The problem. The processes and structures in medical practices—from the front desk to the examination room to follow-up and referral—do not always work together to deliver high quality, patient-centered care.
Ralph Gonzales, MD, MSPH, professor of medicine, and epidemiology and biostatistics at the University of California, San Francisco (UCSF), leads research efforts to identify the human and the organizational factors that get in the way—and to create interventions to fix them. He is an alumnus of Harold Amos Medical Faculty Development Program. The program provides four-year awards for postdoctoral research to physicians and dentists from historically underrepresented groups who are committed to developing careers in academic medicine and dentistry. (See Program Results Report for more information.)
Process, says Gonzales, “is what doctors do and what patients do. This is about understanding behavior and behavior change.”
Learning from the restaurant business. Born in 1964 to Mexican migrant farm-workers, Gonzales came to California’s Central Valley at the age of six months. As a single parent, Gonzales’ mother gave up farm work and opened a Mexican restaurant, hoping to create a more stable life for her children.
The family business eventually grew, with restaurants in numerous locations, and Gonzales and his four siblings spent their teenage years bussing tables and waiting on patrons. They learned that everyone had to work together to deliver a good meal and a good experience to diners.
As he moved through his medical training, Gonzales noticed that health care systems had a lot in common with restaurants. “In terms of staff, you are dealing with people who work out front, nurses and administrators, and you are dealing with the ‘chefs,’ in this case the doctors, who work in the back,” he says, “and often the practice is not set up in such a way that they appreciate each other and work as a team.”
The disconnect affects patient care—just like miscues between a chef and the wait staff can ruin someone’s dining experience. “It is really about customer service and the quality of the product you are providing,” says Gonzales. “A lot of that has been lost in medicine. We're not as customer-oriented as we need to be."
Bringing better customer service into medicine has become a guiding principle of his research.
Challenging the overuse of antibiotics. In the mid-1990s, Gonzales became interested in antibiotic use in routine primary care, an area where better processes were needed to improve treatment.
Acute bronchitis, one of the most common reasons for physician office visits, usually has a viral cause, yet antibiotics are over-prescribed 65 to 80 percent of the time. The impact is not benign—their overuse can make other infections more dangerous and harder to treat.
Gonzales used his Harold Amos fellowship, awarded in 1997, to fund an educational initiative aimed at changing that. With colleagues, he developed educational materials for the 25,000 patients and 25 physicians at the Kaiser Permanente Clinic in Denver—stressing that antibiotics are useless against acute bronchitis.
To address patient attitudes and expectations for antibiotics that influence physician prescribing decisions, he designed a poster that was placed in examination rooms to explain how respiratory infections should be treated. To address physicians’ behavior, they were shown the high rates at which they had prescribed antibiotics for acute bronchitis.
Together, these measures sharply reduced antibiotic use for acute bronchitis, Gonzales says (see his 1999 article in the Journal of the American Medical Association [JAMA] about the intervention). Gonzales subsequently led the development of antibiotic prescribing guidelines with the Centers for Disease Control and Prevention, and these led to the creation of a national quality indicator aimed at reducing inappropriate treatment of uncomplicated acute bronchitis with antibiotics.
Continuing his work in this area, Gonzales tested educational interventions to reduce antibiotic use in primary practices in Central Pennsylvania (see article in JAMA) and in emergency and urgent care departments across the country (see article in Annals of Emergency Medicine), both of which proved effective. He also tested a relatively low-cost mass media education campaign in Denver, which resulted in a 10 percent drop in antibiotic utilization (see article abstract in Medical Care).
Reducing unnecessary specialty referrals. Another process issue that interests Gonzales is the number of high-cost referrals to specialty care.
“Specialty care utilization continues to skyrocket,” he says. “If you look carefully at those visits, just like with antibiotics, many of them are not necessary, or could be avoided with some simple information exchange.”
Gonzales and his research team instituted a computer-based decision-support system within eight primary care and 13 specialty practices at UCSF. When a primary care doctor is considering a referral for a patient with rheumatoid arthritis, for example, a list of medical criteria for an appropriate referral pops up on the computer. The menu also indicates the tests or pre-referral work-ups that need to be done in advance—“rather than a patient showing up at the rheumatologist and being told ‘I can't do anything until I see the x-ray,’” Gonzales says.
After the program was launched in April 2012, referrals to specialists declined by 20 percent. A few months later, the medical clinics instituted a program that allows specialists to provide consultative advice to physicians without seeing the patient. Specialists get reimbursed for this “e-consult,” but at a much lower rate than an office visit.
The program turned out to be a win-win for everybody, Gonzales says. The primary care physicians got expert advice immediately and patients liked having fewer medical appointments. For their part, specialists appreciated having more time to see complex cases, which is also better for teaching in an academic medical center.
The program also drove down costs through savings on professional fees and fewer lab tests and procedures. Emergency department visits also appear to have declined, possibly because primary care doctors could provide more appropriate care when their questions were answered quickly by specialists.
With funding from the University of California Center for Health Quality and Innovation in 2014, Nathaniel Gleason, MD, (principal investigator) and Gonzales are instituting the e-referral program across the five University of California health systems and will evaluate its effects on cost and outcomes. Gonzales also is working with two junior faculty to test the e-consult program in rural California and with Medicaid primary care providers, where access to specialists is limited.
Physician-patient communication. These research efforts demonstrate the potency of educating physicians and patients and harnessing technology to make office processes more efficient. But those strategies are unlikely to completely fix the problem, Gonzales says. “There is a vocal minority of patients who want antibiotics and demand them from their doctors. There is another vocal minority of patients who believe that the best care for them is to have a specialist weigh in on everything.”
Talking about those issues can be uncomfortable for doctors, who sometimes accede to a patient’s wishes, even if they are medically inappropriate, rather than engage in confrontation. A further complication is that patients and family members do play an important role in medical decision-making.
“Patients have a strong influence on how we practice medicine and that is appropriate,” Gonzales says. “We have to be able to solicit those preferences from patients and understand what their expectations and needs are. What is good for one patient may often be different than what’s good for another.”
New avenues. Gonzales credits the Harold Amos fellowship with helping him to establish himself in health services research at a time the field was new and career awards were few. Access to a network of mentors, “protected time” to build a research foundation, and the sense of playing on a national, rather than a local, stage were all gifts of the experience, he says.
Gonzales continues his interest in more effective processes at UCSF’s Clinical and Translational Science Institute where he heads up a program in implementation science—a new field designed to equip researchers to affect sustainable change in individuals, communities, institutions, and policies.
“It is really the science of understanding the how and the why of behavior change and using that understanding to design interventions that are more likely to be effective,” Gonzales says. “We can have a huge effect on health right now with all the treatments and discoveries we have already made—if we can get them better taken up and adopted.”
RWJF perspective. The purpose of the Harold Amos Medical Faculty Development Program, launched by RWJF in 1983, is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry.
The program supports one of RWJF’s major objectives: to increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.
Of Amos program scholars, RWJF senior program officer David M. Krol, MD, MPH, says:
“Ultimately, we would like to see these individuals from disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder.”
Ralph Gonzales is one of more than 180 Amos program alumni in academic medicine today. His career and research exemplify the academic achievement and professional contributions that the program was designed to stimulate.
“The measure of the success of the program is the success of the individuals who participate in it and how they impact the culture of health in the United States,” says Krol.
Ralph Gonzales draws lessons from restaurant business to improve health care quality/customer satisfaction