Wednesday Jun 28, 2017

Primary Care Needs -- and Deserves -- More Research Dollars

More research is needed in primary care, but proposed federal budget cuts threaten to make evidence-based resources and guidelines even harder to come by. 

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Monday May 22, 2017

It's Complicated: What We Wish Legislators Knew About Health Care

Health care truly is complicated. We asked our new physician bloggers what policymakers need to understand if they're going to help create a better system. 

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Wednesday Mar 22, 2017

AHCA Won't Help Patients Who Need It Most

We asked our new physician bloggers how the American Health Care Act would affect their patients. Most said the legislation would hurt the poor, the elderly and the disabled.

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Monday Mar 06, 2017

Primary Care Needs a Raise -- All of Us

Family physicians and the rest of the primary care team deserve better compensation. Natasha Bhuyan, M.D., writes that investing more money in primary care would benefit not only physicians, but also their patients, staff and communities.

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Friday Feb 24, 2017

I'm Standing Up for Direct Primary Care

Ryan Neuhofel, D.O., M.P.H., knows legislators won't significantly improve our health care system on their own. Success requires persistent grassroots advocacy, and family physicians need to be a part of that.

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Friday Jan 27, 2017

Trusted Relationship Allows Patients to Confide Horrors of Abuse

Detecting abuse can be difficult. Venis Wilder, M.D., writes that continuity of care and a level of trust can help patients share their painful stories.

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Monday Jan 16, 2017

Don't Throw Away Your Shot to Make the World Better

What can physicians learn from a Broadway musical? Gerry Tolbert, M.D., writes that Hamilton provides some important lessons about language and being willing to take a stand.

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Tuesday Oct 11, 2016

Will You be Prepared When Disaster Strikes?

Whether you live in an area that is vulnerable to hurricanes or other natural disasters, there are steps family physicians can take to help patients and families, as well as their own practices and communities, prepare for the worst.

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Monday Aug 29, 2016

Family Physicians Can Cut Unnecessary Surgeries

Robust clinical trials demonstrate relevant outcomes of various surgeries. Does a surgery extend a patient's life? Does the surgery decrease a patient's pain? Does it improve the patient's quality of life? Answering these questions, along with weighing risks and other treatment options, should help guide decisions regarding whether to pursue surgery. But even with better data, unnecessary surgeries are still common.

Family physicians are able to take a holistic, unbiased and evidence-based view that can play a vital role in counseling patients on appropriate treatment options.

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Wednesday Mar 02, 2016

Leadership Conference Gives Voice to Family Physicians

On May 5, current and future family medicine leaders will devote three days to shaping and strengthening our specialty through two focused tracks at the AAFP Leadership Conference in Kansas City, Mo. One track, the Annual Chapter Leader Forum (ACLF), is tailored for the leaders who concentrate on issues specific to where their colleagues work and live, while the National Conference of Constituency Leaders (NCCL) amplifies the voice of the underrepresented in Academy leadership.

In 1990 what has become  NCCL convened for the first time as the National Conference of Women, Minority and New Physicians with the promise to begin "the 1990s as a 'Decade of Transition,' during which the AAFP will strive to more effectively integrate the perspectives and concerns of Academy members from these important constituencies, to the benefit of an increasingly diverse membership and patient population."

© 2016 Tiffany Matson/AAFP
Here I am testifying during the 2015 National Conference of Constituency Leaders. This year's event will be held May 5-7 in Kansas City, Mo., as part of the AAFP Leadership Conference.

Through the last two and a half decades, member constituencies -- now women, minorities, new physicians, international medical graduates (IMGs), physicians who self-identify as gay, lesbian, bisexual or transgender (GLBT) or who support GLBT issues -- have gathered each spring to discuss important issues and advance AAFP policy.

When the NCCL convenes for the 26th time this year, the event will be slightly different, in that the traditional new attendee orientation will take place during the evening of May 4, prior to the official start of the conference. We also have the privilege of hosting several amazing speakers and teachers as well as the yearly policymaking and business sessions.   

I first attended the National Conference of Special Constituencies (a previous name of NCCL) in 2012 as the new physician delegate from Kentucky. I was in awe of the camaraderie and amazing ideas flowing from this incredibly diverse group of individuals. Even with disparate viewpoints, backgrounds and practice environments, the attendees worked together to craft important resolutions that have impacted the larger membership as a whole.

This will mark my fifth consecutive NCCL, and I can't wait to hear what my colleagues have to say about the many issues our specialty faces. I will continue to come back each year, whether in a leadership position or not, so I can support the idea that everyone needs a voice.

This year, I have the privilege and responsibility of being the convener for the conference. That means I get to help plan the meeting and guide those plans to fruition with lots and lots of help from both AAFP staff and my co-convener team, a group of elected physicians representing each of the constituency groups. We've already been working hard to put together not only the content portion of the conference, but also to encourage every state chapter to register and send delegates to represent each of the constituency groups. The Academy even sets aside funding, available to each chapter, to offset the cost of travel for one new physician delegate. If you or someone you know is interested in representing your state as a new physician or in one of the other constituency groups, contact your chapter leadership.

Much like the conferences of years past, our goal is to give voice to the members of the AAFP who may otherwise lack representation. We want to hear from you! Whether as a new physician, woman, minority, member of the GLBT community, or international medical graduate, we all need a voice and a way to be heard. This conference provides that venue and encourages all of us to represent our "increasingly diverse membership and patient population." Any attendee can also volunteer to participate with the reference committees responsible for reviewing subsets of the resolutions put forth by the members in attendance or run for one of several leadership positions, including the constituency co-conveners and the new physician member of the AAFP Board of Directors.

On the other track of the leadership conference, chapter-elected leaders, aspiring leaders and chapter staff will refine their leadership skills, learn from each others' experiences and strengthen their relationships at ACLF.

Whether you are interested in a leadership position or not, the conference offers a unique opportunity that most other medical organizations have only begun to embrace. We each have a voice and things we are passionate about. Let your voice be heard and plan to attend the 2016 AAFP Leadership Conference May 5-7 in Kansas City.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert.

Tuesday Feb 17, 2015

At a Loss: If Educating Parents About Vaccines Won't Work, What Will?

Fifteen years ago, the CDC declared measles had been eradicated in the United States. But last year, there were more than 600 cases reported in 27 states. As of Feb. 6, there were 121 cases reported in 17 states this year.

The vast majority of recent cases were linked to an outbreak that originated at Disneyland. The high number of cases and the high-profile location has sparked some interesting and controversial debates ranging from discussions about a federal vaccine mandate for the collective good to parents' right to choose for their children. And in certain circles on the Web, I’ve noticed some are rehashing the demonization of vaccinations sparked by faulty evidence.

© 2014 David Mitchell/AAFP

A 1-year-old girl receives the measles, mumps and rubella vaccine. More than 120 cases of measles have been reported to the CDC already this year.

However -- and I can’t believe I’m writing this -- on this subject I agree with Hillary Clinton. The former senator (and a presumed candidate for the Democratic presidential nomination in 2016) recently responded to a pair of Republican presidential hopefuls who had spoken in favor of parental choice with a tweet that said, "The earth is round, the sky is blue, and vaccines work. Let's protect all our kids."

Although the debates continue, this outbreak has presented only one question for me as a family physician: How can I convince parents who refuse to vaccinate their children to change their minds? The measles, mumps and rubella (MMR) vaccine is a poster child for immunizations. More than 95 percent of people who receive a single dose develop immunity to all three viruses. Measles, on the other hand, is a poster child for contagion, causing infection in 90 percent of unvaccinated individuals who come in contact with an infected person.

The decision to vaccinate would seem simple enough to me even though I've never even seen a case of measles. After all, it was declared eradicated before I started medical school.

But maybe that's part of the problem. Before the vaccine was introduced in the 1960s, measles was nearly as common as death and taxes. Parents had good reason to fear it. There were 3 million to 4 million cases annually in the United States. People were familiar with the illness and the problems it could cause, including hospitalization, pneumonia, blindness, brain damage and death. Most moms likely could have made the diagnosis at home even without the Internet.

But now I wonder if I could make the diagnosis. Seriously, before this highly publicized outbreak, how many of us were closely examining a child with fever and runny nose for Koplik's spots? I think younger generations of parents have no idea of the devastation this disease can wreak, and without that fear, not vaccinating seems like a viable alternative to some parents.

Keeping that in mind, education had been my approach to vaccine-hesitant parents in the past. Surely if I could impress upon them the risks of the disease -- not only to their own children but to others', as well -- and then illuminate the infinitesimal risk posed by vaccines, they would be overwhelmed by the logic of it all. When I think back on this, I realize I had limited success, and those battles were hard won.  

In fact, there is good evidence to support that this approach is likely folly. An interesting article published last year in Pediatrics looked at this issue and determined that this approach is not effective. In fact, in some instances it makes parents less likely to vaccinate their children.

So I do not admit this often, but I am at a loss. I need your help. This is a pressing issue in our practices at a time when isolated measles outbreaks are on the rise, fueled by pockets of unvaccinated children. The tool I had always considered my most powerful -- educating parents and partnering with them in decision-making -- appears to be broken.

On a personal note, I have good friends with four children who subscribe to a "natural" approach with their children, who are not vaccinated. Although we agree on some health care issues, such as avoiding overuse of antibiotics and over-processed foods, we don't agree on this subject. The mother recently posted a link on Facebook to a site that discourages vaccinations. Although I know immunizations are important, and I worry for these children, I am struggling with how to approach these situations without alienating this family, as well as parents in my practice who have similar beliefs.

Although the evidence has indicated what does not work, there are no studies that I have found that tell us what will work. It is in these instances when the family of family medicine is the most important. If anyone has an approach that has worked well, please share it in the comments below.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Wednesday Oct 22, 2014

Want Change? Get Involved in Your Academy

Peter Sundwall, M.D., wasn't totally satisfied with his AAFP membership a few years ago. Specifically, he thought the Congress of Delegates -- the Academy’s policy-making body -- was spending too much time on certain issues at the expense of others that were more important to him.

A conversation with (then) AAFP President Jeff Cain, M.D., encouraged Sundwall to do something about it, so the Alpine, Utah, family physician got involved with the Utah state chapter and became a delegate to the Congress. This week, he is back at the Congress for the second time, working to ensure that the AAFP's policies address the issues he sees in his practice and those of his fellow chapter members. That's important, because he now is president-elect of the Utah AFP.

 Here I am testifying during the Reference Committee on Practice Enhancement at the Congress of Delegates.

I share Peter's desire to improve the care we provide to our patients, and being involved in developing Academy policy can help achieve that goal on a broad scale. Although I am still a new physician, I served two years as an alternate delegate for the Utah AFP and am now experiencing my first year as a full-fledged delegate.

Unlike Peter, my path to the Congress was not sparked by one specific issue, but by a general desire to improve the state of health care. And many positive changes can come from this meeting.  This week, the Congress considered dozens of issues. Here are just a few examples of topics that were debated that could directly impact our patients' health:

  • simplifying the preauthorization process;
  • studying and regulating electronic cigarettes and second-hand vapor; and
  • reforming the DEA's ruling on electronic prescribing of controlled substances to ease the regulatory burden.

Resolutions such as these inform the AAFP's Board of Directors and Academy staff about members' priorities for the coming year. That, in turn, allows the Board and staff to best direct the Academy's action on various issues, which could involve work by one of the AAFP's commissions, the Board and/or staff. The result could conceivably be the development of a program or resource or advocacy with the appropriate regulatory agencies or Congress.

This experience is giving me the ability to help my patients outside the clinic. Many of us chose family medicine, in part, so we could make a difference, and participating in the Congress of Delegates provides avenues to accomplish this. I submitted my first resolution this week, and I enjoyed the process of testifying to the reference committee and working with others to get it passed.

Even outside of the formal parliamentary procedure, those who participate in the Congress can seek out and interact with others with similar interests -- a process that often leads to other positive outcomes. For example, I met a colleague at a previous Congress, and together we developed and submitted a research proposal to the Council of Academic Family Medicine's Educational Research Alliance. We should find out in the next month or two if our idea is accepted.

It's worth noting that the Congress coincides with the AAFP Assembly, so thousands of family physicians are already traveling to the same city for the Assembly experience. That means members interested in sharing the Congress experience can simply add a couple of days on the front end of their trip to catch all the action. Although only delegates may vote during the Congress business sessions, any AAFP member present may give testimony during reference committee hearings.

I also have the privilege of working on the Commission on Governmental Affairs, one of seven AAFP commissions that provide feedback to the Board and assist in its efforts to implement resolutions the Congress adopts. That opportunity has offered me significant insight into the behind-the-scenes work required to improve our Academy and, consequently, our practices and the health of our patients.

Not only has participating in the Congress and on the commission fulfilled my desire to work for my patients and practice on a broader scale, it has also been a lot of fun. I would encourage anyone who would like to get involved this way to talk with your chapter leaders about potential roles in the Congress or commissions.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Tuesday Sep 09, 2014

The Value of Family Medicine: Stating the Obvious to the Oblivious

I recently participated in a state-level meeting with Medicaid administrators that also included a number of subspecialists. The discussion revolved around the appropriate dosing of proton pump inhibitors for acid reflux, with some Medicaid representatives opining that these medications were being over-prescribed by "general physicians." Some, in fact, called for implementing a stricter prior authorization process if drugs in this class are to be prescribed by primary care physicians.

Both the administrators and the subspecialists offered misguided statements, such as

  • "Family physicians can't follow treatment guidelines because of the complexity and ever-changing nature of those guidelines."
  • "Treating acid reflux should be left strictly to subspecialists."
  • "Primary care physicians don't actually think about what they do but reflexively prescribe medications that they don't fully understand."

As the lone family physician in the room, I defended our specialty. However, thoughts like these remain prevalent among some payers and subspecialists who fail to understand the value we bring to the health care system.

I know I am not the only one facing these gross misperceptions, so I want to refresh everyone's memory about why family medicine is the foundation of health care and, thus, one of the most important areas of medicine in any health care system.

We Care for the Whole Patient
Probably the biggest reason family physicians are best suited to caring for patients is our broad training and how we apply it to patient care. For example, a patient's depression impacts his or her diabetes, which, in turn, can affect his or her chronic obstructive pulmonary disease and heart failure. Medication side effects often worsen another disease process. And a patient's social context frequently provides significant insight into his or her symptoms. Understanding how to look at all of these pieces and see beyond a specific organ system to the complete person provides many of the clues to proper diagnosis and treatment. Comprehending how these issues fit into the patient's framework of values, beliefs, community and culture presents the key to healing.

We Blend the Evidence With Our Knowledge of the Patient
Providing quality care for patients is a central principle of family medicine. We use the best medical evidence to guide our diagnostic and treatment recommendations, but we also recognize when the context of a patient's illness calls for tempering that evidence-based approach. The medical decisions we make in conjunction with patients may not always look best to an administrator, but that doesn't mean they're the wrong decisions. They simply reflect the biopsychosocial model of family medicine training that uniquely positions us to respond to a wide variety of complaints and situations to better meet patients' needs.

We Provide Value to Our Patients and the Health Care System
Family physicians deliver higher quality care for a lower price than does any other specialty. This topic has been studied extensively by researchers, such as Barbara Starfield and others, who recognize the impact family medicine has on individuals, as well as systems. With the ever-increasing costs of health care, the solution to the problem is to better utilize the value that family physicians provide instead of viewing us as merely a source of referrals to subspecialty care. But reaching that solution -- providing the value that we as a specialty are truly able to deliver -- means safeguarding the time we spend with each patient from being restricted by payers.

By no means is this intended to disparage the contribution subspecialists make, because we all recognize their worth and how necessary they are in treating many of our patients. But our health care system is never going to be able to overcome its main pitfalls if more people cannot recognize the essential role of family physicians. It is our responsibility to continue to educate those around us about our role so that together, we can continue to improve the health of our individual patients and the performance of our entire health care system.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Friday Jul 11, 2014

Acting on Our Convictions: Court Ruling Shows Need to Stand Up for Evidence-based Care

I recently had an office visit with a patient who was in need of contraception. She is 19 years old, going to school part time and working. With an ever-changing schedule, no plans to start a family and a history of migraines with aura and somewhat heavy menses, we discussed the evidence-based options of progestin-only methods versus nonhormonal methods.

Fortunately, her insurance covers all forms of contraception, and we were able to schedule her for a progestin intrauterine device (IUD) insertion. If her insurance had not covered IUDs, my patient would not have been able to afford the birth control method that is medically most appropriate for her.

The U.S. Supreme Court’s June 30 decision in Burwell v. Hobby Lobby Stores Inc., and Conestoga Wood v. Burwell has set off a flood of press coverage and commentary about what the ruling means. A major concern for many physicians is that the ruling could affect how we practice medicine.

“The Supreme Court’s decision allowing companies to deny coverage for important health services sets a precedent that threatens the nation’s health," said AAFP President Reid Blackwelder, M.D., in a statement. "With this decision, the court has moved health care decisions out of the exam room where patients can consult with their physicians -- and where such decisions should be made -- and put them into the hands of business owners who base decisions on personal beliefs rather than medical science.”

The American Congress of Obstetricians and Gynecologists (ACOG) and the American Public Health Association (APHA) issued similar statements.

Since the ruling, bills has been introduced in the House and Senate that would countermand the court's decision by preventing for-profit companies from using religious beliefs to deny employees coverage of health services -- including contraception -- required by federal law.

Laws that interfere with our ability as physicians to care for our patients using what we, in concert with our patients, determine to be the best, evidenced-based approach are problematic. In medical school and residency, we are taught to listen attentively to a patient’s history, perform a focused and careful physical exam, and obtain any additional resources we may need (laboratory values, images, etc.) to develop our assessment and plan.

As family physicians, we are attuned to considering additional factors when determining our plan, such as a patient’s social history, insurance status, access to follow-up and mental health. What is not usually part of our training, however, is learning how to navigate a health care system in which judges and legislators can create barriers -- that are not grounded in evidence-based medicine -- to our patients’ ability to access the care that will best serve their health needs.

As new physicians, we are often focused on ensuring that the day-to-day care we provide for our patients is appropriate and consistent with what we learned during all our years of training. As this new blog's posts have accurately portrayed, there is a lot to grapple with during these first few years out of residency; feeling confident in our diagnoses, asking for assistance when needed and figuring out how to balance our new careers with our life outside of work are just a few examples. I would add to this list finding a way to advocate for our patients on a larger scale, outside of our offices and clinics.

Physicians do not yet have a loud enough voice in the legal decisions and debates that have been politicizing medicine in recent years. But our voices are incredibly important and can affect our patients’ lives.

Making our voices heard may seem like a daunting task to add to our already busy lives, but there are simple ways to start advocating against any and all interference with the physician-patient relationship. If you hear about proposed legislation that is not evidence-based and would negatively affect your patients, call or write your lawmakers to let them know where you stand. Better yet, make a face-to-face appointment to explain your concerns as a physician.

If you see an editorial or article in your local newspaper about a legal decision or law that would interfere with physicians’ medical practice, write a letter to the editor to lay out your concerns.

You can also get involved with advocacy organizations (such as your state chapter) that can keep you informed about new developments and laws that may affect your medical practice and patients and will help you make your voice heard.

As physicians and patient advocates, we have a responsibility to speak up in the face of court rulings and laws that threaten our patients’ ability to access the health care they need. How will you fulfill that responsibility?

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services, including osteopathic manipulation, at a community health center in the Bronx, N.Y. She is actively involved in teaching residents and medical students to deliver evidenced-based care to underserved communities.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.