Working With Others Key to Successfully Transforming Our Practices

Good partners can make all the difference when transforming a practice.

For example, one of the family physicians in my practice, Andrew Drabick, M.D., was so concerned about the obesity problem in our community that he led our efforts to open a weight loss clinic. Many of our patients found the extra help they needed, and we added an important revenue stream.

One of my other partners, Stephen Moore, M.D., is passionate about practicing family medicine, but he has little desire to be involved in the business of medicine. Stephen puts his trust in others to make sure we are running a sound business. I also love being a family physician, but I have the interest in business that my partner lacks. Together, we provide balance to a practice that has expanded three times in a little more than five years.

We not only have doubled the physical size of the practice, we grew from three physicians and one nurse practitioner to five physicians, two nurse practitioners, one physician assistant and a dietician, as well as an athletic trainer who works with us on a contract basis and a massage therapist who rents space from us.

However, our partners aren't limited to those who work in our office. We've succeeded in improving and transforming our practice because we've been willing to branch out, reach out and find like-minded people who are willing to help us lower our costs while improving care.

One example is the independent practice association (IPA) we've belonged to for more than a decade. The IPA represents about 145 physicians from nearly 50 practices. Members learn best practices from each other, which makes us more efficient and helps us improve outcomes.

Two years ago, the IPA mandated that by the end of 2011, every participating practice had to reach National Committee for Quality Assurance (NCQA) Level 2 or 3 patient-centered medical home (PCMH) recognition. Amazingly, the IPA group lost only three practices, added four new ones and has others interested in joining.

Our practice achieved NCQA Level 3 recognition in 2010. It wasn't easy, but being a member of the IPA made a difference. The organization used funds from member dues and pay-for-performance funds to hire a consultant who helped practices with paperwork related to the process.

Our commitment to the PCMH model already is paying off. Blue Cross and Blue Shield of North Carolina, which covers half our patient population, offers higher fee-for-service payments to primary care physicians who provide patient-centered care. Practices must meet certain criteria, including NCQA recognition.

Due to the IPA’s successes and data proving we help control costs, other businesses and insurers have approached us as well. These opportunities have tremendous potential.

Some physicians are overwhelmed by the thought of the work and investment practice transformation requires. For my practice, it was worth it. Thanks in part to Blue Cross, we experienced more than a 10 percent increase in revenue last year with no significant increase in patient volume. After having almost $2 million in collections in 2010, that 10 percent increase was significant. 

We owe some of our success with Blue Cross to yet another partnership -- our involvement with the North Carolina AFP. Our state chapter has been communicating with the health plan for years about the value of primary care. BCBS is starting to get the message and responding with improved payments.

Though individual FPs might not know the key contacts of a state health plan, your state chapter likely does. They are great resources.

Help is there, if you know where to look. The Academy has numerous resources available, and the AAFP and its wholly-owned subsidiary TransforMED recently made Delta Exchange -- a social networking resource focused on practice transformation -- free to Academy members. 

The bottom line is that you don't have to go through practice transformation alone. By partnering with the right people and getting the right pieces in place -- both inside and outside of your practice -- you can learn how to make your practice more efficient, more profitable and more enjoyable.

The business of medicine is changing. Are you?

Conrad Flick, M.D., of Cary, N.C., is a third-year member of the AAFP Board of Directors.

Posted at 01:54PM May 16, 2012 by Conrad Flick, M.D.  |  Comments[0]

AAFP.org Coming Soon to a Mobile Device Near You

When it comes to interacting with for-profit companies, consumers expect to be able to do just about anything -- banking, downloading music, paying bills, shopping or even making dinner reservations -- via their mobile device.

Although most nonprofit companies aren't quite as advanced in mobile technology, the AAFP is working on making it possible for us to engage with the Academy on our smartphones or tablet computers as easily as when we buy something on Amazon.com. That means we won't have to be in front of a desktop or laptop computer to

•  find and report CME;
• engage with our peers on AAFP Connection;
  
• register for AAFP events;
• access Academy resources;
• read AAFP news and journals; and
• view and make purchase from the Academy's catalog.

The upgrade also will allow us to, ahem, pay dues anytime, anywhere.

With more than 20,000 web pages to optimize for mobile devices, however, it likely won't happen overnight. The website also will be redesigned during this process, and the goal is for both projects to be completed by June 2013.

I realize that's a little more than a year from now, but I wanted to let you know the Academy is working on this because communication is critical in a member organization. When this work is completed, we will all be able to communicate with each other and the AAFP even better.

Glen Stream, M.D., M.B.I., is president of the AAFP.

Posted at 03:57PM May 14, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[1]

Proposed Increase in Medicaid Payments Helps Patients and Docs Both

Thirty-six percent of AAFP members do not accept new Medicaid patients, and nearly 20 percent don't see Medicaid patients at all, according to a 2011 member survey. Considering that in 2008, Medicaid paid an average of 34 percent less than Medicare for primary care services, those numbers aren't surprising. In nine states, the difference was more than 40 percent.

However, that sizable gap between the two programs will disappear starting in January.

This week CMS announced a proposed rule  to implement a provision of the Patient Protection and Affordable Care Act that requires Medicaid to pay family medicine, general internal medicine, pediatric medicine and related subspecialists at Medicare levels in 2013 and 2014. At least 60 percent of a physician's billings must come from specified primary care services to qualify for the payment increase.

The proposed rule would increase Medicaid reimbursement for family physicians significantly in at least 40 states. It also would increase reimbursement for immunizations given through the Vaccines for Children program.

The AAFP has been advocating health care for all for more than two decades, and these changes are important steps forward in ensuring access to care regardless of economic status. In 2010, Medicaid covered 48.6 million Americans, or nearly 16 percent of the nation's population.

The cost of bringing Medicaid reimbursement in line with Medicare -- $5.5 billion a year -- will be covered entirely by the federal government. However, the cost estimate from the Congressional Budget Office does not consider potential health care savings created by increased access to care and avoidance of care costs downstream because of increased access.  

We all know that patients who don't have health care coverage often put off preventive services and wait until a small problem has turned into a crisis, which costs the entire health care system more. Increasing Medicaid payment for primary care services likely will result in an increase in access to care, improved outcomes and lower overall health care costs.

In fact, a recent study by the Commonwealth Fund shows that a 10 percent Medicare payment increase for primary care ambulatory visits -- a provision of the Affordable Care Act that took effect last year -- will increase primary care visits by nearly 9 percent. And, although the costs for overall primary care visits are expected to increase 17 percent, the study projects a 2 percent net savings for Medicare.

Under the proposed rule, we will have two years to prove it, and the Academy will be pushing Congress to continue the increased payments beyond 2014.

Meanwhile, those two years buy us time to analyze new payment models that are being studied by the Comprehensive Primary Care Initiative, health plans and others.

Although Medicare remains unstable -- with a 30.9 percent reduction in the payment rate scheduled to take effect on Jan. 1, 2013 -- there was good news on that front May 9 with the introduction of a bipartisan House bill  that would eliminate the sustainable growth rate and revamp the Medicare payment system.

In contrast to our member statistics on Medicaid, 90 percent of AAFP members participate in Medicare, and 83 percent are accepting new Medicare patients. So how will increased Medicaid payments for primary care affect your participation in that program?

Roland Goertz, M.D., M.B.A., of Waco, Texas, is Board Chair of the AAFP.

Posted at 02:39PM May 11, 2012 by Roland Goertz, M.D., M.B.A.  |  Comments[0]

Students, Residents: Stand Up and Make a Difference for Family Medicine

Did you know that people in power, including our country's leaders, are talking about family medicine with knowledge and respect? Even more importantly, they are asking for our opinions. I experienced this first-hand during recent meetings with members of Congress and congressional staffers where I advocated for family medicine regarding the sustainable growth rate formula and funding for graduate medical education.

People finally are recognizing that primary care has to be the foundation of an improved health care system in this country, and primary care is family medicine.

Advocating for family medicine, however, is not a role just for the elected leaders of the AAFP. Everyone can play a role, particularly medical students and residents because you are our future. Each of you can take part in the discussion that is developing about the future of health care. The resulting decisions will affect how you practice medicine, regardless of specialty, and how your patients receive care.

Advocacy is not a routine part of medical school or residency training, yet one of the most important duties of a physician is to advocate. You are an advocate for your patients, your practice, your community, and your specialty. It is critical that as an advocate you are informed and active. It's never too early to get involved. Now is the time for you to find a way to be connected on a regular basis. Happily, there are many ways for you to do just that.

I encourage you to come to the National Conference  of Family Medicine Residents and Medical Students. This event, scheduled for July 26-28 in Kansas City, Mo., is one of the Academy's three annual leadership events. Contact your chapter for information about representing your state as a delegate to either the student or resident congress. Delegates play an important role in writing resolutions and debating those resolutions during the student and resident congresses. Some resolutions go on to be considered by the AAFP Congress of Delegates, the Board of Directors or the Academy's commissions.

National Conference also is the venue for elections for student and resident leaders. The Academy selects representatives from both groups to serve on all of its commissions (including governmental advocacy) and the Board of Directors. Jessica Johnson, who will graduate this weekend from the University of Connecticut School of Medicine, and Brent Smith, M.D., a third-year resident at the University of Mississippi Medical Center, are your elected Board members.

Students and residents also can make a difference through Speak Out. This resource connects you with your elected representatives in Washington. Draft letters on critical issues -- such as physician payment -- are available for you to review, edit and send to your lawmakers, and it only takes a few minutes.

This blog is another resource that can help you stay connected. Here you can meet your AAFP leaders and learn about the Academy's priorities. Please reach out to us. Family physicians love to connect people. It is something that we do well, beginning with our patients and their families, and extending to our network of providers in our patient-centered medical homes. We know how to share information and coordinate effort. We can tell a good story that captivates an audience. Now that audience includes legislators and Congressional committees.

This website has some outstanding advocacy tools. There are links to our medical student section, our resident section, and the Family Medicine Interest Group, which includes a toolkit for advocacy.

The Academy also is using resources that students and residents have been tapping into for a long time. We are on Facebook and our medical student page is dynamic and interactive.

You can find almost all members of the AAFP Board of Directors on Twitter as a result of our students, residents, and special constituencies asking us to add it to our repertoire. I encourage you to follow AAFP President Glen Steam, M.D., M.B.I., on Twitter @aafpprez  or Facebook to keep on top of our advocacy efforts in real time.

This is the best time to be a family physician. Advocating for our patients and principles and connecting through social media will allow us to change the world. Link up, speak up and Speak Out!

Reid Blackwelder, M.D., of Kingsport, Tenn., is a third-year member of the AAFP Board of Directors.

Posted at 10:48AM May 09, 2012 by Reid Blackwelder, M.D.  |  Comments[0]

More Academy Members Mean More Influence for Family Medicine

By now, many of you have heard me say that family medicine is the unstoppable force that will transform our nation's dysfunctional health care system.

That force is becoming even more powerful. When I return to Washington later this month, I'll be able to tell legislators, Congressional staffers and federal officials that I represent nearly 106,000 members. To Congress, more members mean more constituents and more voters, which makes us more relevant.

Our membership now stands at 105,900, up more than 5,000 from a year ago and an increase of more than 11,000 from just three years ago. We are the nation's second-largest physician specialty organization, and our growth in the past year has been across the board:

• active membership increased by 1,500 physicians to 64,900;
• resident membership increased by 600 to 10,500;
• and our student ranks swelled by 3,500 to 20,600.

We now represent one-fourth of U.S. allopathic medical students. Those students are receiving a quarterly newsletter, e-mails and other resources related to family medicine as we continue to increase our visibility. Our student website  is receiving record traffic. Clearly, student interest in family medicine is growing.

Time will tell if the surge in student membership will translate into higher Match rates. Obviously, not all of our student members will match into family medicine residencies, but having future subspecialists involved now will expose them to family medicine and give them a better understanding and appreciation of what family physicians do. That could lead to better collaboration and communication with our subspecialist colleagues.

As I've said before, for family medicine and our Academy, the future looks bright.

Glen Stream, M.D., M.B.I., of Spokane, Wash., is president of the AAFP.

Posted at 10:29AM May 02, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[2]

Uniformed Services President Stays Connected During Deployment

I had never met Col. Michael Place, M.D., when I recently installed him as the Uniformed Services AFP president. Technically, I still haven't.

I attended the USAFP annual meeting March 18-23 in Las Vegas, but Mike couldn't make it -- at least not in person. Thanks to the Internet and Skype, the roughly 600 USAFP members in attendance did get to see their chapter president take his oath, as you can see in the photo below. (I'm the tiny figure in the bottom left corner.)

While we were in a comfortable hotel on the Las Vegas strip, Mike -- commander of a U.S. Army combat support hospital and medical task force -- was more than 7,000 miles away in a tent in Afghanistan.

I've installed 16 chapter presidents during my years on the AAFP Board of Directors, and I've heard some pretty good speeches. But nothing compares to that inspiring day.

During the ceremony, there was a laptop with a webcam on the podium so I could see Mike, and he could see me. Chapter members watched him on a big screen. As we finished the installation, I turned the laptop/webcam to the crowd so Mike could see the people clapping and cheering for him.

It was a tremendous sight. Mike was beaming.

There is a high level of collegiality at most chapter meetings as old friends reconnect, possibly for the only time all year. For most chapters, members are scattered across an entire state. For this chapter, they are scattered across the globe even in the best of circumstances.

Mike has been in Afghanistan for more than five months. Given the time difference and bandwidth limitations, most of his correspondence is by e-mail. He will get plenty of help from his vice president during his deployment, just as he covered for a previous president during a deployment. Mike thought it was important that he be formally sworn in as president, even though he is overseas, because deployments are a real possibility for nearly all of the chapter's members. It was important to him and the chapter to recognize and celebrate the important role that family physicians play in the Uniformed Services during a time of conflict. 

USAFP members serve in small unit aid stations and in a variety of leadership positions up to and including command of a deployed hospital. They prevent illness and injury in addition to treating those who are injured, ill or wounded in combat. Mike is proud -- and rightly so -- to be one of them.

I have great respect and admiration for these men and women and the work they do, and I felt blessed to be with them.

You can read more about the USAFP in AAFP News Now's latest chapter spotlight story.

Glen Stream, M.D., M.B.I., of Spokane, Wash., is president of the AAFP.

Posted at 04:42PM Apr 25, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[1]

Planning Ahead Makes End-of-Life Care Easier for Everyone

Too often, planning for end-of-life care is left to the end of a life. But that stressful, chaotic time is often too late for a patient to make his or her wishes clear, and difficult decisions are left to be made -- and sometimes argued about -- by their relatives.

It doesn't have to be that way.

One of my severely disabled patients, who was in his 30s, recently died after a lengthy illness. His mother choose not to prolong his life with a feeding tube and watched her son waste away. She was at peace with that painful -- but correct -- decision because the family knew what was coming, had time to think it through and was prepared when the time came. My patient died peacefully, painlessly and without fruitless interventions because of advance planning.

End-of-life care is a compelling topic that needs to be discussed before a patient has a health crisis. Unfortunately, a minority of patients will bring up advance directives or living wills with their doctors. More than likely, it will be up to us as family physicians to broach the subject, and that discussion shouldn't wait until a person is in transition from healthy patient to terminally ill.

Too many people think, "It can't happen to me," but the reality is that serious accidents and life-threatening diseases can -- and do -- strike young, healthy people.

Remember Terri Schiavo? She was 27 when she suffered cardiac arrest and brain damage due to a lack of oxygen. Schiavo was in a vegetative state for eight years before her husband petitioned to remove her feeding tube. With Schiavo's wishes unclear, her parents challenged that petition, sparking a seven-year legal battle that reached the Florida Supreme Court.

With a little guidance from us, patients can plan ahead, make their wishes known and reduce the burden on their family during an already difficult time.

We can discuss the subject of end-of-life care in a nonthreatening way far in advance of a patient needing it if we bring it up as a routine matter in the same way we regularly ask "What meds are you on?" Questions about end-of-life planning should become second nature so patients become accustomed to it.

When a patient reaches the age of maturity, it's time to start the conversation. They don't have to decide everything at 18, but the conversation needs to be initiated.

Health organizations in Lacrosse, Wis., developed a community-wide planning system in the 1990s called Respecting Choices. That system includes defined roles and expectations for physicians, patient engagement, incorporating advance directives in clinical care and protocols for emergency personnel.

An evaluation of that program showed that 85 percent of adults who died in the community during an 11-month period had an advance directive, and treatment decisions were consistent with patients' wishes 98 percent of the time when they did have directives.

The program now has been initiated in more than 80 communities in the United States.

Though many of our communities don't have similar initiatives, that doesn't mean patients can't be proactive or that their physicians shouldn't encourage them to plan ahead. Several models have been developed that are more specific and more useful than standard do-not-resuscitate forms or living wills. Here are just a few.

Five Wishes is an advance directive that covers more issues than a typical living will or power of attorney document. The document, which meets legal requirements in more than 40 states, lets physicians and a patient's family know:

• who should make health care decisions for a patient when they can't;
• medical treatment they want (or don't);
• how comfortable they want to be;
• how they want to be treated; and
• what they want loved ones to know.

"Let Me Decide" is an advance directive book written by a geriatrician. Each book contains a four-page form designed to clearly state patient's wishes, as well as a sample form. The author encourages patients to consult their health care professional before completing the document.

The document is designed to:

• give individuals the opportunity to choose different levels of treatment according to his or her wishes;
• relieve family and friends from the burden of decision making; and
• guide physicians in making important decisions when family members are unavailable.

Physician Orders for Life-Sustaining Treatment, or POLST, uses a form that converts patient preferences into written medical orders based on a health care professional's conversation with the patient and/or a proxy. POLST programs have been implemented in at least a dozen states and are in development in at least 20 more.

The AAFP also has resources that can help. American Family Physician offers a collection of articles on end-of-life care. FamilyDoctor.org offers resources for patients, including information about advance directives and do-not-resuscitate orders.

Regardless of what approach is used, patient interaction with a physician and documentation of their wishes is critical. Some physicians feel uncomfortable having this discussion because it is an emotional, complex task, and reimbursement also is an issue. But we can help our patients, their families and the health care system by encouraging patients to have a plan in place.

How do you talk to your patients about end of life care?

Richard Madden, M.D., of Belen, N.M., is a second-year member of the AAFP Board of Directors. He is a practicing family physician and a clinical assistant professor of family and community medicine at the University of New Mexico School of Medicine, Albuquerque.

Posted at 03:31PM Apr 24, 2012 by Richard Madden, M.D.  |  Comments[0]

I'm Still Listening; So What Do You Have to Say?

Last fall the AAFP launched three new tools to help Academy leaders better communicate with members: the AAFP Leader Voices blog, the AAFP President Facebook page and the AAFPPrez Twitter account.

The idea was simple:

• Use Facebook and Twitter to communicate what the Academy is doing on your behalf -- including real-time updates of our lobbying efforts in Washington and meetings with large health plans -- and to respond to your comments or questions.

• Use the blog to communicate more detailed information about those activities and, again, to respond to your comments or questions.

So how are we doing?

A little more than half way through my term, I have tweeted 194 times in 221 days from 11 states; Washington, D.C.; and Canada from meetings with legislators, CMS, the AMA, AAFP chapters and others.

One of my goals was to reach 1,000 Twitter followers. With about 180 days to go, we're half way there. I may not make it, but the AAFPPrez account will transition to President-elect Jeff Cain, M.D., when he takes office in October. I hope the numbers of those following the three new social media platforms will continue to grow under successive presidents. The connections we make and the feedback we receive from you can help make us more nimble in responding to issues.

(By the way, Dr. Cain recently joined the twitterverse, and you can start getting to know him by following @JeffreyCainMD.)

The AAFP President Facebook page has had 111 posts and 64 comments in seven months. I read all your comments and do my best to respond in a timely manner. The same is true for the AAFP Leader Voices blog. The last four blog entries have received a total of 30 comments, including a lively discussion about scope of practice and the future of family medicine training.

In the past few months, the blog has expanded to include input from other Board members, and you will be hearing from more of us in the coming weeks. The Board is a diverse group of family physicians with representation from students, residents, new physicians, solo doctors, large practice physicians, urban and rural doctors, and academic physicians from all parts of the country.

Some of us are brand new to social media. When my term started, Skype wasn't even on my radar, but I now have used the technology to conduct a video conference call with our Family Medicine Interest Group coordinators  and more recently to install the president of the Uniformed Services AFP (more on that in my next blog) who is serving the U.S. Army in Afghanistan.

I also had the privilege of recently appearing on the Family Medicine Rocks podcast  with Mike Sevilla, M.D., for a discussion about the AMA/Specialty Society Relative Value Scale Update Committee (RUC) and the AAFP's Primary Care Valuation Task Force. That one-hour interview provided listeners with a more intimate, detailed discussion than what I could provide in my own message to members.  That podcast drew more live listeners and downloads than any in the five-year history of Mike's show, which demonstrates there is a strong social media community in family medicine, and it's continuing to grow.

Mike, who I've dubbed the king of family medicine social media, will be the presenter in a session about social media during the Annual Leadership Forum  May 3-5 in Kansas City, Mo. I've learned a lot in the past seven months, but I'm ready to learn more.

How are you using social media to connect to your patients and colleagues?

Glen Stream, M.D., M.B.I., of Spokane, Wash., is president of the AAFP.

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Editor's Note: In addition to the AAFP Leader Voices blog and the AAFP President Facebook and Twitter accounts, you can connect with the Academy through many other social media accounts, including:

Facebook
American Academy of Family Physicians (AAFP)

AAFP Annual Leadership Forum (ALF)

AAFP International Medical Graduates

AAFP National Conference of Family Medicine Residents and Medical Students

AAFP - National Conference of Special Constituencies (NCSC) 

AAFP New Physicians

AAFP Scientific Assembly

American Family Physician 

Annals of Family Medicine

familydoctor.org

Family Medicine Interest Group (FMIG) Network

Family Practice Management

Tar Wars 

Google +

AAFP 

 

Twitter
@aafp

@familydoctor

@AAFP_FMIG

@AAFPAssembly

@AFPJournal

@aafpncsc

 

Blogs

American Family Physician Community Blog 

FPM - Flow 

FPM - Getting Paid 

FPM - Noteworthy

 

You also can find us on Flickr, LinkedIn, Slide Share and YouTube.

Posted at 10:46PM Apr 19, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[0]

What Happens When a Doctor Becomes the Patient?

It is a nice, but cold, calm spring day. We haven't had one of those in a while, so I saddle my horse, Cimarron, and walk him around the arena. (That's Cimarron and me in the photo below.)

Boy, it is good to be back in the saddle again. From a walk to a trot, then a trot to a lope, Cimarron cruises like he has not had time off for the winter. He stops on a dime, and then we lope in the other direction. Well, I think, I better not work him too hard on his first day back in action. Just as I decide that, his right front hoof catches a rock. He tries to recover, but fails as he falls to his knees and crashes on his face.

I am thrown forward, and my chest hits the saddle horn before I'm tossed in front of Cimarron. The 1,300-pound horse rolls on top of me.

Darkness. Then pain. Have I broken my back?

My feeble yells do not bring help.

"I guess no one is coming," I think.

I move one leg and then the other. That's a relief. I move my head, and my c-spine seems OK. I am, however, starting to develop significant left upper quadrant pain.

"Well, it's now or never," I say to myself as I get on my feet. I don't feel half-bad standing. Cimarron, who is fine, looks at me to see if I'm OK. It's a cowboy thing to get back in the saddle if you fall off so the horse still understands who is boss. I try to put my foot in the stirrup, but that is not going to happen.

I lead Cimarron 300 yards back to the barn and take off his saddle. What amazes me is that this doesn't cause any pain. I put Cimarron in his stall and head to the house. The closer I get, the more pain I feel. Everything hurts, and I'm lightheaded.

"Are you OK?" my wife asks. "What happened?"

"You don't look so good," she adds as I pass out on the living room floor.

When I come around, my abdomen is hurting. We live a half hour from town. I think it will be quicker to have my wife drive me to the emergency department (ED) than to call paramedics. I don't want to scare her, so I tell her it will be OK. As we drive, my left upper quadrant is feeling more swollen, and I am getting more lightheaded.

The medical assistant at the ED bay grabs my shoulders and chest and pivots me into a wheelchair. Well, I guess this is good test to make sure I don't have a spine injury. I almost pass out from the pain.

The assistant asks what happened, and I am able to say, "Horse accident, blunt trauma LUQ, near syncopal."

She gives me a quizzical look and says, "Would that be trauma?"

"Yes, that would be trauma."

Things move fast, then. They start an IV in my left antecubital fossa. "Not there," I tell them, but I am ignored.

I tell them I am allergic to shellfish, iodine and most narcotics. They fill me with Solu-Medrol and Benadryl and take me off for a CT scan. The room is air conditioned, and I am naked. I shiver, exacerbating the pain. I am unable to move from the gurney to the CT table, so they roll me over. They pull my arms over my head for the CT scan. More pain, and I am shaking visibly.

Back to the ED room. The nurse finally gives me warmed blankets. Yes! I am informed I can't have anything for pain because of my allergies, but I eventually talk them into Toradol. That helps a lot.

I am told that the trauma surgeon was called for a motor vehicle accident, and it will be a while before I will be seen. Five hours later, the surgeon enters the room laughing. "I bet you are in pain, aren't you?"

Hilarious. Luckily, I don't have a fractured spine or spleen. My blood work is fairly normal. Interestingly, my blood pressure is slightly high. Gee, I wonder why.

What I do have is five fractured ribs, both anteriorly and posteriorly. Believe it or not, there is no pneumothorax. I am admitted to the ICU because of my allergies to narcotics, and they can monitor me better there.

I know most of the ICU nurses. That is a comfort until I realize that I am going to have to urinate eventually.

I don't have an allergic reaction to a test dose of fentanyl, so they give me a regular dose. I am feeling better -- and hungry. It has been 18 hours since I last ate.

"Sorry, the kitchen is closed. Maybe your wife can go get you something."

No wonder I have not had to urinate -- yet.

Like most ICUs, there are no doors, bathrooms or privacy. Little things start to bother me, like the fact that it is 2 a.m., and the nurses are talking at normal volume and laughing at jokes.

"Dr. Spogen, why don't you sleep some? You will feel better in the morning."

I can't sleep, and every time I flex my left arm, the IV alert rings until the nurse silences it. That is why I didn't want them to put the IV there.

I don't feel better. In fact, every inch of me hurts. Worse yet, I have to pee. I finally muster the confidence to ask the nurse. They pull a curtain around me while holding my shoulder so I don't fall.

That urgent problem solved, I now notice that I am hot. My skin is burning up, and I am really red. Everyone decides I must be having an allergic reaction. I get another shot of Solu-Medrol.

Guess what? I get redder. Then it dawns on me that one of the side effects of steroids is flushing. As the Solu-Medrol works its way out of my body, the redness fades.

Finally, I get out of the ICU and am transferred to the medical floor. Maybe now I can sleep? The nurses on that floor are all quite nice. "Just let us know if you are having pain, Dr. Spogen, and I will get you some fentanyl. It's already ordered."

A couple of hours later I start to cough. If you ever have coughed with broken ribs, you know it is not comfortable. The more I try not to cough, the more I want to cough and the more painful it becomes. I finally call to ask the nurse for pain meds. She answers on the intercom that she will be right with me. Two hours later, she arrives and wonders why I refuse the medicine. The thing about broken ribs is that if you don't cough, sneeze or move, the pain goes away. My coughing fit had passed already.

On the second night of my stay, I try to go to sleep at 10 p.m. At 11, the nurse brings me ibuprofen. At midnight, the nursing assistant comes to check my vital signs. Every time I flex my arm, the IV alarm goes off, so the assistant shows me how to silence it. At 3 a.m., I get another round of meds. At 4 a.m., the phlebotomist comes for a blood draw. At 5 a.m., another set of vitals.

The nursing assistant asks how I slept. Is she kidding?

I begin to feel strange, somewhat like I am getting a viral infection. I feel myalgias, neuralgias, slightly nauseated and lightheaded. The nursing assistant checks my vitals. My pulse is OK. My blood pressure is OK. I don't have a fever.

"That's strange," she says.

"What's strange?"

"Your oxygen saturation is 78 percent. Why don't you take a couple of deep breaths?"

I do. No change in the oximetry.

"I'll go get the nurse."

What's odd is I don't feel short of breath. But it makes sense that I might have a little atelectasis, so I get out the incentive spirometer. Gradually, I feel better. Finally, at 7 a.m., two and a half hours later, the nurse comes in, mainly because there is a shift change.

"What about my oximetry?" I ask.

"Just keep taking deep breaths."

"How about you check my oximetry, just for fun?"

It is 95 percent.

They decide to keep me in the hospital another night because of my low oxygen. My pain is fairly well controlled with a fentanyl patch and ibuprofen, so they hook me up to a continuous pulse ox. The day passes uneventfully. I get ready to sleep at 10 p.m. I'm soon fast asleep, but the pulse ox alarm, which is set to go off if my saturation falls below 87 percent, wakes me up. I call for the nurse. A half an hour later, the alarm continues to blare and still no nurse. I struggle to get out of bed and manage to silence the alarm. I go back to bed and immediately fall back to sleep, but what seems like seconds later, the alarm rings again. This happens 12 more times before the nurse finally shows up.

I am furious, exhausted and maybe a little drug impaired.

They finally put me on supplemental oxygen. The alarm does not go off, but now I can't sleep. I get up at 5 a.m. and take the oxygen off because when I am up my oximetry is fine.

When the nurses change at 7 a.m., I ask them when the doctor is making rounds. They have no idea. How did I know that would be the answer?

I don't want to spend another night in the hospital, but I do need home oxygen. Having discharged a lot of patients on oxygen in the past, I know that getting insurance verification takes hours, so I am proactive and ask the nurse to see if the doctor can order home oxygen. Hours pass. No comments from nurses or doctors.

At 11:30, I'm pretty upset because there is no communication, and the ward clerk doesn't know anything. Shortly after that, transportation comes in to take me down for a chest x-ray.

"Good morning, Mr. Spongen. I'm here to get you for a chest x-ray. Do you know why you are getting an x-ray today?"

Already frustrated, this pushes me too far.

"That is DR. SPOGEN, to you. And NO, I have no idea why I am getting an x-ray."

I hate to play the doctor card, but I'm angry. I realize that this is the wrong person to vent my frustrations on, but it gets things done. The tech goes to the desk, and the nurse immediately appears. I tell her what I think needs to be done if I am to go home on oxygen, and she calls the doctor's office.

I get the x-ray, and when I return to my room, the doctor's nurse practitioner is there. He warns me that he needs to do a complete exam so they can send me home. Apparently, he has no clue what a complete exam is because all he does is listen to my chest and check my grip strength. I am pulling more than 3,000 cc on the incentive spirometry, so he confesses there is no reason to keep me in the hospital. He agrees that I should have home oxygen for at night, and says he will put in the order. He gives me two weeks of narcotics and tells me I should be OK to work in four days, but "Don't work or drive on narcotics."

Hmm … that does not compute. Oh well, I am getting out of here.

My wife arrives a few hours later. The nurse says I'm OK to leave. No signing papers, no wheelchair ride, just goodbye.

On my way out, I get a call from the home oxygen supply company. The order was not placed until 3 p.m., and they can't get insurance verification. They tell me I might want to spend an extra night in the hospital if I need oxygen because they cannot deliver it without verification. I cannot believe it! Finally, they agree to leave the oxygen if I give them a check for $1,500 in case insurance does not cover it.

I am home now and recovering from my injuries. I am a respected doctor who works every day in this hospital, yet look how I was treated. I now understand why some of my patients are upset with their hospital care.

The biggest flaw was poor communication. I had considered having my family doctor admit me instead of the surgeon. My family doctor would have listened to my concerns and would have communicated to me why I was getting an x-ray (I still don't know if it was ever read) and would have known to order the oxygen early enough to make sure there was insurance verification.

It was a good lesson for me, however. I will handle my inpatients differently in the future, and I will make sure they have their orders on time. I have admitted patients in the past who are doctors or nurses. As their physician, I will make sure they get private rooms, and that their privacy is respected. My students and residents will hear about my experience, and they will know the issues patients face.

As a physician, I knew when my treatment was not ideal, but most patients do not have this same knowledge. Maybe if all doctors and nurses spent some time as patients, we could make the system better.

Daniel Spogen, M.D., of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.

Posted at 03:19PM Apr 11, 2012 by Daniel Spogen, M.D.  |  Comments[7]

Let's Help Our Patients Make Informed Decisions on Tests, Procedures

Nearly one-third of health care delivered in the United States is unnecessary. Ordering tests or procedures that aren't recommended puts our patients at risk and drives up the already skyrocketing cost of health care, which is projected to account for nearly 20 percent of the nation's gross domestic product by the end of the decade -- unless things change.

And change is exactly what we're recommending.

Today, the AAFP released a list of five tests and treatments family physicians and our patients should question because they often are overused or misused. According to a study in the Archives of Internal Medicine, tests and procedures being overused in primary care are costing the health care system more than $6 billion a year.

One example of overuse is prescribing patterns for antibiotics. These drugs are prescribed in more than 80 percent of the 16 million annual office visits for sinusitis, despite recommendations against the practice.

The AAFP created its top five list of overused tests and treatments as part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, which is focused on identifying tests and/or procedures commonly used in medical specialties that may not always be necessary. The Academy is one of nine physician specialty organizations that initially agreed to participate in the collaboration.

The AAFP's goal in participating in the Choosing Wisely campaign is to provide evidence-based clinical information that we can use -- along with AAFP consumer education materials -- to start conversations about tests and procedures with our patients. This information will provide a solid foundation for shared decision making between us and our patients that is directed toward the best possible care while avoiding unnecessary and potentially harmful testing and treatment. It will make it easier for everyone to make the best possible choices.

Although we have taken an important step in developing our list of tests and procedures, our work is not done. In the coming weeks and months, Consumer Reports will be issuing patient education materials on each of the five issues we are addressing. As those resources are released, our Web page on the Choosing Wisely campaign will be updated.

Family physicians have a dual opportunity and responsibility regarding Choosing Wisely. First, we must use best evidence for the care we provide. And second, we must be a resource to our patients when they need subspecialty care. Many of our subspecialty colleagues are participating in the Choosing Wisely campaign as well, and I applaud them for their efforts. You can read all nine of the lists released today on a Choosing Wisely Web page.

Glen Stream, M.D., M.B.I., of Spokane, Wash., is president of the AAFP.

Posted at 04:31PM Apr 04, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[3]

AAFP Taking 'Watchful Waiting' Approach to Supreme Court's Consideration of Health Reform Law

For more than two decades, the AAFP has supported the idea of health care for all. Two years ago, the federal government took steps toward making that concept a reality when the Patient Protection and Affordable Care Act was signed into law.

This week, the U.S. Supreme Court is reviewing the law, which is being challenged by more than half the states. That concept of health care for all -- in a country with approximately 45 million uninsured people -- is at the center of the debate.

• On Monday, the justices heard arguments about whether a penalty consumers would pay if they fail to obtain health care insurance is actually a tax. If the court rules it is a tax, the Anti-Injunction Act dictates that no challenge to the law can be brought until after the tax is paid.
• Today, justices heard arguments questioning whether Congress can require people to buy health insurance.
• And on Wednesday, the discussion will turn to whether other provisions of the Affordable Care Act can stand if the coverage mandate does not.

We will be following these arguments closely. The Affordable Care Act is not perfect, and our own membership has been split on its merits. There is no question, however, that the law contains provisions that address key issues the Academy has been calling for:

• Assure that all people in the United States have health care coverage and access in order to foster a healthy and productive society.
• The patient-centered medical home (PCMH) should be the basis of the health care system, improving efficiency and quality and providing comprehensive primary care for children, youth, adults and the elderly.
• Providing a PCMH for every American will require a robust family physician workforce. The United States already is facing a shortage of 45,000 primary care physicians by the end of this decade.
• Payment for primary care services also must increase in order to sustain primary care practices, allow for investment in practice transformation, and narrow the income gap between primary care and subspecialty physicians that represents a barrier to medical students entering family medicine.

The Supreme Court is expected to rule on the Affordable Care Act in June. Regardless of the high court's ruling, however, the AAFP will continue to push forward on these critical issues.

Posted at 03:34PM Mar 27, 2012 by Glen Stream, M.D., M.B.I.  |  Comments[3]

Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training

During the past two years, all 12 of the residents who completed the family medicine program at the University of Nevada School of Medicine started their careers as employed physicians. They're not alone.

According to AAFP data, more than 60 percent of AAFP members are employed physicians, and more than 80 percent of new physicians -- those who completed residency within the past seven years -- are employed. Thirty years ago, employed physicians were a minority in family medicine, but a slow shift to the employed model during the past two decades has eroded our collective scope of practice.

That erosion has occurred because some employers dictate scope of practice. Many family physicians have taken jobs with hospital groups who need primary care physicians to coordinate outpatient medicine. They don't necessarily need FPs to provide obstetric or pediatric care.

A recent AAFP member survey indicates that fewer than 20 percent of AAFP members have hospital privileges for routine obstetric delivery, and fewer than 60 percent have privileges for newborn care. Those numbers are down from 25.7 percent and 64.7 percent, respectively, in 1995. According to the American Board of Family Medicine (ABFM), fewer than 10 percent of family docs are providing maternity care, and fewer than 42 percent perform in-office procedures.

These numbers likely will continue to decline as more of us take employed positions.

One of the factors that typically draws students to family medicine is the broad scope of practice. Traditionally, family medicine has offered us opportunities to do a bit of everything. We have treated and cared for entire families -- from cradle to grave. But many new physicians are finding that they can't do that.

Employers are just one factor contributing to the problem. Restrictions on duty hours have reduced residency training and experience, leaving new physicians feeling less prepared for practice than in previous generations.

Although many small towns and rural areas continue to need primary care physicians who can provide a wide range of services, the percentage of family physicians taking those kinds of jobs is small. Fewer than 20 percent of AAFP members practice in rural areas, down from 31.7 percent in 1994.

And even rural areas aren't immune to these changes. According to the ABFM, more than 70 percent of family physicians -- regardless of whether they practiced in urban areas, rural areas or areas with health care professional shortages -- were "attending to the specialized needs of women" in 2003. By 2010, the percentage of physicians in all three categories who offered those serviced had dropped to less than 50 percent.

These are troubling trends. We have advocated against expanding the scope of independent practice for nurse practitioners (NPs), but if family physicians aren't providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?

As more residents are becoming outpatient docs, we have to ask ourselves:

• Where are we going with training?
• What needs to be done with curriculum design?

I recently attended the Association of Departments of Family Medicine (ADFM) winter meeting. Half of a day of the four-day event was dedicated to scope-of-practice issues. The Council of Academic Family Medicine, which includes the ADFM, is in the process of evaluating training and curriculum. Meanwhile, the ABFM is surveying test takers about what skills are truly needed by family physicians.

The aforementioned reduction in training time coincides with an ever increasing amount of complexity in the specialty. Patients are living longer while coping with more chronic conditions. Meanwhile, physicians are expected to be more tech savvy, implementing electronic health records and transforming practices to the patient-centered medical home model. How do we teach everything in a condensed time frame?

One potential solution is expanding residency programs to four years. The extra year would make up for time lost to work restrictions and give residents a chance to develop an area of concentration. The Accreditation Council for Graduate Medical Education has announced a pilot to examine length of training, and a call for proposals was released March 16. Up to 25 residency programs will be selected for a pilot scheduled to begin in July 2013.

The AAFP needs to be involved in these important discussions, and the Academy needs to know what members think. So I pose these questions to you:

• Is it important to you that your Academy advocate for full scope of practice?
• Should we instead move forward, focusing education and training on outpatient adult medicine and population management issues?

The AAFP Board of Directors is expected to discuss this issue at its May meeting. Your input here could help inform that discussion.

Daniel Spogen, M.D., of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.

Posted at 11:37AM Mar 22, 2012 by Daniel Spogen, M.D.  |  Comments[18]

Office Champions Project is Opportunity for FP Offices to Improve Smoking Cessation Efforts

You probably know that cigarettes are the leading cause of preventable death in this country, contributing to roughly 443,000 -- or one in five -- deaths each year. Staggering, but not surprising when you consider than nearly one in five U.S. adults smokes, and high school seniors are close behind at nearly 19 percent.

What you might not know is what a huge difference you can make. In fact, talking to your patients about quitting tobacco is one of the most effective prevention activities that family physicians can do in their offices. According to the surgeon general, 70 percent of smokers want to quit. And patients who are advised to stop smoking by their physicians have a 66 percent higher rate of success in doing so.

The AAFP is doing its part to help family physicians be even more successful with tobacco cessation by offering you effective tools with our successful Office Champions Tobacco Cessation project. Based on the Academy's evidence-based Ask and Act smoking cessation program, the Office Champions quality improvement project trains a physician or staff member to identify and implement changes that promote the integration of tobacco cessation activities into daily office routines.

We know the program can be successfully implemented in busy family medicine offices. In fact, last year, 49 primary care practices completed a 13-month pilot project and successfully implemented 85 percent of the tools (e.g., quit-smoking posters, patient education materials and other Academy resources) they had included in their implementation plans. Ninety-eight percent of practices expressed confidence that the changes they made could be sustained.

Office Champions is a proven way to increase awareness about tobacco cessation in your practice. It also helps you identify who needs help. In the pilot, the percentage of patient charts with documentation of tobacco use status increased from 82.1 percent to 90.2 percent. Documentation that patients were offered cessation assistance increased from less than 50 percent to 72.1 percent.

Now the Academy is recruiting 50 family medicine practices -- with an emphasis on states with a smoking prevalence of more than 20 percent -- for nationwide dissemination of the Office Champions project.

Practices that complete the program will receive $2,000 to cover administrative costs. The deadline to apply is May 8. Applications and additional information are available online. 

Together, we can make a difference.

Jeffrey Cain, M.D., of Denver, is president-elect of the AAFP. He is the chief of family medicine at Children’s Hospital Colorado and an associate professor in the Department of Family Medicine at the University of Colorado Health Sciences Center. He also is a co-founder of Tar Wars¸ the Academy's award-winning, tobacco-free education program for children.

Posted at 01:37PM Mar 21, 2012 by Jeffrey Cain, M.D.  |  Comments[0]

As Match Day Nears, Student Board Member Shares Wishes for Family Medicine

Of all the milestones in a physician's life, Match Day ranks highly among them. On March 16, more than 15,000 U.S. medical students will collectively tear open the envelopes that hold the key to their next steps in training.

Even more exciting about this Match Day is the potential for continued increases in U.S. seniors filling family medicine residency positions. Last year's Match saw an increase from 7.9 percent to 8.4 percent of U.S. seniors who chose family medicine. Anecdotal evidence from around the country says we're on target for another increase. Programs are reporting unprecedented numbers of applicants for first-year positions. Many had to offer additional interview days or expand the size of their interview class to accommodate the increased interest.

These numbers are on par with the growth we're seeing at the AAFP. The Academy has more than 17,000 student members. Students also are the fastest growing segment of membership. One in every four medical students is now a member of the AAFP.

More importantly, the quality of applicants is also reported to be more impressive than ever before. Academic achievements, leadership commitments, and community service pack the resumes of today's medical students. And they are choosing family medicine. The students I met on the interview trail were talented and compassionate -- these are your future family physicians.

Students also are being drawn to residency programs with "innovative curricula." Although this is a broad category, there have been so many training advances in recent years that there is something to appeal to every application. The P4 Program (Preparing the Physician for Personal Practice) set the stage by implementing and rigorously evaluating curricular innovations. The data from this initiative (sponsored in part by AAFP subsidiary TransforMED) is incredibly promising -- all of these programs have completely filled their intern classes in the past two years. Students are drawn to patient-centered medical home principles, electronic health record capabilities, fourth-year training opportunities, and longitudinal integrated learning.

Today's trainees desire more flexibility in their education to ensure they are trained with the medical knowledge, practice skills and systems-based perspective that will be required in future practice. Family medicine is leading the change.

Unfortunately, with all the growth we have seen in recent years, we still lag far behind the 40 percent family physician workforce recommended by the latest COGME report for ideal health outcomes. The lifetime income gap between primary care physicians and subspecialists -- estimated at $3.5 million -- is a major driver of inadequate numbers. Lifestyle considerations and eroding scope of practice fall a close second. On these fronts, too, the AAFP's advocacy efforts are making headway to both improve the practice environment and to attract the students needed to fill extra workforce demands.

I chose family medicine for many reasons, but most of all because I value the relationships I will one day form with my patients. Although many of the recent curricular and practice changes will never replace our commitments to our patients, they do supplement our ability to provide comprehensive and patient-centered care.

I eagerly await this Friday, when the next step in my path will be made clear. I have every hope that the 2012 Match will be another year of growing success for family medicine.

Jessica Johnson, the student member of the AAFP Board of Directors, is a student at the University of Connecticut School of Medicine, Farmington.

Posted at 01:22PM Mar 14, 2012 by Jessica Johnson  |  Comments[0]

'Inspirational' Forum Grooms FP Leaders, Helps Chapters

Who will lead the next generation of family physicians? Who will be a force for change in your state chapter? Could it be you?

Many Academy leaders start their journey in the AAFP with the wonderful skill-building opportunities provided at the the National Conference of Special Constituencies (NCSC), the AAFP’s forum to address member issues specific to women, minorities, new physicians, international medical graduates, and gay/lesbian/bisexual/transgender physicians.

But less recognized are the skill-building benefits of the AAFP's Annual Leadership Forum (ALF), where chapter leaders and newly elected Board members learn from their peers what a state chapter can accomplish. 

In 1986, J.J. Smith, M.D., a family physician colleague from Anchorage, Alaska, pulled me aside and asked me if I wanted to be on our state chapter's CME committee. Fresh out of residency training and in my first job at the Alaska Native Medical Center in Anchorage, I was honored and surprised. Attending my first State Officers Conference, as ALF was called then, was an eye opener. I met impassioned family docs from all over the country, working at the state and local level to promote the tenets of family medicine: legislative advocacy, promotion of healthy lifestyles, participation in clinical medical education, and sharing tips and tricks on practice enhancement.  

Over the years, I found this annual meeting to be incredibly inspirational and rewarding. Each year I returned to my state with a new vigor and outlook on my practice. New attendees from our chapter became our new chapter leaders, and the baton was passed to freshly minted chapter leaders who were infused with the spirit and joys of family medicine practice and excited about the opportunity to make a difference.

I learned tips and tricks for organizing my work habits, and rediscovered how to achieve a better work/life balance. I especially enjoyed the opportunity to talk with inspiring colleagues who had taken on some of the challenges I was facing and found success.

The ALF/NCSC conference is a unique opportunity to blend networking with leadership skill-building, and it offers the opportunity to get back in touch with the core values that made me choose family medicine in the first place.My return to my practice and chapter always benefited from a renewed enthusiasm after attending the ALF/NCSC gathering. My fellow chapter colleagues in attendance developed a shared vision of where to take our chapter in the upcoming year, and we identified resources through conference networking that we shared with our chapter executive and staff that made success in our projects more likely.

As a small AAFP chapter with geographic challenges and limited resources, Alaska has benefited greatly from the opportunity to attend this terrific annual leadership event. The financial support for new attendees has been invaluable. I, for one, would not have continued to meet with my regional and national colleagues year after year if it were not for ALF and the NCSC.

I am appreciative that the AAFP has consistently supported and funded this very worthwhile conference for leadership development, and hope that those of you who are considering becoming more involved in community leadership and AAFP chapter activities choose to attend. You will not be disappointed.

This year's events are scheduled for May 2-4 in Kansas City, Mo. I'll see you there.

Barbara Doty, M.D., of Wasilla, Alaska, is a second-year member of the AAFP Board of Directors.

Posted at 02:55PM Mar 07, 2012 by Barbara Doty, M.D.  |  Comments[0]