An Aspiring Post-Acute/Long-Term Care Physician Blogs About the Future Program


 Foundation Futures Program is an intensive learning experience designed to expose young physicians to the numerous career opportunities available in long-term care. This year, Caring asked Futures participant Sarah Payne, DO, to “blog” from the program, which took place March 5 in Charlotte, NC. A graduate of Michigan State University, East Lansing, she already has completed a family medicine internship and residency and is currently in the geriatric fellowship program at Banner Health/St. Joseph’s Hospital in Sun City, AZ. 

She and classmates from across the country received admission to the Futures program, registration to the AMDA Annual Symposium, transportation to and from the meeting, four nights’ lodging, and AMDA membership for 1 year. In her Futures application, Dr. Payne wrote that she wanted to learn “what goes on behind the scenes of a long-term care facility. I want to learn what it means to be a medical director, what it means to play both the role of clinician and administrator.” She says that by the end of the day she learned all that—and even what an F tag is.

7:45 am

The day of the Futures program is finally here. There are approximately 60 of us. Last night, we had the opportunity to meet each other, mingle, and meet some of our mentors. Conversations ranged from who had a job lined up and how in the world they found it to what got all of us interested in geriatrics. There are geriatric fellows here from across the nation—how exciting to meet so many like-minded individuals. I’m handed my symposium packet, inside is a ribbon to put on my name badge that says “I’m a 2009 Futures Participant.” I know it may sound silly, but as I put the ribbon on my badge, I feel a certain pride in myself and in those around me. We are the future of geriatric medicine and long-term care.


8:00 am

The chairman of the Foundation, Jonathan Musher, MD, CMD, is giving the welcome introduction. He says he has a feeling we will all be “hooked on AMDA” after the Futures program and the rest of the Annual Symposium. I think I already am. He’s telling the group what wonderful networking opportunities we will have here this weekend and in the future as members of AMDA.


8:25 am

Things get going. Our first presentation is by Cari Levy, MD, CMD, Futures program cochair. It’s “Long-Term Care: A Look at the BIG Picture.” She says we (as physicians) play only a very small role in the delivery of health care in long-term care, with nurses being the backbone. Think about what your long-term care experience would be like without your nursing staff and nursing assistants. I know I’d be lost, and I’m only a fellow.

But Dr. Levy is putting a new spin on how we should view long-term care. The long-term care environment today is so much more intense. It’s like “the hospital of 20 years ago” without the consultant base. Long-term care docs tend to “think more, think harder.” I like that. It’s the true practice of medicine in every sense of the word.

She’s now talking to us about costs, workforce challenges, PPS, RUGs, and F tags. F what? This really is a new language, isn’t it? Now Dr. Levy is talking to the group about the measure of quality in long-term care and the MDS (minimum data set) and how important it is to really know the MDS so that you can improve upon the quality of care provided in your home someday. There is a “culture change” in nursing homes today, making them more “homelike” and “giving residents rights.” Isn’t it funny that this is just now catching on?

She’s telling us that, as medical directors, we should be at our facility when a state survey is conducted and at the exit meeting so that you can “be collaborative and respond in real time.” I didn’t know you could be there when the state survey was going on, I thought it was taboo or a faux pas to be at your facility while it is under the microscope. If you come prepared, not only will it look good, but it will do wonders for your facility. I’m still not quite sure what an F tag is.


9:15 am

I’m hoping this presentation will give me some insight into my options in long-term care: “It’s All Possible: Practical Approaches to Long-Term Care” by Heidi White, MD, MHS, CMD. The objectives are to answer the following questions, “Is long-term care a viable professional practice option?” and “How can I get started?”

Dr. White is telling us that a practice in long-term care has low overhead and schedule flexibility. This is where I need to be! She is telling us, “no one is in the waiting room looking at their watch wondering where the doc is.” Since I hate the time constraint of “the 15-minute appointment,” which just shouldn’t even exist, I now realize just one of the many reasons I’m drawn to long-term care. I can actually take time with my patients. And, if someday I have a family, this schedule flexibility will also be an added bonus.

Dr. White says we don’t have to start off as medical directors. We can start off as an attending doctor in the nursing home and build a reputation for ourselves that way.

Think about becoming a “SNFist.” Okay, if I go home and tell my family I’m going to be a skilled nursing facility-ist, they’ll think I’ve gone mad. Horrible name, but what a great concept. Now the presentation is coming to a close and, as you can well imagine, there are a lot of questions, ranging from, “How many hours do I need to devote to medical director duties?” to “How do I get paid in long-term care and as a CMD?”

Take-home message, “don’t undersell yourself.” Even though you are not “in charge”—so to speak—as a medical director (chuckles throughout the room) you have influence, so use it. Build rapport, be approachable, be on time, make friends with the activities coordinator and go on an outing with residents. Then someone in the crowd commented, “But being in charge is still better.” This got a lot of laughs. Either way, a long-term care practice is certainly in my future.


10:00 am
Break time!


10:20 am

Jeffery Kerr, DO, CMD, is giving his presentation on “Risk Management in the Long-Term Care Facility.” Dr. Kerr starts with a picture of a woman lighting her cigarette with the candles on her 100th birthday cake. He goes on to say that we are “quality-of-life specialists.” I like this term.

Dr. Kerr is talking to us about how to deal with the unhappy alert resident. “Validate their concerns and frustrations and deal with clues in real time.” He’s now talking about how to deal with the unhappy family: “Set goals, negotiate risk.” Call a family meeting, create a family spokesperson, offer solutions, don’t say you can’t; instead, offer to negotiate.” Communication is key!

Dr. Kerr tells us, “Bad things can and will happen, but learn from that. He is giving us real-world insight into physician liability. Most physicians are none too willing to share what bad things are said and done against them, but how helpful it is for a young physician to learn from these experiences.


11:35 am

Frederick Rowland, MD, PhD, CMD, and chairman of the CMD Board, is telling us what being a Certified Medical Director (CMD) means. You can be a medical director and not be a CMD. So why become certified? Well, Dr. Rowland tells the group that being a CMD means “you are showing a commitment to your work and developing relationships with colleagues and friends. Having a medical director who is a CMD makes a difference in the quality of care. Dr. Rowland tells of the path you need to take to be prepared. I had no idea what steps you needed to take to become a CMD, nor did I realize how long it took.


Lunch time!

AMDA Foundation board members are seated at our tables. At ours is John Morley. MB, BCh. He offers valuable insight into the practice of long-term care. This is a great lunch!


1:00 pm

I’m off to attend one of the breakout sessions of the afternoon. I choose Dr. Kerr’s “Surviving Your First State Survey.” I’d like to survive my first state survey someday.

It’s standing room only. Dr. Kerr starts off by telling us who the survey team is made up of and what their training is. He continues with care issues and care plans. You actually can write an order to have the care plan updated—good to know. “The care plan should be realistic and not ‘blue sky,’ ” he tells the group.

He tells us that you should really “wear both hats” as a CMD and attending doc in your facility. Dr. Kerr tells the group that “being a CMD is a 24/7 job.” This is difficult to swallow in one sense, but if you really think about it, how many of us don’t already consider what we do a 24/7 job? I think that’s what draws us to geriatrics and will make us good medical directors someday.

Dr. Kerr gives us some tricks of the trade like implementing Coumadin flow sheets and taking notes at all QA [quality assurance] meetings. And did you know that state surveyors can revisit your facility to make sure you corrected your deficiencies?

Now it’s back to those darn F tags! Dr. Kerr is talking about federal citations, or F tags, and then goes on to elaborate about how you should think like a surveyor every day as a medical director. Develop routines, grow your staff, teach them, be their mentor so they will go from being learners to teachers. Have a keen sense of your surroundings, Dr. Kerr suggests. Look around at what potential things you could get “dinged” if the survey team were to come into your facility today. Have all staff help out on fixing problems. What an empowering and enlightening presentation.


2:20 pm

It’s time for the panel discussion of doctors from different specialty areas. We have an academic research doctor, Steven Handler, MD, MS, CMD; a medical director, Karyn Leible, MD, CMD; and a full-time, long-term care physician, Christopher Herman, MD, CMD. Dr. Herman speaks first about his job and experiences.

He tells the group that in his line of work, you get to enjoy your autonomy. There is no “bricks and mortar” clinic, but instead, many different facilities where you get to work with other caregivers. I really find this a very interesting concept. goes on to let us know that if you are the type of person who enjoys going to the same place everyday, then this may not be the job for you. Hmm, I may need to think about this some more.

The medical director on the panel is now speaking. Dr. Leible tells us that this is an exciting job because you have the opportunity to take a nursing home and turn it around. This is so exciting. I never really realized all of the different opportunities that were out there in the world of long-term care. The world is my oyster! That’s why it’s called the “Futures” program.

Now it’s time for the research side of things from Dr. Handler. He tells the group that long-term care is good clinical ground for research. He also gives the group three “pearls” about long-term care research: 1) Never rule it out. 2) Go to a place that values research. 3) Find a supportive mentor. Great advice wouldn’t you say?

There are a ton of questions, especially for Dr. Herman. Questions range from “What is the reimbursement as a long-term care physician?” to “On average, how many patients are seen per day?” We ask Dr. Handler what types of research projects are out there and how can they be funded?


3:15 pm
Break time!

I’m going to energize for the rest of the day with some snacks and maybe get a few names and e-mails of other Futures participants.


3:35 pm

Time for one of the presentations I’ve been quite anxious to hear, “A Day in the Life of a Medical Director.” Dr. Levy runs through a standard day as a medical director starting off with waking up at 5:10 am Happy thoughts are going through your head because it’s QA day at your facility.

She tells the group about quality indicators and what they mean to your facility and to state surveyors. 6:30 am: Arrive at the facility, and the social worker confronts you with some serious resident behavioral issues. Time for some risk management. 8:30 am: Your cell phone rings. It’s a resident’s daughter. Time for some family interactions.

Dr. Levy tells us that it’s a good thing to show up at family council meetings at your facility if you can. It is an invaluable experience and gives you great insight as to what the growing concerns are in real time. 9:48 am: You notice that the facility hair stylist is not in today and find out it’s because she’s ill. Time for some employee health and safety and infection control. 10:20 am: A nurse reports an abnormal lab value and then tells you the resident’s doc is out of town. Who’s the covering doctor and what’s the policy in the home on how to handle these situations? 10:46 am: Medical records comes calling and tells you that “Dr. So-Busy’s” charts have not been completed. Dr. Levy tells the group to develop a strategy to deal with such problems.

“Be nice and helpful, but don’t start patterns that can’t be sustained over time.” This is good advice. 11:35 am: The pharmacist tells you that the use of psychoactive drugs in skyrocketing in your facility. Oh, boy. 12:30 pm: Finally, time for the QA meeting. Remember, this is what you were excited as your day began as a medical director. Again, Dr. Levy reminds the group to do your homework and come to the meetings prepared. 1:00 pm: The corporate medical director appears on the scene to help with some problems. (I didn’t know there was such a person.) Whew, what a day I’ve had in the shoes of a medical director. But Dr. Levy asks, “What makes you return to do it again tomorrow?” Well, it’s “the opportunity to affect care delivery and change lives.”


4:40 pm

It’s time to talk about the mentoring program offered through AMDA. Each Futures program participant is paired up with a mentor to help guide and navigate them through the waters of long-term care. I think I speak for everyone when I say how grateful we all are for this program and how thankful we are that there are docs out there willing to help guide and mold young, up and coming geriatricians and medical directors.


5:00 pm

The Futures program concludes. What a fabulous day! I cannot remember the last time I had so much fun learning, the last time I experienced a day jam-packed with such thought-provoking information. Thank you, AMDA Foundation!



Sarah Payne, DO, is a fellow in geriatrics at Banner Health/St. Joseph’s Hospital in Sun City, Ariz. She was one of 60 young physicians selected to participate in the AMDA Foundation Futures Program March 5 at the 2009 AMDA Annual Symposium.