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Monday Mar 14, 2016

FPs Must Demystify Colorectal Cancer Screening

During the nearly two decades I worked as a health correspondent for our local NBC affiliate, my cameraman was a kind, funny man who seemed to know everyone in town. Phil not only was my colleague but also my friend.

Phil and I talked about the health segments we were working on, and he also frequently asked my opinion about health issues he and his family members were dealing with. He wanted my perspective on immunizations, medications and more.

Unfortunately, one health topic Phil never asked me about was colorectal cancer. I was heartbroken when I learned this wonderful man recently died a preventable death just a few weeks shy of his 61st birthday.

If Phil had asked me about colorectal cancer, I would have told him that his age and his race put him at increased risk, and screening would have been appropriate. Blacks have the highest incidence of colorectal cancer and the highest mortality rates of all racial groups.

Colorectal cancer is the second-leading cause of cancer deaths in the United States, yet nearly one-third of adults ages 50 to 75 aren't screened as recommended. Two years ago, the AAFP joined the National Colorectal Cancer Roundtable, which seeks to increase the percentage of adults ages 50 and older who are screened to 80 percent by 2018. It has been estimated that reaching that goal would avert roughly 280,000 new cancer cases and 200,000 cancer deaths within 20 years.

Family physicians can help by screening patients -- or referring patients to screening when appropriate -- and also by answering questions and demystifying the process.

It's worth noting that the U.S. Preventive Services Task Force issued a draft of updated screening recommendations in October. The Academy has offered feedback for the final recommendation, which is pending.

Others are doing research to learn how we can increase screening rates and close gaps in care. For example, the Patient-Centered Outcomes Research Institute (PCORI) -- an independent nonprofit that seeks to improve the quality and relevance of evidence available to help patients, physicians and others make informed health decisions -- is funding several projects related to colorectal cancer screening and treatment.

  • Screening rates are substantially lower among Hispanics than non-Hispanic whites. A project at Thomas Jefferson University aims to improve screening rates among Hispanics by implementing an intervention that will identify the participant's preferred screening test and work with patients and their primary care providers to facilitate testing.
  • A project at Indiana University will provide clinical evidence and patient input to guide decision-aid designers on how to present patients with comparative effectiveness information about screening methods.
  • A North Carolina project aims to survey more than 1,000 colorectal cancer patients to develop measures for use in improving communications between physicians and patients.

Years ago, I lost an aunt to colorectal cancer in an era when screening was not yet widely accepted. She often was on my mind when I spent years lobbying in my state's capital for legislation that now requires insurers to cover screening.

Today, patients have more access to care and more options for potentially life-saving screening. It is up to us to ensure that they understand their risks and their choices.

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

Monday Mar 07, 2016

E-prescribing Holds Potential to Curb Opioid Abuse

Nearly 2 million Americans have substance use disorders involving prescription pain relievers. Roughly 44 of them will die today, and 44 more the day after that, because prescription opioid abuse leads to more than 16,000 deaths each year.

The problem is complex, and there are no easy answers. However, one step we should all be considering seems obvious. Since Vermont came on board in August, electronic prescribing of controlled substances is now possible in all 50 states. E-prescribing provides better tracking and reduces diversion by creating a direct link between the physician and the pharmacy.

Conversely, paper prescriptions can be easily manipulated. Signatures can be forged. Numbers can be altered. And paper prescriptions can be lost or given to -- or stolen by -- others.

According to a report published in May 2015, nearly three-fourths of U.S. pharmacies were capable of receiving electronic prescriptions for controlled substances in 2014. Based on recent conversations with industry sources, the number now may be closer to 85 percent.

So if e-prescribing is the answer to reducing death and diversion, physicians must be rushing to get on board, right?

Not yet.

According to that same May 2015 report, only 1.4 percent of physicians who write physicians for controlled substances are set up to do so electronically. The fault, however, doesn't lie solely with prescribers.

In many cases, physicians are handcuffed by the limitations of their electronic health records systems and vendors' reluctance to make any changes without additional investments. Instead, they would prefer to nickel and dime physicians while people continue to die.

Family physicians are repeatedly asked by payers, the administration and others to make changes that require investment. Last year, the Academy joined a White House-led effort to curb opioid abuse. As part of that initiative, the Academy set goals to increase

  • family physician education in appropriate opioid prescribing practices,
  • the number of family physicians who complete training in how to provide medication-assisted treatment for opioid addiction, and
  • overall awareness about opioid abuse and pain management.

The Academy also joined the AMA Task Force to Reduce Opioid Abuse, a group of more than two dozen physician organizations seeking to identify best practices to combat abuse and implement those practices nationwide.

The White House asked for our help, and we've responded. Family physicians are taking more education about opioids and pain management. According to the American Board of Family Medicine, more than 22,700 family physicians have completed the ABFM's pain management self-assessment module in the past six years. Furthermore, in each of the past four years, more than 16,000 family physicians per year have reported CME credits related to pain management or opioids, and those FPs reported completing an average of eight CME credits on this important topic.

Now it is time for electronic health record system vendors to also take responsibility for public health and ensure physicians have the tools available to address this crisis without the burden of another crippling expense.

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

Tuesday Mar 01, 2016

Teaching Abroad Helps Grow Family of Family Medicine

I recently returned from Saudi Arabia, my fourth trip there in the past seven years and the first with a new passport. Planning for the trip gave me the occasion to thumb through my old, expired passport and reflect on all the places I have traveled to on behalf of the AAFP's Advanced Life Support in Obstetrics (ALSO) program.

Lots of memories -- joyful and wonderful experiences, frustrating travel disruptions and memorable international colleagues who struggled to provide the best possible medical care under often challenging circumstances.

And yet, in my years of teaching ALSO in resource-challenged countries, I rarely encountered family physicians providing maternity care. In almost every case, the participants in the global ALSO courses were obstetricians or nurse midwives. In many of the countries I have visited, family medicine is not well established, and physicians who provide general medical care in the community rarely interact with hospitals or provide maternity care.

That clearly is changing around the world as family medicine residency programs are established and graduates enter their communities to provide comprehensive, family-centered care across generations.

In decades past, many U.S. physicians generally thought of global medicine as missionary medicine. American doctors, the thinking went, travel to developing countries to provide short-term medical care to underserved populations, often in association with philanthropic and faith-based organizations. But there are incredible examples of dedicated family physicians who contribute their time, energy and funds to support international programs and provide continuity of resources to communities that otherwise would not have health care. Several of my extraordinary community colleagues rank among them.

The AAFP partnered with the Kansas-based non-profit organization Heart to Heart International and the AAFP Foundation to start Physicians with Heart in the former Soviet Union in 1993. In nearly two decades, the project helped provide support, training and mentorship to local family medicine associations and family physicians in the countries of the post-Soviet era. In collaboration with local health authorities and ministries of health, Physicians with Heart developed and conducted family medicine education and training events. The project also coordinated airlifts of much needed pharmaceuticals, medical equipment and supplies, as well as educational materials.  

I got started in international and global medicine when Physicians with Heart brought the ALSO course to the former Soviet Union. Today, the Academy continues to support our members in their global health work and initiatives to support nascent family medicine associations, provide basic and continuing medical education, sustain ongoing family medicine residency training, and help support family physicians in countries where the specialty is having difficulty becoming established and growing.

Our Academy members' participation in the World Organization of Family Doctors, or Wonca, has expanded our international horizons even further. The incredible energy and enthusiasm of our young family physicians in Wonca's Polaris Movement for New and Future Family Physicians in North America is wonderful testimony to the realization that we are one global community, all striving to improve the life and health of those we serve.

Many medical school applicants have already participated in global health activities, and many U.S. medical schools and family medicine residency programs have well-established international and global health rotations, areas of concentration and global health tracks. Involvement in global health lets us see and learn more about conditions that are rare in U.S. medical practice. But it also equips us to provide care to underserved communities and multi-cultural populations in the United States, including refugees, immigrants, asylum seekers and other transnational groups.  

It is important to remember how much we can learn from our international colleagues. The United States ranks last among the most highly developed nations in life expectancy, penetration of universal preventive health measures and global cost of care. Those countries that have better health care outcomes with lower costs have strong family medicine and primary care communities, as well as proven strategies to ensure primary care access for everyone.

I started this blog talking about my recent trip to Saudi Arabia for a reason. You see, during my second trip to Riyadh in 2011 I was introduced to Abdullah al-Owayed, M.D., a United Kingdom-trained family physician who was the first chair of the first department of family medicine in Saudi Arabia. I was asked to give a talk on the patient-centered medical home (PCMH) to a group of family physicians, all of whom had received their primary care training outside Saudi Arabia. Months after that visit, al-Owayed came to the United States and spent time in my group practice learning about our PCMH journey, and about our practice’s relationships with our local medical school and family medicine residency program.

On his return to Saudi Arabia, al-Owayed established his country's first family medicine residency. Just last month, I had the pleasure of having one of the first graduates from that residency participate in an ALSO instructor course. She is one of the pioneers of the new generation of family physicians in Saudi Arabia, providing maternity care as part of a comprehensive, full-scope family medicine practice.

How can you contribute to family medicine's development abroad? The AAFP has several networking mechanisms that may help you match to your interests and abilities with global health needs and efforts. An AAFP member interest group focused on global health and a number of member-initiated regional groups, as well as the annual AAFP Family Medicine Global Health Workshop, can provide you with resources, member experience and connections for your global health engagement. And the Academy's Center for Global Health Initiatives supports the professional needs of AAFP members who want to be globally engaged.

Carl Olden, M.D., is a member of the AAFP Board of Directors.

Tuesday Feb 23, 2016

Finding Right Fit Key to Match Process

"I'm going into family medicine."

This statement could be easily overheard in a multitude of settings, including the classroom, clinic, hospital or community. Yet it took me three years to develop the confidence to openly express my true passion.

Here I am visiting Yosemite National Park between residency interviews in California. I interviewed at 11 programs from Seattle to San Diego. Match Day is March 18.

Although I already was interested in family medicine before entering medical school and specified my interest upon matriculation, I was surprised to meet a lot of resistance toward my chosen specialty.

While attending one of 10 U.S. medical schools that lacks a family medicine department, I have listened to multiple lecturers comment on how family medicine "will be replaced by nurse practitioners and physician assistants," and I have been told that I am "too smart" for the field. This quickly taught me to tread cautiously. I would say things like, "I'm interested in primary care but open to other specialties," to ward off unwanted advice.

I didn't express my interest in family medicine again until during a family medicine elective rotation at a nearby community hospital. It felt so validating to hear words of encouragement from both the residents and faculty. Furthermore, the diverse range of patients I interacted with -- both inpatient and outpatient -- reminded me of the primary reason why I chose to pursue a career in medicine: to provide quality healthcare for all, regardless of background.

As I started the residency application process, I quickly realized how dramatically different residency programs could be. I initially searched for programs through the AAFP Family Medicine Residency Directory, but I was overwhelmed by the sheer number of programs in ONE state. I contacted my family medicine advisor from the community hospital (who ended up being the mentor for all three of the family medicine applicants from my school), and the first question she asked me was "What kind of program are you looking for?"

This simple question stumped me. While my classmates who were pursuing subspecialty interests were focused on finding large academic institutions with strong reputations and opportunities for fellowships, I had the unique opportunity to reflect on the differences between a community-based program affiliated with a medical school versus one not affiliated with a medical school, rural versus urban, underserved settings, as well as opposed or unopposed programs.

Most importantly, my mentor pushed me to probe deeper and contemplate how I envisioned practicing medicine. Based on my goals, we reviewed programs whose mission and philosophy seemed to align with my own. I had never heard of half the programs she suggested, but I maintained an open mind and applied to them.  

Once I started on the interview trail, my fellow classmates and I often shared our interview experiences, and we noticed dramatic differences between the processes followed by primary care and surgical subspecialty programs.

  • My pre-interview dinners typically occurred in a resident's house, sometimes with homemade food while my classmates often went to either a happy hour or a three-course, sit-down meal.
  • My interview days had three to 12 applicants compared to my classmates' sizeable 30- to 40-person groups.
  • I typically had two to three interviews that lasted 30 to 60 minutes, while my classmates had up to 10 interviews, lasting 15 to 20 minutes each.
  • The questions I was asked focused on getting to know more about me, my view of wellness and my vision of family medicine in 10 years. My classmates reported occasionally answering medical knowledge or research questions.
  • My interview days lasted approximately five to six hours. In contrast, my classmates' days lasted up to 10 hours.
  • My interviewers were more likely to ask me, "Why is X program a good fit for YOU” rather than “Why are YOU a good fit for X program?"

How often do you hear medical students comment on finding the right "fit"? That seemed to be a much bigger concern to the family medicine programs than the subspecialty programs. The process of the Match should be a two-way process in which not only is the program looking for particular characteristics in a candidate, but that the program knows candidates are also seeking specific qualities.

The applicants I met from across the country shared their various visions of how they wanted to practice family medicine, and these interests sparked unique discussions throughout the interview day as well as at dinner. My appreciation and pride for family medicine continued to grow throughout the interview trail as I learned more about the increasingly diverse scope of care family medicine can provide.  

The most difficult part of the application process isn’t necessarily the interviewing, but rather, the rank lists (which are due this week). Each program has a unique approach to training future family physicians. Some programs' styles paralleled well with my own vision, and I did indeed experience the visceral reaction people often label as a “gut feeling of finding the one.” Certain programs spoke to my goal of training in an underserved area focused on community-oriented primary care with dedicated time focused on behavioral health as well as opportunities to pursue the numerous other interests I have.

Ultimately, while some of my classmates created extensive excel sheets to numerically rank factors, and based their decision on the total sum, I viewed each program as a potentially new family. The most important part of a family is the people who are willing to support each other through the ups and downs presented in life's journey. In the end, I know I’ll get great training no matter where I go, but it's the people who matter the most to me.

This journey on the interview trail has taught me how unique family medicine is compared to other specialties. I’ve met a lot of incredible individuals during this process, and I would be honored to grow and learn with them.

I'm proud to say that I'm going to become a family physician. Soon, I'll find out where.

Tiffany Ho, M.P.H., is the student member of the AAFP Board of Directors.

Wednesday Feb 17, 2016

Let's Shine a Light on Black Contributions to Medicine

For some, February means an extra day off work for Presidents Day. Many look forward to Valentine's Day each year. Still others see the month as an opportunity to raise awareness of cardiovascular disease in women.

For me, February represents a time to reflect on the contributions of people of color who helped make this country great. In the field of medicine, there have been many black scientists, physicians and technicians who invented, improved or initiated practices from which we benefit today. 

NIH image

HeLa cells are seen dividing under electron microscopy. The cells, originally taken from a young black patient, Henrietta Lacks, without her knowledge, have been used in medical research for decades.

I also think about the people who have contributed to science without even knowing it. 

We celebrate Black History Month to highlight stories that have somehow faded into the background of U.S. history. Although we rejoice in the victories of people such as Rosa Parks and Martin Luther King, Jr., there are myriad others whose names most of us would never recognize.

My grandparents lived in Haiti when it was one of the few independent black nations in the world, if not the only one. They reminded me that when they were still children in the early 1900s, walking freely in Haiti, life was far different for blacks a relatively short distance away in the United States.

Until recently, science often advanced on the unknowing backs of minorities. The blister of the Tuskegee syphilis trial conducted from 1932 to 1972, still causes us to flinch today. 

It is within this context that I remember Henrietta Lacks. If you haven't read The Immortal Life of Henrietta Lacks by Rebecca Skloot, I strongly recommend it. In 1951, this wife and mother died at age 31 from cervical cancer. Her cells were harvested without permission for study.

Better known as HeLa cells, they were used in the development of the polio vaccine and were the first human cells to be successfully cloned. The cells' replicability allowed them to be mass-produced and distributed all over the world for research. This was done without the knowledge of the Lacks family, whose members were neither recognized nor compensated for this contribution. It was not until 2013 that NIH officials formally recognized the Lacks family for their matriarch's contribution to medical research.

Indeed, the incredible scientific gains made using the cells of this woman stand in sharp contrast to the fact that many of her descendants lacked the means to pay for their own medical care. Such disparities reverberate throughout the black community. They serve as a constant reminder of the chasm between quality and equity. For some, this experience serves as a litmus test for each encounter with a medical professional. Indeed, it's important that we as physicians recognize there's a steep hill of skepticism we need to climb when caring for many of our patients.

One of the reasons why we celebrate Black History Month is that we, as a culture, do not count black history as part of our history. We don't hear enough about the Henrietta Lackses, the Charles Drews or the Daniel Hale Williamses in our collective history classes.

We relish the fruits of many black authors, philosophers and academicians, but there is so much black history that goes unseen by mainstream culture. We aren't taught, for example, about the slaves used for medical experimentation in the antebellum American South.

Some might argue that there are many contributors to our society, from all backgrounds, that go unheralded. Others might retort that all people, regardless of background, should be recognized for their merit. I agree with both perspectives.

However, our institutional systems of learning remain anemic in color. The value placed on contributions to science is determined by our ingrained bias. It is demonstrated by Nobel prizes awarded and NIH grants received. It is displayed by who is prominently recognized in our history books versus who is mentioned as an afterthought.

Ideally, one would have the ability to see value and worth without the tainted spectacles of bias. However, bias is rooted our subconscious and requires methodological maneuvers to surface. We as scientists can all relate to that. As one of my mentors in medical school taught, "You don't know what you don't know."

We are trained as doctors to believe that the history is the most important part of the physical exam. I have come to appreciate the truth of this simple statement. Each patient is the result of generations of history, good and bad. Part of my job is to decode that potential. 

Today, I wanted to share a bit of black history -- our black history -- because whether or not you knew the story behind the HeLa cells, chances are that you have benefited from them. I hope that one day our learning experiences will reflect the kaleidoscope of culture and diversity that makes us Americans.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Friday Feb 05, 2016

Get the Candidates Talking About Family Medicine Issues

After months of buildup, Iowans like me finally voted in our caucus this month.  

Presidential candidates had been meeting with voters in the Hawkeye State for the past year to explain how they would lead the country (and how they would do it better than their opponents). The experience for me started last April during a meeting with Sen. Marco Rubio, R-Fla. I was invited by a friend, and we sat around a table with 15 others to hear Rubio's thoughts and to ask questions.

Of course, I asked about health care, and Rubio said he would repeal and replace the Patient Protection and Affordable Care Act (ACA). I asked what he would replace it with, but his response was vague. Since that meeting, Rubio has reiterated his desire to get rid of the ACA, but he still has not offered a specific plan for a replacement.  

This is a frustrating part of the process, and it certainly is not unique to one politician or one party. The candidates like to repeat their favorite soundbites, but they rarely offer detailed solutions. Too often, discussions on the campaign trail are about getting elected rather than solving real problems.

In Iowa, candidates continued to meet with voters in increasingly large groups across the state as their campaigns went on. We were bombarded with TV and print ads. And for the unfortunate families that still have landlines, the phone calls were frequent. In recent weeks, our local newspapers covered every candidate visit and recapped what was said.

We Iowans take this process seriously; we try to stay informed and influence where we should go as a country. A record 186,874 Republican voters participated, while the Democrats drew 171,109 caucus-goers. That equates to a turnout of 15.7 percent of eligible voters.

It's worth noting that in states with primaries, polling stations typically are open throughout the day, and people can vote at their convenience. A caucus requires attendance and registration at one specific time of day, so voter turnout of nearly 16 percent is remarkable.

During the Republican caucus that my wife and I attended, roughly 450 people participated. Representatives for each candidate spoke for three minutes or less -- except Rubio, who spoke for himself -- in one final opportunity to reach voters. The speeches were respectful and in stark contrast to the contentious discussions and often unsavory behavior we have been subjected to in the candidates' televised debates.

Too often we can't talk about politics in our society. Many issues are polarizing, and people aren't willing to listen to what others have to say. Before the caucuses, my wife and I attended a discussion on civility. The speakers talked about things such as how to discuss controversial topics without being judgmental and how to defuse a tense situation. I think we were able to use that in discussions with our friends, neighbors, and colleagues to bring back meaningful political discussion. Just because someone disagrees with me does not make them wrong or uncaring. It simply means they have a different view on how the problem should be solved. We need to be able to work together to solve our problems, both locally and nationally.

We are done with the presidential candidates here in Iowa. Our state has only six electoral votes, so we likely won’t see them again before Election Day.

Many of you, however, will still have opportunities to vote in your state's caucuses and primaries. You can make connections with candidates or their staff members and talk with them about the problems our practices and our patients face -- issues that deserve more than their well-practiced talking points. Make your voice heard, and make your vote count.

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

Tuesday Feb 02, 2016

Family Medicine: The Force Awakens

I recently saw the latest Star Wars movie with my family, and I could not help but compare the plight of the Jedi to that of family medicine. With the many challenges facing us as family doctors -- payment reform, endless paperwork, putting patients back at the center of care, electronic health records and recruiting the brightest young family physicians -- it often seems like the good in all we do is menaced by the darkness of partisan politics, back-room lobbying and catering to special interests. But like the young Jedi Knights, if we are attuned to the Force, we can wield its power.

In medicine, the Force is the collective voice that speaks for our patients. Physicians use it when we defy the status quo and pressure the government, insurance companies, hospital corporations and Pharma to heed our concerns because we are the front line of medicine. 

In The Force Awakens, we cheered for the Resistance, a group of passionate people who rally together to reclaim the good in their world. In the world of medicine, we got a great start on reclaiming the good when we won repeal of the Medicare sustainable growth rate last year, and CMS' announcement several months later that it plans to end meaningful use as we know it could be a good next step. But it will take determination to keep this momentum going so future payment models and new ways of measuring quality health care support our work as physicians.

Another family physician who covers OB call with me recently said, "I honestly know how much my voice matters. I know that I should be more present advocating on behalf of my patients, but I don't have the energy or the time. I can barely keep afloat in my small, rural practice."

He's been practicing for more than 20 years, and now he feels burdened by meaningless work to the point of exhaustion. He knows there is a sacred component to walking with patients through their important life moments -- a delivery, seeing a child grow to maturity, working through chronic addictions and illness or the end of life -- but he feels pressured to reduce all that to clicking boxes and being "productive." We mustn't allow the business of medicine to pull us from what we as physicians vowed to do, which is care for patients, and we must find the energy to fight for what matters. 

I know that the doctors who the AAFP and our sister organizations represent are looking for their representatives to press CMS, Congress and others harder to enact meaningful change. Our practicing physicians deserve it and so do our patients. But success won't come if that burden rests only on the shoulders of a few. Everyone has to play a part to reclaim medicine and resist the bureaucracy that tries to steal the joy of practice from us. 

Our members need to become emboldened. Each individual within our own Resistance has a special role to play. If we as family doctors do not speak to our legislators, then we have no ground to stand on. If we do not take the time to educate our communities about the things that make our practice of medicine difficult, then we lose their trust. If we do not continue to press the government by developing new and innovative practice models, then we will continue to fall prey to meaningless bureaucracy. 

Our collective voice and our individual stories have weight and meaning. We can become the doctors we wrote about in our medical school personal statements. We have the power and the right to protect our practices, our patients and our joy of medicine. We have to remember that without us, the system of medicine fails. Let us not be bullied.

Colleagues, I urge you to contact your legislators and tell them your story. Stop accepting half-done business deals from the hospitals you work with. Take the time to write to the local paper. Contribute to FamMedPAC so it can continue to back candidates who support family medicine. Most importantly, don’t stop believing in the power we have as healers of our nation.

As a wise woman says in the movie, "Close your eyes. Feel it -- the light. It's always been there. It will guide you."

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Wednesday Jan 27, 2016

Win-Win? Cardiology Project Could Benefit Patients, FPs

Cardiovascular disease (CVD) is the leading cause of death in the United States, claiming more the 600,000 lives each year. That's more than the population of Wyoming.

CVD accounts for 17 percent of U.S. health expenditures, and those costs are expected to triple between 2010 and 2030. Improving prevention and care processes, however, could substantially reduce morbidity, mortality and the costs associated with CVD, and the AAFP is participating in work that aims to do just that.

I recently attended a meeting at the Brookings Institution in Washington with representatives from the American College of Cardiology, the American College of Osteopathic Family Physicians and the American College of Physicians, as well as CMS, private-payer organizations, health systems, medical schools, research groups and the Veterans Health Administration. Our goal for this meeting, and the conference calls that preceded it, is ultimately to produce a policy paper that would serve as a model to improve the way primary care physicians and cardiologists work together.

The end product could result not only in better care for our patients, but more equitable pay for primary care. Our patients and our practices both have a lot to gain in the process.

It was interesting to see how much common ground primary care has with our subspecialty colleagues. We discussed numerous opportunities to close gaps in care, reduce overtreatment and address undertreatment.

Inadequate communication between physicians, patients and caregivers is one obvious problem we agreed on, and universal dismay was expressed -- from primary care, cardiology and payers -- about the state of electronic health record systems. Current products are not meeting needs and are a barrier to innovation.

We also agreed that physicians -- regardless of specialty -- need more time with our patients than what is typically possible in the fee-for-service world of health care. Cardiology is still firmly based in that fee-for-service model. Roughly three-fourths of practices are owned by health systems. Meanwhile, a recent study showed that roughly one-third of family physicians already are pursuing value-based payment.

So how do we pull the cardiologists into our patient-centered neighborhood? A representative from CareFirst BlueCross BlueShield pointed out that the payer has had tremendous success with the patient-centered medical home (PCMH) model, lowering both ER visits and readmission rates related to CVD. Primary care practices, he said, are receiving better payment as a result of this hard work. Health systems representatives also pointed to the PCMH as a means to improve quality and lower costs.

In addition to how we might work better together, we also discussed how improving care, coordination and communication could also affect payment, including pay-for-performance programs, bundled payments, shared savings and more.

This project, which is an initiative of the new Duke-Margolis Center for Health Policy, still has a long way to go. There will be followup work still to come. But the possibilities are intriguing, and if we can get it right, this could serve as a model for how primary care works with other subspecialties, as well.

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

Tuesday Jan 19, 2016

Patient Perspective Vital for Practice Improvement

When my practice was planning to move to a new facility, we involved most of the people you might expect -- architects, builders, consultants, etc. Our new office includes all the modern technology we need in a patient-centered medical home (PCMH).

But as one of my colleagues likes to say, it's not patient-centered until the patient says it is. When we asked members of our patient advisory board for feedback about the new office, they offered perspectives we had clearly missed in the planning stages.

"There's no place to hang my coat," one man said.

Although we had put exhaustive time into considering what two family physicians, a physician assistant and office staff would need, we had failed to consider a basic amenity -- hooks on the doors -- that patients want in an exam room.

Today, we strive to put the patient at the center of everything we do, and payers need to acknowledge that work. Our small, rural practice achieved level three PCMH recognition from the National Committee for Quality Assurance a few years ago, and it's changed the way we do things. We extended our hours and added open-access scheduling. We added a health coach and adopted team-based care. We're doing more tracking, which means we're doing a better job at both providing preventive care and following up.

Our patient advisory board has been invaluable. The group meets monthly and provides direct feedback that not only helps us solve problems, but in many cases alerts us to their very existence. For example, when we implemented a new phone system, calls were going to voicemail too quickly rather than rolling to other staff members. We weren't even aware of the problem until our patient volunteers voiced their frustrations.

It’s all about the patient experience, and people want and need to talk with other people -- not machines.

Of course, all of these factors related to patient-centered care take additional time and effort, and that's one of the points I made in a recent meeting with HHS. On Jan. 14, I represented the AAFP in a roundtable discussion about patient engagement. The Academy was the lone physician organization at an event that also included representatives from consumer and patient advocacy groups, payers, health systems, a nurses' organization and an electronic health records vendor. HHS wanted to foster a discussion about "how engaging and empowering individuals in their health is an essential part of transforming our health care system."

More than one-third of AAFP members already practice in recognized PCMHs, but I said that if HHS and other payers truly want to move the needle on patient engagement, they must pay primary care physicians appropriately so practices can afford to make needed changes.

As we move from a payment system based on quantity of services delivered to one based on quality of care provided, payers must recognize the significant investment they are asking our practices to make. When that happens, we can move beyond discussions of the triple aim -- enhancing the patient care experience, improving population health and reducing costs -- to focus on a system that embraces the quadruple aim by adding the goal of improving the work life of health care professionals.

Mott Blair, M.D., is a member of the AAFP Board of Directors. 

Tuesday Jan 12, 2016

U.S. Needs More Than Baby Steps on Paid Maternity Leave

Maybe, just maybe, Americans are finally waking up to a truth that has already been accepted globally: Paid maternity leave has far-reaching health implications for both mothers and their children, including facilitating breastfeeding.

Last month, Air Force Secretary Deborah Lee James said that branch of the U.S. military will triple its paid maternity leave benefit to 18 weeks, following the example set by the Navy back in August.

The international corporate world also took some big steps in the past year. Nestlé, the largest food and beverage marketer in the world, announced that it was extending its paid parental leave for primary caretakers from six weeks to 14 weeks for its workers globally, and it also will allow employees to take 12 unpaid weeks.

Nestlé CEO Paul Bulcke said in an interview with Fortune that supporting breastfeeding was one of the primary drivers behind changing the company's policy. That's an interesting step for a company that has been boycotted off and on for decades for the way it markets its infant formula.

The World Health Organization recommends that women should breastfeed for as long as two years, and the AAFP recommends breastfeeding for at least 12 months.  (The Academy's breastfeeding toolkit has resources for moms and practices.)

It is well documented that breastfeeding is healthy for both mothers and babies, boosting immunity, increasing bonding, reducing risk of postpartum depression and decreasing risk of morbid obesity in babies. With an ever-growing amount of data that support breastfeeding, why does our country have such a dismal rate of mothers who breastfeed past the first six months of life?

Roughly 80 percent of U.S. mothers are breastfeeding during the first 48 hours postpartum, according to the CDC. That drops to approximately 20 percent by six months. Disparities become more pronounced when looking further into the demographics. Women who breastfeed beyond six months tend to be Caucasian, have higher household incomes, stay home and be more educated. Those least likely to breastfeed tend to be black working moms who are less educated and are from homes with lower household incomes.

Although there are many factors that contribute to these shameful statistics, a major one is the persistent lack of parental leave for the vast majority of U.S. workers. This is despite studies that indicate mothers who have sufficient time to transition into parenting not only are more successful with breastfeeding, they also use less sick days, are more productive, suffer less burnout and demonstrate more loyalty to their employer.

The United States is the only industrialized country in the world that does not support some kind of paid parental leave. Many people have little or no time off, even unpaid. Particularly for those affected by poor postnatal outcomes, taking time off could mean risking one's job.

Some might argue that the Family Medical Leave Act, which guarantees one's job after return from a leave due to birth, adoption or the serious illness of a loved one for up to 12 weeks, is sufficient. However, the law does not require the leave to be paid and it generally applies only to people who have worked at least 12 months for an employer who has at least 50 employees.

Unfortunately, only about 12 percent of U.S. employers offer paid maternity or paternity leave, according to the Society for Human Resource Management. That's down from 17 percent in 2010.

No one can deny that becoming a parent is a life-defining moment, one that requires time to which to adjust. However, how can one take that time when there are bills to pay? In my second year of residency, I took only two weeks off after delivering my second child because I was allotted only eight weeks of paid time off and I already had used five weeks for bedrest. (I needed my last week of vacation time for job interviews.)

So why is paid leave so important to one’s ability to breastfeed? Simply put, if I have to return to work before my milk even has time to be established, then how can I be successful in maintaining my supply? Furthermore, women are expected, or perhaps feel pressured, to make up for the time they were away on leave.

Becoming a mother is one of the hardest, yet most rewarding, accomplishments I have under my belt. Let’s not lessen the impact and powerful message working mothers make when they embrace their many important roles both in and out of work. We should celebrate our many roles, including providing nourishment for our children.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Wednesday Jan 06, 2016

Telehealth Is Family Medicine’s Next Big Opportunity

Perhaps, like me, you've noticed that telehealth really hasn't lived up to its promise here in the United States. Although you may find the technology in niche markets, like satellite hospital consultations, there is hardly a transformative, mainstream movement of consumer access to family physician services online or by smartphone. 

Yet the trends are unmistakable:

  • Estimates vary, but perhaps 20 percent of what family physicians do in the office could be accomplished remotely. I would even go so far to say that much of what is happening now in retail clinics could be safely performed as a telehealth visit. (Will retail health be disrupted next?)
  • Although the fee-for-service model has barely paid for telemedicine, the advent of new models such as direct primary care and accountable care organizations could create a sustainable funding source for services that were previously not paid for.
  • Regulators at the state and national level are continuing to modernize the laws around telehealth and telemedicine to encourage physicians to engage patients remotely within clear boundaries that are safe and have utility to consumers.
  • The proliferation of Bluetooth-enabled biosensors that can communicate with smartphones and sync data to cloud-based health information exchanges allow for remote monitoring of patients. These patients are empowered to decide with whom they will share that information. For some patients and family physicians, this might allow for a novel telehealth visit with vitals.

So what does the United States need to do to start participating more? Well, according to the American Telemedicine Association, we are about halfway there. State legislatures and policymakers must continue to remove regulatory barriers such as only requiring insurers to pay for telehealth for rural patients, because suburban and urban areas also have health care disparities and access problems.

Family physicians should not be required to document a barrier to an in-person visit before a health benefit plan covers telemedicine. And nothing should require the use of telemedicine when in-person care by a participating physician is available within the member’s geographic area, or when a family physician determines it is inappropriate. In other words, actual plan networks cannot be remote.

I am amazed at how many patients in this economy may have a tablet computer or a smartphone, but not an automobile. Moreover, just as we use Skype and Facetime with friends and family more than with strangers, I predict the strongest future for telehealth will be between family physicians and their long-time patients, not between strangers connecting to chat.

John Bender, M.D., M.B.A., is a member of the AAFP Board of Directors.

Wednesday Dec 23, 2015

End of Medicare Bonuses Underlines Need for New Payment Models

More than just the calendar year will end on Dec. 31. The New Year also will mark the end of the Primary Care Incentive Program (PCIP).

The PCIP, created in 2010 as part of the Patient Protection and Affordable Care Act, pays family physicians and other primary care providers bonuses equal to 10 percent of the amount Medicare paid them for primary care services if they met certain conditions. This bonus was an overdue step toward recognizing the value of primary care.

The program paid $664 million to primary care practices in 2012, but how much it will be missed depends somewhat on whom you ask. A survey of primary care physicians found that half were unaware of the program's existence. Some physicians "boutique" their practices, limiting their number of Medicare patients. But many practices in rural and underserved areas can't do this, and they benefited greatly from the bonus payments. Practices with large Medicare panels certainly will feel the hit. Qualifying primary care physicians received an average of nearly $4,000 a year.

Although the AAFP and other primary care advocates fought for an extension of the program, Congress showed little interest in prolonging a bonus program based on the fee-for-service model. As we have seen in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) -- the law passed earlier this year that repealed the flawed Medicare sustainable growth rate formula -- legislators are more interested in linking increased physician payments to certain quality and performance standards.

If you haven't already, I strongly encourage you to start making yourself familiar with the alternative payment models and the merit-based incentive payment system (MIPS) described in the new law. By 2019, all physicians participating in Medicare will fall into one category or the other.

MIPS, while attempting to promote quality and added value, still is based on fee-for-service. And as we have seen, that model continues to be a popular target for spending cuts. A multi-year federal budget agreement led to a 2 percent cut to Medicare payments in 2013 and further incremental reductions for several years, and Congress allowed the Medicaid parity program -- a provision of the ACA that raised Medicaid physician payments in line with Medicare -- to expire in December 2014.

The 2016 physician fee schedule called for a modest 0.5 percent increase in the physician payment conversion rate. However, other legal mandates made even that minimal increase too tall a task for CMS because it failed to identify and adjust a required percentage of overvalued CPT codes. As a result, the Medicare physician fee schedule will see a fractional decrease in the conversion factor in 2016, rather than a half-percent increase.

What it boils down to is that alternative payment models are the path forward that will provide stability and give our practices the greatest opportunity to thrive. One-third of family physicians already are pursuing value-based payments.

The AAFP recently submitted detailed responses to 126 questions as part of a CMS request for information on how to implement new payment models associated with MACRA. Early in 2016, the Academy will be rolling out materials that will help family physicians better understand the choices, deadlines and challenges that MACRA presents. Stay tuned.

Robert Wergin, M.D., is Board Chair of the AAFP.

Monday Dec 21, 2015

Government Hears From FPs on Opioid Abuse Crisis

In the 1990s, physicians were told we weren't doing enough to address pain. Millions of Americans were suffering with chronic pain, affecting more patients than diabetes, heart disease and cancer combined. Essentially, we were told we were failing these patients.

Naturally, physicians responded.

© 2015 Shawn Martin/AAFP

Here I am with Surgeon General Vivek Murthy, M.D., M.B.A. Murthy gathered a group of stakeholders Dec. 16 in Washington to address prescription painkiller abuse.

In 1995, the American Pain Society introduced the slogan "Pain: the fifth vital sign," to raise awareness of the need to treat pain. By 1999, the Joint Commission on Accreditation of Healthcare Organizations was on board as well, and that organization published new standards for pain management a year later.

Unfortunately, the pendulum has swung too far. The number of prescriptions written for opioids jumped from 87 million in 1995 to 219 million in 2011. From 2003 to 2013, the number of Americans who died as a result of opioid abuse surged from 4.5 per 100,000 to 7.8 per 100,000. In 2014, 19,000 people died as a result of such abuse.

Now we find ourselves in a difficult situation as federal agencies ask us to curb our prescribing at the same time that our patients are living longer and with more chronic conditions. How do we find a balance and bring that pendulum back to the middle?

Last week I devoted an entire day in Washington to this issue, meeting with staff members from the offices of Sens. Pat Toomey, R-Pa., and Bob Casey, D-Pa., speaking with a national media outlet and participating in a meeting called by the surgeon general.

Toomey and Casey, senators from my state, are hearing a lot from federal agencies, the public and the medical community, and they are trying to determine whether there is a legislative solution. I made them aware of the delicate art and science of caring for patients in pain, and the work that family medicine and AAFP have been doing to curb opioid diversion and deaths.

I also spoke with National Public Radio host Robert Siegel for an upcoming segment of All Things Considered that focuses on our nation's pain and opioid dilemma. One of the things he asked me was how often family physicians have to deal with the issue of pain.

As you know, every day we care for patients with pain because roughly 100 million Americans suffer from chronic pain. So we discussed how to decide who should be treated -- or not -- with prescription medications and what steps we can take to ensure that medications are used appropriately and only for as long as needed. I also highlighted the importance of having an ongoing relationship with a primary care physician.

Many of these same issues rose that day during an event organized by Surgeon General Vivek Murthy, M.D., M.B.A. In addition to the AAFP, representatives from many other health care groups -- including the American College of Physicians, American Congress of Obstetricians and Gynecologists, American Dental Association, AMA, American Osteopathic Association and American Association of Nurse Practitioners -- were present.
The day before this meeting, a study published in JAMA Internal Medicine reported that primary care professionals were the biggest prescribers of painkillers, with family medicine recording 15.3 million prescriptions, internal medicine 12.8 million, nurse practitioners 4.1 million and physician assistants 3.1 million. So you might have expected our specialty to be in the crosshairs during this meeting with federal officials.

However, HHS acknowledged that this is a public health issue that is multifactorial. We also agreed that it's not surprising that family physicians see a large number of patients suffering with chronic pain because FPs provide roughly one in five U.S. office visits.

It was refreshing that this event was essentially a listening session for the federal health agencies. We told them what we are experiencing and what needs to improve. For example, we talked about the importance of physicians participating in prescription drug monitoring programs (PDMPs), working with states to make PDMPs more robust when needed, using real-time data and achieving interoperability among state programs. We also discussed safety issues and the need to reduce diversion.

The CDC recently released a draft of its new guidelines for opioid prescribing, and it's not yet clear what the surgeon general's next step will be. But we do know the AAFP will continue to work with the federal agencies, as our policy on this issue states, "to allow effective and safe opioid prescribing for patients in their pain management programs by their family physicians."

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

Wednesday Dec 16, 2015

At the Crux of Art and Science: I'm a Family Physician

My mother walked the hospital corridors with me at her side. I escorted her around the facilities, showing her my place of work. She turned to me with a proud look in her eyes and said, "Remember that what you do is sacred."

I don't think I will ever forget that day. Growing up in an immigrant household, there was nothing more revered than the work of doctors and clergymen. In my culture, they almost go hand in hand. Care is taken to heal the soul, not to simply treat an ailment. There is a keen art in doing so.

Or at least, there was.

I'm not sure how or when medicine turned from an honored profession to an outcome-based mill. I certainly don't recall when patients turned from people to products. However, this is how practicing medicine now sometimes feels.

We are hindered by protocols, quality measures and satisfaction scores, which make fostering relationships with our patients difficult. And as family physicians, aren't relationships the reason we chose our specialty?

Don't get me wrong. Quality plays an important role in delivering good patient care. What I do not agree with, however, is how the health care system defines quality.

With so much information available in an instant, it is all too common for patients to come to me with a diagnosis in hand, seeking a pill they want to try or a remedy they have seen on TV. The problem is that not all information strewn about various media is valid. How many times have you had patients demand antibiotics for sputum they perceived to be greenish in color?

This concept of drive-through medicine is costing the country millions of dollars in unnecessary testing and medication. So how do we fix this "Have it your way" culture at a time when we're judged, at least in part, on patient satisfaction?

A regular reminder I share with not only my patients, but also administrators, is that health is no more a product than is the wind. It flows and is dynamic. Protocols are guidelines, and I certainly am not a dictator when it comes to the care of my patients. Ultimately, they need to remain informed about their conditions and live with the consequences of their decisions. I am their consultant, I remind them, one who collaborates to help them reach their goals.

I am not a personal assistant. Although I guide my patients regarding their health and wellness, that does not necessitate total agreement. Not every ache and pain requires a CT scan or MRI. Not every cough or sniffle requires an antibiotic. Not every person requires a Pap smear or colonoscopy. To best serve my patients, I need the ability to practice the art of medicine.

In the world of fee-for-service health care, we are measured by how many patients we see per day. We feel the pressure of time limitations. Important conversations about effective treatment options often give way to scheduling restrictions. However, we all know that so-called productivity does not necessarily equate to quality. Somehow, a term used to assess factory-based businesses has crept into the medical field.

I am increasingly reassured that the AAFP’s consistent work to change our health care payment structure to a more value-based model is a win-win. But quality takes time, and more family physicians need to be at the head of the table for discussions affecting all aspects of the health care delivery system so this message resonates at all levels. Who would better understand work flow, quality measures and patient-centered teams than a family physician? We need strong family physicians in leadership roles to continue advocating and directing a shift in the current payment model.

The research stands for itself. Family physicians not only give good care, we do so in the most cost-effective manner. A recent retrospective study found that greater family physician comprehensiveness of care, especially as judged by claims measures, is associated with decreasing Medicare costs and hospitalizations.

So how do we educate our patients about sticking to tests and treatments that are necessary and evidence-based? We remain engaged. We continue to advocate and fight for a system of care that values quality instead of procedures. We focus on health and wellness instead of simply fixing broken bodies. We put the patient back into the center of our care. Otherwise, we will continue to face challenges based on information patients receive from Dr. Google.

In essence, we must remember that more does not equal better. In fact, more can actually be detrimental. Just ask my patient who suffers from urinary incontinence after having a radical prostatectomy for low-grade prostate cancer while in his 70s.

Or ask my patient who was taking more than 20 different medications for management of various symptoms before being whittled down to the six she really needed.

Ask the elderly patient who was taking three different brand names of the same anti-arrythmic drug before her family doctor went through her medications with her.

Ask the young lady who developed Clostridium difficile infection after being treated for multiple "respiratory infections."

The list could go on and on.

After all is said and done, we cannot reduce the practice of medicine to a simple black and white algorithm. Trust between physician and patient must be first and foremost. We must resist the urge to allow insurance companies, pharmaceutical agencies and the media to give misinformed guidance in how we provide care to our patients. If not, then our role as family physicians becomes diluted.

How do we change this "Have it your way" culture? One patient at a time.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Wednesday Dec 09, 2015

Seeking Solutions to Gun Violence at the Scene of the Crime

A couple of months ago, I was invited to participate in an event at the Emanuel African Methodist Episcopal Church in Charleston, S.C., which was the site of a racially motivated shooting earlier this year. The purpose of the event was to bring together stakeholders from legal/judicial, health care, public health, law enforcement, political, faith and other communities to address gun violence prevention.

From the time I started preparing for this event in early October until it actually took place on Dec. 4, the United States witnessed more than 50 other incidents in which three or more people were shot. In just two months, such shootings claimed 90 lives and wounded more than 200 others.

Michael Bowman/Voice of America
A memorial forms outside the Emanuel African Methodist Episcopal Church. Nine members of the congregation died during a June 17 shooting at the Charleston, S.C., church. I participated in a forum on gun violence Dec. 4 at the church.

As a nation, we cannot allow ourselves to grow numb to such tragedy. By the time we convened last week in the same room where nine members of Emanuel's congregation had been gunned down in June, places such as Colorado Springs, Colo., and San Bernardino, Calif. -- where other high-profile, deadly attacks occurred -- had been thrust into the national spotlight.

It was powerful and poignant to be in that church in Charleston. More than 300 people, including state legislators and the presidents of the American Bar Association and the American College of Physicians, participated. The AAFP was represented by state and national leaders, and I participated in a health care panel discussion.

We talked about the scope of gun violence, which has claimed the lives of more than 406,000 Americans in the past 14 years. In the past four years alone, gun-related deaths have exceeded the number of American lives lost in the Vietnam, Korean, Iraq and Afghanistan wars combined.

The issues discussed included adverse childhood experiences, domestic violence, racial disparities, the Second Amendment and more. We learned from a speaker from the American Psychiatric Association that most gun violence homicides are not related to mental health, although conventional conversations would make us believe otherwise. We also discussed the petitions physician groups delivered to Congress a few days earlier (hours before the San Bernadino shooting), seeking repeal of a shameful law that bans the CDC and NIH from conducting research on gun violence.

The obvious question is what can be done about this crisis -- which one speaker, from the Johns Hopkins Bloomberg School of Public Health's Center on Gun Violence, called a social contagion -- in a sharply politically divided country? On one end of the spectrum, there are those calling for bans on guns, while those on the other end believe the solution is to buy more guns.

How do we find middle ground that effectively addresses the problem? Can we reduce gun violence while respecting the Second Amendment? According to constitutional law experts who participated in the event, the answer is a resounding "yes."

For example, speakers pointed to the need to close loopholes in existing gun laws. The FBI has acknowledged that the Charleston shooter should not have been able to legally buy a gun because of his criminal record. However, federal law allows gun dealers to proceed with sales if FBI examiners do not respond within three days. In the Charleston case, clerical errors prevented the FBI from acting before the transaction was completed. Clearly, the system needs improvements, and the three-day period should be re-evaluated.

Meanwhile, some states are actually easing gun laws. Earlier this year, for example, Kansas passed legislation that allows people to carry concealed handguns without a permit and with no training. Although the gun industry promotes its products as keeping families safe, too often, gun owners are doing the exact opposite. During the first 10 months of this year, 13 U.S. toddlers inadvertently killed themselves when adults left loaded guns in places these children could access. Eighteen others injured themselves, 10 injured others, and two killed other people.

Family physicians can play a key role in helping keep people -- especially children -- safe, but the First Amendment rights of physicians aren't being held in the same regard as the Second Amendment rights of gun owners. Florida passed a law in 2011 that restricts physicians' rights to ask patients whether they own guns. Roughly a dozen other state legislatures have since introduced similar measures. The AAFP strongly opposes these dangerous restrictions on patient-physician conversations that focus on prevention.

Why would physicians ask patients about guns? For the same reason we ask parents about bike helmets and child car seats: We can help parents make good decisions that make their families safer. In this case, we can counsel them about safe gun storage.

Changing gun laws, or passing new ones, likely would be extraordinarily difficult in a political environment where our two major parties can't agree on far less divisive issues. But what if we instead approached gun violence as a public health issue? Cure Violence is one such model that is showing success.

A combination of regulation, education and taxation has led to a dramatic decline in smoking rates, from 42.4 percent of U.S. adults in 1965 to 18 percent in 2014. What combination of education, public health, mental health and health care programs could help reduce gun violence?

Clearly, something has to change, but we must do it in a way that protects people's rights -- and not only their Second Amendment rights. This conversation will be coming to your community. When it does, what will you say as a family physician?

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

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