October 20, 2014

Celebrating 25 Years of NPI with Dr. Pfenninger and Dr. Fowler

It’s hard to believe that National Procedures Institute is already celebrating its 25-year anniversary! To mark this occasion, we interviewed two doctors who have been with NPI since the beginning: NPI’s founder, John Pfenninger, MD, and our most senior instructor, Grant Fowler, MD FAAFP. These two men have set the tone for NPI’s growth and success over the years, and are the editors of Pfenninger & Fowler’s Procedures for Primary Care which has become the “bible of procedural medicine.”

Dr. John Pfenninger

What inspired you to found NPI?
I was the director of OB/GYN and procedural training for the FP residency here in Midland for 12 years (1977-1989).  I found it very hard to find good literature and helpful training in the simple procedures that we all wanted to do.  Family docs wanted to be more than just a combination of IM and Peds.  When I left the teaching program and decided to go on my own, I also decided to limit my practice solely to office surgery and procedures.  At the same time, I wanted to teach procedures both through seminars and writing.  I just was not able to do this in an institutional setting, especially since pretty much everyone I talked to said my efforts would end in failure. So, I struck out on my own.

Tell us about the growth of NPI. 
Our first conference was on colposcopy, Mother’s Day, 1990, in Chicago. That was the only day when we could find a decent hotel with open dates and close enough to Michigan so we could drive to it. People joked that we were crazy doing it on Mother’s Day, but we had no choice. Roger Bonds (employed at the hospital and head of marketing there at that time) and I went to the bank and each borrowed $15,000 so we could send out fliers and advertise. Six weeks out, we only had about 30 people signed up. When the course began, we had over 140 registrants. My wife, mother-in-law, and my children helped me assemble handouts up until the day I left for the course. It was a huge success. From teaching colposcopy and offering two courses that year, NPI grew to providing over 210 courses a year covering the full gamut of office surgery and procedural skills. Initially I taught most of the courses with a few people like Dr. Fowler, Dr. Apgar, and Dr. Newkirk helping out. Eventually, NPI had a faculty roster of over 30 lecturers all with national reputations. NPI gained recognition as a sought-after company to teach for. We wanted quality and practicality. We wanted people to feel ready to hit the road when they left our courses.

What importance should be placed on hands-on, live training vs. an online course? 
Information can be transmitted online but it’s much more difficult to teach procedural skills.  For instance, how does one find a pig’s foot to suture? There needs to be feedback to learn surgical skills that you just can’t get online.

What inspired you to create Pfenninger & Fowler’s Procedures for Primary Care
As I travelled the country, attendees at the courses were begging for more information. In my practice, I had to provide consent forms and patient education, buy supplies and equipment, and know how to charge for my services.  I decided just to share what I had found out and what I knew. One could find books with information on how to do a hysterectomy, but no chapters on placing an IUD.  So, I decided to do a “cookbook” of practical information for office procedures.  Mosby, the publisher, fought us (Dr. Fowler and me) because the book was too long and “patient education doesn’t sell.”  We pushed the limits with them and finally the book was published and became a best seller.  With the second edition, they told us to make every chapter as thorough and complete as the best chapters in the first edition! We did and we also expanded the number of topics covered. We did all of this in spite of the naysayers telling us we were wasting our time. Our expressed purpose was to have every common surgery and procedure that primary care physicians might do in that book. If they looked in the book and what they wanted wasn’t there, they might not come back. So, we provided everything they needed to know and the rest is history.

What do you envision for the future of NPI? 
If ACOs really make headway and become a reality, the tide is going to turn. Hospitals will want to provide the least expensive, highest quality of care.  Keeping patients out of the OR will become a priority (just the opposite of what it is now) so it will become important for primary care specialists to once again become generalists and provide these procedural skills. Every referral costs more to the system. Not every FP can provide all services, but they sure can do a lot more than they do now. It reduces delay in providing care, it’s less costly, and it’s fun! Why not do it? NPI has a chance to be the leader in training others in these skills. There could even be nationwide clinics like mine that provide only outpatient medical procedures. Some have suggested that procedures clinics could spring up like urgent care centers did.  Why not have NPI teach and qualify the physicians?  With all the new technology, more and more procedures will be developed.  Someone needs to teach them in an efficient manner.  Why not NPI?

Dr. Grant Fowler

What is changing the most in CME?
The patient simulators and models (e.g., hysteroscopy, hospitalist procedures, advanced colonoscopy, esophagogastroscopy courses) continue to improve. They are VERY lifelike now, very much like practicing on a real, live patient. These really improve the hands-on aspect of CME courses. Also, for ultrasound, there is now pocket-sized, hand-held, high quality equipment that’s great for emergency medicine and musculoskeletal applications as well as others.

What is the most surprising area of growth in CME?
The rapidity and amount of growth in the area of hospitalist procedures, aesthetics, echocardiography, and musculoskeletal ultrasound has surprised me. Approximately 11% of family physicians perform echocardiography these days, a number that has doubled over the last decade. However, this shouldn’t have surprised me since the technology in these areas continues to improve and the cost of equipment has occasionally decreased. Since our patients are getting older, I predict further increases in interest in these areas. 

Where is the industry headed?
We are headed for dramatic changes in health care. As it evolves, it is my opinion that the more procedures that can be performed in a patient-centered medical home (PCMH), the better that PCMH will be prepared for the future. It would allow better continuity, assurance of follow up, better tracking of quality measures, etc. 

Large health care systems are going to discover that the more primary care clinicians they have, the more versatile their system will be. As we move toward more capitated care (e.g., accountable care organizations), primary care clinicians are very cost-effective. Ultimately these large health care systems will decide that they need fewer subspecialists on their payroll. The more procedures their primary care clinicians perform, the more versatile the system will be. Since there simply are not enough primary care physicians, such work will be shared by physician assistants, nurse practitioners, and perhaps retrained subspecialists. These fellow clinicians are also capable of performing a large number of procedures. 

Patients will appreciate having a strong relationship with their primary care clinician. If their primary care clinician can perform their procedures, or someone in their PCMH, I think that will be preferred. Patients are time-pressured, too; they appreciate the time saved by not having to be referred.

You’ve been here since the beginning. Tell us about the growth of NPI.
The goal of NPI has not been about growth, but about quality, hands-on, personalized, practical teaching. So the growth has been slow and gradual, often directed by the learners. Most of the faculty have been teaching for NPI for quite a while, so I have had the good fortune to get to know many of them. If I had to generalize, I would say all of us thoroughly enjoy sharing not only our experiences with procedures but also our personalized styles of teaching. I think we also like to share many practical “pearls” learned over the years in order to improve overall patient care.  Such are the benefits of some of the faculty having a few gray hairs! On the other hand, it has been my experience that the NPI faculty are very technologically savvy, and love to lead the field with recent advances, whether in teaching, equipment or procedures.  

What inspired you to start teaching for NPI?
Jack Pfenninger is why I started teaching for NPI. He is clearly a visionary, has a lot of energy, is very inspirational, and has very high expectations. His mission to provide courses with a “hands on approach for the real, practicing clinician” appealed to me and matched some of my personal missions. The length of the courses also seemed right. Most procedure workshops available elsewhere at the time NPI started were only a few hours long; his proposal for day-long and multi-day courses seemed right. Dr. Pfenninger and I had both worked with a lot of residents and students, both of us enjoyed teaching, but we felt there was a huge need to support the practicing doc out there. More comprehensive, in-depth courses seemed right for these clinicians, whether they had never received training for a procedure or they needed to reinstitute their skills. By his own role-modeling, it became apparent that Dr. Pfenninger expected NPI faculty to be national leaders in their respective areas. In so doing, he also offered many of them the opportunity to publish in their areas of expertise in Pfenninger and Fowler’s Procedures for Primary Care.

What inspired you to create Pfenninger & Fowler’s Procedures for Primary Care?
Dr. Pfenninger gets credit for the creation of this textbook. My part was really just making sure it happened (and writing and editing a LOT of chapters over many years)! From the beginning, it made sense; NPI and the procedures book heavily and wisely complement each other. Most residency-trained family physicians have been exposed to a broad range of procedures, and it’s nice to have a reference for “brushing up” in case they haven’t done a procedure in a while. When working with residents and students, having them read about a procedure before, after, or sometimes during its performance saves a lot of time as they are often able to answer a lot of their own questions. It’s also great for the staff working with the clinician to have a reference for setting up for procedures, especially if it’s a new or infrequently performed procedure.

Where would you like to see NPI in the future?
My dream is that NPI continues to do what it is doing, and continues to improve how it’s being done! I expect we will continue to see more NPs and PAs in our courses. While we frequently have learners from specialties other than primary care, it would be great if we could expand a bit more to include learners from emergency medicine, general surgery, orthopedics, obstetrics/ gynecology, interventional radiology or even dermatology. We frequently have specialties present in NPI courses and the cross-sharing of information is priceless.

At some point, I hope more state academies, residency programs, and departments of family medicine or other specialties take advantage of consultation courses available to bring NPI faculty to their location.

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