Leveling the Playing Field: AAFP Tackles Flu Vaccine Supply Issues
Family physicians often receive their flu vaccine weeks after retail clinics get theirs. The AAFP is talking with vaccine manufacturers and other stakeholders to resolve the disparity.[Read More]
Try PROBE Tool to Help Stave Off Burnout
When a friend of a friend of mine committed suicide recently, it hit me harder than I would have imagined. I didn't know the man and knew little about him other than that he was an emergency medicine resident and a member of the gay, lesbian, bisexual and transgender community.
When I learned of his tragic passing, I went back and read something he had posted on social media a couple of years ago that stood out as particularly poignant: He wished he could be more proud to be a gay physician and support others who struggle with self-doubt.
| Roughly twice as many physicians experience emotional exhaustion as do adults in the general working population.
The pressures of our profession can be stifling, especially for folks who are hesitant to be open about who they really are. Although each of us faces our own set of circumstances and personal needs, the rate of emotional exhaustion among physicians is about twice that of the general working population. Some theorize that too much empathy can induce compassion fatigue, leading to irritability and uncompassionate treatment of those closest to us. Unfortunately, the consequences of burnout are steep. We lose a doctor a day to suicide. But with proper tools and vigilance, we can help foster wellness and prevent medical student and resident burnout, depression and suicide.
Simultaneously, we can't ignore the many systemic failures that contribute to burnout, including disrespectful behavior that erodes empathy, curricula that don't emphasize social responsibility and engagement, and the unwieldy demands of electronic and paper nuisances.
As our vernacular shifts from a mutually exclusive "work-life balance" to a more holistic "work-life harmony," future physicians can find ways to mediate and integrate multiple commitments while bolstering our resolve. One of the paradigms I came up with recently is the acronym PROBE, which stands for Prioritization, Reflection, Organization, Burnout prevention/mitigation and Expectations. The elements of PROBE may help physicians recognize mild to moderate burnout and do better for themselves, their colleagues, and their patients by exploring some of the suggested tools. However, I would implore anyone who is experiencing severe burnout to set aside any perception of the condition as "a weakness" and to promptly seek the help of other professionals.
- Prioritization -- Pamela Vaccaro, M.A., outlined the idea of the 80/20 rule, which states that 20 percent of your efforts provide 80 percent of the results, in a 2000 Family Practice Management article. She recommended engaging in activities that advance your overall purpose in life. I would suggest this includes developing a shared vision of the future with those closest to you.
- Reflection -- Simply by checking in, you can bring awareness to a difficult moment. Apps such as Headspace may help with increasing the regularity of this process, and the MySelfCare.org quiz might help you gauge compassion fatigue. My fellow AAFP Board member Lynne Lillie, M.D., wrote an excellent post on mindfulness meditation a few weeks ago. Progress can be made by monitoring and measuring what you're doing. Debriefing with fellow residents, a partner and/or faculty are great ways to decompress after tough situations. My residency holds monthly sessions (based on Balint group structure) during which residents share patient stories and tips for dealing with stressful situations. Surgical residents at Stanford University developed a comprehensive Balance in Life program that includes faculty mentors, healthy food, stress management and social events.
- Organization -- One's (digital) house is a reflection of one's inner mind, so working to relieve a cluttered inbox, keeping a repository of readings (e.g, on Google Drive, Dropbox, or using the free AAFP app for podcasts and FP Essentials issues), and learning time-saving tricks to use in your electronic health record system can all help you to be more efficient in your day-to-day tasks. This, in turn, may have the egosyntonic effect of giving you more time to enjoy the pleasures in your life.
- Burnout prevention and mitigation -- The Resident Doctors of Canada recently released a Mental Health Continuum pocket card for personal burnout awareness and mitigation that details a spectrum -- healthy > reacting > injured > ill -- with each category listing actions to take and coping skills (e.g., visualization, goal setting, positive self-talk, tactical breathing) to use. The AMA's STEPS Forward collection has an online module highlighting six key aspects for resident wellbeing and the AAFP maintains a list of burnout resources. Finding what works for you in the moment is crucial to avoiding pent-up frustrations that can inevitably release in very unhealthy ways.
- Expectations -- These can be set unreasonably high, leading to unattainable goals. Talking with those with experience in this area may help in setting reasonable expectations, and you may uncover some wise advice for how to avoid pitfalls. It's also important to guide expectations of family members and friends so you don't disappoint them. Whether it's a new job, a new rotation or a new project, setting your own goals can help you come away with a sense of self-growth.
Hopefully, this acronym will help you PROBE the issue of wellness in a systematic way and lead you to contentment in this healing profession. We have a long way to go to prevent the devastation of burnout in our profession; let's work together and take care of our own.
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Breaking Point Offers Med Students Chance to Grow
Saying goodbye to people you care about is rarely, if ever, an easy task. "See you soon" didn't really work on our last day of medical school because we had no idea when -- or if -- we might be reunited. Although we celebrated our graduation, we said our farewells slowly. As the night progressed, each goodbye hug seemed to last just a little bit longer than the previous one.
The past five years in medical school (I spent an extra year to get a master's degree in public health) taught me not only about my future profession, but also a lot about myself. As I transition to the next chapter of my life, I often think about how the people around me have impacted my personal growth.
| Johns Hopkins University School of Medicine students, including me, celebrate our graduation May 16 in Baltimore.
The most distinct memories that come to mind are of the happiest, most lighthearted moments of medical school. My classmates and I have numerous memories we all look back on and laugh at: the awkward times we practiced physical examination on each other while trying to maintain personal space, the random food adventures we managed to pull off at the last minute or the study sessions filled with ridiculous mnemonics.
But medical school was not all joyful times. I grew more during the times of stress, during the times I allowed myself to be vulnerable. Instead of associating these memories with shame, failure or rejection, I have learned to embrace them as wonderful learning opportunities.
The clearest defining moment of growth occurred on my medicine rotation during third year, but I never thanked the classmate who helped me through it for being so supportive during my lowest point in school. As my medicine attending was providing me with feedback on my morning patient presentation one day, she called me insensitive. I was shocked. I racked my brain for reasons, but I couldn't figure out why. My attending said I labeled the patient as a drug addict by overemphasizing the patient's heroin use, which she thought wasn't relevant to the patient's chief complaint. But actually the patient's drug use was the root cause for her presentation. My failing was that I had not made a strong enough case to clarify the connection. Tired, stressed and frustrated that I had not explained that it took me hours to get the patient to open up and confide in me, I surprised even myself when I broke down and cried in front of my attending and classmate.
As medical students, we constantly had to prove that we were worthy of becoming physicians. Residents and attendings constantly evaluated our performance on each rotation. We continually felt stress and the need to shine during morning rounds, and we mentally prepared for a series of followup questions. Simultaneously, we needed to learn the particular style each attending had while digesting the most up-to-date, evidenced-based guidelines or research studies relevant for the field. The pressure on medical students quickly builds. Ultimately, most of us reach a tipping point and we learn how much we can handle before we shut down.
My attending's reaction to my tears caught me off guard. Her stoic exterior immediately melted into a more maternal response as she recognized my distress. She had seen it numerous times in the past, among both students and residents. We spent the next hour discussing the stressors I had encountered on this rotation and clarified expectations. Although the following two weeks did not get easier as our team cared for incredibly sick and complex patients, this became my most memorable rotation because our team grew as a unit. The attending ensured we had a safe learning environment by deconstructing the traditional team hierarchy. Thus, she alleviated several layers of stress and allowed us to focus more on providing quality patient care.
Despite ending inpatient medicine on a positive note, I did not share my powerful experience with anyone until several months after the rotation ended. I still felt embarrassed about crying in front of my entire team. Slowly, my brave friends shared times they, too, broke down on a rotation. Looking back now, we realized how these moments of vulnerability enabled us to gain incredibly valuable experiences for both patient care and personal growth. During these low periods, we grasped and validated our passion for medicine. We had physically and mentally invested in the care of our patients, and we had to understand that we had this safe space to make mistakes and learn from them.
Although I am sad to leave an incredible group of friends, I am also excited to start residency. Instead of constantly feeling the pressure to prove myself, I know I can focus on my personal growth as a family physician. I look forward to the joyous, comical memories I will share with my cointerns. Instead of trying to wish vulnerability goodbye, I hope to embrace it to grow into a stronger, more compassionate family physician.
Tiffany Ho, M.D., M.P.H., is the student member of the AAFP Board of Directors.
Give Back: Making a Plea for Family Medicine Preceptors
"This is so cool!" my medical student says as we run from the clinic to the ER.
I agree. It is only 50 yards or so, but my heart is beating hard -- not because of the distance, but because of the urgency of the nurse's phone call. We were called out of a well-child exam to examine a patient with chest pain and hemodynamic instability.
"I had no idea family docs did so much," the student says.
| My clinic has a rotation for medical students, and we also make time for pre-med students, such as Isaac Mitchell (left) of Northwest Nazarene University.
I hear this from many medical students, who often don't realize the full scope of family medicine, especially as practiced in small communities like mine. When I look at my practice through the eyes of a medical student, it tends to shake me out of my complacency and makes me appreciate the incredible diversity of what we do. It really is cool.
This is a plea for more community preceptor sites. We need medical students to experience family medicine away from academic medical centers. If students don't see what we do and where we do it, how can they possibly choose to become community family physicians themselves?
Bringing medical students into your community and clinic is incredibly rewarding and useful. My practice has been accepting medical students for years, and it has become an integral part of our practice.
After 20 years, my practice fits me like a glove. It is easy to become comfortable and even blasé about the day-to-day care my community needs. Mentoring medical students keeps me on top of my game, especially with a generation of medical students who fact-check most of the things I tell them. Indeed, I use them to stay abreast of the latest in medical research, both by keeping me interested in pursuing the literature and by having them teach me. They question everything, which makes me do the same.
I enjoy seeing them realize the incredible breadth of knowledge required in family medicine, as well as the complexity of an office visit, and I tease them about whether they think they're smart enough to be a family physician.
I also explain that they are only seeing the tip of the iceberg when it comes to a patient's history. I spend a lot of time talking about who is related to whom and what unspoken stressors are present -- the whole backstory of why the patient is in the exam room.
I used to worry that my patients would object to having medical students in the exam room, but I have rarely seen this. Rather, most enjoy being a part of medical education.
I often hear patients ask students why they are doing a rotation in our clinic in Valdez, Alaska, although it often comes out as, "Who did you piss off to get assigned here?"
When students answer that they had to beat out 10 of their peers to get the opportunity, my patients leave with a thoughtful expression. The rotation is competitive because we don't have enough community preceptors.
I get it. Teaching medical students does take time, especially if you do it right. But I see my role as not only teaching about family medicine, but also about work-life balance, good relationships, a good medical team approach, a healthy diet and exercise. We take students on adventures to model the concept of work hard, play harder. I freely admit that my partner, Michelle, is an enormous part of this.
The medical students earn their keep, though, seeing patients when it is busy and being an integral part of the health team. Like all family physicians, I have many patients who are complicated and require more time than I can give. I have found medical students are able to address many of the social determinants of health that complicate care, as well as spend the time that many of my patients need.
Given our isolated location on the Alaskan frontier with limited resources and hours away from a tertiary care center, the students often play a critical role. On one occasion, a school bus carrying teenage skiers hit a semi truck on an icy road. Our medical student became an essential part of a system completely overloaded by a mass casualty event.
Another student assisted me in an emergency cesarean delivery of twins during a snowstorm. Students have helped me with severe hypothermia cases and often do a better job than I do on counseling teenagers about health issues.
More than 32,000 medical students are AAFP members, and many of them will gather to learn and share their enthusiasm at the National Conference of Family Medicine Residents and Medical Students, July 28-30 in Kansas City, Mo. They all need our assistance and expertise. There is a shortage of family medicine rotations, made worse by competition with students of nurse practitioner and physician assistant schools, many of which pay clinic sites to precept their students.
These medical students are our future, and they need places to experience the full range of family medicine. I know they won't all go into family medicine as a specialty, but I do expect them to treat family physicians with the same respect as they would members of whatever specialty they ultimately choose. I want them to understand the value of family medicine and how they will work with family physicians if they choose another specialty.
Most importantly, these students remind us who we are as family physicians and why we do what we do.
John Cullen, M.D., is a member of the AAFP Board of Directors.
AAFP Award for Excellence in GME: And the Winners Are …
Native Americans account for just 0.3 percent of U.S. physicians, but Hailey Wilson, M.D., overcame those long odds to achieve her goal and now works at a federally qualified health center that serves a largely Native American population.
David Tran, M.D., the son of refugees, also beat the odds to become a physician, overcoming homelessness and the loss of his father during college.
Jerry Abraham, M.D., M.P.H., has served in leadership roles for his county medical society and state medical association board, and this month was a member of the AAFP delegation to the AMA House of Delegates in Chicago.
I could go on about the winners of the AAFP's Award for Excellence in Graduate Medical Education, but the curricula vitae of the 12 honorees -- along with their personal statements and letters of recommendation -- take up some 166 pages of degrees, honors, volunteering, leadership roles, publications and other accomplishments.
The Academy's commissions are tasked with making selections for several awards the AAFP gives in recognition of exceptional service and commitment to family medicine, and it has been my honor this year to serve as the board liaison to the AAFP Commission on Membership and Member Services. At our recent summer meeting, commission members finalized the selections for the aforementioned award, which is given each year to a dozen second-year family medicine residents. The honor, supported by a grant from Novo Nordisk, recognizes outstanding residents for their leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine.
Every member of the Commission on Membership and Member Services reviewed each of the more than 100 applications we received. It was an extraordinary time commitment to be sure, but every reviewer echoed a sense of incredible appreciation of the quality and diversity within our specialty. It was difficult to select 12 winners from the numerous exceptional candidates who applied with the support of their residency program directors.
As I thought about writing this piece, I reflected on how much our Academy and its members have influenced the medical school admission process, the selection process for family medicine residents, and the support for new physicians and emerging medical leaders.
Those medical schools with a strong commitment to family medicine and primary care include family physicians on their admission committees. They look for candidates who have connections to rural communities, an interest in a broad spectrum of practice, premedical experience working with diverse populations and underserved communities, and who have been exposed to family medicine. They seek candidates who demonstrate a breadth of knowledge and experience, as well as a desire for lifelong learning that will prepare them for the incredible variety of interactions that characterizes the practice of family medicine.
The medical students who are part of a family medicine interest group and student members of our Academy have demonstrated an early commitment, and extraordinary pre-doctoral faculty across our country are instrumental in encouraging and facilitating the journey of those students toward a family medicine residency program.
Family medicine residency programs apply similar selection criteria, sifting through the myriad of applicants for each of their residency slots, and extending invitations to those whom they feel will fit well into an established health care team that cares for a broadly diverse population. Many residency programs have a special commitment to a specific underserved population and eagerly seek applicants who have special experience and interests that will better prepare them for a future practice serving those communities.
This year's award applications included extraordinary examples of commitment to underserved populations and research, as well as compassion, communication and knowledge-based decision-making. I applaud the commission members who made the difficult selection process work.
The winners will be recognized at a special breakfast on Sept. 22 during the Family Medicine Experience in Orlando, Fla. At last year's award ceremony, I sat with the parents and residency program directors of two incredibly humble individuals who spoke not of themselves or their accomplishments, but instead described how much the mentorship they experienced from practicing family physicians meant to them.
When I read about the 12 individuals who will receive this year's Award for Excellence in Graduate Medical Education, I appreciated how successfully family physicians have influenced the premedical education of our high school and college students, the pre-doctoral education of our medical students and the training of our family medicine residents. Behind each and every individual who receives this award are the thousands and thousands of family physicians across our country who make a difference every day in caring for our patients, their families and their communities. You make it possible for us to recognize a few exceptional family medicine residents. We all should take pride in the impact each of us has in growing the future of family medicine.
Here are the winners:
- Jerry Abraham, M.D., M.P.H., University of Southern California Family Medicine Residency Program at California Hospital;
- Margot Brown, M.D., Santa Rosa Family Medicine Residency;
- Stewart Decker, M.D., Cascades East Family Medicine Residency;
- Daniel Gordon, M.D., Memorial University Medical Center Family Medicine Residency;
- Christina Kinnevey, M.D., Sutter Health Family Medicine Residency;
- Adam Kowalski, M.D., Carl R. Darnall Army Medical Center Family Medicine Residency Program;
- Catherine Moore, D.O., Mercy Family Medicine Residency;
- Charles, Salmen, M.D., University of Minnesota/North Memorial Family Medicine Residency Program;
- David Tran, M.D., Long Beach Memorial Family Medicine Residency Program;
- Juan Carlos Venis, M.D., M.P.H., Indiana University Health Ball Memorial Hospital Family Medicine Residency;
- Hailey Wilson, M.D., Swedish Cherry Hill Family Medicine Residency; and
- Jason Woloski, M.D., Penn State Milton S. Hershey Medical Center Family Medicine Residency.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
Time for Congress to End 20-year Ban on Gun Research
If I told you the U.S. government stopped funding research into one of its most pressing public health concerns, you might conclude that the problem had been solved. But that would be incorrect. When a homegrown terrorist shot more than 100 people this weekend in an Orlando nightclub, it was the 176th time that the United States had experienced a mass shooting (four or more people injured) in a year that is not even half over.
Every year, more than 33,000 Americans die because of gun violence and more than twice as many are injured. Yet for two decades, Congress has restricted the CDC from conducting research related to gun violence.
The AAFP and more than 100 other stakeholder organizations sent a letter to Congressional leaders in April, urging them to end the ban on gun violence research. Today we are again calling on Congress to address this important issue.
Research into gun violence could provide us with valuable information about protecting children from accidental shootings, suicide prevention, the impact of various state gun policies and more.
As these events continue to happen -- from Newtown, Conn., to Fort Hood, Texas, and San Bernadino, Calif. -- there will be opportunities for physicians to step forward and ask what we can do differently. Ending the ban on research would be a wise first step.
I'm at the AMA meeting this week in Chicago, and the AAFP and other physician organizations are pledging to do what we can to heal our nation. I am proud of my colleagues at the American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists, and American Psychiatric Association who joined with me to share the message of hope and healing below. Our nation must have an honest and frank discussion on reducing both the tendency and capacity for violence in our society. Hopefully, now is that time.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Catching a Dream: Participating in Leadership Keeps 'Goblins' at Bay
When we feel consumed by the constant flux of the health care system and its seemingly endless clicks and prior authorizations, we need something to nourish our nature as healers.
It helps to remember that we hold the key to the health of our patients, a point that was driven home at this year's AAFP National Conference of Constituency Leaders.
I often hear that this conference is the heartbeat of the Academy, the place where key issues are tackled with an emphasis on change. Each chapter is invited to send representatives from constituencies historically underrepresented in AAFP leadership: women; minorities; new physicians; international medical graduates (IMGs); and gay, lesbian, bisexual and transgender (GLBT) physicians and those who support GLBT issues.
This conference, which coincides with the Academy's Annual Chapter Leader Forum (ACLF), serves as a platform for innovation and policy transformation within our organization. Energy pulses throughout three jam-packed days, and new leaders emerge. Friendships are made. Connections are strengthened. Morales are boosted.
In this environment, those lurking goblins that once held us back in our practices are stifled by the web of our dreams as leaders in our specialty and the health care system.
Looking at the more than 200 participants in this year's conference, I was struck by the image of the dream catcher. In Native American tradition, this circular web of natural materials hangs above a sleeping area where the morning light can hit it. The dream catcher attracts dreams to its web. Bad dreams do not know the way through the web and get caught -- then, the first light of day causes them to melt away and perish. Good dreams go through the center of the web and slide down to the sleeper below.
In today's medicine, we are the dream catchers. We, as family physicians, are a mixture of different media held together by the bond of providing excellent care to keep our health system focused on what matters. Just as the web of the dream catcher captures dreams and channels the ones with purpose to its beholder, we consider policy and reformations to enact change within our Academy and beyond. Through more than 60 resolutions at NCCL, delegates voted their consciences on topics such as payment, transgender care, burnout, student debt, and parental leave.
The role of a dream catcher is not simply to ward off malignant thoughts or dreams. More importantly, dream catchers propel those they watch over to an improved reality. This is the exciting aspect of NCCL. It is a place where our Academy has invested resources that enable underrepresented constituencies to suggest policies that directly affect us and the people we serve. It is a way to bring new leadership into the organization and help current leaders refine their skills.
The vision of diversity in leadership is a recurrent theme at the conference. As important as it is to create a space for budding leaders to emerge, it is equally important that we in leadership, on both the state and national levels, be deliberate in our attempts to recruit leaders from diverse backgrounds. There is nothing more beautiful than to see the creative exchange of ideas from people of diverse cultures, backgrounds, practice types and roles. This is how dreams evolve into reality.
Another important theme that resounds in the conference is the interconnectivity of social determinants of health and health outcomes. We understand that our patients live within a context that is uniquely their own. Without basic provisions such as transportation, adequate access to food, a stable home environment and safe schools, the families for whom we care cannot focus on their health. We know this innately, but we as an organization have been challenged, in part through venues like NCCL, to put meat to this understanding. It was through the persistence of resolutions adopted at NCCL that stances on childhood obesity, transgender care and protection of physician autonomy germinated. These resolutions guide our Academy to dig deeper into the issues and form evidence-based opinions that can further empower our members. More importantly, we are reminded that we are accountable for treating our patients within their unique contexts.
So vision and accountability stem from an electric gathering of people from all over the country. I would also contend that hope and joy abide in this space! What better way to combat burnout than to come and work for improvement alongside equally passionate individuals?
I am thankful that our Academy invests in its future through conferences such as NCCL. The AAFP pays airfare or mileage for each chapter to send a new physician delegate in addition to three other individuals attending NCCL or ACLF. I hope to see all chapters represented next year, when the conference is held April 27-29 in Kansas City, Mo. I promise you it will be time well spent among the dream catchers.
There are two more AAFP events this year where members can help shape Academy policy. The National Conference of Family Medicine Residents and Medical Students is July 28-30 in Kansas City, Mo. The Congress of Delegates is Sept. 19-21 in Orlando, Fla.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
We're Getting the Media to Spread the Word About Family Medicine
We've posted in this blog before about the importance of working with the media to share public health messages and to educate the public and policymakers about complex health issues. We have shared stories about what Academy leaders are doing nationally while also encouraging members to work with the media at the local level.
Last year, the AAFP decided to take an in-depth look at our media outreach and get a professional assessment of how we're doing. The results, which were presented to the Academy's Board of Directors this month, are encouraging.
The AAFP contracted with GYMR, a Washington, D.C.,-based communications firm that specializes in health care and social issues, to perform a yearlong analysis of media coverage of the AAFP and a number of its peer organizations: the AMA, American College of Physicians, American Academy of Pediatrics (AAP) and American Osteopathic Association (AOA).
The intent of the analysis was to determine how well the AAFP was performing in 26 strategic, targeted media outlets, including large daily newspapers (such as the Los Angeles Times), national publications (such as USA Today), wire services (such as the Associated Press), trade media (such as Medical Economics) and policy outlets (such as Politico). We also wanted to know how well our message was being relayed and how our coverage compared to that of our peers.
The Academy's public relations staff receives media requests and also pitches story ideas to contacts. The result is that the AAFP is mentioned in hundreds of media outlets each month. Looking at only the 26 targeted outlets, in fact, the AAFP is a constant presence, with an average of 38 mentions a month -- 23.5 in health care trade publications, 11 in national media outlets and 3.4 in policy-related outlets.
GYMR also analyzed numbers by mission area. Nearly a third of the articles that mentioned the AAFP dealt with practice advancement. That's good news, because it's critical for policymakers to know how issues such as payment, regulations and administrative burdens affect physicians and their patients.
Twenty-eight percent of the articles that mentioned the Academy had to do with health of the public issues, such as electronic cigarettes and breastfeeding. AAP also did well in this area because of the interest in children's health care issues. We can work to educate the media about the fact that family physicians care for the entire spectrum of age groups, and family physicians care for millions of children, particularly in rural and underserved areas.
To break it down a different way, a quarter of the education and a third of advocacy articles in the analysis mentioned the AAFP. There are many more stories here we can tell, including the fact that our nation's graduate medical education system is not producing an adequate number of primary care physicians.
Interestingly, the AAFP accounted for 25 percent of all quotes in the hundreds of stories that were considered, more than any other primary care group. Academy representatives were quoted in 63 percent of the stories that mentioned the AAFP, nearly double the rate of the AAP and far more than the AMA and AOA.
The analysis also looked at who should be quoted. Some health care organizations use a staff member as a spokesperson. On the other hand, the president is the official spokesperson of the AAFP. One reason the Academy is frequently quoted is because each year, the organization has a new person who can share fresh stories and practice perspectives with reporters. Rather than a policy wonk sitting behind a desk, we have practicing family physicians talking about how important issues affect us, our patients and our colleagues. On an almost daily basis, I'm telling reporters stories that start with, "I have a patient who …"
Family physicians have a unique ability to tell stories and connect issues to patients. We can humanize important health messages and make them easier for the public to understand. Ultimately, we are getting the right messages to the right people on behalf of family medicine.
You can join us by sharing stories in your own community, whether it be at the Rotary Club, a Boy Scout meeting or with your local newspaper. We can help the public understand the importance of issues such as immunizations by speaking out. In the process, we expand public awareness of family medicine, who we are, what we do and what we offer the health care system.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Let's All Commit to Reverse the Opioid Epidemic
Last week, AMA President Steven Stack, M.D., issued a letter entitled "Confronting a Crisis: An Open Letter to America's Physicians on the Opioid Epidemic." We have been working closely with the AMA and other physician organizations on this issue through the AMA Task Force to Reduce Opioid Abuse.
As family physicians, we see the havoc opioid abuse is causing families and communities across the United States. That's why we're working hard to provide adequate pain management for our patients who need it, while at the same time, raising awareness that addiction to opioids is a national health crisis.
© 2016 Sheri Porter/AAFP
I am discussing the nation's opioid crisis with Surgeon General Vivek Murthy, M.D., M.B.A. We met April 18 in Washington to discuss possible collaborations between the Academy and the surgeon general's office.
A recent AAFP study showed that opioids are not our first choice when we're treating patients with chronic pain -- four other treatment methods (physical and occupational therapy, oral non-aspirin nonsteroidal anti-inflammatory drugs, acetaminophen, and antidepressants) are prescribed or recommended for our patients dealing with non-malignant chronic pain before opioids. While this is not a surprise to you, it is important to share this information with patients, payers, legislators and policy makers.
Please know that your AAFP is working closely with other organizations to combat the scourge of opioid abuse -- the White House, HHS, the surgeon general of the United States, and the CDC to name a few. And we have multiple resources readily available to you -- with more to come in early June.
We all need to do our part to end this epidemic. Showing our resolve, by voluntarily increasing our individual CME hours dedicated to opioids and pain management, is a step that we can each take. The AAFP has collated the CME on this topic to make it easier for you to locate, complete and report your hours. Please log in and refresh your knowledge on these critical issues.
Family physicians are dedicated to being a part of the solution to help slow this national crisis. Please join me. Together, we can address this devastating epidemic -- balancing pain relief for our patients in need with our sincere desire to always do no harm.
Wanda Filer, M.D., M.B.A., is president of the AAFP.
Can Mindfulness Meditation Deliver Us From Burnout?
What do you do for fun? This is an important question I have started to ask patients so I can get to know them better and assess whether they find joy in their lives. I appreciate that the absence of joy can be a significant contributor to absence of personal health and sense of wellness.
I often wonder if we should be asking our physician colleagues the same question. A recent survey of nearly 36,000 physicians found that 63 percent of family physicians suffer from at least one symptom of burnout, an increase of 12 percent in just three years.
Not surprisingly, the same survey, which was published in December in Mayo Clinic Proceedings, found that physician satisfaction with work-life balance was falling nearly as fast as burnout was rising. The percentage of family physicians who were satisfied with their work-life balance in this survey was roughly 35 percent, which was down from 50 percent in the previous study done three years earlier.
Although the AAFP, its constituent chapters and other physician organizations are working hard to address the many drivers of burnout that exist in our external environment -- including electronic health records, reimbursement and administrative burden -- it also is important that we, as physicians, ask ourselves what else we can do to survive and thrive amidst the current chaos.
A growing body of evidence points to mindfulness meditation and practicing the principles of mindfulness-based stress reduction as a key answer to this important question.
Back in 2013, there already was ample evidence that mindfulness meditation could help people reduce stress when researchers at Carnegie Mellon University used MRI scans to show that the process, after just eight weeks, appeared to shrink the amygdala and thicken the prefrontal cortex. In other words, participants' connection to their fight-or-flight response got weaker as their attention and concentration improved. Researchers reported that the scale of these changes correlated with the amount of time spent on meditation.
Earlier this year, a research team that included the authors of that 2013 study found that mindfulness meditation stimulated areas of the brain that may help control emotional reaction and attention and decreased blood levels of interleukin-6, which is associated with inflammatory disease risk, meaning the process may protect participants' from emotional distress and decrease inflammation.
Yet another study published last fall in the Journal of Continuing Education in the Health Professions found that participants' heart rate, blood pressure and Maslach Burnout Inventory scores improved after eight weeks of mindfulness meditation, and results continued during a 10-month followup period with low attrition and high compliance rates.
Not surprisingly, I'm hearing more and more about mindfulness wherever I go. Daniel Friedland, M.D. recently gave a presentation on how mindfulness can play a role in leadership during the AAFP's Annual Leadership Conference. And Renee Crichlow, M.D., an assistant professor in the department of family medicine and community health at the University of Minnesota in Minneapolis, recently presented the evidence for using mindfulness meditation to prevent burnout at the Minnesota AFP's annual meeting.
Skeptics might be reluctant to invest time on something they aren't sure about, and maybe you aren't comfortable with the idea of sitting in the lotus position and getting in touch with yourself. The good news is there are plenty of free resources to help you get started and you can practice mindfulness meditation in whatever position is comfortable for you in just few minutes a day.
As this short video on the basics of meditation from Happifyhealth.com says, meditation is simple, secular, scientifically validated exercise for your brain. Another short YouTube video from Happify explains why mindfulness is a powerful tool for your well-being.
If meditation isn't for you, there are other options to reduce stress and build resiliency. A Minnesota community that lost two physicians in a short time period -- including one to suicide -- started a Bounce Back campaign that aims to improve physician and public health by making the community a happier place. The initiative encourages people of all ages to perform random acts of kindness.
Family Practice Management recently published a three-part series by family physician and burnout expert Dike Drummond, M.D., that covers recognizing symptoms and causes of stress, reducing stress and work-life balance. All three articles are eligible for AAFP Prescribed CME credit for one year from the date of publication.
I appreciate that none of these tools is going to improve reimbursement, make payers more reasonable about prior authorizations or improve the interoperability of our electronic health records systems. However, these tools can help us be the best we can be in our "inner space" while we struggle to eliminate the challenges and burdens that occupy the "outer space" of our practice of medicine. After all, if we can't take care of ourselves, we won't have anything left to care for others.
Lynne Lillie, M.D., is a member of the AAFP Board of Directors.
FPs Can Be Trusted Guides When the Dying Don't Specify Wishes
Each day when I walked into his hospital room, I greeted him with, "Hello there, Mr. Gold! How are you?" His cerebral amyloid angiopathy, resulting strokes and severe dementia had left him chronically debilitated and nonverbal, but his gazing eyes were enough for me to acknowledge our shared humanity.
For nearly a month, I took care of him on our inpatient service, treating him through seizures, aspiration pneumonias, intubations and extubations. I learned at his funeral service that he had gone by the nickname "Cuz," and when asked by the pastor to give a few words, I admitted that I had not had the benefit of knowing my patient in his prime. However, I had the distinct honor of helping him through his final days. And I was inspired by the love his family showered on him.
Every day, I sat down with Mrs. Gold (not the family's real name) and discussed the care plan, hopeful that her husband could return home to her capable care. But as his situation progressively worsened, it became clear that he might not ever make it home from the hospital.
She struggled with granting an "allow natural death" status that would forfend the high-caliber interventions that were becoming more and more futile. The only direction she had received from her husband on this difficult topic before his illness was that if his heart stopped, he wanted to be brought back.
Never mentioned in their conversations was a scenario in which he had progressive dementia and organ failure. Never discussed was the option of withdrawing care in the context of loss of dignity and quality of life.
So, in this situation neither of them had foreseen, she was doing her best to extrapolate what his end-of-life preferences would be from the minimal information he had imparted.
Reluctantly, she agreed to press on with full code interventions. By the second intubation, the palliative care team and I discussed with her the option of in-hospital hospice, where he could be extubated and spend his final days in the company of family without invasive tubes, lines, bells and whistles. He passed there peacefully, but his family's ordeal may have been less traumatic if he had made his wishes clear.
The Health is Primary campaign released patient materials earlier this year that discuss palliative care and advance directives, and American Family Physician has a collection of journal articles related to end-of-life care that include content for patients as well as physicians. These tools can help your practice and your patients with end-of-life discussions.
Often, family members are put in situations that require them to make decisions on behalf of their loved ones. Sometimes they disagree on how these decisions should be made or carried out. Difficult conversations can often be managed skillfully by family doctors who have developed trust and intimate knowledge of those they care for. Being able to give people a wide array of options is an honor. Putting the needs of those we serve above our own is an even higher honor.
Helping Mrs. Gold through this process was deeply inspiring for me. In the closing paragraphs of Mr. Gold's funeral service program, she quoted an anonymous poem: "So I gave to you life's greatest gift, the gift of letting go."
It's worth noting that a growing number of dying patients will soon have the ability to control their fate, allowing them to experience a far different process than my patient in Maryland. A new law in California that goes into effect June 9 will allow qualified patients the ability to self-administer a prescribed medication to aid in the dying process. For many, this would be preferred to the common hospital scenario of prolonged suffering, often alone.
The California AFP has responded with a set of resources that includes a series of four podcasts (each less than 10 minutes) on end-of-life conversations, an American Board of Family Medicine Part IV (Performance in Practice) Maintenance of Certification Module, a guide to weaving palliative care into your practice and additional information on the new California law (which is similar to laws already in place in Washington and Oregon).
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Keeping a Promise to Share What I Know
When we take the Hippocratic Oath we pledge, among other things, to share our knowledge and teach the next generation of physicians. Like a lot of promises, however, this one isn't always fulfilled.
I was a volunteer community preceptor for a decade in my small town, which is near the University of Wisconsin School of Medicine and Public Health. Three afternoons each semester, or six times a year, one first-year medical student and one second-year student would come spend time in my clinic.
|Here I am answering a question from Tyler Grunow, a first-year medical student at the University of Wisconsin School of Medicine and Public Health, between patients. I have been a volunteer community preceptor for more than a decade.|
My role was to help students develop history taking skills (illness, chief complaint, past history, family history, current meds, etc.), practice physical skills (such as listening to the heart and testing reflexes) and understanding the doctor-patient relationship and why it's valuable.
It sounds simple enough, and yet our specialty finds itself in a situation where far too few family medicine practices are willing or able help. I get it. A few years ago I was chair of an AAFP commission while also serving on the local board of health and working full time. Something on my overloaded schedule had to go, so I took a break from precepting.
It was a mistake.
While I was on that break I was asked to talk about precepting during a panel discussion at a family medicine conference. One of the questions, ironically, was how do you find time to help students and meet all your other commitments.
I was reminded of a student named Scott, who came to visit my clinic for the fourth time on a particularly busy day. I told him before we got started that he could shadow me that day but that I wouldn't have time for didactic learning.
I felt guilty because I didn't stick to our usual routine, and at the end of the afternoon I apologized. "I hope you got something out of that," I said.
He looked at me surprised.
"Dr. Schwartzstein," he said, "that was our best session yet. I learned so much from watching you interact with patients. It was wonderful."
Scott had learned by observing. He got a sense of the doctor-patient relationship and how it is at the core of what we do. Family medicine is about relationships, and he saw how I interacted with my patients and the level of comfort they had with me.
As I told that story at the conference, I realized precepting wasn't something I could give up in good faith. And I realized it wasn't something I had to give up to maintain productivity. I can do this.
So the med students are back in my clinic, three afternoons a semester, six times a year. Physicians are pressed for time, and many likely think med students will slow them down, hurt their productivity or force them to work late. The reality is that it shouldn't be that big of a burden. In fact, students can add value to a practice.
I find out what students are studying before they visit. If, for example, it's cardio, I make sure they get to listen to patients' hearts. I start by asking if there something specific they want to get out of a visit, and if there is I try to help them with that particular interest.
I try to answer questions between patients or at the end of the day. I ask, did you learn anything today? And I'm eager to hear their answers. Students have different perspectives about new ways to do things, and their questions keep me on my toes.
In addition to teaching when we have students in our clinics, we are recruiting future family physicians. While they no doubt notice the administrative burdens and imperfect EHRs and ask about that, I am careful in how I address those issues. Despite these challenges, I still love being a family doctor, and I am careful to talk about, and show students, that love as I see patients with them.
A long time ago during med school graduation I pledged that I would share what I learn. Now, and until I retire, I will follow through on that promise.
Alan Schwartzstein, M.D., is the vice speaker of the AAFP Congress of Delegates.
Seeing the Diseases Vaccines Prevent Illustrates Importance of Immunizations
Editor's Note: In recognition of National Infant Immunization Week, the AAFP is participating in a blog relay to discuss the critical role vaccines play in protecting children, families and communities against vaccine-preventable diseases. You can follow the conversation on social media using #NIIW.
It was a hot, humid day in Cap-Haitien. I was a premed student serving as both an extra pair of hands and as a medical interpreter during my first medical mission trip to Haiti.
The magic of being in the country of my roots enveloped my senses. A deep sense of pride swelled within me as I heard the ocean in the distance, smelled the spices that I had grown up eating and marveled at the intense beauty of the terrain. However, that pride was repeatedly flattened by grief from the immense poverty that surrounded me. Even though it has been more than 10 years since that trip, the images of so many people in need of the type of care I had taken for granted continue to drive me today.
I remember seeing a teenager stiff from tetanus and unable to swallow. His mother held him and pleaded for help.
I held an infant, feverish with pneumonia, who improved after my group paid for penicillin, IV fluids and oxygen.
We forget that American children used to routinely die from diseases that now can be prevented by vaccines. However, this is not the reality in many countries.
Today marks the beginning of National Infant Immunization Week which highlights the importance of protecting infants from vaccine-preventable diseases and celebrates the achievements of immunization programs across the country.
As a family doctor, one of the most important roles I play in my patients' lives is preventing disease and improving health. Every day I discuss the role of vaccines in health maintenance with my patients as a means to protect them and at-risk populations.
Thankfully, we are in an era where terrible diseases like polio, Haemophilus influenzae type B and measles are no longer commonplace in our country. However, in California (where I live), there are many parents who still choose not to vaccinate their children despite overwhelming evidence that demonstrates the safety and effectiveness of immunizations. As a result, we have witnessed the devastating effects of disease outbreaks.
Family physicians and other primary care stakeholders in my state have had to work hard mitigating a measles outbreak and the dangerous rise of pertussis, or whooping cough, in recent years.
The importance of vaccination resonates with me, personally, as a mother of three. When I returned to work after the birth of my youngest child, I had to consider exposing my child to potential antigens brought home from work. I was concerned that the decisions of others could affect the health of my own newborn.
I changed my practice and became more proactive in educating parents about vaccinations. Some parents entrusted their children to my counsel. For others, I decided that I may not be the right physician for them. Although I was torn between caring for patients and doing no harm, I knew I could not withhold vaccinations from a child who lacks the ability to make an informed decision. I also knew that not vaccinating families put others in our community at risk. With that said, I have gladly welcomed families who may have questions about immunizations or decide to use a catch-up schedule.
In California, we have adopted a law that emphasizes an individual's obligation to protect others. Specifically, it eliminates religious and personal belief exemptions for vaccines. This is an important step because the benefits of immunizations are not confined to the individual. Vaccination -- or lack of it -- can affect others unknowingly. Consider the newborn, too young to get vaccinated, or the immunocompromised person undergoing chemotherapy.
In a world that is so interconnected, we must be diligent to protect those at most risk, our children. Giving children the recommended immunizations by age 2 is the best way to protect them from more than a dozen serious -- but preventable -- diseases.
The CDC is right to trumpet the role immunizations have played in reducing the burden of illness in our society. Primary care physicians can add our voice by posting information in our waiting rooms and exam rooms. The CDC also has resources to help physicians get the word out by working with local media, using social media and more. We all can do our part.
It is easy to forget our past and to ignore the fact that the threat of preventable disease is palpable in other countries. For me, I remember those days on the mission field and the children whose fates were sealed without the option of prevention that too many among the privileged are rejecting.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Rural Recruiting, Retention Proves Daunting
I went to college in St. Louis, med school in Cleveland and residency in the Houston suburbs. If you had asked me back then where I would be living when my training was complete, I never would have guessed a rural mountain town on the West Coast. But this city girl has grown to love rural medicine.
The beautiful scenery, family life and the ability to be present in the day-to-day functions of our home were the main reasons my husband and I first decided to leave an urban environment for a much quieter setting, but my desire to work with the underserved translated naturally to this new setting, as well.
| Here I am talking with patient Gail Ruby during a recent office visit. Unfortunately, I'm leaving my rural practice in California because of the local hospital's lack of support for primary care.
I quickly realized that the struggles related to poverty and access don't discriminate based on location. Many of the same health challenges I saw in med school and residency infiltrate our small community, and my patients can attest to my value as a family doctor in the clinic, the hospital or in the operating room.
With so much that I have gained from being in rural practice, it pains me to have to leave. My contracted hospital has not been able to provide a work environment that supports me as medical director, and I find myself once again giving preference to work over family. That was the problem that led me to move from a big city environment in the first place.
Before I arrived here, there were only two obstetrical physicians covering more than 15,000 patients for 18 months. During the last five years, our community lost four physicians, including three family doctors. I am the only young primary care physician in town, and most of the practicing physicians are nearing retirement. So, as a new physician working in a great community, I am concerned by the ever-demanding needs of a small practice, little support and lack of new hires into the area.
Although my family loves this close community, I find myself sinking deeper and deeper into the inefficiencies of a practice that does not support physician leadership. More importantly, I realize that the hospital recruitment has been ineffective, and my work-life balance has suffered as a result.
Sure, there are alternative practice models, like direct primary care. However, it is difficult to limit a practice panel when a community is already suffering from attrition of physicians. One could open up his or her own solo practice, but the start-up costs and overhead can be prohibitive. Frankly, when faced with $100,000 of debt -- or more -- coming out of residency, it is intimidating to think of incurring even more debt to start a business.
The truth is that in small towns, the local hospital is the main financial resource for recruitment and retention of physicians. Factor in that most new physicians are looking for some kind of employment model, and the cost of recruiting usually cannot be absorbed by smaller practices. Despite the important role of primary care, especially in small communities, I find myself often defending my value -- to the community and the hospital -- as a family physician practicing obstetrics.
The cost of recruiting a family physician is roughly $100,000. But what is the value lost when you lose a family doctor? Research shows that having a family doctor cuts costs in unnecessary testing, reduced hospital readmissions and better continuity of care. We also know that family doctors generate revenue for affiliated hospitals, to the tune of $1.5 million in annual revenue per FTE.
Although doctors and hospitals functioned in a more segregated way in the past, it is now almost expected that hospitals collaborate with physicians in order to provide better population medicine. This is certainly a paradigm shift in focus and priorities, and at least where I live, is not well-received by the corporation that owns my local hospital.
One thing is certain. Traditional recruitment models have not attracted any doctors to my town in at least the last five years. Something has to change.
Leaving my town has real consequences in how medical care will be delivered, especially in relation to obstetrical care. We know that if rural communities lose their hospitals, it is a sentence for increased maternal-fetal deaths, more high-risk deliveries, more inappropriate home births and a loss of economic stability to the community. It also leaves the door open to poor health outcomes for the chronically ill.
So what is the answer? How do we appeal to young physicians and encourage them to invest in these areas? The answer may be much simpler than you think. If you build it, they will come.
Young physicians are looking for a place in which we can thrive both personally and professionally. As I continually stressed to my hospital, new recruits want to know that the people who work in that setting are supported, that innovation is welcomed and that the management or corporation is forward-thinking. We also want to be compensated appropriately for the level of work and expertise we offer. The new recruit wants to be in a place that supports and upholds the importance of the physician's role in the delivery of patient-centered care.
We aren’t afraid to work hard, but we don’t want to do so in vain. Although this is not unique to a rural setting, the financial component is amplified due to lack of resources compared to larger cities with larger markets.
My colleagues here tell me that these expectations represent quite a change in mentality from even 10 years ago, when physicians did not require as much from corporate entities. I’m not completely sure how this shift occurred, but part of the answer lies in the increased demand for data sourcing and the challenge of electronic health systems that do not communicate with one another. Couple that with reduced reimbursement rates for primary care, and we have a good start to answer that question.
Call it a generational change of mind or maybe a realignment of priorities. However you want to label it, this trend isn’t going away. Gone are the days when a person would work without being afforded respect and validation. As innate servant-leaders, family doctors have a tendency to gloss over those business aspects, but I hope our savvy new physicians will push all stakeholders into the right direction. I hope that we will return to a world where a family doctor is able to choose whatever practice model fits his or her lifestyle best, whether that is running a small business or as an employee.
My family will miss the community we have grown to love, but moving is the price to pay in order to have a continued presence in my home. As we prepare to move to another community with a small-town feel, I can definitely say that being part of a rural town has left us with a great impression of family life. I hope that my departure creates the pressure the local hospital needs to revamp strategies that will attract and keep primary care alive in this area. When my family returns to visit, I pray that the medical scene will beat to a different tune.
Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.
Women in Leadership Build Support for Other Female Physicians
At a recent family medicine meeting, I took pride in the fact that this year the AAFP president, the speaker of Congress of Delegates and the president of the AAFP Foundation are all women. That's a rarity given that Wanda Filer, M.D., M.B.A., is only the third female president in the Academy's 69-year history.
I believe we’ll see more female physicians on the forefront of leadership in the future. When I graduated from medical school, women accounted for roughly 10 percent of the U.S. physician work force. Today, the number is closer to one-third.
| Women in leadership positions in family medicine include, from left, AAFP President Wanda Filer, M.D., M.B.A.; myself (speaker of the AAFP Congress of Delegates); and AAFP Foundation President Evelyn Lewis&Clark, M.D., M.A.
In family medicine, the trend is even stronger. More than 40 percent of AAFP members are women, and the numbers are higher among our youngest physicians. Fifty-four percent of family medicine residents are women, and 57 percent of our new physician members are women.
As our percentage of membership increases, so does our representation. Three dozen presidents and presidents-elect of our constituent chapters are women. And nearly 50 women serve on AAFP commissions. Female physicians should feel empowered by the changes we are experiencing.
Despite the advances women have made, obstacles remain. A recent Medscape survey indicates that female physicians still earn far less than our male counterparts. Illinois AFP President Alvia Siddiqi, M.D., recently launched our chapter's Women in Leadership Member Interest Group to address such disparities. The group's first event, held in late February, aimed to help women improve their contract negotiating skills.
Siddiqi said the chapter's intention is to "provide an open forum to discuss issues relevant to female family medicine physicians, including contract negotiations, balancing career and family lives, and career development." The group will encourage female physicians to participate in leadership and offer opportunities for mentoring, and personal and professional development through education and other programming.
On a broader scale, Michigan AFP President Kim Yu, M.D., recently started a social media effort to connect female family physicians across the country. Yu launched Physician Moms in Family Medicine on Facebook in January, and the group had 800 members within a few days. It now has more than 1,100.
Only family physicians can join the group, Yu said, because she wanted members to have a place "to ask their questions within the safety of our own specialty."
"It has been eye opening to hear directly from physicians on topics from ABFM certification questions, celebrating when someone becomes an AAFP fellow or delivers a baby, how to deal with threatening patients, interesting or difficult cases, how to teach circumcision to residents, favorite board review courses, info on FQHCs, best CME courses, procedures, or sharing about our favorite conferences," Yu said.
Yu said her goal for the group is to provide a venue where women can find a community to share their joys and difficulties and support each other.
The group is open to women who are not mothers, but Yu said it will keep its name so women know they also can "discuss issues that affect us as physician moms, not just as physicians."
Yu also hopes the group can encourage its members to become more involved in advocacy for their patients and the specialty.
As Women's History Month comes to a close, I'd love to hear what other chapters and groups are doing to provide mentoring and resources for female family physicians.
Finally, I want to remind you that the National Conference of Constituency Leaders will be May 5-7 in Kansas City, Mo. That event, which provides a platform to five AAFP special constituencies -- women, minorities, new physicians, international medical graduates and physicians interested in gay, lesbian, bisexual and transgender issues -- is co-located with the Annual Chapter Leader Forum.
Javette Orgain, M.D., M.P.H., is speaker of the AAFP Congress of Delegates.
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