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Wednesday Aug 24, 2016

Right Thing to Do: Making the Case for Drug Pricing Transparency

Americans spent $419 billion on prescription drugs in 2015, up nearly 12 percent from the previous year. Estimates for 2016 project an increase of as much as 13 percent.

Although spending on new drugs and increased use of existing drugs explain some of last year's spending spike (2.7 percent and 0.5 percent, respectively), more than 8 percent represents price increases for existing drugs. As manufacturers continue to raise prices, spending will continue to soar.

The combination hepatitis C drug ledipasvir-sofosbuvir (Harvoni) led the industry in 2015 with $14.3 billion in sales. Small wonder, when the typical 12-week, once-a-day course of treatment for patients with hepatitis C infection costs a whopping $94,500 overall.

Similarly, the treatment regimen for another hep C drug made by the same manufacturer -- Gilead Sciences Inc. -- consists of the same 84 pills taken over a 12-week course. At $1,000 a pill, sales for sofosbuvir (Sovaldi) also add up quickly. (That same pill, by the way, costs less than $5 in some other countries). Many find the discrepancy outrageous, but the drug's manufacturer was determined to weather any backlash when it set the price.

Of course, one manufacturer alone isn't responsible for a problem this big. Last year, Turing Pharmaceuticals and its (then) CEO Martin Shkreli generated headlines for making a similar egregious and unconscionable price increase. Turing, which holds sole rights to market pyrimethamine in the United States -- where it is sold only as the brand-name medication Daraprim -- boosted the price of the drug, which is used to treat toxoplasmosis and prevent malaria, from $13.50 per pill to $750.

Needless to say, the rising costs of prescription medications -- both brand-name and generic versions -- continues to create affordability challenges for patients and payers alike.

Many of the medications routinely prescribed by family physicians for conditions such as asthma have been priced out of the reach of many patients, including those with health insurance. Lifesaving medications such as epinephrine for anaphylaxis and naloxone for opioid overdose reversal have also been subject to unjustified price increases.

Pharmaceutical company practices, such as "pay for delay" tactics that protect existing drug patents and delay the entry of generic medications to the market, stymie access to these less costly therapeutic alternatives and violate AAFP policy meant to ensure the availability of formulary medications that demonstrate "a proper balance of cost, efficacy, quality and ease of use to optimize individual outcomes in the context of resource conservation."

I recently attempted to prescribe antiretroviral medications for a young man I had screened and diagnosed with HIV. He was devastated by the news but willing to start treatment right away. Imagine how disheartened he felt when the pharmacist told him he needed to pay $1,129.35 toward his deductible before he could buy the lifesaving medications for $45 per month. My patient asked me if he should quit his job to qualify for a public assistance program. Instead, I'm helping him acquire supplemental assistance through the Maryland AIDS Drug Assistance Program.

How can family physicians advocate for making medications more affordable? Supporting legislation at the state and federal level could help.

State Legislation
Although more than two-thirds of states have adopted some type of anti-price-gouging statute, the laws do not specifically extend to pharmaceutical costs. Most address unjustified price increases for certain commodities during emergencies, such as raising the price of snow shovels during a snowstorm.

In June, Vermont became the first state to require drug manufacturers to justify large price increases. However, this was only a first step because many critical actionable elements were removed from the bill before passage. Moreover, the Vermont legislation did not include specific price-gouging provisions to address unjustified increases in drug prices.

In California, state Sen. Ed Hernandez recently withdrew his drug bill from consideration after it was weakened by several amendments. That bill would have required payers to report data on pharmaceutical drug costs to state regulators, and it also would have required drug manufacturers to notify payers, pharmacy managers and state agencies of impending price increases.

However, a November ballot initiative in California, Proposition 61, would prevent state agencies from paying more for a medication than the amount paid by the Department of Veterans Affairs (VA), which receives a discount off average manufacturer prices.

Federal Legislation
In addition to state-based efforts to promote drug pricing transparency, several national proposals intended to foster transparency have emerged, including measures to allow the federal government greater negotiating power and to limit manufacturers' ability to engage in anticompetitive practices that keep prices high.

  • The MAC Transparency Act (H.R. 244) would reform how maximum allowable costs (MAC) lists are determined and how frequently pharmacy benefits managers update them. It also would establish an appeals process for pharmacies to dispute reimbursements and would extend reforms to Medicare Part D, TRICARE and the Federal Employees Health Benefits Program.
  • The Medicare Prescription Drug Price Negotiation Act (H.R. 3061/S. 31) would give Medicare the same negotiating power that exists within the VA, which pays roughly 40 percent less for medications than Medicare Part D plans.
  • The Preserve Access to Affordable Generics Act (S. 2019) would prevent drug companies from buying competitors and/or paying incentives to delay generic drug companies from producing new products. 
  • The Medicaid Generic Drug Price Fairness Act (H.R. 2391/S. 1394) would require generic drug companies to provide a rebate to Medicaid if price increases exceed the rate of inflation.
  • Under the Medicare Prescription Drug Savings and Choice Act (H.R. 3261), the Agency for Healthcare Research and Quality would assess a drug's clinical effectiveness, comparative effectiveness, safety and prescription adherence as part of the drug formulary review process.
  • The Safe and Affordable Drugs from Canada Act (S. 122) would permit patients to import a 90-day supply of medication from Canada. It also would require the federal government to develop a list of approved Canadian pharmacies to ensure consumer safety.
  • The Price Relief, Innovation and Competition for Essential Drugs Act (H.R. 5573/S. 3094) would shorten the exclusivity period before brand-name biological products could be offered as generics from 12 years to seven.

Unfortunately, movement on these bills is unlikely before the November election, and they would have to be reintroduced during the next Congress. But following these proposals through to enactment is vitally important to ensure the health and financial well-being of Americans.

Also of concern is the fact that there is little insight into the background and financial interests of the experts that the nation's largest pharmacy benefits management companies rely on to decide which drugs will be covered and which won't. AAFP guidelines on patient-centered formularies state, "Formulary changes must be made known to physicians and pharmacies prior to implementation."

As family physicians, we have the opportunity to advocate for our patients' expanded access to affordable medicines, and as an organization, we can amplify that sentiment throughout the house of medicine and to state and federal governments, as well as to corporations that control much of what impacts the patients we serve.

Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Wednesday Aug 17, 2016

AAFP Delivering on Maternity Care Training, Resources

In many rural communities, family physicians are the only maternity care providers. The AAFP provides training and support members need to play this vital role.[Read More]

Wednesday Aug 10, 2016

Men's Health Campaign Offers Opportunity to Tout Family Medicine

A report on men's health the AAFP released on Aug. 9 gave Academy leaders an opportunity to tell the media about the importance of having a family physician. Two AAFP officers conducted interviews with 39 media outlets in less than six hours.

[Read More]

Tuesday Aug 02, 2016

FMX Offers Something for Every Family Physician

The AAFP Family Medicine Experience (FMX) offers physicians the ability to earn an entire year's worth of CME, a jam-packed expo hall, and abundant social and networking opportunities.

[Read More]

Wednesday Jul 27, 2016

Bringing a Small Town Approach to Urban Practice

Whether urban or rural, every patient needs a primary care physician and open lines of communication with that physician.

[Read More]

Tuesday Jul 19, 2016

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]

Tuesday Jul 12, 2016

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.

Tuesday Jul 05, 2016

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.

Tuesday Jun 28, 2016

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.


Wednesday Jun 22, 2016

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.

Monday Jun 13, 2016

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.


Wednesday Jun 08, 2016

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.

Thursday May 26, 2016

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.

Friday May 20, 2016

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

Here 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.

Wednesday May 18, 2016

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.

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