The Center for the History of Family Medicine: At First, I Didn't Care Either. But Now I Get It
Probably like many of you, I don't think about history much. Between the responsibilities of my practice, my family and my service to the Academy and its members, I just don't have a lot of time to study the past.
So when I was appointed recently as the Academy's representative to the Board of Curators of the Center for the History of Family Medicine, I did not know what to expect. As the principal resource center for the collection of the specialty's history, the center struck me as a dull abstraction at best and at worst, a waste of time, space and money. With all of the many issues and challenges facing our specialty, it just didn't seem important to me.
Photo courtesy the Center for the History of Family MedicineArthur "Lud" Ludwick Jr., M.D., won the Silver Star while serving as a physician on the frontline during World War II. Ludwick is one of the many physicians whose stories are told through the Center for the History of Family Medicine.
But then I came to the center and saw it for myself. And now I get it.
The center is much more than just a place where old papers are stored. It is the collective memory of family medicine.
Told through its many documents, photographs, videos and artifacts, the story of our specialty is one of hardship, struggle and, ultimately, triumph. It begins in 1947, when a group of general practitioners -- facing the almost certain extinction of general practice -- formed the organization that we know today as the AAFP. It's a story worth remembering as we venture into the future and turn our sights to addressing the challenges and opportunities ahead through the Family Medicine for America's Health project.
But fundamentally, the story of family medicine is a story about people. It's a patchwork of the intensely personal stories of the many GPs and family docs who, throughout the history of our country, have served on the frontline of American medicine, caring for patients in wartime and in peacetime, and from birth to death.
Take for example, the story of Arthur "Lud" Ludwick Jr., M.D., who won the Silver Star for "gallantry in action" while serving as a GP on the Italian frontline during World War II and then went on to have a long and distinguished career practicing in Wenatchee, Wash.
Or the story of Olin Elliott, M.D., of Des Moines, Iowa. Described by one colleague as "a delightful, well-rounded doctor, loved and respected by patients, colleagues, family and acquaintances alike," Elliott was renowned for his compassion and dedication to his craft. In 1957, when his wife was diagnosed with amyotrophic lateral sclerosis, he became her primary caretaker while still continuing his medical practice, providing her with medical treatment until her death. In later years, Elliott volunteered at a clinic for the homeless in Des Moines, and even after being diagnosed with pancreatic cancer in 1981, he continued to care for his patients up until the day of his death the following year.
Or, more recently, the story of Regina Benjamin, M.D., M.B.A., a family physician from the small fishing village of Bayou La Batre, Ala., who went on to become the 18th surgeon general of the United States.
All of their stories -- and the stories of many others -- are told through the center's collections.
And there are practical applications for the center's holdings, too. An important educational resource for the specialty, each year, the center sponsors both a research fellowship and an internship program. The information contained in the center's collections helps us understand -- and hopefully avoid -- the mistakes of the past, thus saving us time and money that might otherwise have been spent trying to reinvent the wheel. It also plays an important role in advancing our specialty by supporting and enhancing public relations and marketing efforts through interesting and informative exhibits.
In short, the center allows us to make a direct and vital connection between family medicine's distinguished past and its exciting future.
So now I get it. And I hope that you will have the opportunity one day to visit the center -- either in person at the Academy's Leawood, Kan., headquarters or through its website -- and discover this for yourself.
After all, in the words of author and historian Theodore Draper, "If history can teach us nothing, we have nothing that can teach us."
Robert Lee, M.D., is a member of the AAFP Board of Directors.
Primary Care: Defending What it Means and What It's Worth
Medicaid cuts are coming.
Section 1202 of the Patient Protection and Affordable Care Act increased Medicaid payments to Medicare levels for certain primary care services in 2013 and 2014. But unless Congress acts during the lame-duck session, Medicaid parity paymentsfor primary care physicians will stop, and payments will return to 2012 levels on Jan. 1.
This issue was debated in depth during the recent AMA Interim Meeting in Dallas. This was an important discussion because there is disagreement within the AMA about what constitutes primary care. In fact, many of our subspecialist colleagues claim that they provide primary care -- and therefore should qualify for parity payments -- because of their involvement in the management of certain diseases such as Parkinson's, diabetes and cancer.
|Jerry Abraham, M.D., M.P.H., of Los Angeles, and Joanna Bisgrove, M.D., of Fitchburg, Wis., represent the AAFP at the AMA Interim Meeting. Abraham, a first-year resident at the University of Southern California, was elected an alternate delegate to the AMA's Resident Fellow Section. Bisgrove is the AAFP delegate to the AMA Young Physicians Section.|
The globally accepted meaning of primary care, however, comes from Barbara Starfield, M.D., M.P.H., who defined it as "first contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system." From the AAFP perspective, only family medicine, general pediatrics and general internal medicine are the specialties that train physicians to deliver true primary care. Other specialty physicians might from time to time deliver certain services described as primary care, but they are not trained to deliver comprehensive primary care.
Although some subspecialty groups at the meeting attempted to change AMA policy regarding who should get Medicaid parity payments -- if they, in fact, continue -- the Academy's delegation was able to prevent action by the AMA House of Delegates that would have expanded the Medicaid parity payments well beyond their initial focus on primary care physicians only. This means that the AMA's support for proposed legislation that would extend parity payments for two more years will continue.
Next to repeal of the sustainable growth rate (SGR) formula, this is the most crucial piece of health care legislation the AAFP is focused on for passage during the lame-duck session. The continued cohesive voice of organized medicine on this issue represents an important success.
In addition to Medicaid parity, the AAFP's delegation also testified on other important issues, such as the significant threat to our patients and our members from the increasingly troubling network narrowing that we see impacting practices in more and more states. The AMA recognized that this is a significant challenge, and resolutions were moved forward to address this directly.
It's worth noting that the AAFP, the AMA and more than 100 other organizations recently sent a letter to the National Association of Insurance Commissioners voicing support for model legislation that would serve as a template for revising state provider network adequacy standards.
With strong AAFP support, AMA delegates also passed a resolution asking CMS to halt penalties related to meaningful use (free registration required) and look for ways to continue to incentivize use of electronic health records.
In addition, recognition of the changing landscape in terms of telemedicine was also a focus during the meeting. Related resolutions moving forward are consistent with ones we have acted on in the AAFP's Congress of Delegates.
The AAFP has one of the larger specialty society delegations to the AMA. Moreover, many of the 115,900 Academy members our delegation represents are themselves AMA members. These are dedicated family physicians who advocate for their patients and their communities through involvement with their state medical societies. Having more family physicians from different backgrounds at the AMA creates exciting opportunities for us as we continue to try to find a way to move the house of medicine in a coordinated fashion to recognize and value family medicine and primary care.
Over the years, our delegation has gained a stronger presence within the AMA as we continue to work to inform our discussions and share AMA policies. This is helped by the fact that there are five AAFP members who are on the AMA Board of Trustees:
- Past Chair David Barbe, M.D., M.H.A., of Mountain Grove, Mo.;
- Chair-elect Stephen Permut, M.D., J.D., of Wilmington, Del.;
- Gerry Harmon, M.D., of Pawleys Island, S.C.;
- William Kobler, M.D., of Rockford, Ill.; and
- Albert Osbahr III, M.D., of Hickory, N.C.
The Academy greatly values the relationship we have developed with these leaders of the AMA, and we look forward to more opportunities to work together. Your delegation is quite well respected within the house of medicine and is led by Joseph Zebley, M.D., of Baltimore, and co-chair Daniel Heinemann, M.D., of Sioux Falls, S.D.
Recently, we have been blessed by an influx of dynamic family physicians who are early in their careers. This year, our delegation included Uniformed Services chapter member Janet West, M.D., of Pensacola, Fla.; Aaron George, D.O., a third-year resident at the Duke Family Medicine Residency in Durham, N.C., and Ajoy Kumar, M.D., of St. Petersburg, Fla. In fact, we had many people from other delegations praise our organization for being able to bring younger voices to the table.
An impressive accomplishment for our delegation during this meeting was that Jerry Abraham, M.D., M.P.H., of Los Angeles, one of our resident members, was elected as an alternate delegate to the AMA's Resident Fellow Section. A first-year resident at the University of Southern California, Abraham will be sitting in the House of Delegates this summer during the AMA's Annual Meeting. This speaks well to his leadership skills not only within the AAFP but also the AMA.
The Academy continues to work for our members and our patients in every venue we can. The AMA meeting is certainly a different body and culture from our AAFP Congress of Delegates; however, the issues discussed at AMA directly impact our patients, our communities and our members. Thanks to all of the family physicians who are involved in the AMA. This is another important avenue for advocacy, and we appreciate your efforts. As they say at the AMA, together we are stronger!
Reid Blackwelder, M.D., is Board chair of the AAFP.
Exposing Students to Rural Health Key to Producing Rural Docs
Less than half an hour from the U.S.-Mexico border, the tiny town of Patagonia, Ariz., lies nestled between a sprawling state park and a massive national forest. Although I was born and raised in Tucson and started my practice there, I came to Patagonia in the 1990s when I was offered the opportunity to work at the small town's federally qualified health center.
Why would a big-city physician leave home to come to a town that was literally 1,000 times smaller?
I liked the idea of practicing full-scope family medicine. I liked the challenge of doing more with fewer resources, putting pressure on myself to become a better clinician. And I wanted the chance to develop true, close relationships with my patients. I got all that in Patagonia because in a town of less than 1,000 people, it didn't take long to become a vital part of the community. I stayed for 13 years.
Photo courtesy Chandra TontschUniversity of Arizona College of Medicine student Chandra Tontsch, right, completed a family medicine rotation in Lakeside, Ariz., with preceptor Elizabeth Bierer, M.D. The college places medical students in rural settings in hopes that they will later choose to practice in underserved areas.
In 2006, the University of Arizona recruited me to teach rural health in Tucson. Earlier this year, I took on the role of director of the university's Rural Health Professions Program. Although I am no longer providing rural health care as an individual physician, my goal is to show medical students the rewards this area of medicine offers and hopefully draw more of them to this important practice setting.
More than 20 percent of the U.S. population lives in rural areas, but rural physicians account for only about 10 percent of the physician workforce. Compounding the problem is the fact that many of the physicians practicing in these areas are approaching retirement and not enough young physicians are stepping up to take their place. In fact, less than 5 percent of physicians who graduated from medical schools from 2006-08 went on to practice in rural areas.
At the state level, as much as one-third of Arizona's population lives in primary care health professional shortage areas. The state has more than 140 primary care shortage areas (including some inner-city areas), and it has been estimated that Arizona would need more than 300 additional primary care physicians to address the problem.
In our Rural Health Professions Program, 22 students are selected at the end of their first year and placed in rural settings, primarily working with family physicians. During their third year, students are required to complete a clinical rotation in a rural setting in family medicine, internal medicine, pediatrics, obstetrics, or surgery. (Many do more than one rotation in rural areas.) Finally, during their fourth year, students are encouraged to go back to rural settings for a four-week preceptorship, and roughly three-fourths of them do. It's worth noting that the university's Phoenix campus runs its own similar program.
One of the challenges in my new role will be tracking outcomes to see how many of our graduates are practicing in rural areas. In the past few years, we have added a number of new physician preceptors who participated in the Rural Health Professions Program as students. Having been through the program, they can provide good mentorship to new students and encourage them to stay on this path.
Students who have questions about rural health may be interested in an American Medical Student Association webinar that (then) AAFP President-elect Robert Wergin, M.D., of Milford, Neb., participated in last month during National Primary Care Week.
Finally, the AAFP created member interest groups earlier this year as a forum for family physicians to share their mutual interests and address common concerns. One of the six groups that has already been established focuses on rural health. You can learn more on the AAFP website.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
So You've Achieved PCMH Recognition. Now What?
Last year, my health care system -- which has seven hospitals in the Kansas City, Mo., metro area -- received National Committee for Quality Assurance (NCQA) Level 3 patient-centered medical home (PCMH) recognition for 12 of its primary care locations. We set an ambitious goal and realized it within two years.
Now, having met all the NCQA's PCMH criteria, what happens next? Is that the end of the story?
Photo by Dean Shepard
I talked with more than 200 of my health system's physicians during our patient-centered medical home summit. Twelve of our 14 primary care locations have earned National Committee for Quality Assurance (NCQA) Level 3 PCMH recognition.
For us, it's not. The two remaining primary care locations in our system are now starting the PCMH process. For the other 12, we're continuing to transform our practices to enhance care. One example of that ongoing transformation is the new electronic health records system being implemented across all our locations. The change will enhance our ability to manage population health because an upgraded registry function will allow us to better track and manage patients with chronic diseases such as diabetes.
Before we began our path to PCMH, we didn't have a registry at all. We didn't know how many patients with diabetes we had, let alone how many needed additional care. Now we can be proactive, rather than reactive, and we are establishing protocols for reaching out to patients when appropriate.
Team-based care will help us get this done. A year ago, care coordinators didn't exist in our health system, but now most of our primary care locations have one, and we are in the process of hiring more. This is expected to improve care transitions.
To implement this kind of sweeping change, buy-in from physicians and staff is extremely important. I've been encouraged to see that our system's subspecialists are equally enthused and intrigued about how the changes we're making can improve care. They have been eager to learn how we can work together to enhance care coordination.
In fact, we recently brought PCMH advocates Paul Grundy, M.D., M.P.H., and John Bender, M.D., to Kansas City to share their insights. More than 200 of our physicians -- both primary care and subspecialty physicians -- turned out for a PCMH summit.
Grundy, who is IBM's director of global health care transformation and founding president of the Patient-Centered Primary Care Collaborative, encouraged us to see the big picture and embrace it. Specifically, he stressed that managing data is critical in the PCMH because it allows you to manage populations and perform chronic disease management.
Bender, CEO and medical director of Miramont Family Medicine in Fort Collins, Colo., shared the story of how transforming his practice made it more efficient and more profitable and decreased emergency department visits, admission rates and readmission rates.
In short, we are preparing for the future of primary care delivery by utilizing data and exploring new and emerging technologies, while also maintaining our relationships with patients.
If you are actively transitioning your practice to the PCMH model, or simply pondering how to get started down the path to improving patient outcomes, the AAFP has resources that can help. Check out the new set of PCMH checklists and the PCMH Planner, which each reflect three levels of improvement work that can help you find ideas for what to do next, no matter where you are in your practice transformation work.
Michael Munger, M.D., is a member of the AAFP Board of Directors.
California AFP's Success Shows What Chapters, FPs Can Accomplish at State Level
It's that time of year again. For the past 15 years, by the end of October, I would start counting the wins and losses of my favorite college football teams in preparation for the Bowl Championship Series that crowns a national champion. However, with the introduction of a long overdue college football playoff this season, polls and computer rankings are no longer quite as compelling. Although I've been enjoying some great football games, I've been tracking and counting something even more interesting instead.
Like many of you in your own states, I also advocate on health care issues in my home state of California. As the legislative session comes to an end for the California State Assembly, the California AFP's record is pretty impressive. Of the CAFP's 19 priority bills, Gov. Brown signed 17 of them this year. Among the victories for CAFP were budgetary expansions for primary care workforce training and the elimination of a retroactive 10 percent reduction in California Medicaid (Medi-Cal) provider payment to the tune of more than $42.1 million.
Other Medi-Cal related wins include the creation of an oversight body for children's health, streamlining enrollment, and expansion of enrollment eligibility categories. New laws will also require Medi-Cal managed care plans to provide interpretation and translation services to their participants. Several new pieces of legislation will strengthen team-based care by allowing physician assistants to certify claims for disability, authorizing medical assistants to handout labeled and prepackaged medications after consulting with appropriate health care professionals, and requiring schools to provide emergency epinephrine auto-injectors.
On the workforce front, in addition to increased funding for primary care training, new legislation has cleared the way for graduates of accelerated and fully accredited medical education programs to become licensed physicians in California.
Hard work by CAFP staff and members culminated in the passage of a resolution regarding patient-center medical home (PCMH) definition. For the past six years, this piece of legislation was kicked about by some as leverage for their own political ambitions. In previous sessions, it had been snatched from the jaws of victory by last-minute legislative maneuvering and was dismissed by the governor as an "evolving concept."
Just as with any successful football team, team work made the difference in getting it done this time. CAFP enlisted and energized attendees of its All Member Advocacy Meeting by focusing them on passing priority legislation. We trained an army of family physicians to become expert patient advocates on PCMH issues. In addition, contributions to FP-PAC, California's family medicine political action committee, opened doors for our well-trained grassroots advocates to meet with influential legislators.
Furthermore, 2014 was declared "The Year of the Family Physician" in California when a resolution sponsored by CAFP passed the legislature. The hashtag #2014YearFP was a Hail Mary idea dreamed up by Ron Fong, M.D., M.P.H., at the University of California-Davis Family Medicine Residency Network. During the year, it gained momentum within local communities and city councils and was picked up in social media around the nation and the world.
Although the Year of the Family Physician is drawing to a close, an even broader effort touting the value of family medicine and primary care is just getting started. As we embark on the road to achieve the goals of Family Medicine for America's Health and the Health is Primary campaign, I strongly invite your input and involvement in this vital process as we transform our medical neighborhoods. Keep informed and get involved.
And finally, I would be interested to hear about your state chapter's legislative wins in the comments field below. Tell me about your success stories!
Jack Chou, M.D., is a member of the AAFP Board of Directors.
Initiatives Highlight Family Medicine as Top Choice for Students
When I decided during my undergraduate studies to go to medical school, I knew that I wanted to build relationships with patients, serve vulnerable populations and become a patient advocate. I never expected, though, to be where I am today, embarking on a year that will involve representing medical students across the country and working alongside people who have become some of my personal heroes. But as the student member of the AAFP Board of Directors, that's exactly what I'm doing.
As this new door opens, so does another: the Family Medicine for America's Health project and its recently launched, public-facing campaign, Health Is Primary. What a great and exciting time to be a future family physician!
| Here I am talking with former AAFP President Glen Stream, M.D., M.B.I., the board chair of Family Medicine for America's Health. Dr. Stream discussed Family Medicine for America's Health and the Health is Primary campaign with medical students Oct. 24 during AAFP Assembly in Washington.
Check out FMAHealth.org for history and details on this game-changing project, which takes a comprehensive approach to setting family medicine on a track to lead health care transformation that will deliver value and improve the health of Americans.
I'm excited to see the contributions of my peers and colleagues in this project. This initiative wasn't the product of just a small group of disconnected decision-makers working behind closed doors. Medical students, residents and new physicians were involved at every step during the past year-and-a-half of the project's development. They contributed their visions of, and high expectations for, how patients are going to be better served by family physicians and our health care system moving forward. More importantly, patients were involved in this project, and their needs and expectations are being held in the highest regard (as they should be).
The project charges family medicine to lead the way to better care for patients, going beyond the practice of medicine to affect social determinants of health, public health efforts, population health efforts, community leadership and more.
I have struggled at times with what to tell my medical school colleagues about family medicine. I know why I'm choosing the specialty: I enjoy interacting with patients of all ages and engaging them in their health. I want to deliver babies, care for children, offer palliative care at the end of life, teach prevention, treat sports injuries and help my patients in every way that I can. But what has been harder for me to get across, at times, is why my peers should consider family medicine. Now, strengthened by this project, the reasons a future in family medicine looks so bright are more apparent than ever.
Here are a few:
- Evidence shows family medicine is pivotal to reaching the triple aim of better care, better health outcomes and lower costs. Family physicians lead the way to more value and patient-centeredness in the health care system.
- Family physicians are trained to practice a wide scope of medicine that is not limited by patient gender, age, health issue or organ system. As "comprehensivists," family physicians have the power to influence patients and populations in a way other specialties cannot. Family physicians are better equipped than any other specialists to manage complicated chronic illnesses, provide preventive care and, most importantly, deliver coordinated, continuing care to patients with whom they have a relationship. All of these things are shown to improve the value of care provided.
- The Patient Protection and Affordable Care Acts calls for physician reimbursement to be tied to quality and care outcomes, rather than volume. The payment gap between primary care physicians and subspecialist physicians should narrow accordingly.
- Emerging practice models, including direct primary care, will focus on the patient and deliver higher-quality care at lower cost with less waste.
- The graduate medical education system needs to be reformed -- and is being challenged to do so by the AAFP and others -- to deliver the physician workforce our country needs.
- The patient-centered medical home model of care will continue to evolve as evidence directs the movement.
- Preventive and chronic care management will unseat acute care as the focus of the system.
I believe more than ever that family physicians are the right group to lead this charge. The mission of family medicine aligns seamlessly with the ideals of an optimal health care system that delivers on the triple aim.
A future in family medicine offers a chance to be part of much-needed change in health care delivery, to fix a broken system and, most importantly, to make the greatest impact on the health and wellness of patients.
To quote new AAFP President Robert Wergin, M.D., someone I am incredibly excited to learn from and work alongside this year, "Why are we the answer to health care delivery in this country? We are family physicians. Enough said."
Words cannot capture the complex, coexisting feelings of humility and pride I'm experiencing from being able to serve medical students, family physicians and patients this year on the Board and to call family medicine my specialty of choice. If you haven't been paying attention, now's the time to start. Stay tuned.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
Spread the Word: Health is Primary
Last week I told you that the Academy and other family medicine organizations were poised to roll out a three-year national advertising campaign -- the public component of the Family Medicine for America's Health initiative -- to educate key stakeholders and decision-makers about the value of family medicine and primary care. The campaign also is designed to educate patients and get them more involved in their own health care.
It's now my privilege, in one of my first official Leader Voices Blog posts as your president, to share the latest update from the Family Medicine for America's Health Board of Directors.
Family Medicine for America's Health
Organizational Update: October 2014
Health is Primary has launched! Family Medicine for America's Health -- a new, five-year coalition of eight national family medicine groups -- kicked off the three-year campaign last week during the AAFP Assembly in Washington. The goal is to demonstrate the value of primary care in delivering on the triple aim of better health, better care and lower costs.
| I was honored to speak last week during the launch of Health is Primary. The three-year campaign aims to raise awareness of the role of primary care in improving the health care system.
The Health is Primary campaign will use national advertising, partnerships and stakeholder outreach to raise awareness of the role of primary care in improving the health care system. Family Medicine for America's Health will also drive a five-year strategic initiative to transform family medicine to meet the changing needs of the health care system.
Health is Primary will travel to cities around the country to engage local stakeholders and showcase community-level interventions that are working to enhance and expand primary care and improve health. The campaign will also partner with employers, disease groups and health advocates to activate patients on major health issues such as chronic disease management and smoking cessation and advance the use of technology tools for patient communication.
At the same time, Family Medicine for America's Health will work to modernize the family
medicine specialty and transform the nation's health care system. The strategic effort will focus
on expanding access to the patient-centered medical home, ensuring a strong primary care
workforce and shifting from fee-for-service to comprehensive primary care payment. Family
Medicine for America's Health is establishing six tactical teams with broad representation from
the primary care community that will focus on key areas for transformation: payment, practice
management, workforce education and development, technology, research, and engagement.
The campaign launch coincided with the release of a special supplement to the October issue of the Annals of Family Medicine that provides background on the planning process and the framework for execution.
To learn more about the campaign, we invite you to join us for our first webinar at 7 p.m. EST on Wednesday, Nov. 5. We will be holding these sessions periodically to update the family medicine community on our work and our progress.
Of course, you can always find us at HealthIsPrimary.org and FMAHealth.org. If you would like to donate to support the efforts of Family Medicine for America's Health, visit the AAFP Foundation website.
We are pleased to report that the board of directors for Family Medicine for America's
Health is now fully formed. Our 12th member, Lauren Birchfield Kennedy, is the director of
health policy for the National Partnership for Women & Families. Lauren fills the patient
advocate role on the Board and will bring that important perspective to the campaign.
Representative and Organization/Affiliation
- Glen Stream, M.D., M.B.I., Chair, American Academy of Family Physicians
- Michael Tuggy, M.D., Vice Chair, Association of Family Medicine Residency Directors
- Paul Martin, D.O., Secretary/Treasurer, American College of Osteopathic Family Physicians
- Jen Brull, M.D., represents full-scope, full-time practicing family physicians
- Thomas Campbell, M.D., Association of Departments of Family Medicine
- Jennifer DeVoe, M.D., D.Phil., North American Primary Care Research Group
- Lauren Hughes, M.D., M.P.H., represents family physicians early in their careers
- Vincent Keenan, C.A.E., represents AAFP chapter executives
- Lauren Birchfield Kennedy, patient advocate, National Partnership for Women & Families
- Jerry Kruse, M.D., M.S.P.H., Society of Teachers of Family Medicine
- Robert Phillips Jr., M.D., M.S.P.H., American Board of Family Medicine
- Jane Weida, M.D., AAFP Foundation
Further background, including earlier updates on this project are available on the Family Medicine for America's Health website.
Robert Wergin, M.D., is president of the AAFP.
We Are the Solution: Let's Spotlight Family Medicine's Value
At a state chapter meeting earlier this year I spoke with a family physician who questioned whether the AAFP's elected leaders understand and appreciate the challenges our members -- particularly small practice physicians -- face on a day-to-day basis. It wasn't the first time I had heard this comment, and it might not be the last.
The fact is I am a small-town, small practice physician. I practice full scope family medicine in the same Nebraska town where I grew up in, providing obstetric care, geriatric care and everything in between. I also am medical director for our local nursing home, a team physician for a local school and a volunteer faculty member at the University of Nebraska. I know comprehensive family medicine because it has been my life -- and my passion -- for the past 30 years.
This coming year, however, might be the most exciting yet for me and for family medicine. Today, the Academy, along with seven other national family medicine organizations, will launch a three-year national advertising campaign -- the culmination of the Family Medicine for America's Health initiative -- using advertising, news media, online and digital communications to educate decision makers about the value of family medicine and primary care. The campaign also is designed to educate patients and get them more involved in their own health care. And work will begin this fall on the implementation of a five-year strategic planning effort.
During the next few years we will work to engage and inspire medical students to work in family medicine by connecting them with our vision for the future of health care. The number of medical students choosing family medicine has increased five years in a row, but we need even more family physicians to meet the needs of our health care system. My own son is a fourth-year medical student who is interested in family medicine, but I understand that the staggering debt many of his peers face coming out of medical school makes it difficult for some to see the rewards of family medicine.
One of the focuses for my presidential term will be to break down barriers that prevent students from choosing a career in family medicine. This needs to be approached on two fronts: debt relief for doctors who make the socially responsible choice to be family physicians and improving payment to appropriately value our services.
The current fragmented system of health care delivery is costly and of low quality. The core value of family medicine -- comprehensive, continuous and coordinated care -- is being recognized as the solution to delivering high quality, cost-effective care. Our new campaign will coincide with a five-year strategic implementation effort that will address not only payment reform and workforce development but also practice transformation and research that supports our vision for the future of family medicine in an evidence-based way.
Another aspect of our new initiative will be to define family medicine and the scope of our specialty and to help our members practice to the full scope of their training. I tell students, "You choose your future," and I truly believe that statement sums up the advantages of family medicine. We can be as comprehensive as we want to be. If I have a patient who needs heart valve surgery, I can't provide that service. But I can find my patient an excellent surgeon who can perform that surgery, and I will be right there with my patient throughout that experience. The confidence my patients have in me is immense -- they trust me to do the right thing. I tell students they can have that same kind of relationships with their patients no matter where they choose to practice family medicine.
There are a number of new and expanding medical schools, but our country needs more family medicine residency positions to ensure that graduates have a place to continue their training. The Academy recently introduced a proposal that would drastically change graduate medical education.
Another area of emphasis for me will be to reach out to members, listen to their concerns and work to bring the joy back to practicing family medicine. Whether I'm visiting state chapters, lobbying on Capitol Hill or meeting with health plans, you can keep up to date on what I'm doing on your behalf by following me on Twitter @aafpprez and the AAFP President's Facebook page.
In this coming year we are going to shine a bright light on family medicine and define its value. This is an incredible time to be your president, and I thank you for the opportunity.
Robert Wergin, M.D., is president of the AAFP.
My Year as President: The Honor Has Been Mine
It is hard to believe that a year has passed so quickly. In fact, I was blessed to have a 13-month term as AAFP president, and I did my best to make the most of it. In so many ways, this time on the AAFP Board of Directors has reminded me of my professional path, having worked as a small-town family physician before becoming residency faculty.
I always tell new faculty at East Tennessee State University that you have to work at least five years to see the patterns in medical training and avoid the panic that often comes when challenges arise. Similarly, I am finishing my fifth year on the Board, and I have learned a lot in that time. It has been an exciting period, and I want to summarize some of my experiences.
© 2014 Marketing Images/AAFPSpeaking with students, like I am here at the National Conference of Family Medicine Residents and Medical Students, is one important aspect of being the Academy's president.
When I was running for president-elect, I promised I was going to do my best to say yes -- and I have. This has been an amazing year. I topped 1 million miles on Delta and visited 17 AAFP chapters. One of the most profound experiences was the chance to meet not only the state leaders that we install in those chapters, but to meet our members who have chosen to put their energy into patient care and help our communities. Thank you for your dedication, your inspiration and for working through the many challenges. The time I have spent with you has helped me do a better job of understanding those challenges and representing family medicine in Washington, D.C.
I have spent a significant amount of time trying to reframe discussions about health care, including about scope of practice. Although this remains a significant issue from state to state, it's important to remember that we have a number of states that have allowed nurse practitioners to practice independently for years, and the results demonstrate this isn't the right solution to our nation's primary care shortage. Every state in our country is experiencing poor patient outcomes, decreased provider and patient satisfaction, and high costs.
The solution to these problems is to truly focus on increasing the number of primary care physicians in practice, creating more effective patient-centered medical homes, and providing care in a team-based fashion. The Comprehensive Primary Care Initiative for example, is demonstrating that the kinds of changes the AAFP has been advocating for more than 10 years are the changes that lead directly to improved outcomes and decreased costs.
And there are more data to come, so stay tuned.
One facet of the president's job is to represent the Academy at meetings with other health care organizations, which creates opportunities to network and make important connections. After all, it's critical that team-based care also include organizational teams. I was honored to be invited to meet with a number of organizations -- some for the first time -- and help create new relationships for the AAFP or strengthen existing ones. Among the opportunities I have taken advantage of have been invitations to the Academy of Breastfeeding Medicine, the AMA, the American Academy of Physician Assistants, the American Association of Nurse Practitioners, the American Board of Family Medicine, the American College of Osteopathic Family Physicians, the American Osteopathic Association (AOA), the American Pharmacists Association, the Association of Family Practice Physician Assistants, the National Hispanic Medical Association, the National Medical Association, the Society of General Internal Medicine, the College of Family Physicians of Canada and the Society of Teachers of Family Medicine.
Another important role of the president is to represent the Academy in Washington, and I was fortunate to be able to make numerous visits to the nation's capital. The sustainable growth rate remains one of our biggest challenges, but I truly have hope that we are moving in the right direction. Proposed bipartisan and bicameral legislation already in play could provide a unique opportunity during Congress' lame duck session. Our comprehensive advocacy approach with organizations such as the AMA, the American College of Surgeons, the American College of Physicians and the AOA have created a unified voice for medicine that is getting the attention of those on the Hill.
We have other serious issues ahead, such as avoiding Medicaid cuts and addressing the regulated sunsetting of the primary care bonus, but we are opening more doors and sitting down at more tables to discuss these matters.
Years of effort recently culminated in some major steps forward in graduate medical (GME) reform. The Institute of Medicine released its long-awaited report, with which the Academy substantially agreed. We followed that up with our own recommendations and a GME summit on Capitol Hill that was quite positively received. We are challenging long-held processes in significant ways. Much discussion and negotiation awaits, but once again, we are at another table addressing one of our primary goals.
Just before coming to this week's Congress of Delegates and AAFP Assembly, I attended a premedical health fair at the University of California in Davis, a gathering of thousands of students who are considering careers in the health professions. In addition, I have been blessed to speak with students everywhere I have gone this year. Students are our life blood and our pipeline. These connections are critical, and I look forward to maintaining them.
One key way to stay connected is social media. Three years ago, the Academy made a commitment to giving members real-time updates about how the president is representing family physicians. The AAFP President's Facebook page now has more than 1,400 "likes," and the AAFP President's Twitter account -- @aafpprez -- has 2,400 followers. The Board also is providing regular and more in-depth updates through this blog. The better we stay informed and connected, the better we can advocate for each other.
It has been an honor to represent you, and I will continue to work for you during my year as Board chair. Thank you for the opportunity to take your stories forward. I am excited this week to be handing off the president's role to Bob Wergin, M.D. A small-town doctor who practices full-scope family medicine, he is the right person at the right place at the right time to lead us forward.
Reid Blackwelder, M.D., is president of the AAFP.
The Flight of My Life: Reflecting on Six Years of Service
In its more than 40 years, my little Hatz biplane has had quite a life. In the two decades we have shared the sky, we have introduced more than 400 kids to the thrill of flying and traveled all the way across the country. It has brought me immeasurable joy.
But like all things physical, wear and age were beginning to show. So six years ago, we started the long process of restoration from the ground up. We replaced fabric covering, installed new instruments and a wood propeller, and finished with an updated paint job.
Today, she looks like a beautiful new airplane that's ready for new adventures. When you fly as a pilot and when you restore a plane, you keep a record -- a logbook -- that lists every flight and every improvement you make.
Coincidentally, it was six years ago that I joined the AAFP's Board of Directors. In many ways, looking back over those six years is like opening my Academy logbook.
Just like for my plane, there was a lot of work to be done in family medicine. The specialty was in crisis. Payment was woefully inadequate. AAFP membership was down. Student interest was low. Forty-seven million Americans were uninsured. As a candidate running for the AAFP Board, I asked the Congress of Delegates, rhetorically, if we were actually witnessing the collapse of primary care.
Fast forward to today, and the outlook for family medicine has changed. Day to day, our work in the trenches continues to be challenging, but the forecast for the future from the 10,000-foot level of the Board chair is now encouraging.
Six years ago, we knew family medicine was valued by our patients -- we could see it every day in our offices. Barbara Starfield, M.D., M.P.H., had showcased the value of primary care in her research. Still, recognition of those truths -- and support for primary care – from payers, employers and government was lacking.
Today, the patient-centered medical home model has shown that improving primary care is the key to meeting the triple aim for health care: higher quality, lower costs and improved care for patients. The Comprehensive Primary Care Initiative launched by CMS' Center for Medicare and Medicaid Innovation is changing the way our government pays for primary care -- paying for value over volume -- and it is expanding. A growing number of employers, health plans and government agencies are beginning to demonstrate that they really value what we do. When it comes to payment reform, we haven't arrived at our destination, but we are on the way.
On Capitol Hill, we no longer have to explain to legislators and congressional staff what we family physicians do and why we matter. Federal agencies seek the Academy's input on important health care issues, and legislators are actively looking for ways to train more family physicians to address our country's primary care shortage.
But what about access to care? Today, there are 10 million newly insured Americans thanks to the Patient Protection and Affordable Care Act (ACA). Our uninsured rate now stands at 13 percent -- 5 percent lower than it was six years ago and the lowest it has been since 2000. Americans may be split on the ACA, but there is overwhelming support for some of the basic tenets of the law: getting more people covered by insurance and reforming unfair insurance rules, including no longer allowing denial of coverage based on pre-existing conditions, caps on coverage, or retroactive canceling of coverage after someone becomes sick.
However, there is still much work to be done. We need restraints on rising health care costs, malpractice reform and a path to creating the primary care workforce our country deserves. And we still have millions of uninsured. We haven't arrived at our Academy's ultimate goal of health care for all, but we are on the way.
Interest in family medicine is up nationally. AAFP membership reached a record high this year at 115,900. And for the fifth consecutive year, the number of medical students choosing family medicine climbed higher than the previous year. Twenty-five percent of all U.S. medical students are now Academy members.
To meet the needs of our nation's health care system, those numbers must continue to grow; this year, the AAFP took steps to proactively ensure that they can. Last month, the Academy unveiled a proposal that would significantly change the way graduate medical education is financed. Our proposal would bring transparency and accountability to a system that invests $15 billion a year on physician training but is unable to produce a workforce that aligns with the needs of the nation.
I'm also proud of the work the Academy is doing in public health. Last year, we included the social determinants of health in our strategic plan. And this year, we began the process of reimagining Tar Wars -- a program I helped develop more than 25 years ago -- as part of a comprehensive tobacco and nicotine prevention and control program that will include new tools for family physicians, community programs and advocacy.
We've talked about where the Academy has been, but where are we going? During the AAFP Assembly in Washington next week, the AAFP -- along with seven other national family medicine organizations -- will launch a national campaign that is the culmination of the Family Medicine for America's Health initiative and the biggest thing to happen in family medicine since the Future of Family Medicine project in 2004. This campaign will speak not only to family physicians but also to patients, payers and others, defining what we do as family physicians and why primary care is the vital foundation of our health care system.
Now when I climb in my biplane, I can tell she is still the same plane I have known and loved all these years, yet with new energy and new life -- the way she climbs, handles and how her paint flashes in the sun. She has come a long way.
Today, we are all part of a rebirth of family medicine. Our voice is being heard, our contributions are being valued, and we, too, have come a long way. Our country is counting on us to continue to be "bold champions" for America's health, transforming health care for optimal health for everyone.
As for me, my Academy logbook is now full. It's time to open up a new logbook and start my next adventure. Thank you for granting me the privilege of serving you. It has been the flight of a lifetime.
Jeff Cain, M.D., is Board chair of the AAFP.
Patients Need Nutrition Facts From Their FP, Not Dr. Google
I enjoy discussing nutrition with my patients. It is an essential part of the lifestyle and prevention package that family physicians are uniquely positioned to prescribe.
Although I have not eaten meat in 40 years, I live with three people who consume it on a regular basis. I had to self-educate about nutrition when I chose to stop eating meat because this was before I had the benefit of the four nutrition lectures I got in medical school. During those years, I drank a lot of milkshakes and discovered that it picked me up for a short while, but fatigue would roll in within two to three hours.
Diet for a Small Planet by Frances Moore Lappe was my original textbook and guide. It's hard for me to believe that this book is now more than 40 years old. Fast forward to today, and our patients are taking nutrition advice from TV doctors, the Internet and other sources that might not be evidence based. Shouldn't they be hearing the facts from us?
Every time I sat down to write this blog post, a new latest-and-greatest declaration in some journal or meeting would derail me. But recently, the Annals of Internal Medicine published an NIH-funded study that confirmed some of the things I have been telling patients. Researchers suggest that a diet that cuts down on carbohydrates may work better than trimming fat to aid in losing weight.
There is no one diet that works for everyone. One size does not fit all. (That is one reason there are so many diets out there.) But it's worth noting that this study included males and females and was racially diverse.
The problem with limiting carbs is that it may lead patients to inadvertently skimp on dietary fiber, which is important for heart and colon health, as well as for making our patients feel "full."
I talk with my patients about moderation in a healthier diet, but the exception is dietary fiber. I talk about going from the national average intake of 14 grams a day up to 30 grams a day, increasing intake slowly. First we assess their consumption, and then we add only 3 more grams per week until we reach our goal. This regimen brought my own LDL cholesterol down by more than 40 points and has been quite effective for a number of my patients, although sometimes our guts tell us that they are not happy with our diet.
The motto of "First, do no harm" is critical, and that applies to supplements. Through my sports medicine affiliations I have been fortunate to glean excellent information on this topic. Just because something is natural does not imply it is safe. I have diagnosed new-onset hypertension in a number of patients who thought they were doing a good thing by taking a multivitamin but did not realize that in those supplements they also were taking herbs that raised their blood pressure. By taking them off the multivitamin, we were able to return patients' blood pressure to normal without medication.
At the end of the day, it is about balance and moderation and trying to get your nutrition from as primary a source as you can.
After I finish my term on the AAFP Board of Directors this month -- and eventually finish the patient-centered medical home recognition process, achieving meaningful use and transitioning to ICD-10 codes -- I think I will sit with a cup of tea and start an outline for a nutrition piece for American Family Physician to update our information because obesity is a prevalent disease, and family physicians are in a position to make a major impact.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Asking Right Questions Critical to Making Right Match
It may seem like the academic year just started, but for fourth-year medical students, the decision about where to spend the next three or more years is just around the corner. And the fall and winter, also known as "interview season," is when it gets really interesting.
Fall is the time for fourth-years to prepare for the National Resident Matching Program -- better known as the Match -- by visiting and interviewing with potential residency programs. The AAFP offers a tremendous free resource -- Strolling Through the Match -- that can be helpful to students regardless of year or specialty interest. The 80-page PDF covers a wide range of topics:
- residency application timeline and checklist;
- introduction to the Electronic Residency Application Service and the specialties that participate;
- a residency program evaluation guide;
- residency selection steps and interviewing tips;
- examples of how the Match works for applicants;
- new tips on post-interview etiquette; and
- tips on writing a curriculum vitae and a personal statement.
We used Strolling Through the Match widely at the University of Alabama when I was a student, and the information is practical and thorough. Still, some of the most valuable advice I received when preparing for interview season came from those who had been through the process and got their desired Match results, So, I thought it might be helpful to share the tips and takeaways from my experience just last year.
The most important thing to evaluate at each interview is how well you fit in with the faculty and, most importantly, the residents, because you will be working closely with them for the next three years (or more). If you can't get along with them, your life will be miserable.
After that, you have to prioritize the features you desire in a program, such as teaching exposure and the amount and extent of care you will provide to pediatric, obstetric and adult patients, as well as the amount of time you will spend working in inpatient versus outpatient settings. Your residency experiences form the bulk of your medical training, and if you aren't trained on something during residency, it's far more arduous to make that happen after residency.
If you have a spouse or significant other, involve that person in the decision-making process, especially if you are moving somewhere new. You will be extremely busy during residency, and he or she will have to spend a lot of time without you. Your loved one needs to be happy where you are going.
Realize that you aren't likely to find a perfect program, but you will have a gut feeling about where you belong, and that is more important than anything else.
You may already have interviews scheduled, but do you know what questions to ask? Here are some things to consider asking at each of your visits:
- What are the program's board passage rates? This will give you an idea of how good the clinical experience is.
- Where do the program's graduates get jobs? This will tell you whether the graduates are respected and perceived to be well-trained by the local community.
- What are the strengths and weaknesses of the program?
- What kind of interaction do residents and faculty have outside of work?
While you are evaluating the programs you visit, keep in mind that you also are being evaluated at every moment, not just during the formal interviews. Residents will scrutinize you for your "fit" at any moment they interact with you, including meals and tours, so treat every moment seriously and always be on your toes.
Residency representatives will want to know why you are interested in their program and what specific aspects drew you there, so show you have done your research and be prepared to name something about that program other than just its name or reputation.
While fourth-year medical students are planning for the long term, it's not too early for first- through third-year students to start building CVs, learning as much as they can about each specialty, and seeking experiences that can help prepare them to choose their future. Here are some possible scenarios to consider:
- First-year students, you can use your only summer off during medical school to experience family medicine. Find international service opportunities for students, or find a family physician to shadow. Your faculty or state chapter can help you with this.
- Second-year students, build your CV by pursuing leadership opportunities on your campus -- for example, with your school's family medicine interest group.
- Third-year students, get out of the academic health center during your elective rotations and experience primary care where it occurs most often -- in the community. Use the AAFP's clerkship directory to find an elective rotation.
Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.
The Countdown Begins: One Year to ICD-10
One year. That's how long we have to get ready for the official implementation of ICD-10. Oct. 1, 2015, is the day we have been nervously awaiting since July, when CMS confirmed that as the revised compliance date for the new coding system.
Later this month, the Academy will offer CME courses related to ICD-10 to help us prepare during the AAFP Assembly in Washington. Will your practice be ready?
Every time I read an article about ICD-10, I wonder how small practices like mine will survive this new hurdle. A study conducted by Nachimson Advisors and published by the AMA estimated that small practices could suffer costs between $56,000 and more than $226,000. A large practice's financial impact is estimated to range from $2 million to $8 million. These figures are three times what was estimated by the same research group just five years ago.
ICD-10 has more than 68,000 diagnostic codes compared with ICD-9, which has a little more than 14,000 diagnostic codes. This is a significant shift for family medicine. The differentiation of right, left and bilateral accounts for about 40 percent of the increase in codes for ICD-10. Initial versus subsequent diagnosis codes might create an obstacle for the busy physician but will ultimately be helpful for tracking purposes.
According to the American Health Information Management Association, the new coding system will result in higher-quality data that can improve measures of quality and performance, provide "increased sensitivity" to reimbursement methodologies, and help strengthen public health surveillance.
But how do we get there? Updates to my practice's electronic health record (EHR) system have allowed us to "bridge" to ICD-10 for the past eight months. Testing and payment disruptions are variables that are impossible for me to anticipate, and every consultant we talk to offers a different opinion as we try to assess how to proceed.
In my search for assistance on the web, I found "The Road to 10: The Small Physician Practice's Route to ICD-10," an online resource an online resource to help small physician practices transition to ICD-10. This tool was developed by CMS in collaboration with industry partners. It allows a small clinical practice to create a customized action plan for ICD-10 readiness and preparation. It provides a five-step action plan that covers planning, training staff, updating systems and processes, engaging partners, and testing.
Although that resource is geared to small practices, the AAFP and its journal Family Practice Management have resources that can help practices regardless of size.
In addition, CMS recently announced the dates that it will do readiness testing using ICD-10 codes. What are you doing to prepare?
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
We’re Doing Our Part to Keep SGR Issue on Congress' Radar
I will only be AAFP president for three more weeks, but there's a lot to do in this final month of my term. Throughout the year, I have had opportunities to represent the Academy at meetings with a number of organizations as we discuss important concepts such as team-based care and the patient centered medical home. One such opportunity came just this week when I participated on a panel for a Capitol Hill briefing that addressed payment reform, including the need to repeal the Medicare sustainable growth rate (SGR) formula.
This event was organized by the Society for General Internal Medicine (SGIM), which reissued a 2013 report developed by the National Commission on Physician Payment Reform. Many of the principles and recommendations in the report are in line with what the AAFP has been advocating for several years. Given the urgent need to push for passage of the bipartisan, bicameral legislation on SGR repeal already in play, this was an ideal time for the commission's report to be reissued.
I joined a panel that was moderated by SGIM president William Moran, M.D., and included SGIM health policy chair Mark Schwartz, M.D., and American College of Physicians EVP Steven Weinberger, M.D., also a member of the commission. We used this opportunity to review the principles and recommendations in detail with a room packed with legislative aides from both the House and Senate. Our most important ask was to encourage legislators to pass the SGR repeal proposal before the Congress adjourns in December.
The commission's report, like the Academy's longstanding advocacy position, stressed the need to repeal the SGR, which again poses a looming threat to cut physician Medicare payments by more than 20 percent if Congress doesn't act by March 31.
As part of this briefing process, we reviewed many of the report's recommendations, which are in line with what the Academy has been saying in our own discussions with CMS, legislators and congressional staff for years.
Some of these important recommendations include the need to transition away from the fee-for-service model. We outlined the perverse incentives that this model has given rise to in our health care system. Although fee-for-service will continue to be important for some aspects of payment, we have to fix the disparities in current fee-for-service payment rates because they will be a foundation for future payment models. There have to be opportunities to rebalance fee-for-service payments, to boost undervalued evaluation and management codes, and to recalibrate overvalued codes -- many of which have not been revisited in more than 20 years despite huge gains in efficiency.
Our patients' health is becoming increasingly complex to manage, especially in a Medicare population in which 60 percent of patients have three or more chronic conditions. This additional complexity further accentuates the dramatic disparity between how our fee-for-service model pays for procedural services compared to primary care services. New technology has reduced the time it takes to perform certain procedures, yet payment for these services has not been reduced. This contributes to the erosion of primary care incomes which exacerbates our primary care workforce shortage.
We emphasized the real need to recognize that compared with procedural services, primary care services require face-to-face time that cannot be shortened to increase volume without decreasing patient-centeredness and quality.
Another recommendation specifically addresses the significant potential for cost savings and improved care for patients with chronic conditions. The commission report noted that 5 percent of patients in this country account for 50 percent of our health care spending. This will continue to drive an increasingly disproportionate share of spending as more and more patients develop multiple chronic conditions. This is an area that has significant potential for cost savings as we continue to transform our practices.
As family physicians, we know what to do. Much of the answer lies in the patient-centered medical home, and implementing better and more efficient team-based care. Our country needs a stronger primary care foundation -- the essential message of the Commission’s report. The more incentives we can find for primary care and improving access for all of our patients, the more we will save in terms of downstream costs.
We must move away from “wrong care, wrong place, wrong time” to ensuring patients get the right care, in the right place, at the right time and from the right person.
Overall, attendees of the briefing were interested in the recommendations. We stressed that this push is a unique opportunity that brings together all of organized medicine in support of proposed legislation. In addition, once the 2014 midterm elections are over, the unique political landscape of a lame-duck session could grease the skids for passage of the bill.
Once the 114th Congress convenes in January, the SGR repeal legislation will lapse. In addition, because of retirements and potential election-driven shifts in power, significant changes will occur within the committee leadership in Congress, posing potential roadblocks to restarting the bipartisan process. Therefore, this lame-duck session is a unique and rare opportunity for some congressional lawmakers to put a feather in their hat by moving forward on an important and long-sought-after repeal of this fatally flawed formula.
You can help by contacting your legislators to let them know this must be a priority!
Reid Blackwelder, M.D., is president of the AAFP.
The Doctor is Out: Retention Poses Major Challenge for CHCs
HHS announced Sept. 12 that it is making nearly $300 million available to nearly 1,200 community health centers (CHCs) across the country. The funding is intended to help CHCs hire more than 4,700 new health care professionals and offer longer hours and expanded services, including oral health, behavioral health, pharmacy and vision.
The funding is expected to help CHCs reach about 1.5 million new patients.
Although the funding for additional staff is needed -- and welcome -- the change doesn't address one of the biggest problems CHCs face -- retention. Not only do these clinics need more physicians, they need the physicians already working in these settings to feel motivated to stay in communities where they are desperately needed.
© 2014 Casey Health InstituteMy first job after residency was at a community health center, but I now work at an integrative primary care practice. Research has shown that family physicians at community health centers have lower rates of job satisfaction.
Federally qualified health centers (FQHCs) are a source of primary care for millions of uninsured and underinsured patients. They're also the place where many family physicians -- like me -- get their first "real" job outside of residency.
I spent my first four years out of residency at a CHC, and I loved it despite the challenges. I served a culturally and socioeconomically diverse population that was in need of good health care. I truly felt like I was living up to being the doctor I wrote about in my medical school personal statement.
In addition to the reward of serving a community desperate for medical care, many physicians are drawn to CHCs by offers of loan repayment -- either as part of a National Health Service Corps commitment or through state and local programs. Although many physicians enter these doors excited and eager to help the people they went to medical school to serve, too often, physicians are just as eager to leave after their loans are repaid.
Research tell us that family physicians at CHCs are less satisfied with their work situation than other physicians. The reasons are multifactorial, including low compensation and excessive workload. Isolation from cultural activities and limited career opportunities for physicians' spouses in rural areas also contribute to dissatisfaction.
I saw several colleagues come through, do their time, repay their loans, and move on. This is a common theme, because family physicians often feel burned out after just a few years at a CHC. Many went to an FQHC not just to get their loans paid off, but rather to make a difference and fulfill a personal mission to serve the underserved. One friend and colleague told me she planned to come back to an FQHC at some point in her career. But after five years of having worked in that setting, she felt that if she hadn't left when she did, she would never have wanted to go back.
More than half the states and the District of Columbia are expanding their Medicaid programs under provisions of the Patient Protection and Affordable Care Act. Many of these new Medicaid enrollees will be seen at CHCs because many private practices don't accept Medicaid. This could lead to an increase in patient visits -- and potential headaches -- at the centers, which often struggle to fill vacant positions for physicians and other clinicians. To make matters worse, the low retention often creates a burden for those who do stay.
My interest in CHCs started in high school because I had a mentor who worked in that setting. Later, I volunteered at CHCs during medical school, and I had no doubt where I wanted to go after residency.
When I left my first job at a CHC, it wasn't because I was burned out. I had an amazing opportunity to work as a White House Fellow and spent a year advising the U.S. Department of Agriculture on a range of issues related to nutrition. When my time there was up, I didn't go back to an FQHC. Although I don't miss the headaches, I do miss serving that population.
Today, I'm the medical director of an integrative primary care practice where we incorporate some of the features of an FQHC to ensure access to care, including a sliding payment scale for uninsured patients and a sliding scale for insured patients who seek services that may not be covered, such as chiropractic, acupuncture and massage therapies. At the same time we're trying to ensure access in the way FQHCs do, we're trying to avoid some of the pitfalls these centers face. We try to give our clinicians the time, space and support they need in order to be there for patients and to make them feel valued and respected.
So how do we get more CHCs to operate the same way and improve their recruitment and retention rates?
- The Bureau of Primary Health Care (BPHC), a segment of HHS that funds health centers, should track physician retention at FQHCs and publish these data along with other quality measures. Ultimately, the goal would be to create a recommended standard for clinician retention that centers can be compared against.
- Once a physician commits to a community for the long term, that community has a powerful advocate. The BPHC should encourage FQHCs to create strategies for physician recruitment and retention. The National Association of Community Health Centers has already done a lot of work in this area.
- The AAFP recently established member interest groups to provide a forum for AAFP members with shared professional interests. A CHC member interest group would provide physicians who work in these settings to communicate with each other and develop relevant AAFP policy. If you are interested in starting a member interest group for family physicians in CHCs, you can find more details -- including information regarding the criteria and application process -- online.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
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