In August, I met my medical revivalists. They did not inspire like Billy Graham, rant like Elmer Gantry or seek financial contributions like many TV preachers. They conducted a course for the American Medical Directors Association, or AMDA. Pronounced "am duh," the acronym belies their sense of dedication and commitment.

First, I should declare my bias to avoid confusing readers. Many current writers avoid declaring their biases, and then claim to maintain objectivity. But even the revered New England Journal of Medicine admitted its bias in article selection. So as I approach the decrescendo of my career, my bias follows. I think continuity of care and direct patient care are the cornerstones of good medical care. Episodic and piecemeal delivery of specialty care provides expertise often needed, but it allows the practitioner to focus on a particular body part or a particular incident while ignoring many issues affecting the life and death of the individual. There, I said it.

But what is AMDA? It focuses on the long-term care of nursing home patients. Nursing homes, you know the place we send patients when the discharge planners say they no longer meet inpatient criteria yet cannot function independently. So with feeding tubes in place, bruised IV sites on their arms and walkers in tow, these patients are whisked by ambulance off to the "sniff"--skilled nursing facility (SNF).

They arrive only with continuation orders and a brief description of their inpatient stay. Because the discharge summary is still to be dictated, the patient is at the mercy of the receiving facility. Since hospitalists do not follow patients outside the hospital, new physicians enter the picture. If a patient is lucky, his personal physician in the community assumes the care. More often, the office-based physician prefers not to take that responsibility and allows the SNF to assign the patient to a willing nursing home physician.

In my community, the number of physicians willing to care for the elderly in SNFs dwindled rapidly over the past decade. Why? Money! The payment for a regular nursing home visit dropped below an extended office visit. Enter AMDA and the American Geriatric Society. Somehow these organizations convinced the Centers for Medicare and Medicaid Services that caring for the elderly in nursing homes deserved more payment. In 2006, a visit to a nursing home for a sick call or regulatory visit to review medications and assess ongoing care actually pays a little more than a detailed office visit.

The AMDA course trained medical directors for SNFs and all physicians attending patients in long-term care facilities. Federal law requires all licensed SNFs to retain a physician medical director. The intense six-day instruction covered regulatory requirements, committee structure, quality improvement, family interaction, ethics and leadership skills needed to become a Certified Medical Director. CMD training is voluntary. For the 16,000 licensed SNFs, only 2,000 physicians are CMDs. The voluntary faculty practiced primarily geriatrics. Many held faculty appointments with local universities. All had assumed the care of unassigned patients at long-term care facilities.

Over 35 years of attending courses and lectures resulted in my biases. My initial skepticism of this course turned to admiration. No gimmicky lectures. The entire faculty exuded commitment and dedication to caring for the weakest among our society. The frail, often demented, elderly with many co-morbidities approaching their final destination need this effort. The AMDA training revived my belief that our profession must remain beneficent and committed to long-term patient care.

Lytton W. Smith, MD, editor for the OCMA, is a physician practicing family medicine with the St. Jude Heritage Medical Group in Yorba Linda. Dr. Smith welcomes feedback on his articles and can be reached at editor@socalphys.com.