More Than Meets the Eye: Value of Small Practices Shouldn't Be Ignored
For years, we've been hearing about the decline -- even death -- of the small primary care practice, but I'm here to say that obituary is premature, if not flat-out wrong. When a recent study published in Health Affairs touted the value of small practices, I didn't need convincing. I'm a small practice owner and have been for nearly 30 years.
The study found that primary care practices with one or two physicians had one-third as many preventable hospital admissions compared with practices with 10 to 19 physicians. The study also reported that smaller practices achieved their impressive results despite caring for a higher percentage of patients with chronic conditions than larger practices.
© 2014 Texas AFPMy rural, two-physician practice recently achieved Level 3 patient-centered medical home recognition from the National Committee for Quality Assurance.
So how did the small practices in the study manage to have better results regarding preventable admissions (and likely lower costs) than their larger counterparts? The authors point out patients in smaller practices may have closer relationships with their physicians, which might offer greater insight into patients' comprehensive health needs while facilitating ready access to care.
Patient-centered care, which includes enhanced access to care along with other elements, has become a focal point of the movement to improve our health care system in the past decade and, increasingly, is being embraced by small and large practices alike. Large practices, in particular, are likely to benefit from economies of scale that enable them to readily invest in health information technology and other organized care processes recognized as components of the patient-centered medical home (PCMH) model. And indeed, in this study, some of the larger practices appeared to use more such processes than the smaller practices, yet didn't fare as well in keeping patients out of the hospital.
Clearly, there's more to the story.
An abundance of evidence tells us that the PCMH can lower costs and improve outcomes. Just think: How much more could we bolster those outcomes if we combined the efficiencies of a Level 3 PCMH with the strengths and accessibility of a small practice?
Welcome to my small rural practice, which recently achieved Level 3 recognition from the National Committee for Quality Assurance (NCQA).
Regardless of a practice's size, there are hurdles to jump through on the way to PCMH recognition. The process can be overwhelming at the outset, and the AAFP has discussed the need to simplify the process with the NCQA and other such groups.
Although the process can be especially difficult for small practices, which lack the time, capital and resources of larger practices, it can be done. My two-physician practice achieved Level 3 recognition, from start to finish, in two years. We did it by working together with other small practices in our area, combining our efforts and resources.
The key, for me, was taking the process one step at a time, which made it seem more attainable. To that end, the AAFP has created a PCMH Planner to help practices of all sizes transform to the new model; that resource offers a step-by-step guide to follow.
I'm sure many small-practice physicians look at the PCMH checklist and think, "I'm already doing this. I'm already patient-centered."
I was one of those docs. And I was wrong. That's a difficult thing to realize, but my practice is better now than it was two years ago. We've improved vaccination rates, lowered the number of missed screenings and made care more accessible.
I realize now that it's important to be open to change and to always be looking for opportunities to improve. For example, I initially thought a patient portal -- a requirement to achieve the recognition level we did -- would be money wasted, but it's actually changed the way I practice. Giving patients access to their individual records improved the overall quality of our data. I've had patients point out mistakes in their records that were quickly corrected, and I even had one patient point out something we hadn't billed for that we should have. One benefit I had not expected is that my patients who are hearing-impaired now communicate with my office more often and with greater ease through the portal.
For our patients, the quality of care we provide has improved; so what's the payoff for the practice? BlueCross and BlueShield has agreed to a 5 percent payment differential for small practices in the group we are working with if they achieve Level 3 recognition. Four of the practices already are there, and six have Level 2 or Level 3 paperwork pending.
Moreover, my accountable care organization, which also is made up largely of small primary care practices, is in negotiations with two other payers to increase payment for those who have achieved PCMH recognition.
For years, payers marginalized small practices, which lacked the bargaining power of our larger counterparts, leading to more and more employed physicians and fewer and fewer small practices. But if those of us in small practices continue to prove our value, our future may be a lot brighter than anyone anticipated.
As the authors of that recent Health Affairs article noted, "Small practices have many obvious disadvantages. It would be a mistake to romanticize them. But it might be an even greater mistake to ignore them, and the lessons that might be learned from them."
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
When It Comes to Mentoring, Both Giving and Receiving Are Important
Many mentors helped guide and direct me to medicine, in general, and to family medicine, specifically. There are too many to name here, but there was always someone to help me when I reached the next transition point. From high school to college and through medical school and residency, I could list a steady stream of physicians who were there to offer support, guidance and teaching along the way.
I truly valued these relationships and took to heart the importance of mentoring. Along my path, I have made a point of reaching back to offer the same guidance to others that was given to me. I treasure being a mentor, continue to learn from the students I teach, and I can't wait to see what they will do in their own careers.
| Here I am with AAFP President Reid Blackwelder, M.D. It's important to have a more experienced physician we can turn to for guidance even after we've transitioned from resident to new physician.
I was satisfied with my own transition from mentee to mentor -- or at least I thought I was -- until I had a recent conversation with my husband.
My husband, an administrator in education, had been contemplating a position change. During the application process, he mentioned several mentors that he was turning to for strategic advice. After he accepted the position, he was promptly paired with a new mentor to help guide his professional development.
When I contemplated my own position change, I looked around and, for the first time in my career, saw no one there to help me. My first few years out of residency had been spent at a community health center with several seasoned doctors, one of whom was a mentor and had been faculty at my residency program. Those more senior physicians provided a great bridge to the real world.
However, at my current job, I'm the doctor who has been in primary care practice the longest, despite the fact that I'm only in my seventh year out of residency. I'm also the only family physician.
Although I know the mentors I have called on in the past would still answer my call, it is easy to get caught up in the daily grind and not have time to reach out. Unlike residency, where there is always an attending around the corner, there are fewer people above us to help guide us after we move into our own leadership roles.
New physicians are pulled in many different directions, and those who have families and/or are relocating may find it especially difficult to take time to reach out to other doctors and potential mentors. Doctors in small and single physician practices, as well as those in rural areas, are also at risk of feeling like they have to go it alone.
My recent state chapter meeting, however, reminded me that we are not alone. While there, I had the opportunity to discuss my career goals and aspirations with AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., whom I also now call a mentor. In addition, the meeting provided a chance to reconnect with friends and colleagues and swap stories and experiences. State chapters have a wonderful opportunity to bring family physicians of all different career experiences together, and that can facilitate these types of exchanges between new physicians and our more seasoned colleagues.
The chapter meeting's educational program was appreciated, but what really will stick with me is having that opportunity to reconnect with peers and learn from those more experienced than I am. I can't wait to do it on a grander scale at the AAFP Assembly in October. I hope to see you there.
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
On Air: AAFP President Engages With Students in Online Forum
I recently returned from the AAFP's National Conference of Family Medicine Residents and Medical Students -- which set attendance records, by the way, with more than 1,200 students and nearly 1,100 residents -- and I am tremendously fired up! The energy of that group, and the challenges they put before us, motivate me and all of our Board members to do an even better job representing these critical members of our Academy.
With that in mind, I want to share some innovative new things we have been working on to connect with students and residents.
| My Google Hangout with Family Medicine Interest Group leaders in July allowed students to ask questions on a variety of topics, including direct primary care, leadership development and patient satisfaction.
Almost a year ago, I was invited to be a featured speaker for the American Medical Student Association's National Primary Care Week webinar series, part of the AAFP's collaborative efforts with AMSA on this annual event. I participated in a webinar with a number of student leaders. This exciting experience allowed me to get the message of family medicine out to students nationally. That led me to think about ways we could start a similar process within the AAFP. I have been trying hard to increase our use of technology and to find new ways for the Academy to connect with medical students where they are and how they want to be reached. Many medical students and residents are extremely adept at using Facebook, Twitter, YouTube and Skype and actually prefer to access information digitally.
I often have ideas and send out frequent emails to Academy staff asking questions and seeking suggestions for growth. On this topic, our Medical Education Division responded quickly with a suggestion that we try Google Hangouts to connect with students. I had never heard of this tool before, but the Academy staff members responsible for increasing student interest in family medicine were exceedingly excited about the opportunity. We explored the resources, did test runs, and mobilized our dynamic Family Medicine Interest Group Network leaders to work through it. This process is similar to platforms like Skype; however, in addition to connecting people by video, it also allows users to share screens, use PowerPoint, correspond with other participants in the session and perform other tasks. The utilities seemed ideal for some of the things that we wanted to do.
We had our first Hangout on July 8, and you can watch it on the FMIG Network's Google Plus page or on YouTube. We recognized that this resource would allow us to reach out to medical students and residents all over the country. We also realized that we needed to focus the content so that these video installments, which are 15 minutes in length or less, are long enough to be informative but short enough for busy med students to work into their schedules.
The results of the first Hangout were outstanding. We received a great deal of positive feedback, and, most importantly, the FMIG Network leaders were excited about having a new tool to help them coordinate FMIG groups all over the country. Google Hangouts allow us to create an immediate connection between AAFP leadership and our students and residents. This is one of the things that we love most -- being able to talk with these enthusiastic members personally, answering their questions and sharing our passion for family medicine. This platform could help connect students who don't have much exposure to family physicians at their medical school with FP leaders who can provide them with insights on important issues in health care.
In addition to using Google Hangouts, I'd like to find other ways of tapping into this technology to help all of our members. For example, one of the biggest challenges we all face in these busy times is traveling to and from meetings. Although face-to-face meetings are critical for some functions and discussions, a great deal of what occurs at many meetings could easily be handled in a different fashion. Email is not always ideal, because visual cues and clues are still important and connect people in significant ways. Perhaps, however, Google Hangouts could allow us to have some meetings in a more dynamic fashion and respect people's need for work/life balance. Any time we can minimize travel and still get the work of the Academy done -- that is a good thing!
Moreover, especially with students and residents, utilizing this technology may allow a quicker connection between these member groups and our leadership for such things as noon conferences, forums and talking groups. In fact, some of you may have ideas about how to use this and similar technology. I would love to hear your thoughts, and I hope we can continue to move our Academy into a more efficient future. In so many ways, this is actually an aspect of the patient-centered medical home (PCMH) because what we can do for ourselves to become more effective and efficient is something we can then also do for our patients.
These days of telemedicine and telehealth are challenging us to expand our boundaries. I look forward to continuing that expansion with all of you. Our next Google Hangout will be about the PCMH and is scheduled for 12:30 p.m. EDT on Aug. 26. You can join us on Google Plus or YouTube.
Reid Blackwelder, M.D., is president of the AAFP.
Walk the Talk: Students, Residents Step Up to Support AAFP Advocacy Efforts
If you want students and residents to get involved in an issue, sometimes all you have to do is ask.
At an AAFP Board of Directors meeting earlier this year, we heard a report on FamMedPAC, the Academy's political action committee, which helps elect candidates to the U.S. Congress who support the AAFP's legislative goals and objectives.
During the National Conference of Family Medicine Residents and Medical Students, we challenged our respective member segments to see who could raise the most money for FamMedPAC, the Academy's political action committee. Residents and students donated more than $1,000 during the three-day event.
The report included data on the relatively small category of student and resident support. As the resident and student members of the Board, we thought that category could -- and should -- be much larger. The perception has been that students and residents don't have a lot of money to contribute and, therefore, typically aren't a focal point for fundraising efforts.
However, we thought our colleagues would step up to the plate if given the opportunity, so we came up with the idea of the FamMedPAC Challenge. During the National Conference of Family Medicine Residents and Medical Students in Kansas City, Mo., last week, we rallied our respective groups of students and residents to support the PAC. We knew that the residents and students would answer the call and donate, but the results exceeded our expectations.
Advocacy consistently ranks among the top Academy priorities for students and residents, and both groups consistently bring issues to the AAFP's attention because they feel so passionate about the advances that can be made for our specialty and, more importantly, our patients. There were nearly two dozen resolutions in the resident and student congresses at National Conference that related specifically to advocacy.
During the conference, AAFP President Reid Blackwelder, M.D., of Kingsport, Tenn., gave a presentation on advocacy, and the room was packed. As part of that session, students and residents worked up an advocacy issue, which they then transformed into short "elevator speeches" in small groups. Each group practiced pitching their talking points to the entire room, and we were blown away by how well they articulated their messages.
Throughout National Conference, we spoke about the FamMedPAC Challenge and the PAC from the stage, but we also got the word out through social media and, of course, lots of old-school, face-to-face chatting. Both of us handed out donation forms with $1 (an actual dollar bill from our personal accounts) and a PAC donor ribbon attached. Many students and residents had already donated during the past year, but some gave again by adding $9 to our $1 for a $10 contribution, the minimum amount to get their respective group a point toward winning the challenge. Most donors, however, were new.
The FamMedPAC Challenge was a huge success. We had 51 donations: 31 residents contributed a total of $629, and 20 students gave a total of $431 for a three-day total of $1,060, which is by far the most money ever donated to the PAC during National Conference.
Now we'd like to challenge the rest of the AAFP membership. If medical students and residents -- with their ever-growing student loan burdens -- can reach into their pockets and make a donation to help advance our specialty, won't you?
Kimberly Becher, M.D., and Tate Hinkle, M.D., are the resident and student members, respectively, of the AAFP Board of Directors.
Reality Check: Residents Aren't Prepared to Deal With Patients' Financial, Coverage Limits
In medical school, our patient encounters typically consisted of completing a history -- including talking with patients about any concerns or issues that led them to seek care -- doing a physical exam, and developing a diagnosis and treatment plan with the resident and attending.
In the real world, it turns out, it's not that simple. I recently began the first year of family medicine residency, and I quickly realized that some important steps were left out of the learning process. As students, we were not often exposed to what happened next for patients. We missed the part where the physician talked with the patient about his or her insurance, what it covered and what it did not.
| This week I'm attending the AAFP's National Conference in Kansas City, Mo., which offers students and residents opportunities to learn about clinical skills, leadership and more. One thing students don't learn in medical school is how to manage patients who lack the means to pay for needed treatment.
I recently saw a patient, a woman in her mid-30s, who came in for a checkup. In addition to her chronic conditions, including hypertension and diabetes, she complained of joint pain in her knees and hips. After taking her history and talking with her about her discomfort, I wanted to have her tested for rheumatoid arthritis.
Her first question was, "How much will that cost?" The patient had private insurance, but her plan left a lot to be desired. It covered office visits and some medications, but it did not cover labs.
The patient, a single mom who also was supporting her mother, informed me that she already was paying off a large lab bill from a previous visit. She needed to repeat labs related to the medications for her chronic conditions, but she couldn't pay for those, let alone for a blood test for rheumatoid arthritis.
I could have ordered the labs, but there wasn't any point in doing so because she told me it would have to wait. It's not that she would have been noncompliant, she simply couldn't afford to do what needed to be done. From her perspective, doing the labs would have meant asking the people she supports to sacrifice something else.
I asked her to come back in two months so that we could reassess her situation -- both physically and financially. For now, she plans to continue treating her joint pain with OTC medications.
This situation is hard for me to get used to. I can't do what I want to do -- what I've been trained to do -- to help some of my patients. Instead, I have to consider a patient's medical, social and financial situation and work within those limitations.
Medical students should have more exposure to this part of the process so they are more aware of the reality that awaits them. What do you do -- or what can you do -- when your patients' financial or coverage limitations are barriers to needed care?
Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.
Heads Up: School Sports Season Is Upon Us
My practice of family medicine includes sports medicine, and I care for a number of athletes in my community. However, it was an athlete I never cared for -- someone from the other side of the country, in fact -- who changed my practice and the care of young athletes across the United States.
Zackery Lystedt was playing football for his junior high school when he was injured in a game in 2006. He did not lose consciousness, and he returned to the field in the second half. He collapsed and had to be air-lifted out of the area for life-saving surgery. After several strokes and three months in a coma, Zack woke up. But it took nine months before Zack could begin to speak again and nearly three years before he could stand on his own.
I learned about Zack during a presentation by Stanley Herring, M.D. -- a team physician for the Seattle Mariners and Seahawks and a member of the Head, Neck and Spine Committee of the National Football League (NFL) -- at an American College of Sports Medicine (ACSM) meeting in 2009. He described how Zack and his family had taken up the cause of trying to prevent other young athletes from suffering similar experiences. That same year, the Washington state legislature passed the Lystedt Law, which requires concussed athletes to be cleared by a physician knowledgeable in traumatic brain injury before being allowed to play again.
I had met Herring 10 years earlier when I served as the AAFP liaison at the ACSM's Team Physician Consensus Conference. He played a major role in advocating for the Lystedt Law in Washington, and he asked me to spearhead advocacy efforts for similar legislation in Delaware. It was a great learning experience in policy making as I worked with a state legislator, the NFL and others, and the law was signed by our governor in 2011. By 2013, all 50 states had passed legislation that prevents a concussed athlete from returning to practice or competition for at least 24 hours, and their return to play depends on clearance by a clinician.
There is still much to learn about concussions, as highlighted by a recent White House summit that brought together a diverse group of stakeholders, including the AAFP. Protecting young athletes is an important part of our job as family physicians, and there are resources worth highlighting.
- With support from the NFL and the CDC Foundation, the CDC has created tools for health care professionals as part of its Heads Up campaign.
- The agency's resources include a free online CME course that applies not only to young athletes, but also to other concussed patients.
- The AAFP's sports safety Web page links to journal articles on the topic, including the American Academy of Neurology's guidelines for managing concussions in athletes, as well as to other resources.
- With schools around the country starting soon, now is a good time to think about preparticipation exams to ensure that our young athletes are in the best possible condition for competition before their season starts.
May all of our patients be safer because we learn to protect them from injuries like the one Zack Lystedt and his family live with every day.
Rebecca Jaffe, M.D., M.P.H., is a member of the AAFP Board of Directors.
Rural Practice May Pose Challenges, But It's Where I Was Meant to Be
Two years ago, at the beginning of my second year of residency, I signed a contract to work in a rural county in West Virginia. Although I've known where I was going for quite a while, I don't think I really understood what living here would mean until now.
I grew up in what most people would consider a rural area of West Virginia, but my new home is in an even less developed region of the state. You know the kind of area I mean, where you are driving down the interstate and there is nothing to see but trees. There are no gas stations and few restaurants -- it's really mostly just trees. Not only does the town nearest me not have a stoplight, there's no stoplight to be found in the entire county -- nor in an adjacent county, for that matter.
But this is exactly where I want to be. I love growing a lot of my own food and cooking or canning it. I wanted a home where my husband could hunt and my son could fish, and we were fortunate to find just that. The sense of community in these rural areas is genuine and is part of what drew me to work and live here. I did multiple rotations away from my medical school and residency, and those that really stood out for me were the rural ones. It was obvious to me that rural West Virginia was where I was meant to practice. Often, people will live in a larger city and commute to work because that is what resonates with their family or their lifestyle. Not us. We wanted to hear nothing but bugs when we open our windows at night.
There are things that I hadn't considered about living here, however, that quickly revealed themselves. The first neighbor I met warned me that the power goes out often, and that if it stays off long enough, there is no water either (not that I'm all that excited about tainted West Virginia water), because an electric pump brings it up the mountain.
I've also been warned that the road floods, and that I might get stuck at home or be unable to get home if there is too much rain, too much snow, or -- the more common scenario in a West Virginia flood -- too much of both together.
And then there is the Internet, which is only available through a satellite provider. It is expensive, takes eons to download documents and, generally speaking, makes it a struggle to even check my email. Gone are the days of streaming World Cup games or watching programs on Netflix.
Also gone is the option of running down to the local Mexican restaurant to watch a game while someone else cooks dinner; that's because the only restaurants in town are a Dairy Queen that closes during the winter and a carry-out pizza place. Oh wait, there's also a Tudor's Biscuit World, a standard found in nearly every small West Virginia town that I can't even begin to explain.
Don't get me wrong, I am happier than I've been in years. We eat food we cook ourselves for every meal and spend far more time outside. We could spend hours identifying birds and picking blackberries. My son is learning to ride his bike on our road, which might see three cars on a busy day. The moon rises behind two distant mountain ridges that we can see from our deck.
I realize this lifestyle is not for everyone. Although many of my patients and I choose to live in a rural part of our state, many are here by default. West Virginia has the highest homeownership rate in the country at 76 percent. That's right -- we are first in something positive.
It is a multifactorial situation driven, in large part, by a tendency to stay close to home, inherit land and homes, but also because there are not adequate employment and education opportunities for many of the state's residents.
One thing I have already learned is that most of the public health and wellness strategies used in larger cities will not work here. There is no venue for truly large-scale advertising because much of the population -- regardless of financial status -- relies on the newspaper and does not have access to the Web due to limited Internet availability. You can't direct patients to healthcare.gov or familydoctor.org. These patients need doctors, often doctors who will go to their homes, and patient information developed with appropriate health literacy in mind. Even a simple obesity intervention such as calorie-counting is often doomed to failure because many people cook from scratch and there are no food labels.
But these are challenges I embrace. I value the trust my patients place in me, and reaching out to connect with them to find solutions to their health care challenges -- especially those complicated by social, financial or logistical hurdles -- strengthens that relationship far more than any simple treatment regimen. I live here; I understand.
In addition to appreciating rural living challenges, I have been experiencing life without health insurance. I didn't go straight through college and medical school so -- like some of my patients -- I've had periods of time without health insurance coverage in the past. I have always found my advocacy voice for the uninsured to be louder than some, partly because of my first-hand experience with the medical system from an uninsured perspective.
The first time I found myself uninsured, I was 22 years old, had just graduated from college (this was before you could stay on your parents' plan until age 26), and was living in remote West Virginia in the Monongahela National Forest working on a research project as a contract employee. I would run on the rail trails nearby, and one evening, I rolled and broke something in my ankle. I don't know exactly what I broke because I didn't have enough money to seek medical attention. I bought a plastic air cast that I duct-taped into a hiking boot and went back to work because there were zero sick days. So, not only did I experience an injury without access to health care, I still live with the implications of an untreated fracture that didn't heal properly.
At least then it was just me. Now I have a family for whom I had provided health insurance for years, but that coverage ended June 30 when I graduated from residency. Why not just start my new job July 1? Insurance companies take up to 90 days to credential health care professionals, and until that process is complete, I can't see patients. So, just as many other graduating residents who have a gap between graduation and starting work, I again do not have health insurance. Granted, there are safety nets in place; I could extend my prior plan under COBRA (the Consolidated Omnibus Budget Reconciliation Act), if needed, and in West Virginia, we have an extensive network of federally qualified health centers where I can pay according to a sliding scale based on my income. However, a gap in coverage is a gap in access to my primary care health professional and to preventive services for my family, as well as being a huge gap in my peace of mind.
I think I am a pretty responsible person, and I value continuity of care. Yet here I sit with no ready access to health care despite knowing the risks and insurance industry protocols. This situation further fuels my desire to promote the AAFP's vision of transforming health care to achieve optimal health for everyone. We have made some progress but we still have a lot of work left to do, and each community provides its own set of lessons to be learned.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Keeping It Real: Preceptorship Exposes Students to Importance of Rural Family Medicine
Roughly 20 percent of Americans live in rural areas, but only 11 percent of U.S. physicians live in those same communities. In fact, the Health Services and Resources Administration (HRSA) has designated more than 6,000 Health Professional Shortage Areas for primary care, and 67 percent of those are in nonurban areas. According to HRSA, it would take 17,000 additional primary care health professionals to achieve a ratio of one clinician per 2,000 patients in these locations.
So, how do we convince more medical students to first choose family medicine and then practice it in the places that need them the most?
I recently had the opportunity to talk to students during the Appalachian Preceptorship, which exposes students from around the nation to rural family medicine in Tennessee. Ten students from seven medical schools participated in the four-week program.
Let them experience it first-hand.
Nearly 30 years ago, Forrest Lang, M.D., retired vice chair of the Department of Family Medicine at East Tennessee State University (ETSU's) Quillen College of Medicine in Johnson City, created the Appalachian Preceptorship to introduce students to rural family medicine in a highly relevant and culturally sensitive way. Since then, hundreds of medical students from all over the country have come to Tennessee to experience first-hand the delivery of primary care in Appalachia.
It is critical that we find ways to connect with medical students early in their first and second years, and this year all of the students participating in the program were sophomores. We know that in the first 18 years of the program, more than 80 percent of the students who participated matched to residencies in primary care, including 60 percent who matched to family medicine programs.
Students are called to medicine to help people, and there is no better way to do so than practicing family medicine in rural, underserved America. In the Appalachian Preceptorship, students participate in one week of didactic sessions at ETSU before spending three weeks with a physician practicing in a rural Appalachian community.
These dedicated family physicians allow students to become part of their practices, and the students see patients, participate in the diagnosis and management of acute and chronic diseases, practice preventive medicine, and enjoy a wealth of other experiences.
The experience is invaluable for both the students and the preceptors. In fact, we dedicate significant resources at ETSU to connecting with our preceptors throughout the year, and we devote a special weekend session to allowing them to offer feedback on our educational methods and identify and address the resources they need.
Another key aspect of this program is the opportunity it gives us to show students that it is possible to not only survive but to thrive in small-town practices. Some of the preceptors are from individual physician practices, and most of the rest belong to small groups. The students are able to experience how health care is provided in these communities and to really understand the nature of physician-patient relationships. In addition, each of these preceptors and the communities in which they work are great examples of different types of patient-centered medical homes. This reinforces to the students that team-based care is not about having everyone located under the same roof; but rather the resources that are available within the community to care for its residents.
Another advantage of this process has been the chance it offers to expose students from all over the country to our school's residency programs. Almost every year, students who have participated in the preceptorship interview with at least one of our three family medicine residency programs. These are outstanding students, and we are frequently blessed that at least one of them matches with us. This is important because data from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care indicate that up to 75 percent of physicians will practice within 100 miles of their residency. In this way, the ETSU programs are consistently fulfilling their mission to provide rural family physicians for our patients.
On a personal note, I had the privilege of talking with students about a number of issues, including the importance of herbal medicine in Appalachian culture, bedside manner and patient-centered communication. I encourage each of you to consider how you can be a part of such a process in your community.
If you are academician, are there ways you could create student or even resident experiences that can mirror some of these goals of exposing students to underserved areas? If you are in private practice, is there a school or residency in your area that you could connect with to create a unique and transformative experience for learners?
Although we struggle nationally with physician pipeline issues, this is how we can walk our talk and directly influence students. This is a great opportunity to remember that the root word of doctor is docere -- to teach!
Reid Blackwelder, M.D., is president of the AAFP.
Like Father, Like Son: How I Raised a (Future) Family Physician
Like many small-town family physicians, I've volunteered over the years as a team doctor for our local school's athletic teams. On Friday nights, I often found myself on the sidelines, watching football and cheering on the local team (which often included many of my patients). More often than not, my son Brett would tag along, soaking up anything there was to learn.
On one particular fall evening, one of our players was badly injured, and I hurried onto the field to evaluate his condition. In retrospect, I probably should have paused just long enough to tell my son, who was about 7, to stay put.
Last weekend I represented the AAFP at the Nebraska AFP's board meeting. My son Brett, left, is a student member of our state chapter's board of directors.
As I kneeled next to the injured young athlete, I heard a small voice from behind me say, "Dad, there's blood."
That's Brett. Always eager to experience and learn something new. It wasn't the last time he got an up-close view of his dad trying to help someone who needed it. We've lived in a few small Nebraska towns that lack urgent care facilities and hospitals. So when people needed help in a hurry, they often call me directly. If Brett was with me I got one of those calls, he often came along to the office.
I remember one day when Brett was about 10, a young girl fell and needed stitches in her chin. Brett and I were out running errands when I got the call, so we went straight to my office to meet the girl and her parents. With the permission of the patient and her parents, Brett watched me clean the wound and stitch it closed.
Through these types of encounters, Brett learned not only about medicine but about the importance of building relationships with patients, families and the community.
As a high-school student, he participated in a medical interest group and expressed interest in becoming a family physician. He followed up on that by shadowing other family physicians in our area.
When he enrolled in a college halfway across the country, I thought he might come back with plans to become a subspecialist because although Brett has seen all the positive things that family medicine has to offer, he is aware of the payment issues and other challenges we face, as well.
He also knows the time demands of being a family physician. One year, Brett and I signed up for a father-son basketball camp. The night they were taking photos of the sons with their fathers, I got tied up at work and was late. The other kids got a nice memento to remember the fun experience they shared with their dads, and Brett got a photo of himself. Alone.
But Brett has stayed the course. Now in his fourth year at the University of Nebraska Medical Center, he is a student member of the Nebraska AFP Board of Directors. This past weekend, I represented the AAFP at the Nebraska AFP's annual meeting, and my son was there as a member of our state chapter's board. It was a proud moment, and Brett has given me plenty of those.
He's served as president of the Student Alliance for Global Health and in the student senate at UNMC. But the point of this post isn't just for me to say how proud I am of my son. It's to point out the importance of mentoring. Brett obviously got an early start, but if we expose students -- in high school or college -- to the broad scope of family medicine and show them the relationships we develop with our patients, they will understand and value what we do.
And some, no doubt, will follow.
Robert Wergin, M.D., is president-elect of the AAFP.
Is Anybody Out There? Tell Us What You Think
It has been nearly three years since the AAFP launched the Leader Voices Blog with the goal of improving communication between Academy leaders and members.
During that time, we've posted more than 200 blogs on a wide range of topics affecting family medicine. We've let you know about Academy meetings with legislators and meetings with payers. We've talked about the challenges facing small practices and a host of clinical issues.
AAFP directors -- who come from small private practices, big group practices, academia and everywhere in between -- have shared deeply personal stories about where they practice and why. We also have shared stories of our own personal health crises.
And we've seen spirited debate on some controversial topics, such as gun violence.
Although this blog's readership numbers have been steady, the online conversation has grown quiet. We missed a few opportunities to respond to comments earlier this year, but we're committed to doing better going forward. Some of you, no doubt, grew frustrated with a technical issue we experienced this spring with our comments field. That problem has been resolved.
To paraphrase past AAFP President Glen Stream, M.D., M.B.I. -- who had the vision to use this tool to create a two-way conversation between leaders and the members we are elected to serve -- we're listening. And we value your feedback.
The landscape in medicine remains quite active and rapidly changing, and your Academy remains engaged on your behalf. This blog is an opportunity for all members to not only hear what the AAFP is doing, but to be heard by sharing your opinions in the comments field. Tell us what you think -- good or bad -- about the issues we face and how the Academy is addressing those issues.
Start today. We’re listening.
Michael Munger, M.D., is a member of the AAFP Board of Directors.
Women's Health: Do You See the Big Picture?
I had a new patient come to me last year, a woman in her 60s, complaining of back pain. Over the course of several months and multiple visits, and after indicated tests and imaging, we worked together to formulate and execute a pain management plan. Her acute condition improved, but I found myself wondering: Had I done a thorough job? Or had I let myself get caught up in dealing with one specific problem and had failed to see the bigger picture? Had I offered this patient all of the other tests and screenings -- such as colonoscopy -- that were recommended for her age group?
Patients often, and understandably, focus on the problem that is bothering them right now. But back pain isn't what is going to eventually kill that patient. Cancer, heart disease and other factors are much more likely to cause serious, long-term problems. As physicians, it's our job to stress the importance of doing all the other things that can help keep patients healthier longer.
So how are we doing?
A CDC study published this month in JAMA Internal Medicine indicates that when it comes to women's health, we could do better -- possibly much better. Researchers looked at data from more than 60 million preventive health visits to OB/Gyns and primary care physicians and compared what services were being offered by the two types of physicians.
Perhaps not surprisingly, OB/Gyns were more than twice as likely as primary care physicians to offer screenings for breast cancer and cervical cancer and almost twice as likely to test for chlamydia. However, women who saw a primary care physician were likely to receive a much broader range of services.
For example, 34.5 percent of women 45 or older received cholesterol screenings from their primary care physicians compared to only 5.4 percent of those who saw an OB/Gyn. Women who saw a primary care physician were four times more likely to be tested for diabetes.
But both OB/Gyns and primary care physicians have room for improvement. Colon cancer is the third-leading cause of cancer-related death in women. But the study found that among women ages 50-75, a total of only 6.1 percent were screened -- 7.2 percent of women who saw a primary care physician and 3.9 percent of those who saw an OB/Gyn.
The study also examined whether women received counseling about four key health issues: diet, exercise, obesity and tobacco use. Researchers found that 81.5 percent of women who saw an OB/Gyn and 73.5 percent of women who saw a primary care physician did not receive counseling on any of those important topics. Although not all patients need counseling on these issues, the numbers seem shockingly high given that more than one-third of U.S. adults are obese and nearly one-fifth smoke.
Despite the low overall numbers, primary care physicians fared better than OB/Gyns in all four areas. A little more than 19 percent of primary care visits involved counseling for diet compared to 12.4 percent of visits with OB/Gyns, 14.3 percent of primary care physicians offered counseling about exercise compared to 9.9 percent of OB/Gyns, 7.5 percent offered counseling for obesity compared to 4.2 percent of OB/Gyns, and 3.4 percent offered counseling for tobacco compared to 2.6 percent of OB/Gyns.
Time is obviously a factor. There's only so much ground we can cover in a 15-minute appointment, and patients often come with their own questions and concerns that have to be addressed. But taking a few seconds to show a patient where he or she stands stand on the BMI chart can be powerful, eye-opening and the first step in pointing that patient in a new direction. Patients who want to stop smoking can be referred to quitlines. We also can schedule a follow-up for patients who need more time to address their issues.
Communication likely is another factor. We need to let our patients know what tests and screenings are recommended and appropriate for their age. For our patients who see both an FP and an OB/Gyn, we also may need to do a better job communicating with our OB/Gyn colleagues to ensure that someone is taking responsibility for offering the appropriate services.
It's worth noting that the study's data were drawn from visits during 2007-2010 -- before the Patient Protection and Affordable Care Act mandated that health plans cover a wide range of preventive services. If this issue is re-examined in a few years, it will be interesting to see how much our numbers improve.
How does your practice use electronic health records, patient registries or other tools to ensure that patients receive recommended tests or screenings?
Kisha Davis, M.D., M.P.H., is the new physician member of the AAFP Board of Directors.
Inside the Affordable Care Act: One Patient's Story
Whether folks thought it was a good piece of legislation or not, the Patient Protection and Affordable Care Act (ACA) is the law of the land. And recent polls show that roughly two-thirds of Americans favor retaining and, perhaps, modifying the health care reform law rather than repealing or replacing it.
A Bloomberg National News poll published in June found that 66 percent of respondents favored letting the law stand or retaining it with modifications. A month earlier, a Kaiser Health poll found similar results with 59 percent favoring keeping and improving the law.
By far, most people who responded to the Kaiser poll (60 percent) said the law had no direct impact on them, while 24 percent said the law had hurt them, and 14 percent said it had helped them. Nearly one-third said they knew a previously uninsured person who was able to get insurance because of the ACA, while less than one-quarter said they knew someone who had lost coverage.
I'd like to share the story of one of my patients -- we'll call him John -- who was helped greatly by the ACA.
John was a healthy child growing up in my hometown in Nebraska before he contracted polio at age 3 in 1952 (three years before the polio vaccine was introduced). The disease left him temporarily paralyzed from the neck down, and his parents were told that he would never walk again.
John proved the physicians wrong, and he did walk. But he has suffered for decades from an array of complications, including severe scoliosis, muscle wasting and restrictive lung disease.
As an adult, John could easily have qualified for disability, but he learned a trade, opened his own business and raised a family. His health insurance costs were high, but manageable, and he looked forward to saving more money for his retirement once his children were grown and out of the house. But John's health care insurance costs increased dramatically in the 1990s, and he suffered the consequences, at times, of not being able to afford coverage. In the past 20 years, John has paid more than $200,000 in premiums alone.
Before the health insurance exchanges opened this year, his deductible was $6,000, and his premium was more than $1,300 a month. When the exchanges opened, John went online and found a plan that cost him $32 a month. His deductible dropped to $450.
"It completely changed my life," he told me.
John's new plan was through CoOpportunity Health, one of nearly two dozen Consumer Operated and Oriented Plans set up nationwide under the ACA; this particular health care cooperative started in Iowa and Nebraska with funding provided through HHS. The Iowa AFP and Nebraska AFP were instrumental in securing that funding and making the plan available through the health care exchange.
The new plan lowered John's costs for medications and treatments, including the oxygen he uses at night. In addition to me, John has a respiratory specialist in another town. His out-of-pocket cost to see that physician had soared to $400 per visit on his old plan, so John hadn't seen that subspecialist in years. After he enrolled in the new plan, John made a long-overdue (and affordable) visit to that doctor and found out about new tips to help his breathing that he could have learned a lot sooner if he'd had ready access to affordable care.
The ACA may be far from perfect, but this one example shows its potential. The Academy is working to support the provisions of the act that help family physicians and their patients and is continuing to advocate for change where it's needed.
As for John, he's in his 60s and still running his business, but the money he is saving on insurance will allow him to finally start saving, in earnest, for a well-deserved retirement. John tells me that he feels as though a huge burden has been lifted from him, and the new insurance plan is literally helping him breathe easier.
Robert Wergin, M.D., is president-elect of the AAFP.
Teamwork: AAFP, PA Groups Find Common Ground
I recently represented the AAFP at meetings with leaders from the American Academy of Physician Assistants (AAPA) and the Association of Family Medicine Physician Assistants (AFMPA), and I was honored to be an invited guest to the AAPA meeting in Boston a few weeks ago. The leadership of the AAFP and the AAPA have previously attended each other's board meetings to review proposed legislation at state and national levels. This is a critical interaction that allows our organizations to identify areas in which we can work together.
For example, in Boston, I learned about a proposal in Missouri regarding so-called assistant physicians, who are not PAs but medical school graduates who have not completed residency training. Not only does this proposed measure create potential confusion because of the title of these would-be health care providers, it also would create significant challenges in terms of how unlicensed providers should be designated, regulated and utilized.
|I recently met with leaders from the American Academy of Physician Assistants, including (from left) President John McGinnity, PA-C; President-elect Jeffrey Katz, PA-C; CEO Jenna Dorn; and Board Chair Lawrence Herman, PA-C.|
This issue was directly addressed by the AMA House of Delegates at its annual meeting last month. The AAFP delegation coordinated with our PA colleagues and testified about concerns raised by this issue. A resolution opposing the use of medical school graduates as assistant physicians was adopted with wide support.
Our common interests with the PA groups aren't limited to advocacy. PAs are trained in the medical model of care involving diagnosis and treatment, as are physicians, and they follow rigorous and standardized educational, certification and licensing processes. Last fall, we reached a unique arrangement with the AAPA, which was working to identify activities that would fulfill the performance improvement requirements for its new certification of maintenance program. The AAPA came to us seeking a collaborative agreement through which the AAPA could offer the Academy's four METRIC (Measuring, Evaluating and Translating Research Into Care) performance improvement modules within the AAPA's own learning management system.
METRIC is the AAFP's flagship performance improvement product line and is critical for lifelong learning and maintaining certification. This agreement has been finalized, and PAs may now purchase and access the AAFP's METRIC modules directly from the AAPA, which coordinates marketing and accreditation of the modules. This joint venture represents an important way to share resources and not reinvent educational wheels as we move toward quality improvement in continuing education. Moreover, this relationship reinforces the value that others see in our educational offerings.
This is all worth noting, in part, because 40 percent of AAFP members work with PAs, who assist us in ensuring that we provide effective care and improve our patient outcomes. Team-based care is important to meeting the goals of the quadruple aim -- improving patient outcomes, improving patient and provider satisfaction with the system, and doing so at lower cost.
Family physicians and PAs are working together not only at the practice level but also at the national level, and I look forward to further discussions and collaborations with these groups. Together we are making progress in providing better, more effective care for our patients.
Reid Blackwelder, M.D., is president of the AAFP.
Follow the North Star: Global Health Is Focus of New Wonca Group
A growing number of medical students, family medicine residents and new physicians are interested in pursuing global health experiences. In fact, more than 30 percent of U.S. medical students completed a global health rotation in each of the past four years.
|Polaris, the new and future physicians movement for Wonca North America, was one of the topics discussed when I attended the winter meeting of the College of Family Physicians of Canada's Section of Residents.|
In the United States, we are fortunate to have structured, well-developed clinical rotations and residency programs for our family physicians-in-training, but in many other countries, recent medical school graduates are often faced with the prospect of building their own family medicine experience. To address this need, the Europe region of the World Organization of Family Doctors, or Wonca, formed the first new physicians organization -- referred to as a young doctors' movement -- in 2005 to focus on networking and providing a platform to connect physicians across borders. Other Wonca regions have since followed this example -- all except the North America region.
The 2013 Wonca World Conference in Prague triggered renewed discussions about establishing a new and future physician movement in North America. Members of the AAFP, the College of Family Physicians of Canada and the Caribbean College of Family Physicians have worked together to establish the movement's framework, including its charter, name, logo and a governance structure. On May 19 -- World Family Doctor Day -- Wonca North America announced the creation of its new and future physicians movement, Polaris, to provide an avenue for the exchange of ideas and actual observational experiences in different countries.
Polaris is not simply a platform for launching medical mission work. Rather, it is a comprehensive forum for global health. In many of the discussions leading up to its formation, the difference between mission work and global health was emphasized, and organizers envisioned one possible goal of the program to be changing the perspective that medical missions are global health to the reality that medical missions are only a small part of global health.
Although mission work is often how physicians gain global health experience, family doctors practice in all parts of the globe, and the vast differences that exist among medical systems, available resources, patient populations and disease processes offer amazing learning opportunities that can enhance physicians' work in their own communities and offices.
A global view of patient care is becoming more necessary as both our demographics change and our health systems adapt, and family medicine is the natural home for that viewpoint. Two-thirds of family medicine residency programs now offer international rotations or electives, and even those without formal programs teach the skills and population management competencies needed to work in any community, which produces physicians who have interests and/or abilities well-suited for global health delivery.
Aside from skills development, simply connecting with family doctors in other countries provides a perspective that often helps open our eyes to new solutions and processes we can then use in our own programs and offices. For example, I was fortunate to be invited to attend the winter meeting of the College of Family Physicians of Canada's Section of Residents, where each residency program in Canada is represented. Polaris was simply a glimmer of an idea at that point, but the collaborative effort it represented was well-received.
Canada's postgraduate medical education system is much like that in the United States, but even so, these residents shared our interest in developing a more comprehensive patient approach. Canadians have rural patient populations that make some of our rural sites in the United States appear metropolitan. Not surprisingly, their medical education curriculum includes impressive didactic and skills sessions to meet the needs of students and residents who plan to work in remote settings. I came back to my residency program with ideas for improving our own training based simply on talking with Canadian residents. Imagine the progress we could make in our training if we were able to experience the many cultural variations and nuances that characterize family medicine across continents.
WONCA's young doctors' movements have already established exchange programs to enable their members to participate in observational experiences. Polaris could provide an infrastructure for setting up exchanges to and from North America.
Polaris is still being developed, and much remains to be decided. So if you are a family physician who is interested in global health -- whether you're a seasoned veteran or someone looking for a first global health experience -- take advantage of the many upcoming opportunities to be part of the discussion:
- At the National Conference of Family Medicine Residents and Medical Students, Polaris will be discussed during the global health networking session, which is scheduled for Aug. 8 in Kansas City, Mo.
- Attendees at the Family Medicine Global Health Workshop scheduled for Sept. 11-13 in San Diego, can see a presentation by representatives of the Vasco da Gama Movement, which is the European group for new and future family physicians. The event also will feature a networking session where Polaris will be a topic of discussion.
- An international networking session also will be held during this year's AAFP Assembly, which is scheduled for Oct. 21-25 in Washington.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Implementation Begins on Family Medicine for America's Health
Throughout the year, we have been using this space to provide updates on the Family Medicine for America's Health: Future of Family Medicine 2.0 project. I'm pleased to share that the planning portion of the project is now complete, and we are moving forward with implementation. Our Academy's Board of Directors recently pledged $12 million over the next five years to support implementation of both the strategic and communication plans.
In this latest update, you'll find an announcement of the members serving on the Implementation Committee, the naming of the new chair (former AAFP President Glen Stream, M.D., M.B.I.) and a summary of both the strategic and communication plans. Additional updates will be shared here as the project unfolds. Exciting times for Family Medicine!
Family Medicine for America’s Health: Future of Family Medicine 2.0
Organizational Update No. 7
We are pleased to report that the planning phase of the Family Medicine for America’s Health initiative has been completed. As a reminder, the purpose of this effort was to develop a multi-year strategic plan and communications program to address the role of family medicine in the changing health care landscape. To read earlier updates from Family Medicine for America's Health: Future of Family Medicine 2.0, please visit the project Web page.
The Boards of Directors of each of the seven original sponsoring organizations, plus the American College of Osteopathic Family Physicians (ACOFP), have approved both the strategic and communications plans. The eight organizations have pledged more than $20 million over the next five years to implement both plans, which are described in further detail below.
Moving forward, this effort will be known simply as Family Medicine for America’s Health. An Implementation Committee has been formed that will drive the next phase of this work. Representatives include:
- Glen Stream, M.D., M.B.I. – Chair (AAFP)
- Tom Campbell, M.D. (ADFM)
- Jerry Kruse, M.D., M.S.P.H. (STFM)
- Paul Martin, D.O. (ACOFP)
- Norman Oliver, M.D. (NAPCRG)
- Bob Phillips, M.D. (ABFM)
- Mike Tuggy, M.D. (AFMRD)
- Jane Weida, M.D. (AAFP Foundation)
Four additional members are being recruited for the Implementation Committee, representing the following stakeholder categories:
- Family physician in full-time practice (practice size of five physicians or fewer)
- Young physician leader in family medicine (five to seven years post-residency)
- Patient advocate
- AAFP chapter executive
Strategic planning consulting firm CFAR developed the strategy in an intensive eight-month effort that included:
- A strategy survey (taken by hundreds of family physicians, as well as by other primary care health professionals).
- Current state analysis of family medicine today and the role family medicine plays in the current health care environment.
- Identification of scenarios depicting possible futures for family medicine that were tested at a multi-stakeholder retreat attended by family physicians, other primary care health professionals, public and mental health stakeholders, policymakers and employers.
The framework of the strategic plan is organized according to a few guiding principles:
- Put the patient and family at the center – always.
- Now is the time for family medicine to take up a leadership role in primary care, including reforming payment in ways that make it possible for family physicians to offer patients and their families the highest quality primary care.
- Family medicine must clearly state its vision for the next five to seven years and pursue actions specifically linked to strategies in six critical areas: practice, payment, workforce education, technology, research and engagement.
- Family medicine can’t prove the value of primary care alone. Family medicine leaders must take a leadership role in building partnerships and alliances with a variety of stakeholders in the wider health care system – with patients, other primary care health professions and national policy organizations, among others.
The complete strategic plan will be published in an article in the Annals of Family Medicine later this year.
Communications consulting firm APCO Worldwide conducted extensive quantitative and qualitative research to develop an evidence-based communications program to demonstrate that family physicians are leaders in the new and evolving health care environment and advocates for patient health. (Detailed findings of the research are provided in earlier editions of the monthly reports.) The plan outlined the following goals:
- Position family physicians as leaders and central to the delivery of quality care for patients.
- Increase patient understanding of the value of primary care and of receiving primary care through a family physician.
- Improve patient engagement in prevention and health care management.
- Attract the best and brightest students to the practice of family medicine.
- Shift the payment model to support comprehensive payment reform.
Stakeholder perceptions of family physicians are favorable and higher than those of almost every other medical specialty. With these favorable perceptions come high expectations. The research showed that patients want and need a primary care physician – particularly a family physician – to be at the center of their health care.
A number of concepts and themes were tested for this effort. The winning theme will be launched in October at the AAFP Assembly in Washington, D.C.
This campaign will be used as an advocacy platform to communicate with consumers about their critical role in creating a strong primary care system that improves health. Research examined an exhaustive list of areas where stakeholders believe family medicine must focus. The four focus areas that emerged as most relevant and needed were: prevention and health promotion, health disparities, patient education and engagement, and chronic and complex disease management.
The communications strategy will drive broad, long-term social goals, while strengthening family medicine’s identity, cohesion and capacity to deliver on the triple aim (improving patient care and outcomes and lowering costs). The campaign will use integrated communications and will include policymaker outreach, workplace outreach, paid media, earned media placements, stakeholder engagement, corporate and organizational partnerships, and a strong online presence.
We will continue to provide regular updates on the implementation of this important effort. Watch these reports for opportunities to learn more and weigh in on the process.
Jeff Cain, M.D., is board Chair of the AAFP.
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