Nurse Practitioners.  In addition, as I mentioned above, ask your primary care provider if they admit and retain overall continuity of care of their patients or do they leave it up to the hospital’s hospitalists.

Emergency Rooms

Emergency Rooms (ERs) exist only to deal with medical emergencies.   Unless your situation is life threatening, you will be triaged (a system that determines the order in which patients are seen and treated) by a nurse.  It is not a first come, first serve system, but a need-based system.  If you have a serious or life-threatening condition, you will been seen quickly.  The seriousness of the condition will not be defined by you, but by the nurse.  As we all know, if your condition is otherwise, you will be waiting for quite a while.  
Unfortunately, many people use emergency rooms for their primary health care needs.  Many reputable studies throughout the 1990s found that about 55% of emergency room visits were for non-urgent situations and that people came to the ER more frequently for coughs and sore throats than they did for chest pains.  With the rising costs of health care insurance and the economy (loss of jobs), these visits rose to almost 65%.  The main reason that these people utilize ERs as their primary health care is that no one can be turned away, it is federal law.  Some hospitals that employ doctors experience patients that have been turned away from their doctor’s office because of past bills and no insurance, do a u-turn from the doctor’s office and walk down to the ER.   What you may know or may not is that hospital charges for ER visits are normally about three times higher than what the same service would cost in a doctor’s office.  Some health insurance companies have now made it difficult to get reimbursement for emergency room care that is deemed “not medically necessary”.  It is not my intention to validate any political party’s stance on health care reform, just provide basic facts from someone with health care experience.

Ambulatory Surgery Centers

Ambulatory Surgery Centers (ASC), also known as Outpatient Surgery Center or Same Day Surgery Center, is a health care facility that specializes in providing surgery, pain management and certain diagnostic (e.g., colonoscopy) services in an outpatient setting. Overall, the services provided can be generally called procedures. In simple terms, qualified procedures can be considered procedures that are more intensive than those done in the average doctor’s office but not so intensive as to require a hospital stay. An ambulatory surgery center and a specialty hospital often provide similar facilities and support similar types of procedures. The specialty hospital may provide the same procedures or slightly ones that are more complex and the specialty hospital will often allow an overnight stay. Ambulatory surgery centers do not provide emergency services. 

In the United States, over six million surgeries a year are performed in over 4,000 ASCs. ASCs are in all 50 states and can be found throughout the world. In the US, most are licensed, certified by Medicare and accredited by one of the major health care accrediting organizations. Procedures’ performed in surgery centers are broad in scope. Many knee, shoulder, eye, and other surgeries are currently performed in ambulatory surgery centers. Some heart procedures are even taking place in certain ASCs. In the United States today, over 50% of Colonoscopy services are performed in ambulatory surgery centers.

Ambulatory surgery centers rarely have a single owner. Physicians’ partners who perform surgeries in the center will often own a small part of the facility. A 1% or less ownership might be common, but percentages can vary considerably. Occasionally, a surgery center is entirely physician-owned. However, it is most common for development/management companies to own a percentage of the center.

Although complications are very rare, ASCs are required by Medicare and the accreditation organizations to have a backup plan for transfer of patients to a hospital if the need arises.
The three main accreditors of ASCs are the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (Accreditation Association or AAAHC) and Joint Commission.

Urgent Care Center

A new way of accessing medical care when you want it, where you want it without having to wait for an appointment to be seen, Urgent Care Centers were pioneered by ER physicians as a way to meet the demands of patients seeking an alternative to overcrowded hospital based ER’s that were geared mainly to see the trauma and the gunshot wound patient far more expeditiously than the patient with a back-ache. The care provided at an Urgent Care is typically just that - Urgent Care can be considered”Stat” Care. Most urgent care facilities will provide a high quality of “STAT” or immediate care within a half-hour of the patient showing up at the door. They will also accept patients who do not have health insurance coverage. This ‘immediate’ and ‘on-demand’ delivery of ambulatory care in a facility dedicated to the delivery of medical care outside of a hospital emergency department, usually on an unscheduled, walk-in basis defines the urgent care movement in the US. Most Insurance plans will cover an Urgent Care visit as long as the facility is on their roster of approved Urgent Care Centers. You should make sure that you are not walking into a facility that is called an Urgent Care but is only a regular medical practice marketing itself as an Urgent Care. Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency room. Often urgent care centers are not open 24 hours a day, unlike a hospital emergency room that would be open at all times. However, most real urgent care centers have extended hours in the evenings and are open on all weekends and holidays. Most true urgent care centers will see children of all ages along with adults. Urgent Care centers are usually staffed by people with a background in either Emergency Medicine or Urgent Care Medicine and are able to treat a wide variety of conditions from suturing a laceration to treating a broken bone.

The initial urgent care centers opened in the 1970s. Since then this sector of the health care industry has rapidly expanded to an approximately 10,000 centers until recently when a series of retail pharmacy based centers were closed. Most Urgent Care Centers were started by entrepreneurial ER physicians who have responded to the public need for convenient access to unscheduled medical care. Other centers have been opened by hospital systems, seeking to retain patient flow into their networks. Much of the growth of these centers has been fueled by the significant savings to the health insurance plan and the consumer that urgent care centers provide over the care in a hospital emergency department. Almost all managed care organizations now encourage their customers to utilize the urgent care option over an ER and will direct their members to an approved facility if the member was to call their membership hotline.

Remember, many primary care offices are open for some hours in the evenings and weekends. However, unless these centers are open for walk-in patients of all age groups at all times when open for patients, offer on-site x-ray facilities, and care for most simple fractures and lacerations—these primary care physician offices are not considered true urgent care centers.

Become Your Own Health and Wellness Expert

I want to express the importance of education yourself on even the basics of health care.  This section gives you a start to some basic and detailed definitions, explanations and facts on who, what and where your health and wellness experiences may begin.  However, even before that, educate yourself; know credentials to ask for and their meaning, research inspections, etc, these will enhance your “Return on Investment” for your own health.  There are wonderful health & wellness providers and entities that should be given respect, but demand the same with your own health & wellness.  Be the leader and take charge of your health and wellness.

Dr. Rodney Gross, Ph.D.