Physician Burnout: The AAFP Is Winning Battles For You
I have long been concerned about the impact of physician burnout on the health of our colleagues, our profession and ultimately our patients. Most of us realize that the issues of physician burnout are complex and involve factors related to personal resiliency (which can be addressed at the individual level), practice management (which must be addressed at the system level) and regulatory burdens (which must be addressed at the legislative level).
We all know burnout is a huge problem at a time when primary care physicians already are in short supply. Earlier this year, I wrote a blog noting that more than 40 percent of U.S. physicians experience at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism and a low sense of personal accomplishment). In that post, I wrote about the importance of managing stress, seeking support and removing the stigma associated with burnout.
Since then, additional blogs and editorials published by AAFP News have addressed personal resiliency. One blog post discussed the need to provide residents with resources to recognize, treat and prevent burnout. And we also have confronted the issue of physician suicide.
| AAFP President Robert Wergin, M.D., testifies about electronic health records during a Senate Health, Education, Labor and Pensions Committee hearing.
Although I am glad to see the increased awareness of burnout, I remain dismayed that many of the conversations about issues related to burnout reflect a sense of hopelessness. It is disheartening to realize the sense of frustration of some members who think the Academy isn’t willing or able to help. That being said, I can appreciate that our members on the front lines of primary care may be so busy in practice that they are unaware of all the activities that the AAFP is undertaking on our behalf.
The Academy is, in fact, working to change many of the drivers that lead to burnout, including payment reform and administrative burdens. Here's a look at the progress we've made on some critical issues this year.
The AAFP repeatedly called on CMS to ease the administrative burden associated with meaningful use. In April, CMS included two changes the AAFP advocated for in a proposed rule regarding stage 2 -- shortening the attestation period to 90 days and making requirements related to secure messaging with patients more attainable.
In March, the agency published it proposed rules for stage 3. The Academy pushed back, arguing that implementation should be delayed. Last week, the Senate Health, Education, Labor and Pensions (HELP) Committee agreed, and its chairman, Sen. Lamar Alexander, R-Tenn., called for a delay in enforcement of stage 3 requirements, which are scheduled to take effect in 2017.
The HELP committee has heard from both AAFP President Robert Wergin, M.D., and family physician David Kibbe, M.D., M.B.A., in recent months. Wergin spoke about the burden of electronic health records and the need for interoperability at a March hearing, and Kibbe spoke this month about business practices that impede information sharing.
The Academy also has seized opportunities for public comment and written letters to federal agencies in recent months regarding meaningful use stages 2 and 3 and the Office of the National Coordinator for Health Information Technology's interoperability roadmap. All of this correspondence has stressed the need for improvements in interoperability.
Finally, the Academy's Alliance of eHealth Innovation is conducting a study on the benefit and burden associated with meaningful use and is expanding its work on improving health IT usability and implementation.
For years, family physicians fought for the repeal of the Medicare sustainable growth rate (SGR), the faulty formula that repeatedly threatened to cut physician payments. On April 14, Congress finally passed the Medicare Access and CHIP Reauthorization Act, repealing the SGR formula. The law will provide needed payment stability in the Medicare program with several years of modest payment increases for physicians. The law also funds for two years the Children's Health Insurance Program, the National Health Service Corps, the Teaching Health Center Graduate Medical Education program and the federal community health centers programs.
The Academy will continue to communicate with HHS and CMS as they develop new payment models.
CMS announced this month that it will provide greater flexibility -- a one-year grace period from claims denials and audits -- during the transition to ICD-10 billing codes. The AAFP was one of numerous medical organizations that had written to CMS in March, urging further testing and risk mitigation.
Advance care planning
CMS recently released its proposed 2016 Medicare physician fee schedule. It discusses the establishment of advance care planning codes -- which the Academy has advocated for -- that would pay physicians for our expertise and time in assisting patients and their families with advance care planning services.
The Department of Veterans Affairs (VA) announced in March that roughly twice as many military veterans will be eligible to see a physician who is not affiliated with the VA under a new standard for measuring the distance from a veteran's home to the nearest VA facility. The AAFP pushed for that change while also expressing continued concerns about VA payment rates being less than Medicare rates.
This spring, CMS proposed -- at the Academy's behest -- covering HPV testing in conjunction with a Pap smear test (once every five years for asymptomatic Medicare beneficiaries 30 to 65 years old who wish to extend the screening interval).
I know many challenges and frustrations remain. The increasing complexity and administrative burdens being placed on family medicine have been piling up for years. The Academy is committed to stopping this landslide.
The AAFP is continually communicating with Congress and federal agencies to ensure they know about these important issues. Legislators and policy makers must understand that transforming health care will require a strong family physician workforce, which in turn requires improving the health and wellness of our colleagues, and our practices, by decreasing the regulatory and system burdens that cause physician burnout.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
California's Vaccine Victory Holds Lessons for Other States
In politics and culture, California does not often align with Mississippi and West Virginia, but I feel proud to stand with those states in declaring solidarity on eliminating nonmedical vaccine exemptions.
Even before an extensive measles outbreak erupted from the so-called Happiest Place on Earth earlier this year, many states sought to tackle the issue of vaccination exemptions, and those attempts have only intensified since then. In California -- the epicenter of that outbreak -- the battle over S.B. 277 culminated in a victory for public health advocates over a small but vocal anti-vaccine contingent, including some noted celebrity opposition.
In California and everywhere else these battles have been waged, childhood vaccination should have been a motherhood-and-apple-pie issue, yet debate about requiring vaccines and removing personal and religious exemptions elicited visceral reactions from both sides of the ideological divide.
Surely, such heated discourse couldn't be focused solely on refuting the science and evidence behind immunizations. Even Jenny McCarthy has backpedaled somewhat from her earlier anti-vaccine statements that, arguably, set childhood immunization efforts back a decade. No, what this debate really boiled down to was the notion of preserving individual rights at the cost of placing others in harm's way.
Throughout its history and in virtually all areas of public discourse, our country has tried to carefully balance the needs of individuals against the greater societal good. Nowhere has this been more evident than in our protection of individuals' religious freedom. In this case, one of the primary arguments to remove religious exemptions to vaccines is completely consistent with this goal. After all, no major religion in the world (we're not talking about Scientology here) is against vaccination; we can rely on our pastors and priests, rabbis and imams to agree on this point.
So, we're back to personal freedom. The crux of anti-vaccine supporters' argument against removing the personal/philosophical exemption stems from a fear that the government is dictating -- and, thus, overruling parental control of -- children's health care matters. But consider this perspective: The California law allows an exception to the vaccine mandate for home-schooled children, which, in essence, preserves parents' right to decide whether their children will participate in a community-sponsored benefit or opt out of that process.
Moreover, this law continues to allow medical exemptions as determined by a physician, so we can and will continue to discuss this important issue with our patients. In fact, Gov. Jerry Brown cited the continuation of the medical exemption as the sole reason he signed this bill into law. To some, this clause may appear to allow a loophole for vaccine-hesitant parents to go doctor-shopping. And, no doubt, there still will be some physicians ready to cast doubt on the science of vaccines, but they will continue to be in the minority. Ultimately, the decision will be in the hands of the physician and the child's parents after an evidence-based discussion that takes place behind exam room doors.
One last thought: Perhaps sensing the inevitability of passing this legislation, opponents of the California bill vilified its primary author, Sen. Richard Pan, M.D., a practicing pediatrician -- and good friend -- who represents the state's 6th District. Fortunately, Dr. Pan wisely built a coalition of citizen groups and medical organizations -- including the California AFP -- that worked together to overcome this opposition. For those of you familiar with Sen. Pan, you know he has been a stalwart champion of primary care and public health, even winning CAFP's Champion of Family Medicine award in 2013
My challenge to you, my fellow family physicians, is to take up this public health banner and run with it: no personal exemptions, no religious exemptions. Three states down, 47 to go.
Jack Chou, M.D., is a member of the AAFP Board of Directors.
Are You the Leader We're Looking for?
Before the end of the year, nearly two dozen family physician volunteers will be selected to serve on AAFP commissions, providing invaluable input regarding issues related to continuing professional development, education, finance and insurance, governmental advocacy, health of the public and science, membership and member services, and quality and practice.
If you've ever wanted to get involved, make a difference or make your voice heard, this could be your chance. The Academy sent a letter to its constituent chapters today seeking nominations for 23 commission slots that will be vacated in December. Interested members should contact their chapters before the Oct. 15 deadline for nominations. To be considered, your chapter must provide a
- letter of nomination,
- typed nomination form,
- passport photo, and
- completed online conflict-of-interest form.
Commission members serve four-year terms and participate in biannual meetings, conference calls, project work and other activities. Commission work can be a stepping stone to leadership in our organization. More importantly, it is an opportunity to influence the direction of the Academy and our specialty.
Photo courtesy of Kim Yu, M.D.
More than 100 Academy members volunteer their time each year and provide input to the AAFP's seven commissions, including the Commission on Membership and Member Services.
As an example of how the commission process works, I visited AAFP headquarters in Leawood, Kan., twice this spring to attend meetings of the Commission on Finance and Insurance that took place during budgeting for the new fiscal year. I was impressed by the diligence with which the organization prepares the annual operating budget and the thoughtful questions that were asked by the 10 family physicians volunteers before they forwarded that budget to the Board of Directors for approval. There is a commitment by all involved to spend your dues money wisely.
It's an intense, time-consuming process. Each Academy division director was given 30 minutes to explain who they are and what they do, explain items of note in the budget related to their division and discuss goals and hiring needs for their areas. Commission members listen and ask questions.
Given the scope and breadth of the Academy (more than 120,000 members and more than 400 employees) and the immense number of activities the AAFP is involved with in advocacy, education, practice advancement and public health, one commission member likened the budget process to drinking from a fire hose. The Commission on Finance and Insurance is tasked with striking a balance between being a good steward of Academy funds while also advancing needed products and services to members.
For example, one of the many projects discussed during budgeting was the recently launched Performance Navigator. The ambitious project combines live learning and online resources in a new tool that can help family physicians satisfy requirements for maintenance of certification parts II and IV, earn up to 113.5 AAFP Prescribed credits, and improve our practices while enhancing reimbursement potential. (Registration is now open for the Nov. 4-6 live course in Carlsbad, Calif.)
This commission's responsibility when considering such projects is to look at the big picture, understand what our resources are and make recommendations to the Board of Directors. The members of our other commissions perform similar tasks, reviewing emerging legislation and regulations for possible comment; lending their expertise in developing clinical policies and preventive services recommendations; providing feedback on proposed CME programs and activities; offering insights on new practice tools and processes; and more.
So here is your chance to make your mark and support our specialty. Contact your chapter. October will be here before you know it.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
AAFP Teams Up With NFL Foundation to Raise Concussion Awareness
More than 1.6 million concussions occur in sports and other recreational activities each year in the United States. Making matters worse, athletes, parents and coaches often are unaware of recommendations regarding returning to play and the need to seek medical attention.
A study published last year in JAMA Pediatrics found that 59 percent of female middle-school soccer players played with concussion symptoms, and more than half of the players reporting concussion symptoms were not evaluated by a physician. According to the Center for Injury Research and Policy, at least 40 percent of concussed high-school athletes return to play too soon. In fact, 16 percent of concussed football players returned to play the same day they were injured.
Concussions can occur even in sports that you don't necessarily associate with head injuries. For example, women's lacrosse is supposed to be a noncontact sport, but the ball travels at speeds in excess of 60 mph. At the recent AMA annual meeting, delegates voted to adopt a measure recommending helmets for girls and women playing that sport.
Like many family physicians, I treat sports-related injuries in my practice and also work as a team physician for the local high school. I often have to educate coaches and parents about the need to hold athletes out of practices and games while they recover. And we've also had to take helmets away from injured football players during games when they were far too eager to get right back into the action.
So how do we raise public awareness about the serious nature of concussions, their long-term effects and the fact that they often can be successfully managed? The AAFP has entered a partnership that will pair the evidence-based medical knowledge of the Academy with the influence of the National Football League Foundation. The initiative will produce three free webinars for family physicians, as well as patient education materials. The AAFP will have full control of all educational materials and will retain final editorial authority over the materials.
The Academy will be able to use the NFL's brand and logo on the patient education materials, which should help get the public's attention. NFL games reached more than 200 million unique viewers last season, when the league averaged 17.6 million viewers per game.
Here is a look at what to expect:
- Sports Concussions 101: The Current State of the Game, July 23, 8 p.m. CDT. This webinar will enable participants to define a concussion, and to identify the signs and symptoms of a concussion during an initial evaluation. The event will be presented by Stanley Herring, M.D., medical director of sports, spine and orthopedic health for University of Washington Medicine, co-medical director of the Sports Concussion Program, and a team physician for the Seattle Seahawks and Seattle Mariners; and family physician Matthew Silvis, M.D., associate professor in the departments of Family and Community Medicine, Orthopaedics, and Rehabilitation, and medical director of primary care sports medicine at Penn States's Hershey Medical Center.
- Sports Concussions 102: If You've Seen One Concussion, You've Seen One Concussion, Aug. 6, 8 p.m. CDT. Participants will be able to analyze the variability of the clinical presentation of concussion, construct an individualized, evidence-based treatment plan and recognize when to seek consultation or referral for a concussed athlete. The webinar will be presented by Jason Matuszak, M.D., the director of the Sports Concussion Center in Buffalo, N.Y., and Yvette Rooks, M.D., assistant professor of family and community medicine at the University of Maryland School of Medicine and a team physician for the University of Maryland Terrapins.
- Sports Concussions 103: Debates and Controversies, Aug. 20, 8 p.m. CDT. This webinar will cover long-term brain health in athletes; rule changes, practice and play modifications, and legislative efforts regarding sports concussions; limitations of protective equipment; and counseling parents about sports participation for young athletes. This webinar will be presented by Herring, Matuszak, Rooks and Silvis.
Patient education materials will be mailed to all active AAFP members in August and also will be posted on FamilyDoctor.org. These materials are intended to help patients understand the definition of concussion and its signs and symptoms, know when to seek medical evaluation, understand concerns about long-term brain health in athletes, and understand the limitations of protective equipment.
As part of the initiative, Family Medicine SmartBrief will publish a special report regarding concussions in August. You can sign up to receive SmartBrief, a daily wrap-up of news that affects family medicine.
Family physicians often are the first line of care for patients of all ages. We’re the first to spot these injuries, the first to treat them and the first to discuss the dangers of concussions with patients. This educational initiative will help family physicians and our patients by focusing on safety, the importance of reporting, evaluation of concussions and return-to-play protocol.
Concussions are a serious public health risk, and this educational initiative is the right thing to do.
Robert Wergin, M.D., is president of the AAFP.
What Patients Don't Know Can Hurt Them
It has been more than five years since the Patient Protection and Affordable Care Act (ACA) became law, but many consumers still remain unaware of one of the law's signature provisions: coverage of preventive services without cost-sharing.
A baby receives the rotavirus vaccine. Many Americans remain unaware that most health plans are now required to cover preventive services, including vaccinations, without cost-sharing.
The White House and HHS recently launched a joint Healthy Self campaign, which is designed to connect Americans to the health care they need and encourage them to take a more active role in their health. Fifty events will be held across the country in August to connect patients with care. The effort includes educating people -- particularly the newly insured -- about preventive services they are guaranteed under the ACA, which survived another Supreme Court challenge last week.
A Kaiser Family Foundation poll conducted shortly before last year's open enrollment deadline, showed that less than half of uninsured Americans were aware that the recommended preventive services most health plans are now required to cover must be provided with no cost-sharing. Those services include:
- blood pressure screening;
- breastfeeding support and supplies;
- depression screening;
- domestic violence screening and counseling;
- HIV screening;
- obesity screening and counseling;
- tobacco cessation interventions;
- well-child visits; and
- well-woman visits.
Considering that lack of awareness about these benefits, it's no surprise that half of the uninsured who were polled said they planned to stay uninsured.
However, more than 16 million people have gained health coverage under the ACA, according to the Healthy Self campaign announcement. That's significant because prevention is the key to true health care. Chronic diseases are responsible for 70 percent of U.S. deaths and 75 percent of our health care costs. Imagine the difference we can make simply by helping patients understand the services they have access to in our practices. If people delay preventive care because of cost concerns, they're more likely to eventually end up spending even more money at urgent care centers and ERs.
So what can we do as family physicians? We can use electronic health records to review what services patients haven't had. Our practices can use phones, email, portals and even social media to encourage patients to come in for preventive care. We also can use acute visits to identify preventive service gaps and schedule follow-up.
It's worth noting that CMS has launched a Web page with resources to help the newly insured understand their benefits and to connect them with primary care physicians who can provide preventive services.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Father's Day Flashback: Lessons Learned From Dads
I have been blessed with many father figures in my life, and each one has shared valuable wisdom that has helped me become a better physician, a better leader and a better person. In honor of Father's Day, and fathers everywhere, I want to pay tribute to the special fathers in my life by sharing some of their wisdom.
My great grandfather, Charles Light, was a Mennonite minister. My first memories of him were of a gentle man who lived simply on a farm and enjoyed quilting. He was a member of the Hereford Dairy Project and sailed on that initiative's first trips that brought animals to those living in poverty so they would have sustainable means to provide food and income for their families. He showed me the wisdom of paying it forward.
My great grandpa Otto McBride was a carpenter. My first memories of him were of his wonderful smile, which extended over his entire face and into his eyes. He could create anything with his hands. I still have the cedar chest he built for my grandma to keep my mother’s baby clothes in. He showed me the wisdom of building your own future.
My other great grandpa, Thomas Lloyd, owned his own shoe store in Racine, Wis. My first memories of him were of playing with the hundreds of seashells that he would collect in Florida and bring back home in jars. He showed me the wisdom of appreciating the beauty in nature.
My grandpa Don Beckenbaugh was a salesman in the Midwest who retired and moved to southern California. Six months after his retirement, he was offered a job selling real estate. Six months after that he became a broker who managed a successful real estate business in Laguna Niguel for 20 years. He was also committed to keeping his large family connected, and every time we had a gathering, he would go around the table and make everyone stand up and give a short speech to share what was new in their life. (That was the old-fashioned version of Facebook). He showed me the wisdom of believing in yourself.
My other grandpa, Allen Light, was a salesman who lived his entire life in the Midwest, which allowed me to spend holidays and summer vacations at his home for more than 40 years. He had a great sense of humor and a sharp wit and was an avid gardener and winemaker. He had a strong faith in God and held the importance of family above all other things. He took care of me when I was a baby, and he helped take care of my babies when I became a mom. He always took an active interest in whatever I did in my personal and professional life. When he developed cancer at the end of his life, he taught me what is was like to be a patient. He showed me that the burden of disease cannot break your spirit, but also that it cannot exceed your capability to live with disease. He showed me the wisdom of allowing faith, hope and love to guide your life.
My dad, Bob Beckenbaugh, is a recently retired hand surgeon. He was the first one to introduce me to medicine and show me how physicians can make a difference in the life of others. Dad also taught me to appreciate the power of humor and the importance of having fun. He taught me to laugh and tell jokes and to swim, water ski and snow ski. He even tried to teach me to play golf, but he says I "hit the big ball (planet Earth) more than the little ball (the golf ball)." Most of all, my dad taught me that taking care of other people is the most important service you can do with your life, and that as a physician, patients should always be treated with courtesy and respect. My dad showed me the wisdom of keeping joy in your life and striving for excellence in caring for others.
For the past 36 years, I have been blessed with another dad, my father-in-law Ted Lillie Sr. He is a retired small business owner who cares deeply for his family and strives to help those who are less fortunate then himself. He taught my husband to be a wonderful father, and he has shown me the wisdom of perseverance in the face of adversity.
So this month, I say thank you to all my fathers, and thank you to fathers everywhere who take the time to make a difference in the lives of others.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
Helping Hands: Count on Colleagues' Support During Transitions
Summer marks some major transitions for medical students and residents. Medical school graduates take on the mantle of physicians as they transition to interns. Interns become upper-year residents. Residency graduates move on to practice or fellowship training. With each stage, we gain more knowledge and responsibility.
| Here are a dozen reasons I feel confident about making it through my first year of residency -- my co-interns.
This summer, I am facing the transition from medical student to doctor, while also making some other big life changes with my spouse. He is changing jobs, and we are moving, buying our first home and navigating our basset hound’s newfound separation anxiety. It is a lot to juggle.
It’s also a little scary, but more than that, it’s exciting. Although trading my short student white coat for a longer physician coat is a huge step -- and one not taken lightly -- I am ready.
Even before starting residency orientation, I knew a few things that have made me ready:
- I have been training to become a physician for nearly a decade.
- I can admit when I do not know something and need to learn more.
- I am passionate about my patients and family medicine.
- My mentors and family will help me when I need it, with both medical and personal wisdom.
Now that I have been in orientation for more than a week and have had opportunities to bond with my co-interns and some faculty members, I have found more things -- at least 39 more -- to help me survive my first year as a physician. These 39 include my residency team/family -- 12 co-interns and 27 upper-years.
I have already seen firsthand how my new residency family members help each other both inside and outside of work. At work, we have been there to aid our team members struggling with advance cardiac life support medication doses, and we worked together to solve complicated scenarios. At home, we have lent helping hands moving furniture and shared remedies for homesickness (for both humans and dogs).
I will start caring for my own patients on July 1, but I realize that even though I am taking on new roles and greater responsibility, I am not doing it all on my own. I have a great team and family to support me.
So if you are making a transition this summer, remember to stop and look around -- because none of us is alone.
Kristina Zimmerman, M.D., is the student member of the AAFP Board of Directors.
Vacation? Hardly. AAFP Commission Work Is Tough, but Worth It
I recently returned home from the summer meeting of the AAFP commissions, typically referred to as Summer Cluster by its participants. Such meetings are sometimes called "vacations" by people who aren't involved, but the truth is that they are hard work.
And our hard work is backed up by the hard work of those back home who cover for us.
More than 100 family physicians, residents and medical students volunteer their time to the commissions, which provide input that shapes the direction of the AAFP and family medicine. Members serve four-year terms on commissions, which focus on specific areas, such as advocacy, education, member services, public health, professional development and practice improvement.
Photo courtesy of Kim Yu, M.D.
AAFP President Robert Wergin, M.D., center, speaks during a meeting of the Commission on Membership and Member Services. More than 100 Academy members volunteer their time and provide input to the AAFP's seven commissions.
Liaisons from the AAFP Board of Directors and constituent chapter executives also participate in these biannual meetings, and many of us return home with wry smiles as people ask about the time we spent out of town. Cluster meetings typically are held in the summer and winter in Kansas City (near the AAFP's headquarters), which is known for its climatic extremes. Although it's a fine city, Kansas City in the sweltering summer (or dead of winter) is not an ideal vacation destination.
Here's the long and short of it: When commissioners, Board members, officers and chapter executives are in Kansas City for Cluster meetings, we are working. There is a significant amount of prep work for these meetings, including poring through agendas that often are hundreds of pages long.
Most of us are practicing physicians, and in this era of electronic health records (EHRs), we are never truly away from patient care. Almost all of us have to step out of meetings at some point to take a patient phone call. We consult our EHRs during breaks so we can address urgent patient care needs, and we check in with our staffs. For example, throughout each day of the recent meeting, I made time for various patient care issues. I filled prescriptions, sent portal messages asking for follow-up from six patients on various issues (all sent on one morning, and answered that afternoon), dealt with a patient who had a new problem (which also resulted in a phone call), and reviewed the care of residents I had precepted the day before the meeting started.
In addition to patient care, many of the Board members -- especially officers -- must also find time for media calls (just as we do when we are back home). AAFP President Robert Wergin, M.D., in particular, is essentially on call 24/7 to handle media requests and to dash off to represent the Academy at other events, be it the annual AMA meeting, a White House event or some other important gathering. Not a meeting goes by in which he is not dealing with several phone interviews or email reviews of important media opportunities. These are critical for getting family medicine's message out to the public, and he has done an outstanding job.
I admit that I get so recharged after spending a few days with friends and colleagues at Cluster meetings that anyone could be forgiven for thinking I was coming back from a restful time away. In the end, there is nothing more exciting or rewarding than being able to continue to take care of our patients and our practices, while at the same time doing the important work of the Academy.
Next month, the AAFP will make its annual call on chapters to nominate family physicians to serve on the commissions. I'm grateful for all those who have served because they challenge us as an organization to do what we do even better. But we also owe a debt of gratitude to the people in our practices, communities and, of course, our homes who cover for us and support us, which allows us to do important work for our specialty and our Academy. Thanks to all.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Fellowships Aim to Enhance FPs' Training, Not Limit Our Scope
In just a few short weeks, I will reach the end of my residency, a milestone seven years in the making. Around the country, thousands of newly minted family doctors will be entering the workforce. I, however, will not be one of them. Instead, I plan to further my training with a fellowship in obstetrics. And I am not alone. Each year, roughly 15 percent of graduating family medicine residents enter a fellowship.
Most family medicine residencies offer well-balanced training that will allow graduates to deliver comprehensive care. But some individuals, like me, want to build on that training based on our individual passions. Others may seek to fill perceived gaps in their training. Of course, fellowships are just one avenue to expand our training. Others include focused use of elective time and, in some cases, developing formal areas of concentration.
In recent years, however, I have heard some physicians raise concerns about the growing number of fellowships -- in behavioral health, geriatrics, obstetrics, rural medicine, sports medicine and more -- and the growing number of residents applying for those positions. Specifically, some wonder whether these fellowships pose a threat to the generalist aspect that makes family medicine the vital specialty that it is.
In fact, a recent study in the Annals of Family Medicine found that increasing a family physician's comprehensiveness of care was associated with decreased costs and fewer hospitalizations.
It's true that for specialties such as internal medicine and pediatrics, a fellowship in cardiology or endocrinology will narrow a physician's scope of practice to the specialty that physician chooses. It's also true that a decreasing number of family physicians are providing maternity care and caring for patients in hospitals.
We're told as medical students that family medicine will allow us to care for the whole individual, at every age, and for entire families from cradle to grave. That's my calling. I plan to practice full-scope family medicine and teach after fellowship.
In this way, family medicine fellowships are designed to enhance our training and broaden our scope, rather than limit it. Increased fellowship opportunities give graduating residents the extra training to feel comfortable practicing in the hospital or providing maternity care (as well as satisfying requirements of hospital credentialing committees). And although there are opportunities out there for family physicians who want to focus solely on sports medicine or geriatrics, the vast majority of those completing fellowships will continue to practice broad-scope family medicine. My practice won't be focused on maternity care, but I'll have a deeper knowledge and stronger skillset regarding that subject.
Fellowships themselves aren't the issue. It's how we use that education. Fellowships offer family medicine graduates the flexibility to further our education, augment training in areas of interest and shape our future practices. So although a significant number of family medicine graduates plan to pursue advanced education, most of us will continue to practice general family medicine, albeit with some degree of focus. And learning more can only be a good thing for our patients and our practices.
Andrew Lutzkanin, M.D., is the resident member of the AAFP Board of Directors.
Learning Matters: How Education Affects Health
The recession has been over for nearly six years, and although recovery can be seen in many aspects of our economy -- including employment statistics and housing data -- the same can't be said for our public schools.
At the start of the 2014-15 school year, more than half the states were providing less funding per student than they had before the recession began in 2007. In fact, 14 states have cut per-pupil spending by more than 10 percent. Kansas took things even further, cutting funding for education by more than $50 million during the school year to help cover a massive $400 million budget shortfall.
What many legislators fail to realize is that cutting funding for education now raises health care costs in the future.
Photo courtesy of Reach Out and Read
A physician shares a book with a young patient as part of the Reach Out and Read program. Research indicates that education improves health and increases life expectancy.
How are health and education related? Steven Woolf, M.D., M.P.H., professor of family medicine and population health at Virginia Commonwealth University and director of the VCU Center on Society and Health, recently gave a presentation to the AAFP Board of Directors that illustrated the significant impact education has on health. Based on reports published last year by the Center on Society and Health's Education and Health Initiative, Woolf's presentation focused on how education can increase a person's life expectancy and the quality of that life.
The authors of the report put it succinctly, "Disinvestment in education leads to more illness and higher medical care costs that offset the intended 'savings' of these same budget cuts."
For example, in 2011 the prevalence of diabetes in the United States was 15 percent for adults who did not complete high school. That was twice as high as the rate among college graduates. In the same year, more than one-fourth of adults without a high school diploma were smokers, compared to 8 percent of college graduates. Adults who don't finish high school also can expect to live nine years less than their college-educated peers. And that already sizable gap is widening.
The reasons for the health disparities are numerous, and many should be fairly obvious. Education typically leads to better jobs, more money and many other benefits, including better health insurance, which leads to better access to quality health care. Higher earnings also allow workers to afford homes in safer neighborhoods as well as healthier diets. The median wage for college graduates in 2012 was one-and-a-half times higher than that of high school graduates and more than double that of workers who lacked a high school diploma.
People with lower incomes often live in neighborhoods or communities that present numerous challenges that affect their health, including less access to supermarkets and healthy food choices, less access to green space or other recreational areas, higher crime rates, lower quality schools, fewer jobs and increased levels of pollution.
Low-income areas also often have shortages of primary care physicians and other health care professionals. However, the report points out that people with lower levels of education have worse health than those with more education even when access to care is equal. For example, a 2011 survey of patients in the same health system found that nearly 70 percent of college graduates ages 25-64 described their health as very good or excellent, compared to 32 percent of adults who had not completed high school.
The bottom line is that strengthening schools likely would make our nation healthier and reduce health care spending in the long run. Even if our legislators fail to see the connection between education and health, we can make sure that our patients -- especially children and their parents -- do.
In 2013, 66 percent of U.S. fourth-graders were reading below proficiency levels. Part of the problem is that parents who were not read to as children may not understand the importance of reading to their own kids. In fact, less than half of young children in this country are read to daily, and minority and low-income children are less likely to be read to than others.
So what can we do? Last year, the AAFP entered into an agreement with the Reach Out and Read National Center. That program trains and supports physicians, who give new books to children ages 6 months to 5 years and advise parents about the importance of reading aloud. The program aims to promote early childhood literacy and language development, particularly in low-income families.
Graduation rates -- like immunization rates -- have a huge impact on the health of our communities. Reach Out and Read offers numerous resources for physicians who would like to participate.
Robert Lee, M.D., is a member of the AAFP Board of Directors.
Advocacy Agenda Shifts With SGR Behind Us
Last week, I attended the Family Medicine Congressional Conference (FMCC) in Washington, and for the first time in 17 years, we did not have to lobby legislators and congressional staff about the Medicare sustainable growth rate (SGR) formula.
We did thank legislators who voted overwhelmingly to repeal the fatally flawed SGR. Now we're moving into a post-SGR world. This doesn’t mean everything is fixed, but it does allow us to focus our energies and our voices on addressing other much-needed changes in our health care system, including payment reform, graduate medical education reform and truly valuing primary care.
© 2015 Michael Laff/AAFP
Here I am meeting with Sen. Sheldon Whitehouse, D-R.I., (center) along with members of our Rhode Island delegation: Roanne Osborne-Gaskins, M.D., Keith Callahan, M.D., (second from right) and resident Jason Kahn, M.D. (far right). Hundreds of family physicians met with legislators and congressional staff last week during the Family Medicine Congressional Conference.
FMCC is an inspiring event. I looked around the room and saw remarkable people who I have “grown up with” during six years on the AAFP Board of Directors, including three as an officer. It has been rewarding to see family physicians who I installed as state chapter presidents developing as leaders.
These meetings also affirm one of the core attributes of family medicine -- it really is about relationships. Attending an Academy meeting is like coming to a family reunion. The biggest frustration for me is not having enough time to spend with all the people with whom I wish to catch up. (So, if I didn’t get to you this time, I’m sorry and I look forward to our next meeting!)
FMCC has a different focus than other occasions when AAFP officers are on Capitol Hill advocating for our specialty. The Academy staff does an incredible job providing information to chapter leaders and creating opportunities for legislators to address critical topics.
I was honored that my own congressman, Rep. Phil Roe, M.D., R-Tenn., came to speak at one of the plenary sessions. Although he’s an OB-Gyn, he told stories just like we all do to make his points. He’s excited about moving away from the contentious SGR debates and toward new issues. He has appreciated that near the end of the SGR process, physicians learned to speak with one voice and more clearly about health care reform. He understands the value of primary care, and, in the words of one of our attendees, “He gets it.” More and more of our legislators are getting the message about primary care, and its important role in our health care system. They are beginning to understand that the term “primary care physician” is best associated with the specialty of family medicine, and that we need to make many more changes to link value to this recognition.
At FMCC, we addressed the fact that legislation and regulations need to value primary care in practical and immediate ways. For example, we need to push to remove co-pays from chronic care management fees to remove the hurdle that patients and family physicians face in obtaining and providing needed chronic care coordination, and in accessing primary care.
We need to be sure that the definition of primary care is clearly understood, especially when medical schools are still touting, sometimes in a misleading manner, high graduation rates of primary care physicians. We need to make sure that when people are praising primary care, and vowing to value it, that we’re all on the same page in this regard, and the foundational component of family medicine as the primary care specialty is understood.
Although we are pleased that the National Health Service Corps and the Teaching Health Center Graduate Medical Education program have been funded for two more years, we need to continue to push for these vital programs to be recognized as the successes stories they are. Although they were extended by the same legislation that repealed the SGR, they should be permanently removed from the budgetary chopping block.
GME reform was emphasized as a vital issue during last week's event. We’re challenging legislators to look at ways of increasing transparency regarding GME funding and demanding accountability for the $13 billion put into the medical education system each year. The current system is not producing the workforce we need despite the tremendous investment.
It was refreshing to see things come together regarding the way that families and communities care for each other. FMCC featured a plenary about family caregiving. One of our requests of the legislators we met with was that they join the recently formed Assisting Caregivers Today caucus. This effort creates an opportunity for many stakeholders to work together to find ways to care for people outside of hospitals. In so many ways, this echoes our call for people to receive right care in the right place at the right time from the right person. Ultimately, the best answer for providing this care is through team and community-based care.
Finally, I was honored to join our state chapter leaders during visits with their state legislators and congressional staffers. I was incredibly impressed with the Oregon chapter’s discussions with staff members of Sen. Ron Wyden, D-Ore., the ranking democratic member of the Senate Finance Committee. Melissa Hemphill, M.D., who is just two years out of residency, took the lead during this meeting, and she did as good a job as any AAFP officer or other veteran advocates in articulating our perspectives.
I also joined the Rhode Island delegation for a meeting with Sen. Sheldon Whitehouse, D-R.I. He impressed me with his understanding of medical issues, especially as they related to his state. Roannne Osborne-Gaskin, M.D., and Keith Callahan, M.D., clearly expressed the challenges they face in their practice settings in that state. I was impressed with the good work that our state leaders are doing.
It's worth noting that FMCC came right on the heels of the Academy's Annual Chapter Leader Forum, which offers training in areas such as advocacy, communication and more. The process of leadership development and relying on the informed voices of state leaders is such a key aspect of making change. As an Academy, we continue to advocate for our patients and practices.
There is still much work to be done, but I see several doors opening that had been closed for so long. Thanks for all you do, and keep up the great work.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Face-to-Face With Dr. Oz: Benefits of Touting Family Medicine Outweigh Risks
When discussing treatment options with our patients, we consider the risks and the benefits of the various options available. Ideally, we seek choices with benefits that far outweigh the risks.
The same is true for leadership, but sometimes you have to boldly stick your neck out to make your message heard.
| Here I am talking with Mehmet Oz, M.D., on "The Dr. Oz Show." In a show about facing your fears, my segment dealt with the fact that some patients fear going to the doctor. I emphasized that patients need a family physician who can serve as their trusted health adviser.
Earlier this year, I got a phone call from Mehmet Oz, M.D., the cardiothoracic surgeon, author and TV host better known as Dr. Oz. We had met years before when I was working for the local NBC affiliate as a health consultant and reporter. His staff had initiated conversations with the Academy about interviewing me on his show, and now he was reaching out to me directly.
I hadn't jumped at the opportunity, and with good reason. It's been a rough year for Dr. Oz, who was called before Congress last summer because of concerns with some of the products that have been promoted on his show.
"You need to understand that our members aren't happy with some of your advice," I told him. I also let him know that family physicians are spending too much of our valuable time explaining to patients why we don't recommend some of the products and ideas they've seen on his show.
But again he asked me to come on the show to tell his audience about family medicine, and that audience is vast. Each weekday, nearly 2 million people tune in to watch on television, and many millions more watch online.
So here was a risk with a potentially huge benefit. This was an opportunity to talk to millions of Americans about the importance of family medicine and the critical role that primary care plays in health care. I could give this audience, which hasn't always received evidence-based information, a better understanding of who we are and what we do as family physicians.
As I considered it, the conclusion that I drew was that the benefits would outweigh any risks if I could reach viewers who don't have a primary care physician and make them realize that they should. Incredibly, that goal was accomplished before the show was ever broadcast.
The topic of the episode, which aired today, was fear. Specifically, my segment dealt with fear of going to the doctor, which can keep people away from our practices even when they are in dire need of care.
So we talked about why everyone needs a family physician, a trusted adviser who knows the patient and his or her family history. We talked about the scope of family medicine and the fact that we care for people from the beginning of life until the end. We also talked about our ability to help patients set and reach their personal health goals.
One woman in the audience had not seen a physician in more than a decade because of her personal fears and concerns about costs. When we had finished taping my segment, I walked over to her and said, "Can I help you find a family physician?"
"I would love that," she said.
I followed up with her, and -- with help from the New York State AFP -- was able to connect her with a family physician in her area. If nothing else, I know my appearance on that show made a difference for one person already.
We mitigated our risks with Dr. Oz as much as possible. We discussed beforehand things I would not do on the show, found out who the other guests would be, and received a guarantee that there wouldn't be any medical products or services or nutritional or diet products promoted during this episode.
This effort already helped at least one person in the studio audience. My hope is that viewers who see the episode on TV or online will find their way into our exam rooms. Americans need to understand the value and importance of what we do. For people to hear our message, we may have to take a few bold risks.
Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.
Your Opinion Matters; Here's How to Share It
With more than 120,000 members working in a wide range of practice models in all 50 states; U.S. territories; Washington, D.C.; and U.S. military bases around the globe, we won't always have a consensus on issues that affect family medicine. In fact, we often don't.
Although family physicians are different in so many ways -- based on gender, generation, political affiliation and race, to name a few -- we all share a common goal: to provide the best care possible to our communities. It's important that we communicate and work together as members and as an organization to achieve that goal.
Tiffany Matson/AAFPHere I am talking with attendees at the AAFP Leadership Conference. Hundreds of members and chapter staff attended the event last week in Kansas City, Mo.
Sometimes, the Academy receives feedback from members who feel they aren't being heard. Small- and solo practice physicians, in particular, have vented frustrations about the growing regulatory burdens their practices face and their need for help in addressing these obstacles. I understand because I am a rural, small-practice physician, and there are others like me serving on our Board of Directors. And I can tell you we do hear members' feedback.
AAFP officers, myself among them, offered updates on a variety of issues facing family medicine and took questions from members during a May 1 Town Hall meeting during the AAFP Leadership Conference in Kansas City, Mo. We discussed payment reform, workforce issues and more. Members will have another opportunity to ask us tough, direct questions Sept. 27 during a Town Hall meeting at the Congress of Delegates in Denver.
But these annual events are only two examples of ways that AAFP leaders and staff listen to members' opinions. There are many other ways to make your voice heard.
The Academy regularly solicits member feedback through randomized surveys. If you want to make your opinion known, this is an excellent -- and easy -- way to provide input that affects AAFP products and policies. In 2013, the Academy polled members more than two dozen times on various issues, so if you receive a survey, please complete it!
The AAFP also gathers feedback about twice a month through the Member Insight Exchange. This is a growing group of family physicians -- currently, about 600 of them -- who have provided input on a wide range of issues, including AAFP products, Medicaid, health care apps, direct primary care and more. The Academy would like to expand the numbers of members who participate (log in required) and earn incentives for providing feedback.
It's also worth noting that we send a member of the Board to nearly every state chapter meeting. These meetings offer a chance for us to provide updates about what the Academy is doing nationally, but more importantly, they provide an opportunity for us to listen to family physicians from across the country.
Last year, the Academy illustrated its commitment to helping all members have their voices heard when it created a pathway for the establishment of member interest groups. To date, 10 groups -- including one for solo/small practices and another for rural health -- have been created. Many of these groups plan to meet at AAFP Family Medicine Experience (FMX) in September in Denver.
AAFP leaders also are participating in quarterly online discussions with family medicine interest group leaders to answer questions and discuss issues that matter to medical students.
In addition, AAFP leaders and staff have responded to members' questions and concerns posted on the Academy's listservs. Although we don't respond to every comment, the Academy monitors and discusses comments we receive via social media. And you can communicate with me directly through the AAFP President Facebook page and on Twitter @aafpprez.
I want to assure you your voice and input matter greatly. As a practicing family physician, I understand firsthand many of the frustrations of our members. As an Academy, we will continue to work hard on reducing those frustrations so that we can bring the joy of practice back to our lives.
Robert Wergin, M.D., is president of the AAFP.
Team-based Training Key to Providing Team-based Care
One of the core components in transforming a practice is team-based care, and this concept is a focus of many conversations when I visit our chapters across the country.
My employer, the Quillen College of Medicine at East Tennessee State University (ETSU), also has embraced this concept. And the outstanding group of interprofessional educators I work with are constantly looking for ways to enhance not only the way we provide team-based care, but also how we address the all-important process of teaching team-based care. Truly, to embrace, understand and implement team-based care, we have to have team-based education.
Photo courtesy American Pharmacists Association
Here I am speaking at the American Pharmacists Association's annual meeting. I gave a presentation about team-based care with Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at East Tennessee State University.
During my time as an AAFP officer, I have been honored to speak to the boards of several organizations that represent our colleagues who play critical roles in providing team-based care, including the Association of Family Practice Physician Assistants, the American Academy of Physician Assistants, the American Association of Nurse Practitioners and the American Pharmacists Association (APhA). At each of these meetings, I have had a chance to thank each group for helping improve the care of our patients, and to consider ways to work through challenges to find creative ways of providing education.
There are many others who play important roles in team-based care, including social workers, behavioral health specialists and our county health departments, but today I want to focus on how we work -- and train -- with pharmacists.
Recently, I had the opportunity to work with my friend and colleague, Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at ETSU, on a presentation about team-based care (login required) during the APhA's annual meeting.
We also co-teach several sessions with our medical students, pharmacy students and residents at ETSU. We start with a patient case that relates to considering and implementing evidence-based approaches to caring for patients with cardiovascular disease. We break our audience into small groups of junior medical students and second-year pharmacy students who then work through questions about patients to seek the best evidence about possible treatments and put them into practice. Then the groups defend their decisions in our discussions.
This particular educational activity is critical because during the same rotation, students, family medicine residents and the pharmacy team work together to coordinate post-hospitalization care in our transitions clinic. Students and residents take what they have learned from this and other sessions and apply it to patient care, and the results have led to dramatic improvements. For example, this clinic has helped reduce our readmission rate from 25 percent to 13 percent.
Almost every patient seen in this clinic has benefited from the true medication reconciliation that can occur when these students review the clinic medication list, the hospital list, the pharmacy list and what the patient brings into the appointment.
In addition, we have other opportunities in which our pharmacists and their team see our patients in the anticoagulation clinic. They don't work in isolation. Instead, they work directly with our residents and medical students. In addition, our social worker leads a group of medical students, pharmacy students and sometimes a resident to make home visits with our patients.
These examples demonstrate ways that learners from different professions are able to put theoretical educational processes from the classroom into direct actions that impact care.
Even if a school or community isn't blessed with a college of pharmacy, those of us in education still can reach out to our local pharmacies and find ways to involve some of their learners or employees in our educational process, which will help create better relationships. One of the keys to team-based care is having this kind of relationship-building at every level. And it is not just between health care professional and patient. It also is between each member of the team.
If you are not involved in academics, there is value in having discussions with the team members who work not only under your roof, but also with local pharmacists or health departments. Each member of this community-based team can talk about the kinds of patient care issues they see and how each might be able to contribute to improving care. Much of this can be done without specific contracts or organizational memos. The core principle is improving the care of our patients by working together.
It's worth noting that the Patient-Centered Primary Care Collaborative (PCPCC) published a report in December that looks at how seven different programs use interprofessional health training to deliver patient-centered care. The PCPCC also is offering a five-part podcast series on this concept.
Meanwhile, the Robert Wood Johnson Foundation offers a free resource related to improving care through team work. And the National Center for Interprofessional Practice and Education offers articles, presentations and other tools in its resource exchange.
Finally, the Academy will be offering a session Sept. 29 and Sept. 30 at the 2015 AAFP Family Medicine Experience (FMX) in Denver titled "Capitalizing on Team-Based Care to Improve Quality and Office Efficiency." Thomas Bodenheimer, M.D., and Berdi Safford, M.D., will be among the FMX panelists.
I am hopeful that some of these ideas resonate with you. None of us takes care of patients in isolation, so the first question to ask and answer is, "Who are the members of our teams?" The second step is to get everyone together and think about how we can impact education and patient care. Thanks for being a part of this critical process.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Doctors Need the Straight Dope on Medical Marijuana
Nearly half the states, and the District of Columbia have adopted comprehensive medical marijuana programs, and more than a dozen more have approved use for a limited number of medical conditions. Two states -- Colorado and Washington -- have taken things even further, legalizing marijuana for recreational use.
Of course, none of this changes how marijuana is viewed by federal authorities. The Department of Justice has issued guidance to federal prosecutors, reiterating the agency's commitment to the Controlled Substance Act. The FDA has not approved marijuana as a safe and effective drug for any indication.
Legislators are again impacting the care of patients and the health care delivery system. So where does that leave us as physicians? WebMD polled physicians last year and nearly 70 percent of respondents agreed that medical marijuana can help patients with certain conditions. But physicians were less enthusiastic about making the drug available. Half of the doctors polled in states where medical marijuana is legal supported its legality. In those states still debating medical marijuana laws, 52 percent of doctors supported it.
Hence, although an overwhelming majority of U.S. physicians understand the potential benefits of medical marijuana, roughly half oppose it.
In my home state of Illinois, legislators have legalized medical marijuana. Many patients are asking for it; many have valid reasons, such as cancer or chronic pain. For those who do not, the discussion explaining the reason for denial is lengthy. Illinois, like many states, used model legislation to create its medical marijuana program, and physicians are not required to write prescriptions. Rather, we certify which patients meet conditions that allow them to legally buy the drug at a dispensary.
Sadly, conversations with my patients have highlighted some obvious problems with medical marijuana. I have had patients suffering from chronic pain ask for medical marijuana because they fear becoming addicted to prescription narcotics. They, like many others, don't understand that marijuana can also be addictive. According to the 2013 National Survey on Drug Use and Health, marijuana use accounted for more than 4 million of the 7 million Americans who are dependent on or abusing illicit drugs.
In short, many patients don't know the harmful effects of marijuana. So although there are limited health benefits to medical marijuana, we must also ensure that patients understand the risks.
At last year's Congress of Delegates, the AAFP adopted policy stating that decisions about medical marijuana should be based on evidence-based research and called for further studies into the use of medical marijuana and related compounds. But with new studies being published regularly, it can be hard to keep up on what the latest evidence tells us.
The AAFP can help. The March edition of FP Audio has a clinical topic that will help physicians evaluate current evidence on the use of medical marijuana for the treatment of multiple sclerosis and severe childhood epilepsy. Another edition exploring the topic further is scheduled for July.
The Academy will offer two sessions related to medical marijuana Sept. 29-Oct. 3 at FMX in Denver. An interactive lecture will cover what family physicians need to know about medical marijuana. And during an "Out and About" -- an offsite CME session -- a family physician and a patient will discuss legalized marijuana from the physician and patient perspectives. That session will be followed by a tour of CannLabs, an advisor to commercial, governmental and educational entities focused on the cannabis industry.
State chapters also can play a role. The Illinois AFP is offering its second webinar on medical marijuana and its implications for physicians on April 27. Registration is limited to the first 100 participants, but an archived version will be available. (The event is not limited to Illinois AFP members.)
The bottom line is that medical marijuana is becoming available in a growing number of states. There is a tremendous economic advantage to a state’s economy. Consumer advocacy groups have formed to urge the federal government and the FDA to ease federal restrictions and fund marijuana research. When patients come to us for help, we should know the law governing our actions and what liabilities may exist. And, we should have an informed conversation with our patients about the potential risks and benefits of a drug for which long-term safety for adults and children is not yet truly known. The laws are changing rapidly. Family physicians should become knowledgeable of the laws in our own states regarding the use of medical marijuana. Consult your state medical boards and/or departments of professional regulation for guidance where necessary. The train has left the station.
Javette Orgain, M.D., M.P.H., is vice speaker of the AAFP Congress of Delegates.
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