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Thursday Jan 22, 2015

When Opportunities Arise, You Have to Jump

"OK, it's time to jump.

I have jumped into many challenges during my professional career -- from being an assistant residency director to practicing full-scope family medicine in the small town where I grew up to leadership positions in the AAFP -- but I had never done anything like this.

The U.S. Army recently invited Academy leaders to tour Fort Sam Houston and Brooke Army Medical Center in San Antonio, and I made the trip along with Andrew Lutzkanin, M.D., the resident member of the Board of Directors. The tour provided insights into the world of military medicine as we visited the facility's level-one trauma center, a burn treatment unit and the ICU.

We also toured the Center for the Intrepid, a world-class rehabilitation and prosthesis center. We heard inspiring stories from soldiers who had the will and personal stamina to rehabilitate themselves with the goal of returning to their units. The bond they feel with their comrades is truly hard to describe. In many ways, I thought of family physicians and the common bond we share to help our patients.

We also visited Camp Bullis, a military training site near San Antonio that includes a replica of a forward hospital medical treatment facility. The Army can construct one of these 84-bed facilities -- complete with operating rooms and ICUs -- in as little as three days. Medics and physicians train in this mock up "tent hospital" that could be run off of a generator.

But what about the jump? As part of our three-day visit to San Antonio, we also had the opportunity to make tandem parachute jumps with the elite Army Golden Knights Parachute Team. It was quite an adrenalin rush to leap out of an airplane at 14,000 feet and free fall for about a minute before feeling the chute open with a jolt and then simply floating. I had no experience with parachutes, but when given the chance, I jumped.


© 2014 Ashley Bentley/AAFP
Here I am meeting with our student leaders via Google Hangout. Our family medicine interest group network leaders work to help promote family medicine at campuses across the country.

With our hectic schedules, it's sometimes difficult for family physicians to make the most of every opportunity that comes along. But I also had been asked to meet -- online -- with new family medicine interest group (FMIG) leaders. Their orientation meeting at AAFP headquarters in Leawood, Kan., was taking place at the same time Andrew and I were attending the Army's All-American Bowl, which features 90 of the nation's best high-school football players.

When it comes to speaking with medical students, you find a way to make it happen. Although an Alamo Dome filled with thousands of cheering fans and a marching band might not seem like the ideal place to hold a video chat, Andrew and I managed to find a quiet stairwell in the stadium and met the students via Google Hangout.

Each FMIG leader asked me a question related to the big issues -- such as scope of practice, student debt and new models of care -- that are affecting their peers' specialty choices. I addressed these questions, and I pledged to them that the AAFP will continue to work on issues that matter to students because they matter to the future of our specialty. I also reinforced the importance of the work these students will do this year to increase student interest in family medicine by working to strengthen FMIGs at medical schools across the country.

Before we returned to the game, Andrew -- who is a former FMIG network leader himself -- shared his experience with the students and also discussed how our young leaders will work together in the year ahead. Kristina Zimmerman, the student member of the AAFP Board; Richard Bruno, M.D., M.P.H., resident chair of the AAFP National Conference of Family Medicine Residents and Medical Students; and Brian Blank, student chair of the conference, also participated in the call.

During our visit in San Antonio, we met with several military officers. At one meeting, I pointed out to Andrew there were five generals in the room discussing the challenges they face in military medicine. Family medicine, no doubt, faces its own challenges. But meeting with our student and resident leaders, and spending a few days with Andrew, confirmed what I already knew. Our future is in good hands.

Robert Wergin, M.D., is president of the AAFP.

Sunday Jan 18, 2015

Annual Exams? Tailor Visit Frequency to Patients' Needs

Ezekiel Emanuel, M.D., recently offered some interesting advice to the more than 2 million readers of The New York Times. Emanuel, who is an oncologist, said Americans should skip their "worthless" annual physicals.

This message -- conveyed via our nation's largest metro newspaper -- has caused a great deal of concern among primary care physicians, as well as confusion among our patients. As with so many things, significant aspects of this issue are overt, but many more are nuanced.  

One of the issues Emanuel raises is the increasing evidence that doing a complete annual physical exam does not improve morbidity and mortality. This correlation is actually fairly well proven. In fact, significant data, including the book Overdiagnosed: Making People Sick in the Pursuit of Health, by Dartmouth professor H. Gilbert Welch, M.D., M.P.H., suggest that reliance on routine complete physicals and indiscriminate use of various labs and screenings actually confer more harm than benefit. Such evidence is the basis of Choosing Wisely, the AAFP-supported initiative that identifies overused tests and procedures and encourages physicians and patients to discuss those options before incorporating them into a treatment plan. The Academy has identified more than a dozen tests and procedures that have questionable value for certain groups of patients.


© 2014 Sheri Porter/AAFP
Here I am listening to a patient during an office visit. A recent New York Times editorial against annual exams minimized the importance of the physician-patient relationship.

And although the AAFP does not have a guideline recommending annual exams, we certainly aren't recommending that patients stay home until they have an acute illness. The frequency of visits should be tailored to the patient, based on recommended screenings and conversations between the physician and patient.

It's worth noting that much of Emanuel's argument against annual exams is built on a 2012 Cochrane Collaboration review that considered only asymptomatic patients. According to the CDC, half of U.S. adults have at least one chronic condition, and 25 percent have two or more. Now ask yourself, "What percentage of my patient panel would I feel comfortable not seeing until they had an acute illness?"

Every patient deserves individualized care. Family physicians don't treat the "average" patient. We don't treat diseases, and we don't treat labs. We treat people and families. Accordingly, we have to take the evidence and put it into the context of that specific patient and his or her needs. This can include a patient who feels strongly that he or she should have a screening test or a complete physical even with the awareness that it may lead to a cascade of labs or evaluations that might not be otherwise indicated. Being patient-centered means having these conversations and supporting our patients in their choices even if they go against the evidence.

Emanuel briefly, and grudgingly, acknowledges that an annual exam provides an opportunity to "reaffirm the physician-patient relationship." But in dismissing the exam as having no benefit, he minimizes the importance of that ongoing physician-patient relationship. The annual exam is an opportunity for primary care physicians to strengthen this bond by speaking with our patients and getting to know them better. This helps us provide better care when they ultimately need it and enhances their trust in us.

Establishing this relationship early is critical to yielding the best dividends when people become ill. This trust and caring can only be created in the setting of an ongoing and growing relationship that requires face-to-face visits. The relationship also facilitates the primary care physician's role as a cost-effective coordinator of the patient's health services by making early detection of problems possible.

So what about frequency? Patients should be seen based on their age, their gender, their health care philosophy and needs, their problems and diseases, and multiple other factors. The ultimate goal should be to maintain and nurture the relationship. We should focus on appropriately addressing the patients' concerns, as well as on formulating an agenda based on our understanding of where that patient is in achieving health and minimizing disease. So, not only do we consider what an appropriate screening protocol is for each patient, we also address the all-important behavioral and lifestyle aspects that impact morbidity and mortality.  

What we need isn't reliance on an annual physical. Instead, we need to continue to push for changes in our health care system that ensure the care we deliver is focused on prevention and evidence-supported measures that are individualized for each patient. Family physicians are ideal for this role. We must continue to move health care delivery in this direction, and physician payment should reflect the value and power of this relationship and what we provide.  

Reid Blackwelder, M.D., is Board chair of the AAFP.

Tuesday Jan 13, 2015

Beating Burnout: Get Involved, Call for Change

During AAFP Assembly last fall in Washington, keynote speaker Dike Drummond, M.D., asked family physicians in a packed ballroom to raise their hands if they had experienced symptoms of burnout. Hundreds of hands -- far too many -- went up.

Although disheartening, the response certainly wasn't surprising. According to a 2013 Medscape survey, more than 40 percent of U.S. physicians reported experiencing at least one symptom of burnout (loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment). A 2012 study in JAMA Internal Medicine found that more than one-third of physicians were burned out.

More than 40 percent of U.S. physicians experience at least one symptom of burnout.

Some of the reasons for this crisis -- such as administrative burden, difficulty finding work-life balance, feeling undervalued, frustrations with referral networks, government regulations, and (of course) reimbursement issues -- are shared across different types of family medicine practices. Other factors may vary from practice to practice. For example, employed physicians like me may be struggling with the loss of control over our day-to-day practice. Meanwhile, some small and solo independent practice physicians may be having difficulty figuring out how to meet the latest regulatory requirements with limited staff resources.

In addition to these challenges, physicians face more and more pressure to meet or exceed patient expectations. Patients want to be heard and family physicians want to listen, but in our stressed work environments, we often don't have enough time -- more than the typical 15 minutes – or adequate resources to meet the needs of our complex patients. I've had patients thank me for listening and for being thorough, but how often do we hear that? Based on the current environment, I would say not nearly enough.

A growing number of my colleagues seem discouraged, and it saddens me to hear family physicians say things like, "I don't know if I can do this anymore." Many physicians are responding to burnout by limiting their scope of practice, reducing their work hours, or leaving the practice of medicine altogether. According to a 2012 Urban Institute data analysis 30 percent of primary care physicians ages 35-49 planned to leave their practices within five years. The rate was more than 50 percent among physicians 50 and older. Those numbers should alarm anyone aware of the already glaring shortage of primary care physicians.

Clearly, this is becoming a crucial public health issue. The drivers of burnout are different for each individual physician, but the impact of physician burnout is affecting health and health care delivery for every consumer in the country. If we don't address these drivers and take care of the physicians we have, there will not be enough of us left to care for the health of our nation.

An article published in the November/December issue of Annals of Family Medicine suggested that the triple aim framework -- which calls for better care, an enhanced patient experience and lower health care costs -- needs the additional aim of improving the work life of physicians and our staff members.

So what do we do about it? Individual physicians may be able to help themselves by better managing their stress or by seeking support. But what about change on a broader scale?

I've had my own experience with burnout. When I felt that I needed to get off the hamster wheel, one of the things that helped me refocus was getting involved and advocating for change. I've been involved with the Academy for years through the Congress of Delegates, commission work and the National Conference of Special Constituencies. But the No. 1 issue that prompted me to run for the Academy's Board of Directors last year was burnout. I don't know all the answers to solving burnout, but I know it must be addressed.

The Academy adopted a position paper on the issue last year. And it's worth noting that the AAFP last year created 10 member interest groups to provide a forum for members with shared professional interests. The MIGs provide new outlets for members to make their voices heard.

The AAFP also is working to address many of the drivers that lead to burnout, including payment reform and administrative burdens related to electronic health records.

Finally, we need to remove the stigma from burnout. Physician who need help shouldn't be afraid to ask for it. If you feel burned out, know that this is not a weakness or a character flaw, and you are not alone.

You can help yourself with resources that support personal resilience and time management skills, but you also can tackle the problem on a broader scale by working within your organization to address the drivers of burnout in your practice. And know that the AAFP will continue to work to alleviate regulatory burdens and other factors that contribute to burnout.

Lynne Lillie, M.D., is a member of the AAFP Board of Directors.

Thursday Jan 01, 2015

New Year Brings New Life, New Hope

As the year winds down, the holidays give us an opportunity to share time with our family and friends. It is a time when the young create new memories and the old share theirs.

One of my most memorable holidays as a family physician happened just a few years ago. Brenda and I were preparing for New Year's Eve -- packing things to take to a friend’s house to celebrate the new year with friends and family -- when I got a call from the hospital. One of my maternity patients had arrived and was contracting. I admitted her and told the nurse I would stop by and check on her shortly. On my way to the party, I stopped at the hospital and confirmed my patient was in labor.

© 2014 Sheri Porter/AAFP
Here I am checking on a new patient in the hospital. Maternity care can make things challenging during the holiday season.

I spent the early part of the evening with good friends and family and limited my celebration to sodas and coffee. I received hourly updates about my patient, and by 10:30 p.m., her labor had progressed enough that I excused myself from the gathering and made arrangements for my brother to take Brenda home.

I went to the hospital and sat with my patient and her husband, monitoring her labor’s progress. At 11:30, it was time to start pushing. She did well, and around 12:30 a.m. -- at the start of a new year -- we celebrated the birth of their new son.

Both parents were elated, although the father did ask if we could have "rushed this along a little" so the tax deduction that comes with a new child could have been applied to the year that had just ended. I told him I didn’t have much to do with the timing, and he agreed. The next day, however, the local newspaper took a photograph of the county's first baby of the year, and the family received many gift certificates and congratulations from businesses in the community.

I headed home around 1:30 a.m. Brenda got up, and we opened a bottle of champagne and celebrated the new year, a healthy new baby boy, and a new patient in my practice.

That is family medicine. Sometimes our families have to make sacrifices, but it is part of who we are. And our communities are stronger for it. This was a memorable New Year's for me and this family. I'd like to hear the story of your most memorable holiday spent with patients in the comments field below.

Happy New Year from the AAFP. Take a look at this video to see some of what we accomplished in 2014.  And here's to a prosperous 2015.

Robert Wergin, M.D., is president of the AAFP.

Tuesday Dec 23, 2014

Digital Media: It's Here to Stay, and That's a Good Thing

When I started medical school almost four years ago, I still used paper notes. I printed out lecture slides and scribbled my notes during live lectures. Oftentimes, I had to go back to the recorded, archived lecture to fill in any notes I missed. By the end of the year, my bookshelves were buckling under thick binders full of lecture notes -- notes that I could not readily refer back to because it was too time-consuming to flip through thousands of pages to locate one specific detail. It was faster and easier to search for the information electronically.

This, combined with my desire to be more environmentally conscientious, compelled me to go paperless during my second year in medical school. I downloaded lectures on my laptop and organized them for easy retrieval. I could type my notes more quickly than I could write them, and I could more easily link those notes to specific parts of the lecture. While studying, I used tools on my computer to find keywords and topics within seconds rather than wasting hours leafing through shelves of paper. After making the switch to electronic media, I never looked back.

Not only do electronic files take up less space, but electronic media can be read virtually anywhere and also can be listened to in the car or on the subway.

Now that my medical education has moved beyond the lecture hall into clinics and hospitals where hypothetical scenarios are replaced with real-time patient interactions, easily accessible information is even more important. I cannot bring bookshelves full of notes and clinical pearls from home. And only so much information can fit into a small, white coat-sized notebook. Plus, there's still the issue of quick retrieval. Fortunately, we live in an era when electronic media are readily available. Unlike generations of physicians before me, I only need one information retrieval tool in my white coat pocket -- my smartphone -- and I carry it now more than ever.

From my smartphone, I have quick, easy and unlimited access to the most relevant and up-to-date information I need to verify a diagnosis and/or treatment plan, as well as tools to help me educate patients. Among the electronic resources I use every day are the AAFP website; my medical school library's databases of DynaMed, PubMed and New England Journal of Medicine; and apps such as Epocrates, Micromedex, UpToDate, the American Heart Association's Cardiovascular Risk Calculator, Evernote, and the AAFP journals American Family Physician and Family Practice Management. I can use Dropbox to store my notes and important documents on the Web for retrieval on any of my electronic devices -- my tablet, smartphone or computer.

Some may argue that use of technology in the exam room diminishes meaningful patient interactions and harms the doctor-patient relationship. This has not been my experience. In fact, I would argue that proper use of electronics during a patient visit actually strengthens the interaction and engages patients more fully. For example:

  • There are many instances where the computer screen can be shown to patients, such as when reviewing blood work results, growth or vitals. These numbers and trends can, and should, be shared and discussed with patients.
  • Using electronic health records, various health trends can often be shown on graphs so patients can see how they are doing over time.
  • When documenting/charting patient information, we can let patients see what we are typing and verify with them that the information is correct.
  • Photos can be helpful when reviewing items such as rashes, anatomy or plants they are allergic to, etc. We also can clarify which medications a patient is taking by showing them pictures of the medication on the Epocrates app.
  • And of course, we can use our electronic devices to quickly find an answer to a patient's question when we don't know the answer. 

I have done all of these things, and patients have said that it has made many health topics easier for them to understand and has helped them feel more like a part of their health care team. Many patients appreciate the visuals, especially when they can access them again later at home. 

During one patient interaction, I showed a patient two images of the English plantain, which was the source of his allergy symptoms. One image was a pencil drawing in a book from 1946. The second was a color photograph from Google Images. The patient found the photo more helpful and was happy he would be able to find it later if he forgot what it looked like.

Another reason it is important for physicians to become familiar and comfortable with electronic resources is that our patients are using them. Patients are trying to educate themselves by using the Internet and apps to look up health information and symptoms, track their health and fitness activities, etc. We need to keep up. We need to know what tools they are using and where they are getting their information so that we can guide them to valid, useful facts. 

Are they using Wikipedia, WebMD, Google Scholar, MyFitnessPal, Apple Health, something else? Why are they using certain resources? These are conversations that are important to have. Many patients want to be more engaged in their health. They want to use electronic health tools to access their personal health information through an online portal, track health and fitness goals, and transmit their health data -- such as daily weights, blood pressures, glucose readings -- directly to their medical homes. As physicians, we have to be ready to navigate these new technologies and make them work to our patients' benefit.

Technology will keep moving forward. As it evolves, we need to be sure our ability to use it effectively with our patients does, too.

Kristina Zimmerman is the student member of the AAFP Board of Directors.

Wednesday Dec 17, 2014

Medicaid Cuts Threaten Primary Care Practices, Access to Care

The year is ending with bad news regarding physician payment, and pending cuts may affect patients' access to care.

Section 1202 of the Patient Protection and Affordable Care Act (ACA) increased Medicaid payments for specified primary care services to Medicare payment levels for certain primary care physicians in 2013 and 2014. The provision was designed to help improve access for the significant and increasing number of Americans who are covered by Medicaid, and states received an estimated $12 billion to bolster their Medicaid primary care delivery systems during those two years. 

© 2014 Sheri Porter/AAFP

Here I am examining a young patient. Congress' recent failure to extend Medicaid parity payments for primary care will hurt primary care practices and hinder our ability to care for Medicaid patients.

More than half the states have agreed to expand their Medicaid programs, and nationally, Medicaid enrollment has increased by 7.5 million people since the fall of 2013. But with payment rates for Medicaid scheduled to revert to 2012 levels on Jan. 1, will the newly insured still be able to find care?

When the American College of Physicians surveyed its members earlier this year, 40 percent of respondents said they would accept fewer Medicaid patients in 2015 if the parity payments stopped, and 6 percent said they would stop participating in Medicaid completely if that scenario were to occur.

The reaction isn't hard to understand. On average, Medicaid pays physicians less than 60 percent of what Medicare pays for primary care services, and that gap discourages many primary care physicians from treating Medicaid patients. In fact, when the ACA became law in 2010, 36 percent of family physicians surveyed by the AAFP were not accepting new Medicaid patients because of low reimbursement rates, and 20 percent of our members surveyed were not seeing any Medicaid patients at that time.

Unfortunately, with only a two-year period in which outcomes can be considered -- combined with delays in the implementation process -- it is difficult to judge how much of an impact the parity payments made on access. Physicians were asked to expand access to their practices while facing the stark reality that they might have to either accept reduced payment for treating those patients or turn their backs on those new patients after a relatively short time. Sadly, that choice will soon be at hand unless the 114th Congress acts when it convenes in January.

The good news -- for some -- is that more than a dozen states have indicated they will maintain Medicaid parity payments even without federal funds. From these states, we may be able to better judge how physician payment affects patient access and outcomes. A much larger number of states, however, have said they will not extend Medicaid parity.

The pending payment cuts will vary from state to state, but on average, Medicaid payment for primary care will fall 42.8 percent. The largest cut would be in Rhode Island, with a 67 percent drop, while physicians in California, New York, New Jersey, Florida and Pennsylvania would all see reductions of more than 50 percent.

Unfortunately, many states will have physicians who are unable to keep their doors open to Medicaid patients because of low reimbursement rates. This will once again force patients to get the wrong care in the wrong place at the wrong time, utilizing emergency rooms for both acute and chronic care issues. The goal of our advocacy efforts on this issue has been to ensure that patients get the right care, in the right place, at the right time, and from the right person. That means ensuring access to primary care, where health issues can be identified and treated before they progress too far down the clinical pathway.

Will the end of parity payments affect the number of Medicaid patients in your practice?

Reid Blackwelder, M.D., is Board chair of the AAFP.

Friday Dec 05, 2014

Penny Wise, Pound Foolish: We Can't Afford to Cut Our Investment in Teaching Health Centers

Not that long ago, Pardee Hospital in Hendersonville, N.C., was considering dropping its family medicine residency. Although such a move would have saved the not-for-profit facility roughly $1 million a year, it would have been a severe blow to primary care and the primary care workforce in the area.

Instead, Blue Ridge Community Health Center, a federally qualified health center (FQHC), joined a collaboration last year that already included Pardee and the Mountain Area Health Education Center of Asheville. The move not only preserved a valuable training program, it also gave residents exposure to a second outpatient setting -- an integrated FQHC that offers dental, behavioral health, radiographic and laboratory services; an on-site pharmacy; and interpretive services for a patient panel that includes a large Spanish-speaking population.

Here I am touring the Hendersonville Family Medicine Residency with program director Geoffrey Jones, M.D., (left) and faculty member Magdalena Hayes, M.D. I visited the program Dec. 3 in Hendersonville, N.C.

The changes didn't stop there. After Pardee ceded control of the residency to the FQHC, the program increased its number of residents from three per class to four with funding from the Teaching Health Center Graduate Medical Education (THCGME) program.

That five-year, $230 million initiative provides funds directly to community-based teaching sites with a goal of producing more primary care physicians. One hundred primary care residents have graduated from teaching health centers in the first three years of the program's existence. That's noteworthy because we know that residents who train in underserved areas are more likely to practice in those settings.

I toured the Hendersonville residency Dec. 3 and saw first-hand what a teaching health center is about. I came away impressed by the residents, the faculty and the facilities.

Unfortunately, the Hendersonville program -- and other teaching health centers in 24 states -- face uncertain futures because of funding. Barring a reauthorization by Congress, funding for the THCGME program will end in 2015. That means first-year residents took a giant leap of faith when they entered these programs this summer. Still, residents I talked with this week were focused on their training and optimistic that a solution will be found.

The AAFP is doing its part. The Academy and more than 100 other medical and social service organizations sent a letter to congressional leaders last month, urging that funding for teaching health centers and other important primary care programs be extended.

The second issue facing teaching health centers is that the Health Resources and Services Administration (HRSA) recently announced that it plans to reduce payments for each resident during the 2015-16 school year. The AAFP has responded with letters to HRSA and Congress urging that full funding be restored.

During a recent trip to Capitol Hill, Academy leaders discussed both the need to restore funding for the 2015-16 academic year and the need to extend funding for the program beyond 2015 with congressional leaders and staff. At a time when our nation already faces a dire shortage of primary care physicians, we cannot afford to abandon a program that shows great promise for producing more family physicians.

Robert Wergin, M.D., is president of the AAFP.

Wednesday Dec 03, 2014

Long-distance Support: Thoughts on Telemedicine at 2:30 a.m.

"You may want to use propofol," said a deep, gravelly voice that seemed to come out of nowhere.

I was caring for an older woman, and she was doing poorly. It was 2:30 a.m., the witching hour in medicine, and it looked like we might have to put her on a ventilator. I looked up at the two female nurses who were the extent of the medical team. The anonymous suggestion was welcome, but I had no idea where it had come from. It clearly was not either nurse, and I was fairly certain it was not the voice of God or an auditory hallucination.   

"She appears to be decompensating," the voice said.

In rural areas -- like my practice location in Valdez, Alaska -- telemedicine holds potential to help primary care physicians and our patients.

Now, I may not be at my best at 2:30 a.m., but I was pretty sure that I was awake.

"You've given Lasix," the voice continued. "Good. Tell you what -- I'll put in orders for propofol while you're getting ready."  

Despite my confusion, this was good news. We have an electronic health record system that requires us to type in orders before we can get medications, and I had my hands full at the moment.

That's when I noticed the cart in the corner with a camera tracking the action. We had been talking about signing up for Tele-ICU with Providence Anchorage Medical Center, although I had my doubts about its utility. There is no substitute for having a well-trained physician capable of stabilizing critically ill patients in rural communities, but I was interested in trying the system out. I just hadn't realized it was ready to go.

One of the challenges in rural medicine is the feeling of isolation during an emergency and the heightened sense of responsibility that comes with it. This likely is one of the biggest reasons why rural physicians burn out and leave. Sometimes, all it takes is one bad outcome, especially when the physician -- or the community -- thinks the patient could have been saved.

There have been many patients in Valdez who have required all hands on deck, but there is a cost in terms of lost sleep and function when the medical staff consists of only three people. It sure is nice, though, to have another doctor to talk with. Although I have only used Tele-ICU once so far, I have often called a doctor covering the ICU or ER in Anchorage -- or even a colleague in the lower 48 states -- just to discuss a difficult case. I doubt the doctors at the other end know how important those connections have been for me.    

Telehealth is not new technology, although historically, it has been a solution in search of a problem. I have been angered at the money spent on telemedicine carts that could have been better invested in training new rural physicians or increasing physician payment to improve retention. These types of investments improve the rural safety net more than flashy engineering marvels that do not take into account how or why patients are actually seen.

My experience with the Tele-ICU was different. One of the most important aspects of modern medicine is the team approach and the opportunity it offers to discuss how to best to serve a patient. Rural physicians often have no access to the collaboration that occurs in metropolitan areas. So I think one problem telemedicine could solve is not so much how health care is delivered, but rather, how to collaborate at a distance through systems that support the local providers. These include broadband Internet, dedicated specialists who get paid for their work, and an attitude that the best provision of care happens locally.

Telemedicine has many potential benefits but also a number of pitfalls. For critical-access hospitals facing shrinking patient volumes, there is the potential for keeping more patients, rather than transporting them. This may require additional procedural training of rural health care professionals. If medical transportation rates decreased, this would result in significant health care savings.   

Telemedicine has the potential to improve access to specialty care, but how will this affect rural practices? With proliferation of direct-to-patient sites, there may be decreased viability of the local system, and many rural physician practices are struggling as it is. Regulation currently prevents the establishment of national telehealth systems, although there is significant pressure to relax these rules. My fear is that direct-to-patient telehealth could unravel the rural safety net. Telehealth works best when it supports the local physician because there is no substitute for competent hands-on care.    

Telemedicine also could allow specialists to narrow their field of study while empowering family physicians. I have a dream of sitting with my patient in front of a screen discussing her glomerulonephritis with a nephrologist who spends his day performing glomerulonephritis consults via telehealth. For this to work, a system must be in place that allows payment of the specialist and an adequate originating fee for the family physician.

It is too early to see how this will play out, but we are fast approaching a time of rapid change. From a rural perspective, I can see the allure of having another physician at your shoulder in the middle of the night when the patient is crashing. I might have done things a little differently without Tele-ICU and a virtual intensivist, but it was a good experience, and the patient did well.

John Cullen, M.D., is a member of the AAFP Board of Directors.

Wednesday Nov 26, 2014

A Day On the Hill: Meaningful Use, Medicaid, Medicare and More

There is a long list of time-sensitive issues facing primary care -- meaningful use, impending Medicaid cuts, the Medicare sustainable growth rate (SGR) formula, and funding for graduate medical education, just to name a few -- and on Nov. 20, AAFP officers had a chance to discuss all of these concerns (and more) with legislators, congressional staff and representatives from federal agencies.

Here's an overview of the whirlwind day I spent on Capitol Hill with AAFP President Robert Wergin, M.D.; Board Chair Reid Blackwelder, M.D.; and Academy staff.

ONC

In a meeting with Karen DeSalvo, M.D., M.P.H., the National Coordinator for Health Information Technology, and other senior leaders at the Office of the National Coordinator (ONC), we addressed the fact that the cost of complying with the meaningful use program presents a huge challenge for many family physicians. Specifically, we laid out three of the biggest obstacles family physicians face: 

  • complying with meaningful use stage two and the almost impossible task presented by stage three;
  • the anticompetitive behavior of certain electronic health records vendors, who have established so-called "vendor lock" in many communities around the nation; and
  • the overall lack of accountability among vendors marketing these products.  

The last point is a particularly critical element of our advocacy efforts. Barring a hardship exception, physicians who have not yet attested to meaningful use will see a 1 percent Medicare payment reduction beginning Jan. 1. Those penalties can climb to as much as 5 percent over time.

© 2014 Michael Laff/AAFP
AAFP President Robert Wergin, M.D., (far left), Board Chair Reid Blackwelder, M.D., (second from right) and I meet with Sen. Lamar Alexander (R-Tenn.). AAFP officers and staff met with congressional staff, legislators and representatives from federal agencies Nov. 20 in Washington.

It's a problem the AMA House of Delegates tackled during its interim meeting earlier this month, when the AAFP delegation backed a resolution directing the AMA to urge CMS to halt penalties related to meaningful use. This same point was emphasized during our meeting with ONC representatives. Why do physicians face penalties for noncompliance, but vendors are not held financially accountable for the performance of their products or their service?

SGR
During our time on the Hill, AAFP officers and staff met with legislators and congressional staff from both chambers and both parties. In these meetings, we discussed a variety of topics, including the importance of repealing the SGR and replacing it with value-based payment, preventing cuts in Medicaid, and renewing funding for teaching health centers.

Physicians face a 21 percent cut in Medicare payment beginning April 1 unless Congress intervenes. Legislators have patched the SGR issue 17 times during the past 12 years at a cost of more than $169 billion. Bicameral, bipartisan legislation introduced earlier this year would repeal the SGR and replace it with new methods of value-based payment, but to date, Congress has not passed the bill, in part because legislators have not agreed on how to offset the cost of the fix.

Overall, the mood among lawmakers and staff was that enacting a permanent SGR fix would be challenging during the lame-duck session but that Congress could summon the will to enact the repeal-and-replace legislation by the end of March 2015. You can help by telling your legislators to support the bipartisan legislation.

Medicaid Cuts
For primary care physicians, cuts to Medicaid payments are even more imminent. Section 1202 of the Patient Protection and Affordable Care Act (ACA) required state Medicaid programs to raise payments for certain primary care services to Medicare levels in 2013 and 2014, but barring an extension, states will be free to drop Medicaid payments back to 2012 levels on Jan. 1.

We emphasized that these cuts -- which vary by state but average more than 40 percent -- represent a severe disruption to the business of practicing medicine and pose a threat to patients' access to care. In fact, total health care spending for Medicaid patients could increase if they can't access their family physician and instead turn to emergency departments.

The Academy supports a bill that would require Medicaid programs to extend the parity payments for primary care for two years. This would not only bolster primary care practices and ensure access to care, it would give us more time to show how important it is for patients to have a regular source of comprehensive care. There is long-term value in providing preventive care, and health care costs can be reduced when chronic conditions are controlled.

Here's another opportunity for you to help. Voice your support for preventing cuts to Medicaid by contacting your legislators through the Academy's Speak Out tool.

Teaching Health Centers
Teaching health centers face two obstacles. First, federal funding for the Teaching Health Center Graduate Medical Education program established by the ACA will end after the 2015 fiscal year absent congressional intervention. The AAFP is one of more than 100 organizations that recently sent a letter to congressional leaders about extending support for teaching health centers.

Additionally, the Health Resources and Services Administration (HRSA) announced this month that awards for teaching health centers will be reduced from $150,000 to $70,000 per resident for the 2015-2016 academic year. The Academy wrote to HRSA officials about this issue last week, and we drove the point home again in our meetings with congressional staff and legislators.

Residents who train in these programs are more likely to practice in underserved or rural areas when they complete their training. Not only does the funding need to be continued beyond its scheduled expiration on Sept. 30, it should be expanded.

Other Agency Meetings
We also met with family physician and AAFP member Joe Selby, M.D., executive director of the Patient Centered Outcomes Research Institute (PCORI). PCORI requested the meeting, during which we discussed our practice-based research networks and the work of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

Finally, in a meeting with Rajiv Jain, M.D., assistant deputy undersecretary of health for patient care services at the Department of Veterans Affairs (VA), Wergin discussed our members' ability and willingness to help care for veterans and the need to break down barriers to doing so. Wergin also expressed concern that some family physician practices may struggle to serve veterans if the VA does not pay at least Medicare-level rates.

Wanda Filer, M.D., M.B.A., is president-elect of the AAFP.

Monday Nov 24, 2014

The Center for the History of Family Medicine: At First, I Didn't Care Either. But Now I Get It

Probably like many of you, I don't think about history much. Between the responsibilities of my practice, my family and my service to the Academy and its members, I just don't have a lot of time to study the past.

So when I was appointed recently as the Academy's representative to the Board of Curators of the Center for the History of Family Medicine, I did not know what to expect. As the principal resource center for the collection of the specialty's history, the center struck me as a dull abstraction at best and at worst, a waste of time, space and money. With all of the many issues and challenges facing our specialty, it just didn't seem important to me.

Photo courtesy the Center for the History of Family Medicine
Arthur "Lud" Ludwick Jr., M.D., won the Silver Star while serving as a physician on the frontline during World War II. Ludwick is one of the many physicians whose stories are told through the Center for the History of Family Medicine.

But then I came to the center and saw it for myself. And now I get it.

The center is much more than just a place where old papers are stored. It is the collective memory of family medicine. 

Told through its many documents, photographs, videos and artifacts, the story of our specialty is one of hardship, struggle and, ultimately, triumph. It begins in 1947, when a group of general practitioners -- facing the almost certain extinction of general practice -- formed the organization that we know today as the AAFP. It's a story worth remembering as we venture into the future and turn our sights to addressing the challenges and opportunities ahead through the Family Medicine for America's Health project.

But fundamentally, the story of family medicine is a story about people. It's a patchwork of the intensely personal stories of the many GPs and family docs who, throughout the history of our country, have served on the frontline of American medicine, caring for patients in wartime and in peacetime, and from birth to death.

Take for example, the story of  Arthur "Lud" Ludwick Jr., M.D., who won the Silver Star for "gallantry in action" while serving as a GP on the Italian frontline during World War II and then went on to have a long and distinguished career practicing in Wenatchee, Wash.

Or the story of Olin Elliott, M.D., of Des Moines, Iowa. Described by one colleague as "a delightful, well-rounded doctor, loved and respected by patients, colleagues, family and acquaintances alike," Elliott was renowned for his compassion and dedication to his craft. In 1957, when his wife was diagnosed with amyotrophic lateral sclerosis, he became her primary caretaker while still continuing his medical practice, providing her with medical treatment until her death. In later years, Elliott volunteered at a clinic for the homeless in Des Moines, and even after being diagnosed with pancreatic cancer in 1981, he continued to care for his patients up until the day of his death the following year. 

Or, more recently, the story of Regina Benjamin, M.D., M.B.A., a family physician from the small fishing village of Bayou La Batre, Ala., who went on to become the 18th surgeon general of the United States.    

All of their stories -- and the stories of many others -- are told through the center's collections.

And there are practical applications for the center's holdings, too. An important educational resource for the specialty, each year, the center sponsors both a research fellowship and an internship program. The information contained in the center's collections helps us understand -- and hopefully avoid -- the mistakes of the past, thus saving us time and money that might otherwise have been spent trying to reinvent the wheel. It also plays an important role in advancing our specialty by supporting and enhancing public relations and marketing efforts through interesting and informative exhibits.

In short, the center allows us to make a direct and vital connection between family medicine's distinguished past and its exciting future.

So now I get it. And I hope that you will have the opportunity one day to visit the center  -- either in person at the Academy's Leawood, Kan., headquarters or through its website -- and discover this for yourself.

After all, in the words of author and historian Theodore Draper, "If history can teach us nothing, we have nothing that can teach us."

Robert Lee, M.D., is a member of the AAFP Board of Directors.

Wednesday Nov 19, 2014

Primary Care: Defending What it Means and What It's Worth

Medicaid cuts are coming.

Section 1202 of the Patient Protection and Affordable Care Act increased Medicaid payments to Medicare levels for certain primary care services in 2013 and 2014. But unless Congress acts during the lame-duck session Medicaid parity payments for primary care physicians will stop, and payments will return to 2012 levels on Jan. 1.

This issue was debated in depth during the recent AMA Interim Meeting in Dallas. This was an important discussion because there is disagreement within the AMA about what constitutes primary care. In fact, many of our subspecialist colleagues claim that they provide primary care -- and therefore should qualify for parity payments -- because of their involvement in the management of certain diseases such as Parkinson's, diabetes and cancer. 

Jerry Abraham, M.D., M.P.H., of Los Angeles, and Joanna Bisgrove, M.D., of Fitchburg, Wis., represent the AAFP at the AMA Interim Meeting. Abraham, a first-year resident at the University of Southern California, was elected an alternate delegate to the AMA's Resident Fellow Section. Bisgrove is the AAFP delegate to the AMA Young Physicians Section.

The globally accepted meaning of primary care, however, comes from Barbara Starfield, M.D., M.P.H., who defined it as "first contact, continuous, comprehensive, and coordinated care provided to populations undifferentiated by gender, disease, or organ system." From the AAFP perspective, only family medicine, general pediatrics and general internal medicine are the specialties that train physicians to deliver true primary care. Other specialty physicians might from time to time deliver certain services described as primary care, but they are not trained to deliver comprehensive primary care.

Although some subspecialty groups at the meeting attempted to change AMA policy regarding who should get Medicaid parity payments -- if they, in fact, continue -- the Academy's delegation was able to prevent action by the AMA House of Delegates that would have expanded the Medicaid parity payments well beyond their initial focus on primary care physicians only. This means that the AMA's support for proposed legislation that would extend parity payments for two more years will continue.

Next to repeal of the sustainable growth rate (SGR) formula, this is the most crucial piece of health care legislation the AAFP is focused on for passage during the lame-duck session. The continued cohesive voice of organized medicine on this issue represents an important success.

In addition to Medicaid parity, the AAFP's delegation also testified on other important issues, such as the significant threat to our patients and our members from the increasingly troubling network narrowing that we see impacting practices in more and more states. The AMA recognized that this is a significant challenge, and resolutions were moved forward to address this directly.

It's worth noting that the AAFP, the AMA and more than 100 other organizations recently sent a letter to the National Association of Insurance Commissioners voicing support for model legislation that would serve as a template for revising state provider network adequacy standards.

With strong AAFP support, AMA delegates also passed a resolution asking CMS to halt penalties related to meaningful use (free registration required) and look for ways to continue to incentivize use of electronic health records.

In addition, recognition of the changing landscape in terms of telemedicine was also a focus during the meeting. Related resolutions moving forward are consistent with ones we have acted on in the AAFP's Congress of Delegates.

The AAFP has one of the larger specialty society delegations to the AMA. Moreover, many of the 115,900 Academy members our delegation represents are themselves AMA members. These are dedicated family physicians who advocate for their patients and their communities through involvement with their state medical societies. Having more family physicians from different backgrounds at the AMA creates exciting opportunities for us as we continue to try to find a way to move the house of medicine in a coordinated fashion to recognize and value family medicine and primary care.

      Over the years, our delegation has gained a stronger presence within the AMA as we continue to work to inform our discussions and share AMA policies. This is helped by the fact that there are five AAFP members who are on the AMA Board of Trustees:

  • Past Chair David Barbe, M.D., M.H.A., of Mountain Grove, Mo.;
  • Chair-elect Stephen Permut, M.D., J.D., of Wilmington, Del.;
  • Gerry Harmon, M.D., of Pawleys Island, S.C.;
  • William Kobler, M.D., of Rockford, Ill.; and
  • Albert Osbahr III, M.D., of Hickory, N.C.

The Academy greatly values the relationship we have developed with these leaders of the AMA, and we look forward to more opportunities to work together. Your delegation is quite well respected within the house of medicine and is led by Joseph Zebley, M.D., of Baltimore, and co-chair Daniel Heinemann, M.D., of Sioux Falls, S.D.

Recently, we have been blessed by an influx of dynamic family physicians who are early in their careers. This year, our delegation included Uniformed Services chapter member Janet West, M.D., of Pensacola, Fla.; Aaron George, D.O., a third-year resident at the Duke Family Medicine Residency in Durham, N.C., and Ajoy Kumar, M.D., of St. Petersburg, Fla. In fact, we had many people from other delegations praise our organization for being able to bring younger voices to the table.

An impressive accomplishment for our delegation during this meeting was that Jerry Abraham, M.D., M.P.H., of Los Angeles, one of our resident members, was elected as an alternate delegate to the AMA's Resident Fellow Section. A first-year resident at the University of Southern California, Abraham will be sitting in the House of Delegates this summer during the AMA's Annual Meeting. This speaks well to his leadership skills not only within the AAFP but also the AMA.

The Academy continues to work for our members and our patients in every venue we can. The AMA meeting is certainly a different body and culture from our AAFP Congress of Delegates; however, the issues discussed at AMA directly impact our patients, our communities and our members. Thanks to all of the family physicians who are involved in the AMA. This is another important avenue for advocacy, and we appreciate your efforts. As they say at the AMA, together we are stronger!

Reid Blackwelder, M.D.is Board chair of the AAFP.

Friday Nov 14, 2014

Exposing Students to Rural Health Key to Producing Rural Docs

Less than half an hour from the U.S.-Mexico border, the tiny town of Patagonia, Ariz., lies nestled between a sprawling state park and a massive national forest. Although I was born and raised in Tucson and started my practice there, I came to Patagonia in the 1990s when I was offered the opportunity to work at the small town's federally qualified health center.

Why would a big-city physician leave home to come to a town that was literally 1,000 times smaller?

I liked the idea of practicing full-scope family medicine. I liked the challenge of doing more with fewer resources, putting pressure on myself to become a better clinician. And I wanted the chance to develop true, close relationships with my patients. I got all that in Patagonia because in a town of less than 1,000 people, it didn't take long to become a vital part of the community. I stayed for 13 years.

Photo courtesy Chandra Tontsch
University of Arizona College of Medicine student Chandra Tontsch, right, completed a family medicine rotation in Lakeside, Ariz., with preceptor Elizabeth Bierer, M.D. The college places medical students in rural settings in hopes that they will later choose to practice in underserved areas. 

In 2006, the University of Arizona recruited me to teach rural health in Tucson. Earlier this year, I took on the role of director of the university's Rural Health Professions Program. Although I am no longer providing rural health care as an individual physician, my goal is to show medical students the rewards this area of medicine offers and hopefully draw more of them to this important practice setting.

More than 20 percent of the U.S. population lives in rural areas, but rural physicians account for only about 10 percent of the physician workforce. Compounding the problem is the fact that many of the physicians practicing in these areas are approaching retirement and not enough young physicians are stepping up to take their place. In fact, less than 5 percent of physicians who graduated from medical schools from 2006-08 went on to practice in rural areas.

At the state level, as much as one-third of Arizona's population lives in primary care health professional shortage areas. The state has more than 140 primary care shortage areas (including some inner-city areas), and it has been estimated that Arizona would need more than 300 additional primary care physicians to address the problem.

In our Rural Health Professions Program, 22 students are selected at the end of their first year and placed in rural settings, primarily working with family physicians. During their third year, students are required to complete a clinical rotation in a rural setting in family medicine, internal medicine, pediatrics, obstetrics, or surgery. (Many do more than one rotation in rural areas.) Finally, during their fourth year, students are encouraged to go back to rural settings for a four-week preceptorship, and roughly three-fourths of them do. It's worth noting that the university's Phoenix campus runs its own similar program.

One of the challenges in my new role will be tracking outcomes to see how many of our graduates are practicing in rural areas. In the past few years, we have added a number of new physician preceptors who participated in the Rural Health Professions Program as students. Having been through the program, they can provide good mentorship to new students and encourage them to stay on this path.

Students who have questions about rural health may be interested in an American Medical Student Association webinar that (then) AAFP President-elect Robert Wergin, M.D., of Milford, Neb., participated in last month during National Primary Care Week.

Finally, the AAFP created member interest groups earlier this year as a forum for family physicians to share their mutual interests and address common concerns. One of the six groups that has already been established focuses on rural health. You can learn more on the AAFP website.

Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.

Tuesday Nov 11, 2014

So You've Achieved PCMH Recognition. Now What?

Last year, my health care system -- which has seven hospitals in the Kansas City, Mo., metro area -- received National Committee for Quality Assurance (NCQA) Level 3 patient-centered medical home (PCMH) recognition for 12 of its primary care locations. We set an ambitious goal and realized it within two years.

Now, having met all the NCQA's PCMH criteria, what happens next? Is that the end of the story?

  Photo by Dean Shepard

 I talked with more than 200 of my health system's physicians during our patient-centered medical home summit. Twelve of our 14 primary care locations have earned National Committee for Quality Assurance (NCQA) Level 3 PCMH recognition.

For us, it's not. The two remaining primary care locations in our system are now starting the PCMH process. For the other 12, we're continuing to transform our practices to enhance care. One example of that ongoing transformation is the new electronic health records system being implemented across all our locations. The change will enhance our ability to manage population health because an upgraded registry function will allow us to better track and manage patients with chronic diseases such as diabetes.

Before we began our path to PCMH, we didn't have a registry at all. We didn't know how many patients with diabetes we had, let alone how many needed additional care. Now we can be proactive, rather than reactive, and we are establishing protocols for reaching out to patients when appropriate.

Team-based care will help us get this done. A year ago, care coordinators didn't exist in our health system, but now most of our primary care locations have one, and we are in the process of hiring more. This is expected to improve care transitions.

To implement this kind of sweeping change, buy-in from physicians and staff is extremely important. I've been encouraged to see that our system's subspecialists are equally enthused and intrigued about how the changes we're making can improve care. They have been eager to learn how we can work together to enhance care coordination.

In fact, we recently brought PCMH advocates Paul Grundy, M.D., M.P.H., and John Bender, M.D., to Kansas City to share their insights. More than 200 of our physicians -- both primary care and subspecialty physicians -- turned out for a PCMH summit.

Grundy, who is IBM's director of global health care transformation and founding president of the Patient-Centered Primary Care Collaborative, encouraged us to see the big picture and embrace it. Specifically, he stressed that managing data is critical in the PCMH because it allows you to manage populations and perform chronic disease management.

Bender, CEO and medical director of Miramont Family Medicine in Fort Collins, Colo., shared the story of how transforming his practice made it more efficient and more profitable and decreased emergency department visits, admission rates and readmission rates.

In short, we are preparing for the future of primary care delivery by utilizing data and exploring new and emerging technologies, while also maintaining our relationships with patients.

If you are actively transitioning your practice to the PCMH model, or simply pondering how to get started down the path to improving patient outcomes, the AAFP has resources that can help. Check out the new set of PCMH checklists and the PCMH Planner, which each reflect three levels of improvement work that can help you find ideas for what to do next, no matter where you are in your practice transformation work.

Michael Munger, M.D., is a member of the AAFP Board of Directors.


Wednesday Nov 05, 2014

California AFP's Success Shows What Chapters, FPs Can Accomplish at State Level

It's that time of year again. For the past 15 years, by the end of October, I would start counting the wins and losses of my favorite college football teams in preparation for the Bowl Championship Series that crowns a national champion. However, with the introduction of a long overdue college football playoff this season, polls and computer rankings are no longer quite as compelling. Although I've been enjoying some great football games, I've been tracking and counting something even more interesting instead.

Like many of you in your own states, I also advocate on health care issues in my home state of California. As the legislative session comes to an end for the California State Assembly, the California AFP's record is pretty impressive. Of the CAFP's 19 priority bills, Gov. Brown signed 17 of them this year. Among the victories for CAFP were budgetary expansions for primary care workforce training and the elimination of a retroactive 10 percent reduction in California Medicaid (Medi-Cal) provider payment to the tune of more than $42.1 million.

Other Medi-Cal related wins include the creation of an oversight body for children's health, streamlining enrollment, and expansion of enrollment eligibility categories. New laws will also require Medi-Cal managed care plans to provide interpretation and translation services to their participants. Several new pieces of legislation will strengthen team-based care by allowing physician assistants to certify claims for disability, authorizing medical assistants to handout labeled and prepackaged medications after consulting with appropriate health care professionals, and requiring schools to provide emergency epinephrine auto-injectors.

On the workforce front, in addition to increased funding for primary care training, new legislation has cleared the way for graduates of accelerated and fully accredited medical education programs to become licensed physicians in California.

Hard work by CAFP staff and members culminated in the passage of a resolution regarding patient-center medical home (PCMH) definition. For the past six years, this piece of legislation was kicked about by some as leverage for their own political ambitions. In previous sessions, it had been snatched from the jaws of victory by last-minute legislative maneuvering and was dismissed by the governor as an "evolving concept."

Just as with any successful football team, team work made the difference in getting it done this time. CAFP enlisted and energized attendees of its All Member Advocacy Meeting by focusing them on passing priority legislation. We trained an army of family physicians to become expert patient advocates on PCMH issues. In addition, contributions to FP-PAC, California's family medicine political action committee, opened doors for our well-trained grassroots advocates to meet with influential legislators.

Furthermore, 2014 was declared "The Year of the Family Physician" in California when a resolution sponsored by CAFP passed the legislature. The hashtag #2014YearFP was a Hail Mary idea dreamed up by Ron Fong, M.D., M.P.H., at the University of California-Davis Family Medicine Residency Network. During the year, it gained momentum within local communities and city councils and was picked up in social media around the nation and the world.

Although the Year of the Family Physician is drawing to a close, an even broader effort touting the value of family medicine and primary care is just getting started. As we embark on the road to achieve the goals of Family Medicine for America's Health and the Health is Primary campaign, I strongly invite your input and involvement in this vital process as we transform our medical neighborhoods. Keep informed and get involved.

And finally, I would be interested to hear about your state chapter's legislative wins in the comments field below. Tell me about your success stories!

Jack Chou, M.D., is a member of the AAFP Board of Directors.

Friday Oct 31, 2014

Initiatives Highlight Family Medicine as Top Choice for Students

When I decided during my undergraduate studies to go to medical school, I knew that I wanted to build relationships with patients, serve vulnerable populations and become a patient advocate. I never expected, though, to be where I am today, embarking on a year that will involve representing medical students across the country and working alongside people who have become some of my personal heroes. But as the student member of the AAFP Board of Directors, that's exactly what I'm doing.

As this new door opens, so does another: the Family Medicine for America's Health project and its recently launched, public-facing campaign, Health Is Primary. What a great and exciting time to be a future family physician!

 Here I am talking with former AAFP President Glen Stream, M.D., M.B.I., the board chair of Family Medicine for America's Health. Dr. Stream discussed Family Medicine for America's Health and the Health is Primary campaign with medical students Oct. 24 during AAFP Assembly in Washington.

Check out FMAHealth.org for history and details on this game-changing project, which takes a comprehensive approach to setting family medicine on a track to lead health care transformation that will deliver value and improve the health of Americans.

I'm excited to see the contributions of my peers and colleagues in this project. This initiative wasn't the product of just a small group of disconnected decision-makers working behind closed doors. Medical students, residents and new physicians were involved at every step during the past year-and-a-half of the project's development. They contributed their visions of, and high expectations for, how patients are going to be better served by family physicians and our health care system moving forward. More importantly, patients were involved in this project, and their needs and expectations are being held in the highest regard (as they should be).

The project charges family medicine to lead the way to better care for patients, going beyond the practice of medicine to affect social determinants of health, public health efforts, population health efforts, community leadership and more.

I have struggled at times with what to tell my medical school colleagues about family medicine. I know why I'm choosing the specialty: I enjoy interacting with patients of all ages and engaging them in their health. I want to deliver babies, care for children, offer palliative care at the end of life, teach prevention, treat sports injuries and help my patients in every way that I can. But what has been harder for me to get across, at times, is why my peers should consider family medicine. Now, strengthened by this project, the reasons a future in family medicine looks so bright are more apparent than ever.

Here are a few:

  • Evidence shows family medicine is pivotal to reaching the triple aim of better care, better health outcomes and lower costs. Family physicians lead the way to more value and patient-centeredness in the health care system.
  • Family physicians are trained to practice a wide scope of medicine that is not limited by patient gender, age, health issue or organ system. As "comprehensivists," family physicians have the power to influence patients and populations in a way other specialties cannot. Family physicians are better equipped than any other specialists to manage complicated chronic illnesses, provide preventive care and, most importantly, deliver coordinated, continuing care to patients with whom they have a relationship. All of these things are shown to improve the value of care provided. 
  • The Patient Protection and Affordable Care Acts calls for physician reimbursement to be tied to quality and care outcomes, rather than volume. The payment gap between primary care physicians and subspecialist physicians should narrow accordingly. 
  • Emerging practice models, including direct primary care, will focus on the patient and deliver higher-quality care at lower cost with less waste. 
  • The graduate medical education system needs to be reformed -- and is being challenged to do so by the AAFP and others -- to deliver the physician workforce our country needs. 
  • The patient-centered medical home model of care will continue to evolve as evidence directs the movement. 
  • Preventive and chronic care management will unseat acute care as the focus of the system.

I believe more than ever that family physicians are the right group to lead this charge. The mission of family medicine aligns seamlessly with the ideals of an optimal health care system that delivers on the triple aim.

A future in family medicine offers a chance to be part of much-needed change in health care delivery, to fix a broken system and, most importantly, to make the greatest impact on the health and wellness of patients.

To quote new AAFP President Robert Wergin, M.D., someone I am incredibly excited to learn from and work alongside this year, "Why are we the answer to health care delivery in this country? We are family physicians. Enough said."

Words cannot capture the complex, coexisting feelings of humility and pride I'm experiencing from being able to serve medical students, family physicians and patients this year on the Board and to call family medicine my specialty of choice. If you haven't been paying attention, now's the time to start. Stay tuned.

Kristina Zimmerman is the student member of the AAFP Board of Directors.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.