Chance to Shape FP Training, Education Prompts Career Move
I've lived my whole life in Indiana. My children -- like the three generations before them -- grew up here as well. Those children, now adults, still live near us here in Indianapolis.
My education and training -- from Ball State University to the Indiana University School of Medicine and the family medicine residency at Community Health Network -- all happened in the Hoosier State.
| I'll be leaving my home state of Indiana behind next month to start a new job as the AAFP's vice president of education at the Academy's offices in Leawood, Kan.
My career started in rural private practice in the
small town of Flora, Ind. -- population 2,000 -- before I came back to
Indianapolis as faculty at the residency where I had trained. I stayed with
Community Health Network for more than 20 years as residency director, vice
president of medical affairs for two of its hospitals, chief medical officer
for the entire eight-hospital network and, most recently, as the network's
chief academic and medical affairs officer.
So what would it take to get me to leave my home state? Nothing less than a chance to make a positive, lasting difference in the education and training of medical students, family medicine residents and our active members on a national scale. That, of course, goes hand-in-hand with enhancing the quality of care delivered by our specialty.
I'll be leaving my position on the AAFP Board of Directors on May 3 (after the Board meets during the Annual Leadership Forum and National Conference of Special Constituencies). Nine days later, I'll start a new journey in Leawood, Kan., as the Academy's vice president for education.
I feel as though I have been training for this role for the past three decades. The majority of my career has been devoted to medical education and improving quality of care, so it's a natural fit. For example, for the past five years, my job responsibilities have included oversight of medical student education at our network's hospitals, our residency programs and the CME offerings we produce.
At the AAFP, I will be responsible for the Academy's efforts related to medical education and CME, including the education and training of medical students and residents; student interest in our specialty, including federal policies that affect it; and CME curriculum development, production, accreditation and regulations.
Many challenges await, but I'm excited to lead the AAFP's excellent staff who work in these areas, including those who support two commissions -- the Commission on Continuing Professional Development and the Commission on Education -- composed of family physicians who volunteer their time to address these vital issues.
We must ensure that medical students have top-notch exposure to family medicine and that they have good experiences when they do. That can be difficult, in part, because practicing physicians who enjoy teaching have competing demands for their time. But there is no doubt that good role models help build student interest in the specialty.
We are facing a shortage of primary care physicians that likely will worsen because of an aging population, a sizable number of physicians nearing retirement and a large number of patients gaining access to insurance as a result of health care reform. More -- and more targeted -- funding for family medicine residencies is needed to meet this demand, and GME funding and reform are high on the list of the Academy's legislative priorities.
Family physicians want to keep up-to-date with evidence-based CME, and the Academy will continue to improve and expand its offerings to ensure timely and convenient access to high-quality CME. We will build on the strong programing currently offered, and we always appreciate input from our members on how to better serve their CME needs.
On a more personal note, the challenges of this role also include succeeding the immensely accomplished and respected Perry Pugno, M.D., M.P.H., who is retiring after 40 years in family medicine, including 15 years of service to the Academy.
The challenges are great, but so are the opportunities. The key to improving health care in this country is to make it more primary care-oriented by placing greater emphasis on prevention and wellness. Family medicine is the specialty that does that better than any other. I am proud to have this opportunity to further strengthen our specialty through continuing efforts to enhance medical education at all levels.
Clif Knight, M.D., is a member of the AAFP Board of Directors.
A Well-Deserved Honor for AAFP President
When I was first elected to the AAFP Board of Directors four years ago, I was fortunate to find a mentor waiting for me.
Reid Blackwelder, M.D., would often give me pointers about how I could be more effective in contributing to the Board's deliberations. Sometimes it was an encouraging email, or he might pull me aside to say, "You made a good point on this issue, but you need to be more succinct."
AAFP President Reid Blackwelder, M.D., second from right, recently was honored by the Tennessee General Assembly for his work as a physician, educator and advocate. State Sen. Joey Hensley, M.D., far left, sponsored the resolution. Tennessee AFP officers Kim Howerton, M.D., and Lee Carter, M.D., also were on hand for the presentation.
Well, I'm working on that, and Reid has been a great role model. His criticism has always been constructive, and he has helped me grow, learn and develop my own leadership style. It's no surprise because he's helped mentor countless others, including the more than 1,400 medical students he's taught over the years at East Tennessee State University's (ETSU's) James H. Quillen College of Medicine.
ETSU medical students have named him Mentor of the Year and Family Medicine Attending Physician of the Year multiple times, and he's also received the Dean's Teaching Award. The AAFP awarded him the Exemplary Teacher of the Year Award in 2008.
He also has been honored by the
Tennessee AFP for his exceptional leadership and outstanding service to that organization.
Whether he is teaching, talking with his patients or lobbying on Capitol Hill, it all comes back to communication. Reid is easy to talk with and is a good listener as well. The same skills have served him -- and the Academy -- well in working with the media. He has been quoted in or contributed to more than 670 articles or broadcast features during his tenure on the AAFP Board.
His cumulative body of work recently led to the Tennessee General Assembly passing Senate Joint Resolution 536, which recognized Reid's "exceptional work as the president of the American Academy of Family Physicians," his dedication to teaching, and his advocacy efforts on behalf of physicians and patients. It also recognized him for dedicating his professional career to improving the lives of others.
I can't think of anyone more deserving of the honor, and I'm proud to call Reid my colleague, mentor and friend.
Currently, we have three candidates for four positions on the AAFP Board of Directors. Our speaker, John Meigs, M.D., recently pointed out on this blog the process of nominating candidates and the need for a deeper pool of candidates. I can only say that anyone stepping into these leadership roles will find it a tremendous personal growth experience, and they will gain a new friend and mentor in Reid Blackwelder. Congratulations, my friend, on your well-deserved award.
Robert Wergin, M.D., is President-elect of the AAFP.
Don't Accept Limits on Your Family Medicine Opportunities
With our broad, extensive training, family physicians have opportunities beyond working in family medicine practices. Family docs are working in geriatrics, sports medicine, long-term care facilities, urgent care clinics, hospice care, and as hospitalists, administrators, researchers and more.
It's that diversity that draws some medical students to family medicine in the first place.
When I travel around the country to state chapter meetings, I hear from a lot of family physicians who love what they do. Occasionally, I also hear from members who say they feel trapped.
That was the case recently when I spoke to a colleague who had done research and developed a business plan that would expand primary care services for her health system. The idea, she thought, would improve outcomes and generate new revenue streams.
Her employer, however, was thoroughly disinterested.
Disappointed and disillusioned, she told me she felt stuck in her job because she had signed a two-year restrictive covenant agreement, or noncompete clause, when she was hired. That agreement excluded her from working in other family medicine clinics within 50 miles of any facility owned by her employer, which has locations in multiple counties in her area.
In my opinion, she was so close to her own situation that she had lost perspective. I told her to think about the diversity of her training and reminded her that family medicine is the No. 1 specialty for which recruiters are hiring. We are only trapped if we accept limitations others try to put on us.
These days there are incredible career opportunities across a wide spectrum because primary care is the backbone of our health care system. Family physicians are in high demand. In fact, there were more than 300 new job postings on the AAFP's CareerLink website during the first seven days of this month.
If you're feeling burned out or resentful, it's time to step back and consider what you might be able to do differently. Personally, I've left a job when I wasn't being compensated fairly and was unable to change unsatisfactory circumstances. When advocating for change within your system doesn't work, it's appropriate to consider other opportunities. Don't sell yourself short.
One of my colleagues recently made the decision to leave New England and move to a new opportunity in South Carolina. After more than 20 years of dealing with the same payers, she was ready to try something new.
That brings us back to the issue of restrictive covenants and whether physicians should be signing them. The AMA adopted principles two years ago that discourage physicians from entering employment agreements that contain noncompete provisions or other restrictions on future employment.
Personally, I've refused to sign restrictive covenants twice. Both times, I was told it was standard operating procedure. Both times, I let them know it was a deal breaker for me, and the employers backed down.
If an employer isn't willing to hire you without placing restrictions on your future, maybe it's not the right place for you. It's important to be able to walk away on your own terms, and there will always be other people who will hire you.
With a shortage of primary care physicians, our health care system can't afford to lose our training and expertise. If you're feeling burned out or trapped, you always can reach out to your colleagues or mentors for perspective and advice. Getting involved with your state chapter and national family medicine activities can expand your professional network.
Remember, there are always other options. With training as a family physician, you are invaluable, and you can find professional satisfaction in other settings where you can provide the expert care our nation needs.
Wanda Filer, M.D., M.B.A., is a member of the AAFP Board of Directors.
Candidates Wanted: Four Spots Available for AAFP Board
If you've ever thought about running for the AAFP Board of Directors, now might be the perfect time to do it. As of today, we have fewer candidates than the number of spots available in an election that is just six months away.
Each year, the AAFP Congress of Delegates elects three family physicians to three-year terms on the Academy's Board of Directors. Between meetings of the Congress, the business and affairs of the Academy are managed by and under the direction of the Board. The Board appoints commissions, committees and other work groups as necessary. Directors also serve as liaisons to the Academy's seven commissions and serve on the Board's various subcommittees.
|The Congress of Delegates will select new directors in October in Washington. To date, there are only three candidates for four positions on the AAFP Board of Directors.
It has been my privilege and pleasure to serve on the Board of Directors for the past six years. This has been a tremendous opportunity for me to learn more about the inner workings of the AAFP and also to benefit from the knowledge, experience, expertise and dedication of the Board members and Academy staff with whom I have had the opportunity to work.
I have come to appreciate the reasoned discussion and debate of the Board as issues are introduced and all points of view considered as the Board tries to reach consensus on the issues we face.
I came to the Board with my rural background and 30 years of private practice experience, and I hope that I have been able to contribute in some small way. I always have felt that I have learned far more than I have contributed. I have gained a broader understanding and deeper knowledge on so many subjects and issues, which has helped me to gain a broader perspective and to make me a better resource for my colleagues back in my practice, community and state chapter.
I would encourage anyone who has the time, dedication, drive and commitment to family medicine to consider running for the Board of Directors. For me, this has been an intensely rewarding and enriching experience that has carried over into the other aspects of my professional and personal life. I am more dedicated than I have ever been to family medicine and more convinced than ever that our health care system needs a strong, vibrant, respected and resourceful primary care workforce to deliver the cost effective quality health care that our patients and our country need and deserve.
So who is ready to step forward?
In nine of the past 10 years, AAFP chapters have nominated at least five candidates for three Director positions. In the 20 years I have been attending the Congress, I have never seen an uncontested election.
However, chapters have nominated only three candidates for the election that will take place in October at the Congress of Delegates in Washington. Complicating the matter is the fact that Director Clifton Knight, M.D., has accepted the role of AAFP vice president for education. He will resign his elected position on the Board, with one year remaining in his term, when he begins his new job in May.
That leaves us with three candidates for four spots. So what happens to the candidate who comes in fourth, assuming more candidates come forward? The candidate receiving the fourth-highest majority vote total would fill Knight's unexpired term and would be eligible to be a candidate seeking election to a full three-year term during the 2015 Congress of Delegates in Denver.
Due to the additional vacancy, the deadline for receipt of candidate information for the candidates' website has been extended to May 30 with the site going live June 13.
That leaves potential new candidates plenty of time to be competitive with the three existing candidates. Campaigning typically begins at the Annual Leadership Forum and National Conference of Special Constituencies, which will be held May 1-3 in Kansas City, Mo.
Chapters are encouraged to nominate qualified and interested individuals to run. Candidates for AAFP offices must be officially nominated by their chapters and must submit an official announcement letter and candidate photograph to EVP and CEO Douglas Henley, M.D.
With a diverse, national organization of more than 110,000 family physicians, medical students and residents, we need diverse representation -- not only of genders and ethnicities but practice types and locations. This is an excellent opportunity for family physicians to represent our organization.
You can read the campaign rules on the AAFP website.
John Meigs, M.D., is Speaker of the AAFP Congress of Delegates.
Visit to Army Medical Center Provides Insight Into Military Care
Recently, I had the good fortune to tour Brooke Army Medical Center (BAMC) Fort Sam Houston in San Antonio, and I came away extremely impressed by the great job that the Army does in caring for our soldiers on multiple levels: keeping healthy soldiers healthy, treating the acutely injured and helping the injured recover.
I also was impressed by the many opportunities available for family physicians to serve in military medicine. And it would be hard not to be awed by the largest inpatient medical facility run by the Department of Defense.
I recently toured Brooke Army Medical Center Fort Sam Houston in San Antonio with Col. Karrie Fristoe, commander of the U.S. Army's Medical Recruiting Brigade, and Rebecca Hooper, Ph.D., retired Col., and former assistant director of BAMC's Center for the Intrepid.
But to me, even more impressive was the commitment to improving the overall health of our soldiers and our country. One of our hosts, Lt. Gen. Patricia Horoho, U.S. Army surgeon general, stressed the importance of both the patient-centered medical home and efforts to emphasize health, not just treating illness and injuries. The Army Medicine Performance Triad -- eating well, being active and sleeping well -- are guides for soldiers to lead a better life with more engagement, energy and fulfillment.
The 2.1 million-square-foot, 425-bed San Antonio Military Medical Center has a certified Level 1 Trauma Center that handles more than 5,700 ER visits per month, yet it also offers primary care, pediatrics, OB/Gyn, bone marrow transplants, a cardiac catheterization lab and psychiatric care to service members, their families, veterans and civilians.
BAMC is home to the Army Burn Center, part of the Army Institute of Surgical Research. We were able to see how the Burn Center has the ability to project ICU level burn care anywhere in the world, to bring injured soldiers home in a mobile ICU, and treat them all the way through rehab and recovery.
It also is the site of the Center for the Intrepid (CFI), a world class facility for service members recovering from amputation. Here you can really see the benefit of combining the complete range of state-of-the-art amputee treatment in one facility: prosthetists, psychologists, challenging sports equipment and even virtual reality systems with one aim: bringing wounded warriors back to the highest level of functioning possible. The CFI and their athletes are inspiring, and the facility is far beyond anything offered in the civilian world.
Most family physicians likely know that the Armed Forces Health Professionals Scholarships Program (HPSP) offers full scholarships for medical school, but during my visit, I was struck by the wide number of opportunities available to family physicians practicing in the military. Indeed, by the age of 42 one of my hosts, Lt. Col. Tom Hustead, M.D., family physician and AAFP member, has already served as a clinic director, a flight surgeon, and a department chair in family medicine. In addition, he has been deployed in a military service area.
Hustead said many of the more than 550 Army family physicians, like him, initially joined out of a desire to serve our country, but they remain for the camaraderie and opportunity found in the in Army Medical Corps.
There are nearly 2,000 active AAFP members in our Uniformed Services chapter.
My message today is for them: Thank you for your service.
Jeff Cain, M.D., is Board Chair of the AAFP.
I Matched! And It's Good News All Around
I knew I wanted to be a family physician before I ever made it to medical school. As a college student with an interest in medicine, I shadowed an anesthesiologist and an orthopedic surgeon before our family physician suggested that I shadow one of his partners. It was that experience that set me on this path.
I was impressed that this family physician had patients who had been in his care for 30 years. He knew entire families and had a deep connection with the community. I spent time at that practice during my Christmas breaks and summer vacations, and it wasn't long before I realized, "This is who I am, and this is what I'm supposed to do."
Friday I got the good news that I had matched at the University of Alabama-Birmingham's Huntsville Family Medicine Residency. My classmates Libby Van Gerwen (who matched in internal medicine-primary care at Tulane University School of Medicine) and Brittany Holley (internal medicine at the University of South Alabama College of Medicine) also had reason to celebrate.
One particular patient encounter stands out in my memory. The physician had to inform a woman that she had cancer, and it was inoperable. Despite the horrible news, he was reassuring and told her that she wouldn't leave that day without a plan. The level of trust she had was clear. She valued his opinion and wanted his advice. It was a defining moment for me.
forward a few years to last Friday when I -- like thousands of other medical
students around the country -- received my National Resident Matching Program letter.
I had hoped to stay at the University of Alabama-Birmingham's Huntsville Family
Medicine Residency. I've been here two years for
clinical training, and I wanted to stay here for residency. I know the faculty, the community and the hospital. It's a good school and a
I felt good about my chances of staying, but you don't know where you're going until you open that envelope. It's a big moment after four years of medical school and four years of college. This is your career, the rest of your life.
Fortunately, I got the news I had hoped for, and I'll be staying in Huntsville. Nearly 10 percent of my class matched to family medicine, and news was good for our specialty nationally, as well. The number of medical students choosing family medicine increased for the fifth year in a row, and the number of U.S. seniors matched to family medicine also increased.
Although the numbers were encouraging, we have a long way to go. Our country is facing a shortage of primary care physicians. And it's projected that within a few years, we will be graduating more medical students than the number of residency spots available. The system clearly needs work.
One thing that would help would be having more family physicians such as the one I shadowed back in my hometown. If you're a family physician with a passion for what you do, reach out to students in your area or from your alma mater and show them what you do. You just might give a future family physician their defining moment.
Tate Hinkle is the student member of the AAFP Board of Directors.
The Truth About E-Cigarettes: Unregulated, Unproven and Unhealthy
Here is a burgeoning twist to the tobacco wars and a new public health risk.
In a new television advertisement, electronic cigarettes are being touted as better than traditional cigarettes because the byproduct is "only vapor," not tobacco smoke. Consumers -- including children -- are being told that e-cigarettes are the “smart alternative” to smoking. The implication is that e-cigarettes are safe for the user and the people around them. The truth is the vapor from e-cigarettes contains carcinogens, including arsenic, benzene and formaldehyde.
|Here I am speaking at a news conference to address Chicago's ban on the use of electronic cigarettes in public places. Family physicians can make a difference in public health issues not only in our exam rooms but also through advocacy.|
A preliminary study recently presented at the Society for Research on Nicotine and Tobacco found that second-hand exposure to e-cigarettes can cause harm after the user has left the room or turned off an e-cigarette because nicotine released by the products leaves residue on indoor surfaces.
Tobacco companies have long tried to glamorize their deadly products, and now e-cigarette marketers are doing the same thing, including using high-profile celebrity endorsements.
But the marketers' unsavory tactics don't stop there. Although proponents will argue that e-cigarettes are tobacco cessation devices, the fact is that manufacturers are targeting the next generation of smokers by marketing their products to kids.
If you have doubts, ask yourself how many middle-aged men are reaching for the e-cigarettes that come in cotton candy and bubble gum flavors. Those clearly are intended for kids, and the percentage of middle school and high school students who have tried e-cigarettes doubled from 2011 to 2012.
That's a huge problem because the products aren't regulated, so the amount of nicotine and other chemicals can vary from cartridge to cartridge.
And those touting e-cigarettes as the "smart alternative" to tobacco are ignoring the fact that many consumers are doubling up, using both conventional cigarettes and their electronic counterparts. In fact, a CDC survey found that more than three-fourths of middle school and high school students who use e-cigarettes also smoke. A recent study in JAMA Pediatrics concluded that the use of e-cigarettes "does not discourage, and may encourage, conventional cigarette use among U.S. adolescents."
A recent survey of e-cigarette users found that only 12 percent were former smokers who use the electronic products exclusively. A study in JAMA Internal Medicine found that e-cigarette users did not quit with greater frequency than nonusers. In fact, among smokers who called a quitline, e-cigarette users were less likely to quit than nonusers.
It's also worth noting that poisoning incidents related to e-liquids increased 300 percent in the past year.
So what are we, as a society, going to do to counter a billion-dollar industry that is spending more than $20 million a year
The FDA was granted the authority to regulate cigarettes and other tobacco products in 2009, and the agency has been trying to gain similar control of e-cigarettes for years. Meanwhile, children are allowed to buy products that could adversely affect their health for the rest of their lives, and targeted advertising is unregulated.
We have a duty to protect those children and our communities, and if a product looks like a cigarette and contains nicotine like a cigarette, it should be regulated like one. So while we wait for the FDA to act nationally, we can advocate locally.
Here in Chicago, the Illinois AFP supported a city ordinance passed earlier this year that will subject e-cigarettes to the same sales restrictions as tobacco, and it also subjects the products to the city's Clean Indoor Air Act.
New York, Los Angeles and several counties across the nation also have implemented similar laws that ban the use of e-cigarettes in public places. Some states, including Illinois, prohibit the sale of e-cigarettes to minors. Legislation regarding sales restrictions and use in public places is pending in several states.
But legislators aren't the only ones who need to hear from family physicians about this health issue. Our patients are hearing about e-cigarettes from paid endorsers of the products on a regular basis, but what are we telling them?
Parents need to know that children are using these products, and there are numerous possible harms. Patients who are ready to quit smoking should be encouraged to use evidence-based methods that have been proven safe and effective.
Smoking rates for adults and teens are at historic lows. We must ensure that trend isn't reversed by misinformation and questionable marketing practices.
You can read the AAFP policy on e-cigarettes here. And to learn more about how to talk to your patients about e-cigarettes, the Illinois AFP, the AMA and the Chicago Department of Public Health recently offered a free webinar that is archived online.
Javette Orgain, M.D., M.P.H., is the Vice Speaker of the AAFP.
Academy Tools Could Ease EHR Burdens
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fifth post in an occasional series that will attempt to address the issues members raised -- including challenges associated with electronic health records systems -- during the panel.
Two years ago, my practice implemented an electronic health record (EHR) system. The initial results weren't pretty. Transitioning from paper to electronic files takes time, and my productivity plunged.
I worked at it, learned the system and my productivity has improved. Although
my patient volume has not yet returned to pre-EHR volumes, my clinic is running
much smoother than it did initially because my staff and I have adapted. We
have embraced this change, and the benefits have been numerous.
- We qualified for meaningful use stage one incentive payments, and we are working on stage 2, including the launch of a new patient portal. Those incentive payments helped offset the investment in the EHR and that initial dip in clinic volume.
- My practice previously had one full-time equivalent devoted to pulling and filing paper charts. Now, that information is at my fingertips whenever I need it.
- Our clinic system is spread across three communities, so one of the big benefits of the electronic system is being able to access records -- including labs and X-rays -- securely from any location, including our ER.
- A medication reconciliation process has made us more aware of what drugs patients are taking, which helps us avoid medication errors, interactions and duplications.
- We are developing disease registries that will allow us to track our patients, improve follow-up care and provide better care for patients with chronic conditions.
Health care isn't going back to paper records. This is where we are headed, but qualifying for meaningful use incentive payments can be challenging. That's why the Academy has included a step-by-step guide to meaningful use stage one in its new PCMH Planner, an affordable, subscription-based web tool designed to help practices -- particularly small practices -- transform to the patient-centered medical home model. A guide to stage two is expected be available in the PCMH Planner by the end of March.
The Academy created the PCMH Planner at the request of small practices that were asking for help with practice transformation. I recently saw a demonstration of the Planner, and it is an effective, evidence-based way to start the process of transforming a practice. The Planner also includes Practice Foundations for PCMH, a step-by-step guide to quality improvements and other tasks that should be completed before you begin practice transformation. PCMH 101, which covers the basics of becoming a medical home, will be available later this month, and PCMH 201, which offers more advanced topics, is expected to be available later this spring.
What else is the Academy doing to make EHRs easier to use and more effective? The Congress of Delegates has asked the AAFP to create a clinical data repository that would provide data to family physicians in way that is clinically relevant.
In a 10-practice pilot, we've created registries related to diseases, procedures, medications and lab results and provided the participating practices with analytics and comparison data against their peers. The system is capable of identifying potential gaps in care and patients who should be prioritized for outreach. It also provides revenue and cost efficiency metrics.
Although this is only a pilot, evidence to date indicates that it is working. We have found that the clinical data repository is technically feasible and capable of generating value for practices. The repository also could act as a national specialty registry, which would ease the reporting burden on family physicians by allowing us to report data to a single source.
A decision on how this concept might be rolled out to Academy members as a product likely will happen this summer.
And what about interoperability? When our patients leave our practice and go to another -- for a subspecialist consultation, for example -- my EHR won't necessarily be able to communicate with the subspecialist's EHR. This is a major flaw in our health care system, and the Academy continues to push the Office of the National Coordinator (ONC) for Health Information Technology and EHR vendors on this important issue. Unfortunately, vendors have little motivation to fix it because they want customers to buy their proprietary, unique products. It doesn't help that large health care systems aren't in the habit of sharing information with competing health care systems. Thus, interoperability likely remains at least five years away.
Meanwhile, the Academy is one of the sponsors of the nonprofit DirectTrust, which accredits services that allow physicians to exchange encrypted patient information through secure servers. You can read more about the direct exchange process here.
The AAFP is working to develop resources that save us time and money and reduce our reporting burdens. I'll keep you updated on our progress in these efforts.
Robert Wergin, M.D., is President-elect of the AAFP.
For This State Chapter, It Truly Is a 'Family Affair'
One of the characteristics that truly defines family physicians is that we recognize everything is about relationships. We certainly understand this when to come to our patients.
I worked with a medical student recently, and she was impressed by how much I knew about patients I hadn't seen for months. I told her that it's because we family physicians know our patients, and we value their stories. This is how we help take care of folks and how we put everything into context. It's one of the things that make family physicians special.
|Nevada AFP executive director Brooke Wong is her chapter's sole staff member, but her entire family helped the chapter's annual meeting run smoothly. Here, daughters Alexa, 9, and Kendall, 3, along with Bear Farrimond, 5, assist Jeffrey Ng, M.D., with a raffle drawing.|
We walk our talk in so many other ways, too. This relationship aspect is something I see regularly, and thoroughly enjoy, as I travel around the country and talk with Academy members. One of my responsibilities -- it's an opportunity, really -- as AAFP president is to attend state chapter meetings. Often, I am there to install new officers, provide educational opportunities and update members on what the AAFP is doing for them.
But I think what I am really doing is reinforcing the power of relationships. The connections I am making are phenomenal. Many of the physicians I see at chapter meetings are people I have met at other meetings because we often travel the same paths. However, each state chapter also has physicians who are not involved at the national level. These are the dedicated family physicians on the front lines who are often coming together for their own networking and education.
Behind all of this activity are the chapter executives who do outstanding work for their members. These are truly compassionate and remarkable individuals who help each chapter be the best version of what it can be.
I recently traveled to South Lake Tahoe, Nev., for the Nevada AFP's annual meeting. I was invited to the chapter's meeting last year, but I had to cut that trip short to make an unplanned, but very important, other meeting. I was thrilled that the Nevada AFP asked me and my wife, Alex, to come again this year. We were eager to get the full experience this time.
What was remarkable is that you would never know that this actually is a small chapter. A large number of people attended the very well-put-together CME sessions in a beautiful location. However, what was most powerful to me was how much of a family affair this event was. The moment I arrived, executive director Brooke Wong welcomed me into her bustling command center.
Brooke is a staff of one, but her family provided plenty of help to make the meeting run smoothly. Her young daughters helped with a silent auction. Her husband, Conrad, provided IT support and took photographs. He was everywhere, making sure that the CME came off without a hitch and documenting all of the events.
At registration, Brooke's mother and father greeted people with a smile, offered chocolate and signed attendees up for all of the various events.
As soon as we walked in, we were part of the Nevada AFP family. There is truly no better example of the power of relationships than what occurs at these chapter meetings.
Thanks to all of the chapters I've had a chance to visit, and I look forward to those coming up. It is an incredible opportunity, and I value being a part of each of your families.
Reid Blackwelder, M.D., is president of the AAFP.
Barriers Impede Telemedicine's Potential
Editor's note: During the AAFP's Scientific Assembly in San Diego, a panel discussion on practice transformation generated far more questions than the panelists could answer in the time allotted. This is the fourth post in an occasional series that will attempt to address the issues members raised -- including payment for telemedicine -- during the panel.
We know that telemedicine, the use of technology to deliver care at a distance, has the potential to expand access to care in underserved areas, reduce ER visits and save patients time. Questions remain, however, about how we can best expand telemedicine's use in primary care.
Telemedicine already is used in subspecialty care, including dermatology and radiology. But in our current fee-for-service model, can telemedicine be integrated into primary care without significantly increasing health care costs?
| Kimberly Becher, M.D., left, the resident member of the AAFP Board of Directors, accompanied me on a trip to Capitol Hill while I was a visiting scholar at the AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care. I interviewed more than a dozen representatives of federal government health agencies and congressional staff about telemedicine for my project.
recently spent a month in Washington researching telemedicine and the barriers
to its expansion as a visiting scholar at the Robert Graham Center for Policy
Studies in Family Medicine and Primary Care. Participating in the Larry A.
Green Visiting Scholars Program was an invaluable educational experience, and I
acquired skills that will help me for the rest of my career. The Graham Center
staff provided me with in-depth training on research, including how to plan a
project from beginning to end, proposal writing, information and data
gathering, manuscript writing and more.
The training actually started months in advance as I worked with Graham Center staff to define what my project would be so that I could hit the ground running when I arrived in Washington for one month of intense work.
I picked telemedicine as my topic, in part, because the Graham Center was already in the midst of a research project on the subject. Funded by a $200,000 grant from WellPoint, the project produced a literature review, a report from the meeting of an expert panel, and -- coming later this year -- a survey of AAFP members about our knowledge and use of telemedicine.
It is hoped that the member survey results and my manuscript will be published in peer-reviewed journals. The Academy also intends to share the report from the expert panel.
For my project, I interviewed 14 representatives from government health care agencies and congressional staff to gauge their understanding of telemedicine and to identify barriers to its expansion in primary care and what is required to move beyond those barriers.
Barriers, it turns out, are not in short supply. One of the biggest issues is payment because of the constrained rules that exist in the current payment systems. There are certainly ways that telemedicine can be integrated into care delivery now, but I hope with alternative payment models on the horizon -- where physicians are paid based on quality and value -- we will see more physicians use it to deliver care at a lower cost for their patients.
Reimbursement for telemedicine services vary widely by payer and state. Ten states require Medicaid coverage of telemedicine, and 43 states require Medicaid coverage for some telemedicine services. Eighteen states mandate private payer coverage for telemedicine, and 14 other states have legislation pending.
But telemedicine is complicated in many other ways. According to the American Telemedicine Association, more than half the state legislatures are considering bills related to telemedicine. One of the most prevalent issues is licensure.
In Florida, for example, the state medical association has said that it supports the expansion of telemedicine, but the association is lobbying against a bill that seeks to create statewide standards and establish reimbursement requirements for telemedicine. The association is fighting the bill, which also would create a system for registering out-of-state physicians, because it opposes the idea of physicians licensed in other states treating Florida patients via telemedicine.
That's a significant issue in Florida because of the annual migration of people who spend the winter months in the Sunshine State.
What's at stake? A nonpartisan, nonprofit public policy research institute released a report this month that said reducing costly interventions, such as ER visits, by as little as 1 percent could reduce the state's health care costs by $1 billion a year.
Among my interview subjects, there was broad recognition that telemedicine is an important issued related to access to care. But another barrier we must overcome is that many rural and underserved parts of country still don’t have access to broadband internet. That's important because although the "tele" in telemedicine might prompt people to imagine a physician on a telephone, there's much more to it. Telemedicine can involve video conferencing with a patient from his or her home, electronic monitoring of chronic conditions and so much more. The fact that telemedicine means different things to different people could be a barrier as well. There's no consensus on what the term actually means.
That's unfortunate because more than 50 percent of U.S. hospitals already are using telemedicine in some manner. Incorporating the use of this technology in care delivery is happening, and it will continue to expand, so we have to figure out how it fits in primary care.
A good step forward would be finding a way to expose medical students and family medicine residents to telemedicine. I'm a fourth-year medical student and have yet to experience it. Medical school and residency is where we get our feet wet, and the models we train in influence how we will practice later.
We have the technology and the ability to extend ourselves, improve access to care and save our patients time and money, but there are many questions left to answer. I hope that when the Graham Center's survey lands in your in-box later this year, you will take a few minutes to give us your thoughts on telemedicine. The more people who participate in this important survey, the more valuable our data will be.
How Family Medicine Upstaged Ben Affleck
It's not an everyday occurrence when a family physician proves to be a bigger draw -- at least for a few minutes -- than a two-time Academy Award winner. But that was the case last Wednesday when Sen. John McCain, R-Ariz., stepped out of a Senate Foreign Relations Committee hearing (where Ben Affleck was testifying about issues in the Congo) to talk with me about the sustainable growth rate (SGR) formula and the need to extend funding for teaching health centers.
The AAFP Board of Directors was meeting in Washington, but we made time in the agenda to talk to our own legislators about these critical issues. I had met with McCain's staff several times in previous trips to our nation's capital, but this was my first visit with my state's long-time senator. The meeting was quite encouraging. In fact, McCain was one of nearly two dozen members of Congress who agreed to co-sponsor the SGR Repeal and Medicare Provider Payment Modernization Act last week.
The bipartisan legislation introduced last month in the House and Senate would permanently repeal the SGR and enact reform that would support improvements in health care delivery. If Congress doesn't act before March 31, the SGR would cause Medicare payments to physicians to be cut by 24 percent.
It's easy for individuals to think they can't make a difference against huge challenges like this one, but the reality is that legislators might not even be aware of a problem unless a constituent is willing to bring it their attention. That was the case with the issue of teaching health centers -- or the lack of them -- in Arizona.
Fewer than half of the states have teaching health centers, and Arizona is one of those on the outside looking in. Sen. McCain wasn't aware of that shortcoming. But when I told him about the benefits of teaching health centers and why funding should be extended beyond 2015, he wanted to know more. I will certainly follow up with his staff to make sure he understands the value and importance of teaching health centers.
Arizona, a state with 6.5 million people, has only eight family medicine residencies, including the University of Arizona Family Medicine Residency Program where I am an associate professor. Adding a teaching health center would be a huge step in the right direction, ensuring family medicine becomes a more vigorous force in health care delivery.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Future of Family Medicine 2.0 Gathering Information, Insights
Last fall, the Family Medicine Working Party launched an initiative to define the role of the 21st century family physician and ensure that our specialty can deliver the workforce to perform this role. Here is the latest update on the progress of this important project.
Family Medicine for America’s Health: Future of Family Medicine 2.0
Organizational Update No. 6
We are entering the final months of the Family Medicine for America’s Health: Future of Family Medicine 2.0 initiative. As a reminder, the purpose of this effort is to develop a multi-year strategic plan and communications program to address the role of family medicine in the changing health care landscape. To read earlier monthly updates from FFM 2.0, please visit the project web page.
In February, the FFM 2.0 Steering Committee and Core Teams held a retreat that included approximately 60 members of the family medicine community and 40 external stakeholders, including payers, patient advocates, employers and providers outside of family medicine. The purpose was to seek a range of perspectives as we narrow in on the strategic commitments of family medicine for the next five to seven years. Although there is still much work to do, our Steering Committee came away energized by two realizations. First, although retreat participants did not always agree on tactics, they are very much in agreement about the need for change to improve health outcomes and lower health care costs in this country. Second, because of the alignment around this purpose, the time is right to explore how family medicine can collaborate with others in the health care ecosystem to bring about the changes in primary care we all seek.
In addition to the stakeholder
retreat, we hosted our first of three virtual town hall meetings to hear from
practicing family physicians and family medicine educators, and to inform them
about the work done to date. More than 225 individuals joined this town hall
meeting. The wide-ranging conversation touched on issues related to practice,
education and payment for primary care. An
archived version of this first town hall meeting is available
There will be two additional virtual town hall meetings: 8 p.m. EST on March 5 and 8 p.m. EST on March 26. You can register for the March 5 event by clicking here.
Following is an update on the progress and status of the FFM 2.0 project:
CFAR, the consulting firm leading the strategic planning process, is now in the process of analyzing the output of the strategy retreat and working with members of the Core Team on a set of recommended strategic commitments. CFAR also will continue to work with the members of the Insight Groups to test the rationale for these strategic commitments and their corresponding tactics. The Insight Groups include medical students, residents and young leaders in family medicine who are in the early years of practice. The Steering Committee then will review the recommended strategic commitments in April.
APCO Worldwide, which is leading the communications planning, has completed the quantitative research elements of the project. (Please see update No. 5 from January for more information on the results of the opinion survey). APCO has developed broad concepts that define the external understanding of family medicine. These concepts focus on defining family medicine within the context of primary care and demonstrating the overall value of a system based on comprehensive primary care. APCO will test its concepts in a series of focus groups. Once themes and messages are defined, APCO will develop a comprehensive communications plan aimed at reaching two key audiences: consumers and policymakers/influencers.
Seeking Your Input
Your feedback is critical to this process. We welcome and encourage your comments and questions and have a dedicated email address for input. Since our first report on this initiative, we have received hundreds of comments to this address -- all have been very valuable to the Steering Committee and Core Team.
Please continue sharing your thoughts at firstname.lastname@example.org.
Jeff Cain, M.D., is Board Chair of the AAFP.
Primary Care Education at Forefront of Obama Budget Proposal
Washington, D.C., is always an exciting place to be, but it especially was for me this week because the AAFP Board of Directors is meeting here to advocate for our members and improved health care for all Americans. But today was an even better day than I expected. As we gathered this morning before our meeting, we were encouraged by some good news in USA Today.
For months, the AAFP has been working with the White House and the Health Resources and Services Administration (HRSA) to address the need for increased funding in graduate medical education (GME). Today, information provided by the White House Office of Management and Budget reveals that there will be some good news for primary care Tuesday when President Obama releases his 2015 budget.
Specifically, the document released by the Office of Management and Budget to USA Today (and later shared with the Academy) says the Administration plans to budget an additional $5.23 billion during the next 10 years to train 13,000 more residents in primary care "and other physicians in high-need specialties." The document does not specify what those high-need specialties are, but last year the Council on Graduate Medical Education (COGME) called for increases in GME funding in "high priority specialties," including family medicine, geriatrics, general internal medicine, general surgery, high priority pediatric subspecialties and psychiatry.
The AAFP has long advocated that our country put more resources into graduating more medical students into primary care to meet the workforce needs of our country as our population continues to grow, as it continues to age, and as more patients get health insurance because of health care reform. This proposed budget speaks directly to this need.
Additional residency positions in primary care also are needed to keep pace with the opening of new medical schools and expanding medical school class sizes. COGME recommended that Congress continue funding existing GME positions and increase funding to support 3,000 more graduates per year. The President's budget would take a step in the right direction, providing additional funds through HRSA to train an additional 1,300 residents per year in high-need areas, including rural areas. It is critical, however, that any such increase that is implemented must ensure a majority of these positions be in primary care: family medicine, general internal medicine and general pediatrics.
Reinforcing this need, the document says residencies vying for the additional slots would have to demonstrate that they "train and retain physicians in primary care and use team-based models of care that enable all providers to work at the full extent of their abilities, and adopt new models of care, such as the patient-centered medical home or accountable care organizations."
It is important that we identify and finance training sites that may be outside the traditional hospital setting. The budget document says that for the new competitively awarded residency slots, priority would be given to hospitals and other community-based health care entities.
National Health Service Corps
One proven way of getting physicians into primary care is through the National Health Service Corps (NHSC). During the past several years, we have seen important growth in this program. The number of physicians serving in the NHSC has more than doubled during the current administration, from 3,600 in 2008 to 8,900 last year. The President's proposed budget would provide $3.95 billion in mandatory funds, expanding the number of NHSC health care providers in underserved areas to 15,000 each year from 2015 through 2020.
The AAFP has strongly supported growth in the NHSC, which offers scholarships and loan repayment assistance to support qualified family physicians and other health care professionals who are willing to work in communities across the country that are designated as health professional shortage areas. The program makes it easier for students to choose primary care careers without facing insurmountable debt and helps address critical access issues by placing new physicians in areas where they are needed most.
The AAFP has been advocating for the increase of Medicaid payment rates to Medicare levels for more than four years. The proposed budget would extend increased Medicaid parity payments for primary care services through 2015 at an estimated cost of $5.44 billion.
We thank the administration for this proposed increase, and look forward to working with Congress to extend these increased rates for five years to create a period of access stability as our members continue to transform their practices to more effective patient-centered medical homes, and as we transition away from payment models that pay for volume to models that pay for value.
It's important to remember that Tuesday's announcement will be regarding a proposed budget. These specific proposals from the White House directly address the workforce needs of our country, and would help produce the critically needed primary care physicians Americans need and deserve. We are eager to continue our discussions with this administration and Congress to work to achieve these outcomes.
Much work and debate will remain before it is finalized, but this proposed budget is an important step forward as it is a real and meaningful investment in primary care. It represents recognition of the foundational role that primary care must play in our transforming health care system. The AAFP stands ready to help ensure that all Americans get the right care from the right person in the right place at the right time.
Reid Blackwelder, M.D., is President of the AAFP.
Stories of Successful Underdogs Resonate With FPs
I read my first Malcolm Gladwell book more than 10 years ago when a fellow family physician gave me a copy of Tipping Point: How Little Things Can Make a Big Difference, at an AAFP commission meeting. Since then, I've read Gladwell's Outliers, Blink and What the Dog Saw.
I recently read the author's newest book, David and Goliath: Underdogs, Misfits and the Art of Battling Giants. In this book, Gladwell tests the reader's perception of what obstacles and disadvantages create apparent setbacks in life. His examples include the titular bible story, the dynamics of successful and unsuccessful classrooms and the thought processes of cancer researchers.
As I was reading, I kept thinking about family medicine, the apparent underdog in the playing field of medicine. David, who was skilled with a slingshot, faced Goliath, a man who clearly suffered from an endocrinopathy but who was big in stature and strong.
Family medicine has the right stuff. We are bright and strategic. But unlike the original story, there are many Goliaths on our battlefield, and this is distracting and time consuming, especially when we would rather focus on the things most important to us such as our patients, families and communities. How do we fight the many giant challenges -- dealing with payers, adapting to regulations, etc. -- that stand in our way?
In an interview with INC. magazine, Gladwell said, "Effort is the route available to the underdog. I may not be able to outspend you, but I can outwork you."
Gladwell's David and Goliath has a chapter about people who have been successful despite having dyslexia. Gladwell's theory is that if a task is made slightly harder, a person may learn better because he or she will be forced to concentrate more and is likely to read something multiple times instead of just once.
Family physicians certainly know about hard work. The amount of work required to become a family physician is significant -- 21,000 hours of standardized education and training, including exams overseen by a single certification body.
No one can truly replace us, although others are desperately trying to claim that they can. Gladwell makes a case for the proper number of students in a classroom to make learning optimal. Similarly, we are making a case for the number of hours of training required to provide primary care. Nurse practitioner (NP) training, in particular, ranges from 3,500 to 6,600 hours, and the clinical aspects of their education and training vary tremendously. Each of their three accrediting organizations has their own criteria for certification.
And yet, there are those who claim NPs and physicians are interchangeable. How can this be? Family physicians are the best medicine that the system has to offer.
But where is the best place to be standing in today's times? Should we position ourselves in the midst of the Goliaths who would prefer us to quietly do our work and not cause a fuss? Or do we steer clear of these challenges and let others decide our fate?
Gladwell observes that in many instances, underdogs can prevail with hard work and strong will. As modern day Davids, we, as family physicians, must strategically place ourselves where we can do the most good for the most people. Gladwell writes that while you are working on changing the game, you also have to make sure that you get the most out of the rules that already exist. That is exactly what the AAFP is trying to do. For example, the Academy continues to stay involved with the flawed AMA/Specialty Society Relative Value Scale Update Committee (RUC) rather than being absent from the table and having no voice at all. However, we also are advocating directly to CMS about payment issues.
And although it can be extremely frustrating, we continue to have regular meetings with the nation's largest private payers because it gives us an opportunity to work on common issues while promoting the value and importance of primary care.
We, the family physicians who are strong medicine for America, must emphasize our unique ability to listen, understand and help our patients, offering our valuable time and resources. We must be the brave David and use all our resources to stay in the game and win the fight.
You can learn about being an advocate for our specialty -- including a day of training and a day of lobbying on Capitol Hill -- at the Family Medicine Congressional Conference April 7-8 in Washington. I hope to see you there.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Building the Family Medicine Pipeline
When I was running for AAFP President-elect, I said during a question-and-answer session at the Congress of Delegates that I would try to say yes to every opportunity that came my way. This can be daunting because there are so many opportunities to represent the Academy each week.
However, being president truly is a once-in-a-lifetime experience, and I have tried hard to follow through on my promise. I do everything I can to jump at invitations from state chapters, to medical student functions and other opportunities to meet with AAFP members all over the map.
|Family Medicine Interest Group advisers discuss ways to increase student interest in our specialty during a recent meeting in Nashville, Tenn.|
I recently had one such opportunity on my way back from the Nevada AFP meeting. I was invited to stop in Nashville, Tenn., to be a part of a dynamic workshop for Family Medicine Interest Groups (FMIG) faculty advisers. This leadership summit was an opportunity to bring together medical school and residency faculty and staff from all over the country who serve in adviser or support roles to the student-run FMIGs at their own or an affiliated medical school. One of the most important reasons for doing so is to develop relationships and create a sense of family in this group.
There is a significant turnover in this group because the role of student group adviser often falls to the newest faculty member in a department. In fact, many of the folks present had been involved with their FMIG's for less than a year. This makes it important for us to bring people together so we have an exchange of information as well as support systems for this incredibly important work.
FMIG's are remarkable. There is a great deal of direct student leadership involved for each medical school's group, with a select group of medical students elected or appointed to serve in roles to connect and coordinate between FMIGs. The AAFP recently selected its 2014 FMIG Network Regional Coordinators, who hail from Arizona, Illinois, Missouri, Pennsylvania, and Washington, D.C. These dedicated students work tirelessly to share information with FMIG student leaders at each institution and to provide opportunities for those leaders to connect and share best practices, much like what was done at the FMIG Faculty Adviser Summit.
The advisers all play different roles in this process, depending on their institution, environment and engagement of leaders. They have the responsibility for finding ways of sharing the excitement and passion for family medicine with students during their first two years of medical school, through the FMIG and other department efforts.
Most FMIG's are mainly made up of, and led by, first- and second-year students. Third-year students are on their clinical rotations and have less free time, and fourth-year students have often already committed to specialties. The group of advisers focused some of its discussion on how to keep third- and fourth-year students engaged in FMIGs to help support a family medicine specialty choice among the third-years and to use the fourth-years as mentors for the junior students.
This is a huge and critical aspect of addressing our pipeline challenge. The more we can tell medical students about the joys of family medicine, the more we may maintain their interest as they begin choosing specialties. In these challenging times, the message that our country truly needs primary care physicians is one that medical students need to hear, alongside the message of what's in it for them, which is the opportunity to have the greatest impact on population health and a specialty that provides variety, excitement and deep patient relationships.
This meeting allowed us to discuss the frustrations and the opportunities of a rapidly changing health care system and environment. I promised to take what I heard from the advisers back to the AAFP Board of Directors to help inform our deliberations related to developing our workforce pipeline.
I hope all of our active members work with medical students when given the opportunity. When students are early in their training, they are eager to see true patient encounters. At the same time, we have to recognize how impressionable students are. We need to make sure that our love of our patients and our thankfulness for the opportunities to answer our calling is what comes through. The more we do this, the more students will see that no other specialty creates the opportunities to get to know patients, make a difference and to truly impact families the way family medicine can.
Active AAFP members who would like to be connected with an FMIG faculty adviser at a medical school in their area may contact student interest strategist Ashley Bentley. Thanks for being a part of the learning process.
Reid Blackwelder, M.D., is President of the AAFP.
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